BlueJourney PPO and BlueJourney HMO Generic Standard Formulary (List of Covered Drugs)

Transcription

1 BlueJourney PPO and BlueJourney HMO Generic Standard Employer Group Retiree Plan Standard Option 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID v.11 This formulary was updated on 06/19/018. For more recent information or other questions, please contact BlueJourney PPO Customer Service at or BlueJourney HMO Customer Service at or, for TTY users, 711, Monday through Friday, 8 a.m. to 8 p.m., or visit MED-89 (06/5/18) Y0016_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 Keystone Health Plan Central and Capital Advantage Insurance Company. When it refers to plan or our plan, it means BlueJourney PPO and BlueJourney HMO. This document includes a list of the drugs (formulary) for our Plan which is current as of July 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 BlueJourney PPO and BlueJourney HMO 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 BlueJourney PPO or BlueJourney HMO 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 July 1, 018. To get updated information about the drugs covered by BlueJourney PPO and BlueJourney HMO, 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 i

4 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. 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 7. 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 50mg. 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 BlueJourney PPO and BlueJourney HMO formulary? on page iii for information about how to request an exception. ii

5 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. How do I request an exception to the BlueJourney PPO and BlueJourney HMO 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. iii

6 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. For more information For more detailed information about your BlueJourney PPO and BlueJourney HMO prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about BlueJourney PPO or BlueJourney HMO, 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 BlueJourney PPO and BlueJourney HMO 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 7. 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 BLUEJOURNEY PPO AND BLUEJOURNEY HMO 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 5 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 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 5 % coinsurance % coinsurance Not Covered Not Covered v

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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) 50mg 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 500mg etodolac TB flurbiprofen TABS ibu tabs 600mg 1 ibu tabs 800mg 1 ibuprofen SUSP ibuprofen TABS 00mg, 600mg, 800mg 1 ketoprofen cap 50mg ketoprofen cap 75mg meloxicam (generic of MOBIC) TABS 1 nabumetone TABS naproxen (generic of NAPROSYN) SUSP naproxen (generic of NAPROSYN) TABS 1 50mg, 500mg naproxen TABS 75mg 1 naproxen dr (generic of EC-NAPROSYN) naproxen sodium TABS 75mg naproxen sodium (generic of ANAPROX DS) TABS 550mg piroxicam (generic of FELDENE) CAPS sulindac TABS 1

10 018 GENERIC STANDARD FORMULARY OPIOID ANALGESICS acetaminophen w/ codeine SOLN QL (5000 ml / 0 days) 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 5 QL (10 lozenges / 0 days), PA fentanyl patch 1 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 days) fentanyl patch 5 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 days) fentanyl patch 50 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 days), PA fentanyl patch 75 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 days), PA fentanyl patch 100 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 days), PA FENTORA 5 QL (10 tabs / 0 days), PA hydroco/apap tab 5-5mg (generic of QL (60 tabs / 0 days) NORCO) hydroco/apap tab (generic of QL (60 tabs / 0 days) NORCO) hydroco/apap tab 10-5mg (generic of QL (60 tabs / 0 days) NORCO) hydrocodone-acetaminophen QL (500 ml / 0 days) mg/15ml hydrocodone-ibuprofen tab mg QL (150 tabs / 0 days) hydromorphone hcl (generic of DILAUDID) LIQD hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml B/D hydromorphone hcl (generic of DILAUDID) QL (70 tabs / 0 days) TABS HYSINGLA ER 0mg, 0mg, 0mg, 60mg QL (60 tabs / 0 days)

11 018 GENERIC STANDARD FORMULARY HYSINGLA ER 80mg, 100mg, 10mg QL (0 tabs / 0 days) lorcet hd tab 10-5mg (generic of NORCO) QL (60 tabs / 0 days) lorcet plus tab (generic of NORCO) QL (60 tabs / 0 days) methadone hcl SOLN 5mg/5ml, 10mg/5ml QL (50 ml / 0 days) methadone hcl 5mg (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) 15mg, 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 SULFATE SOLN mg/ml, B/D mg/ml, 5mg/ml, 8mg/ml, 10mg/ml, 150mg/0ml morphine sulfate (generic of MORPHINE SULFATE) SOLN mg/ml, 8mg/ml B/D morphine sulfate SOLN 8mg/ml, 10mg/ml B/D morphine sulfate TABS QL (180 tabs / 0 days) morphine sulfate oral sol NUCYNTA ER 50mg, 100mg QL (10 tabs / 0 days) NUCYNTA ER 150mg, 00mg, 50mg 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 5mg, 15mg, 0mg oxycodone hcl TABS 10mg, 0mg QL (180 tabs / 0 days) oxycodone w/ acetaminophen.5-5mg QL (60 tabs / 0 days) (generic of PERCOCET) oxycodone w/ acetaminophen 5-5mg QL (60 tabs / 0 days) (generic of PERCOCET) oxycodone w/ acetaminophen 7.5-5mg QL (60 tabs / 0 days) (generic of PERCOCET) oxycodone w/ acetaminophen 10-5mg (generic of PERCOCET) QL (60 tabs / 0 days) ANESTHETICS LOCAL ANESTHETICS

12 018 GENERIC STANDARD FORMULARY lidocaine inj 0.5% (generic of XYLOCAINE) B/D lidocaine inj 0.5% preservative free (pf) B/D (generic of XYLOCAINE-MPF) lidocaine inj 1% (generic of XYLOCAINE) B/D lidocaine inj 1% preservative free (pf) B/D (generic of XYLOCAINE-MPF) lidocaine inj 1.5% preservative free (pf) B/D (generic of 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) 5 NM, PA NEBU tobramycin inj 1. gm/0ml tobramycin inj 1.gm 5 tobramycin inj 10mg/ml tobramycin inj 0mg/ml tobramycin inj 80mg/ml ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 5 ALINIA 5 atovaquone (generic of MEPRON) SUSP 5 AZACTAM IN ISO-OSMOTIC DE AZACTAM/DEX INJ aztreonam (generic of AZACTAM) BILTRICIDE CAYSTON 5 NM, LA, PA clindamycin cap 75mg (generic of 1 CLEOCIN) clindamycin cap 00 mg (generic of 1 CLEOCIN) clindamycin hcl cap 150 mg (generic of 1 CLEOCIN) clindamycin phosphate in d5w (generic of CLEOCIN IN D5W) CLINDAMYCIN PHOSPHATE IN NACL

13 018 GENERIC STANDARD FORMULARY clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE) clindamycin soln 75mg/5ml (generic of CLEOCIN PEDIATRIC GRANULE) colistimethate sodium (generic of COLY- MYCIN M) SOLR dapsone TABS daptomycin (generic of CUBICIN) 5 EMVERM 5 imipenem-cilastatin imipenem-cilastatin (generic of PRIMAXIN IV) INVANZ ivermectin (generic of STROMECTOL) TABS linezolid (generic of ZYVOX) 5 linezolid in sodium chloride 5 meropenem (generic of MERREM) methenamine hippurate (generic of HIPREX) metronidazole (generic of FLAGYL) TABS metronidazole in nacl NEBUPENT B/D nitrofurantoin macrocrystal (generic of MACRODANTIN) 50mg, 100mg PA; PA applies if 65 years and older after a 90 day supply in a calendar year nitrofurantoin monohyd macro (generic of MACROBID) PENTAM 00 praziquantel (generic of BILTRICIDE) TABS SIVEXTRO 5 sulfamethoxazole-trimethop ds (generic of 1 BACTRIM DS) sulfamethoxazole-trimethoprim SUSP sulfamethoxazole-trimethoprim (generic of 1 BACTRIM) TABS sulfamethoxazole-trimethoprim inj SYNERCID 5 TIGECYCLINE 50mg 5 tigecycline (generic of TYGACIL) 50mg 5 trimethoprim TABS PA; PA applies if 65 years and older after a 90 day supply in a calendar year 5

14 018 GENERIC STANDARD FORMULARY vancomycin hcl (generic of VANCOCIN 5 HCL) CAPS vancomycin hcl SOLR 10gm, 500mg, 750mg, 1000mg, 5000mg VANCOMYCIN IN NACL ANTIFUNGALS ABELCET 5 B/D AMBISOME 5 B/D amphotericin b SOLR B/D CANCIDAS 5 caspofungin acetate 50mg, 70mg 5 CASPOFUNGIN ACETATE 50mg, 70mg 5 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 5 griseofulvin microsize SUSP griseofulvin microsize TABS griseofulvin ultramicrosize itraconazole (generic of SPORANOX) CAPS PA ketoconazole TABS PA MYCAMINE 5 NOXAFIL SUSP 5 QL (60 ml / 0 days) NOXAFIL TBEC 5 QL (9 tabs / 0 days) nystatin TABS terbinafine hcl (generic of LAMISIL) TABS QL (90 tabs / 65 days) voriconazole (generic of VFEND IV) SOLR voriconazole (generic of VFEND) SUSR; 5 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 5 NM 6

15 018 GENERIC STANDARD FORMULARY atazanavir sulfate (generic of REYATAZ) 5 NM CRIXIVAN NM didanosine (generic of VIDEX EC) NM EDURANT 5 NM efavirenz (generic of SUSTIVA) CAPS NM 50mg efavirenz (generic of SUSTIVA) CAPS 5 NM 00mg efavirenz (generic of SUSTIVA) TABS 5 NM EMTRIVA NM fosamprenavir tab 700 mg (generic of 5 NM LEXIVA) FUZEON 5 NM INTELENCE 5mg NM INTELENCE 100mg, 00mg 5 NM INVIRASE 5 NM ISENTRESS CHEW 5mg NM ISENTRESS CHEW 100mg 5 NM ISENTRESS PACK 5 NM ISENTRESS TABS 5 NM ISENTRESS HD 5 NM lamivudine (generic of EPIVIR) NM LEXIVA SUSP NM LEXIVA TABS 5 NM nevirapine tab 00mg (generic of VIRAMUNE) NM nevirapine tb (generic of VIRAMUNE XR) NM NORVIR CAPS; SOLN; TABS NM PREZISTA SUSP 5 QL (00 ml / 0 days), NM PREZISTA TABS 75mg QL (80 tabs / 0 days), NM PREZISTA TABS 150mg 5 QL (0 tabs / 0 days), NM PREZISTA TABS 600mg 5 QL (60 tabs / 0 days), NM PREZISTA TABS 800mg 5 QL (0 tabs / 0 days), NM RESCRIPTOR NM RETROVIR IV INFUSION NM REYATAZ PACK 5 NM ritonavir (generic of NORVIR) NM SELZENTRY SOLN 5 NM SELZENTRY TABS 5mg NM SELZENTRY TABS 75mg, 150mg, 00mg 5 NM 7

16 018 GENERIC STANDARD FORMULARY stavudine (generic of ZERIT) NM SUSTIVA TABS 5 NM tenofovir disoproxil fumarate (generic of 5 NM VIREAD) TIVICAY 10mg NM TIVICAY 5mg, 50mg 5 NM TROGARZO 5 NM, LA TYBOST NM VIDEX EC 15mg NM VIDEX PEDIATRIC NM VIRACEPT 5 NM VIRAMUNE SUSP NM VIREAD 5 NM ZERIT SOLR 5 NM zidovudine cap 100mg (generic of NM RETROVIR) zidovudine syp 50mg/5ml (generic of NM RETROVIR) zidovudine tab 00mg NM ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine (generic of 5 NM EPZICOM) abacavir sulfate-lamivudine-zidovudine 5 NM (generic of TRIZIVIR) ATRIPLA 5 NM BIKTARVY 5 NM COMPLERA 5 NM DESCOVY 5 NM EVOTAZ 5 NM GENVOYA 5 NM JULUCA 5 NM KALETRA TAB 100-5MG NM KALETRA TAB 00-50MG 5 NM lamivudine-zidovudine (generic of NM COMBIVIR) lopinavir-ritonavir (generic of KALETRA) 5 NM ODEFSEY 5 NM PREZCOBIX 5 NM STRIBILD 5 NM SYMFI LO 5 NM TRIUMEQ 5 NM TRUVADA TAB QL (60 tabs / 0 days), NM 8

17 018 GENERIC STANDARD FORMULARY TRUVADA TAB 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 5 ethambutol hcl (generic of MYAMBUTOL) TABS isoniazid TABS 1 isoniazid inj 100 mg/ml isoniazid syp 50mg/5ml PASER D/R PRIFTIN pyrazinamide TABS rifabutin (generic of MYCOBUTIN) rifampin (generic of RIFADIN) CAPS rifampin (generic of RIFADIN) SOLR RIFATER SIRTURO 5 LA, PA TRECATOR ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS; TABS acyclovir (generic of ZOVIRAX) SUSP acyclovir sodium B/D adefovir dipivoxil (generic of HEPSERA) 5 NM BARACLUDE SOLN 5 NM DAKLINZA 5 NM, PA entecavir (generic of BARACLUDE) 5 NM EPCLUSA 5 NM, PA EPIVIR HBV SOLN NM famciclovir TABS ganciclovir inj 500mg (generic of B/D CYTOVENE) GANCICLOVIR INJ 500MG/10ML B/D HARVONI 5 NM, PA lamivudine (hbv) (generic of EPIVIR HBV) NM MAVYRET 5 NM, PA moderiba tab 00mg NM oseltamivir phosphate (generic of TAMIFLU) CAPS 0mg QL (168 caps / year) 9

18 018 GENERIC STANDARD FORMULARY oseltamivir phosphate (generic of QL (8 caps / year) TAMIFLU) CAPS 5mg, 75mg oseltamivir phosphate (generic of QL (1080 ml / year) TAMIFLU) SUSR PEGASYS 5 NM, PA PEGASYS PROCLICK 5 NM, PA REBETOL SOLN 5 NM RELENZA DISKHALER QL (6 inhalers / year) ribasphere (generic of REBETOL) CAPS NM ribasphere TABS 00mg NM ribasphere TABS 00mg, 600mg 5 NM ribavirin cap 00mg (generic of REBETOL) NM ribavirin tab 00mg NM rimantadine hydrochloride (generic of FLUMADINE) SOVALDI 5 NM, PA valacyclovir hcl (generic of VALTREX) TABS valganciclovir hcl (generic of VALCYTE) 5 VEMLIDY 5 NM VOSEVI 5 NM, PA ZEPATIER 5 NM, PA CEPHALOSPORINS cefaclor CAPS cefaclor SUSR CEFACLOR ER TAB 500MG cefadroxil CAPS cefadroxil SUSR; TABS CEFAZOLIN IN DEXTROSE GM/100ML-% cefazolin inj cefazolin sodium SOLR 1gm, 0gm CEFAZOLIN SODIUM 1 GM/50ML cefdinir CAPS cefdinir SUSR cefepime for inj (generic of MAXIPIME) cefixime (generic of SUPRAX) cefotaxime sodium 1gm, gm, 500mg cefoxitin for inj cefpodoxime proxetil cefprozil ceftazidime SOLR CEFTAZIDIME/DEXTROSE ceftriaxone sodium (generic of ROCEPHIN) SOLR 1gm 10

19 018 GENERIC STANDARD FORMULARY ceftriaxone sodium SOLR 1gm, gm, 10gm, 50mg, 500mg cefuroxime axetil cefuroxime sodium cephalexin (generic of KEFLEX) CAPS 1 50mg, 500mg cephalexin SUSR SUPRAX CAPS SUPRAX CHEW SUPRAX SUSR 500mg/5ml tazicef SOLR TEFLARO 5 ERYTHROMYCINS/MACROLIDES azithromycin PACK azithromycin (generic of ZITHROMAX) SOLR; SUSR azithromycin (generic of ZITHROMAX) 1 TABS clarithromycin TABS 50mg clarithromycin (generic of BIAXIN) TABS 500mg clarithromycin er (generic of BIAXIN XL) clarithromycin for susp DIFICID 5 e.e.s. 00 ery-tab ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin base erythromycin cap 50mg ec erythromycin ethylsuccinate TABS FLUOROQUINOLONES ciprofloxacin SUSR 50mg/5ml ciprofloxacin (generic of CIPRO) SUSR 500mg/5ml ciprofloxacin hcl tab 100mg ciprofloxacin hcl tab (generic of CIPRO) 1 50mg, 500mg ciprofloxacin hcl tab 750mg 1 ciprofloxacin in d5w ciprofloxacin in d5w (generic of CIPRO I.V.- IN D5W) ciprofloxacin inj levofloxacin (generic of LEVAQUIN) TABS 1 11

20 018 GENERIC STANDARD FORMULARY levofloxacin in d5w levofloxacin inj 5mg/ml levofloxacin oral soln 5 mg/ml PENICILLINS amoxicillin CAPS; SUSR; TABS 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) ampicillin cap 50mg ampicillin cap 500mg ampicillin inj ampicillin sodium ampicillin susp 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 penicilln gk inj 5mu penicilln gk inj 0mu pfizerpen-g inj 5mu pfizerpen-g inj 0mu

21 018 GENERIC STANDARD FORMULARY piper/tazoba inj -0.5gm (generic of ZOSYN) piper/tazoba inj -0.75gm (generic of ZOSYN) piper/tazoba inj -0.5gm (generic of ZOSYN) PIPER/TAZOBA INJ 1-1.5GM piper/tazoba inj 6-.5gm (generic of ZOSYN) TETRACYCLINES doxy 100 doxycycline (monohydrate) CAPS 50mg, 100mg doxycycline (monohydrate) TABS doxycycline hyclate CAPS 50mg doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg doxycycline hyclate SOLR doxycycline hyclate 0 mg doxycycline hyclate 100 mg minocycline hcl (generic of MINOCIN) CAPS 50mg, 100mg minocycline hcl CAPS 75mg morgidox cap 1x50mg ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 5 B/D, NM busulfan (generic of BUSULFEX) 5 B/D CYCLOPHOSPHAMIDE CAPS 5mg, 50mg B/D cyclophosphamide (generic of B/D CYCLOPHOSPHAMIDE) CAPS 5mg, 50mg cyclophosphamide SOLR 5 B/D dacarbazine B/D EMCYT GLEOSTINE HEXALEN 5 IFEX INJ GM B/D ifosfamide inj 1gm (generic of IFEX) 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) 5 B/D MUSTARGEN 5 B/D 1

22 018 GENERIC STANDARD FORMULARY ANTHRACYCLINES adriamycin B/D doxorubicin hcl B/D doxorubicin hcl liposomal inj mg/ml 5 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 5 B/D ANTIMETABOLITES adrucil B/D adrucil inj B/D ALIMTA 5 B/D azacitidine (generic of VIDAZA) 5 B/D, NM cladribine 5 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) 5 B/D 1gm, 00mg gemcitabine inj solr gm 5 B/D mercaptopurine TABS methotrexate sodium inj B/D NIPENT 5 B/D PURIXAN 5 NM TABLOID ANTIMITOTIC, TAXOIDS ABRAXANE 5 B/D docetaxel (generic of TAXOTERE) CONC 5 B/D 0mg/ml, 80mg/ml DOCETAXEL CONC 80mg/ml, 160mg/8ml, 00mg/10ml 5 B/D DOCETAXEL SOLN 0mg/ml, 80mg/8ml, 5 B/D 160mg/16ml docetaxel (generic of DOCETAXEL) SOLN 5 B/D 0mg/ml, 80mg/8ml, 160mg/16ml paclitaxel B/D TAXOTERE 80mg/ml 5 B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate B/D vincasar pfs B/D vincristine sulfate B/D 1

23 018 GENERIC STANDARD FORMULARY vinorelbine tartrate (generic of B/D NAVELBINE) BIOLOGIC RESPONSE MODIFIERS AVASTIN 5 NM, LA, PA BELEODAQ 5 NM, PA BORTEZOMIB 5 NM, PA ERIVEDGE 5 NM, LA, PA FARYDAK 5 NM, LA, PA HERCEPTIN 5 NM, PA IBRANCE 5 NM, LA, PA IDHIFA 5 NM, LA, PA KADCYLA 5 B/D, NM KEYTRUDA 5 NM, PA KISQALI 5 NM, PA KISQALI FEMARA 00 DOSE 5 NM, PA KISQALI FEMARA 00 DOSE 5 NM, PA KISQALI FEMARA 600 DOSE 5 NM, PA LYNPARZA 5 NM, LA, PA MYLOTARG 5 NM, LA, PA NINLARO 5 NM, PA ODOMZO 5 NM, LA, PA RITUXAN 5 NM, LA, PA RITUXAN HYCELA 5 NM, LA, PA RUBRACA 5 NM, LA, PA TECENTRIQ 5 NM, LA, PA VELCADE 5 NM, PA VENCLEXTA 10mg, 50mg NM, LA, PA VENCLEXTA 100mg 5 NM, LA, PA VENCLEXTA STARTING PACK 5 NM, LA, PA VERZENIO 5 NM, LA, PA YERVOY 5 NM, PA ZEJULA 5 NM, LA, PA ZOLINZA 5 NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS bicalutamide (generic of CASODEX) DEPO-PROVERA INJ 00/ML B/D ERLEADA 5 NM, LA, PA exemestane (generic of AROMASIN) FARESTON 5 FASLODEX 5 B/D flutamide hydroxyprogesterone caproate (antineoplastic) 5 B/D 15

24 018 GENERIC STANDARD FORMULARY letrozole (generic of FEMARA) TABS leuprolide inj 1mg/0. NM, PA LUPRON DEPOT (1-MONTH).75mg 5 NM, PA LUPRON DEPOT INJ 11.5MG (-MONTH) 5 NM, PA LYSODREN megestrol ac sus 0mg/ml PA; PA if 65 years and older megestrol ac tab 0mg PA; PA if 65 years and older megestrol ac tab 0mg PA; PA if 65 years and older megestrol sus 65mg/5ml (generic of PA MEGACE ES) nilutamide (generic of NILANDRON) 5 SOLTAMOX tamoxifen citrate TABS 1 TRELSTAR DEP INJ.75MG 5 NM, PA TRELSTAR LA INJ 11.5MG 5 NM, PA XTANDI 5 NM, LA, PA ZYTIGA 5 NM, LA, PA IMMUNOMODULATORS POMALYST 5 NM, LA, PA REVLIMID 5 QL (8 caps / 8 days), NM, LA, PA THALOMID 50mg, 100mg 5 QL (0 caps / 0 days), NM, PA THALOMID 150mg, 00mg 5 QL (60 caps / 0 days), NM, PA KINASE INHIBITORS AFINITOR 5 QL (0 tabs / 0 days), NM, PA AFINITOR DISPERZ mg 5 QL (150 tabs / 0 days), NM, PA AFINITOR DISPERZ mg 5 QL (90 tabs / 0 days), NM, PA AFINITOR DISPERZ 5mg 5 QL (60 tabs / 0 days), NM, PA ALECENSA 5 NM, LA, PA ALUNBRIG 5 NM, LA, PA BOSULIF 5 NM, PA CABOMETYX 5 QL (0 tabs / 0 days), NM, LA, PA CALQUENCE 5 NM, LA, PA CAPRELSA 5 NM, LA, PA COMETRIQ 5 NM, LA, PA 16

25 018 GENERIC STANDARD FORMULARY COTELLIC 5 NM, LA, PA GILOTRIF TAB 0MG 5 NM, LA, PA GILOTRIF TAB 0MG 5 NM, LA, PA GILOTRIF TAB 0MG 5 NM, LA, PA ICLUSIG 5 NM, LA, PA imatinib mesylate (generic of GLEEVEC) 100mg 5 QL (90 tabs / 0 days), NM, PA imatinib mesylate (generic of GLEEVEC) 00mg 5 QL (60 tabs / 0 days), NM, PA IMBRUVICA 5 NM, LA, PA INLYTA 1mg 5 QL (180 tabs / 0 days), NM, LA, PA INLYTA 5mg 5 QL (10 tabs / 0 days), NM, LA, PA IRESSA 5 NM, LA, PA JAKAFI 5 QL (60 tabs / 0 days), NM, LA, PA LENVIMA 8 MG DAILY DOSE 5 NM, LA, PA LENVIMA 10 MG DAILY DOSE 5 NM, LA, PA LENVIMA 1 MG DAILY DOSE 5 NM, LA, PA LENVIMA 18 MG DAILY DOSE 5 NM, LA, PA LENVIMA 0 MG DAILY DOSE 5 NM, LA, PA LENVIMA MG DAILY DOSE 5 NM, LA, PA MEKINIST 5 NM, LA, PA NERLYNX 5 NM, LA, PA NEXAVAR 5 NM, LA, PA RYDAPT 5 NM, PA SPRYCEL 5 NM, PA STIVARGA 5 NM, LA, PA SUTENT 5 NM, PA TAFINLAR 5 NM, LA, PA TAGRISSO 5 NM, LA, PA TARCEVA 5mg 5 QL (90 tabs / 0 days), NM, LA, PA TARCEVA 100mg, 150mg 5 QL (0 tabs / 0 days), NM, LA, PA TASIGNA 5 NM, PA TYKERB 5 NM, LA, PA VOTRIENT 5 NM, LA, PA XALKORI 5 NM, LA, PA ZELBORAF 5 NM, LA, PA ZYDELIG 5 NM, LA, PA ZYKADIA 5 NM, LA, PA MISCELLANEOUS 17

26 018 GENERIC STANDARD FORMULARY bexarotene (generic of TARGRETIN) 5 NM, PA DROXIA hydroxyurea (generic of HYDREA) CAPS LONSURF 5 NM, PA MATULANE 5 LA mitoxantrone hcl B/D, NM SYLATRON KIT 00MCG 5 NM, PA SYLATRON KIT 00MCG 5 NM, PA SYLATRON KIT 600MCG 5 NM, PA SYNRIBO 5 NM, PA tretinoin (chemotherapy) 5 TRISENOX 5 B/D PLATINUM-BASED AGENTS carboplatin B/D cisplatin B/D oxaliplatin inj 50mg 5 B/D oxaliplatin inj 50mg/10ml B/D oxaliplatin inj 100mg 5 B/D oxaliplatin inj 100mg/0ml B/D PROTECTIVE AGENTS dexrazoxane (generic of ZINECARD) 5 B/D ELITEK 5 B/D leucovorin calcium SOLR B/D leucovorin calcium TABS levoleucovorin calcium 175mg/17.5ml 5 B/D, NM LEVOLEUCOVORIN CALCIUM 50mg/5ml 5 B/D, NM levoleucovorin calcium 50mg (generic of 5 B/D, NM FUSILEV) LEVOLEUCOVORIN CALCIUM 175MG 5 B/D, NM mesna (generic of MESNEX) B/D MESNEX TABS 5 TOPOISOMERASE INHIBITORS etoposide SOLN B/D irinotecan hcl (generic of CAMPTOSAR) B/D 0mg/ml, 100mg/5ml irinotecan hcl 500mg/5ml B/D toposar B/D topotecan inj mg (generic of TOPOTECAN 5 B/D HCL) SOLN topotecan inj mg (generic of HYCAMTIN) 5 B/D SOLR TOPOTECAN INJ MG/ML 5 B/D CARDIOVASCULAR 18

27 018 GENERIC STANDARD FORMULARY ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap mg (generic of LOTREL) benazepril & hydrochlorothiazide 1 benazepril & hydrochlorothiazide (generic 1 of LOTENSIN HCT) captopril & hydrochlorothiazide 1 enalapril maleate & hydrochlorothiazide 1 enalapril maleate & hydrochlorothiazide 1 (generic of VASERETIC) fosinopril sodium & hydrochlorothiazide 1 lisinopril & hydrochlorothiazide (generic of 1 ZESTORETIC) moexipril-hydrochlorothiazide 1 quinapril-hydrochlorothiazide (generic of 1 ACCURETIC) ACE INHIBITORS benazepril hcl TABS 5mg 1 benazepril hcl (generic of LOTENSIN) 1 TABS 10mg, 0mg, 0mg captopril TABS 1 enalapril maleate (generic of VASOTEC) 1 TABS fosinopril sodium 1 lisinopril (generic of ZESTRIL) TABS 1.5mg, 0mg, 0mg lisinopril (generic of PRINIVIL) TABS 5mg, 1 10mg, 0mg moexipril hcl 1 perindopril erbumine 1 quinapril hcl (generic of ACCUPRIL) 1 ramipril (generic of ALTACE) 1 trandolapril 1mg, mg 1 trandolapril (generic of MAVIK) mg 1 ALDOSTERONE RECEPTOR ANTAGONISTS 19

28 018 GENERIC STANDARD FORMULARY eplerenone (generic of INSPRA) spironolactone (generic of ALDACTONE) 1 TABS ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA) QL (0 tabs / 0 days) TABS 1mg, mg, mg doxazosin mesylate (generic of CARDURA) TABS 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 medoxomil-amlodipinehydrochlorothiazide 1 (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 valsartan (generic of DIOVAN) 1 ANTIARRHYTHMICS amiodarone hcl SOLN amiodarone hcl TABS 100mg, 00mg amiodarone hcl TABS 00mg 1 disopyramide phosphate (generic of PA; PA if 65 years and NORPACE) older dofetilide (generic of TIKOSYN) NM flecainide acetate mexiletine hcl MULTAQ 0

29 018 GENERIC STANDARD FORMULARY NORPACE CR PA; PA if 65 years and older pacerone 100mg, 00mg pacerone 00mg 1 propafenone hcl 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 1 lovastatin (generic of MEVACOR) 0mg 1 pravastatin sodium 10mg 1 pravastatin sodium (generic of 1 PRAVACHOL) 0mg, 0mg, 80mg rosuvastatin calcium (generic of CRESTOR) 1 QL (0 tabs / 0 days) simvastatin (generic of ZOCOR) TABS 1 5mg, 10mg, 0mg, 0mg simvastatin (generic of ZOCOR) TABS 1 QL (0 tabs / 0 days) 80mg ANTILIPEMICS, MISCELLANEOUS cholestyramine (generic of QUESTRAN) cholestyramine light PACK cholestyramine light (generic of QUESTRAN LIGHT) POWD colesevelam hcl colestipol hcl gran (generic of COLESTID) colestipol hcl pack (generic of COLESTID) colestipol hcl tabs (generic of COLESTID) ezetimibe (generic of ZETIA) fenofibrate (generic of TRICOR) TABS 8mg, 15mg fenofibrate TABS 5mg, 160mg fenofibrate micronized 67mg, 1mg, 00mg 1

30 018 GENERIC STANDARD FORMULARY gemfibrozil (generic of LOPID) TABS JUXTAPID 5 NM, LA, PA KYNAMRO 5 NM, PA niacin er (antihyperlipidemic) (generic of QL (90 tabs / 0 days) NIASPAN) 500mg niacin er (antihyperlipidemic) (generic of NIASPAN) 750mg, 1000mg niacor omega--acid ethyl esters (generic of LOVAZA) PRALUENT 5 NM, PA 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 5mg atenolol TABS 50mg, 100mg 1 bisoprolol fumarate BYSTOLIC.5mg, 5mg, 10mg QL (0 tabs / 0 days) BYSTOLIC 0mg QL (60 tabs / 0 days) carvedilol (generic of COREG) 1 labetalol hcl TABS metoprolol succinate (generic of TOPROL XL) metoprolol tartrate SOCT metoprolol tartrate SOLN metoprolol tartrate TABS 5mg 1 metoprolol tartrate (generic of 1 LOPRESSOR) TABS 50mg, 100mg nadolol (generic of CORGARD) TABS pindolol propranolol cap er (generic of INDERAL LA)

31 018 GENERIC STANDARD FORMULARY 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, 60mg diltiazem hcl coated beads cap sr hr 00mg diltiazem hcl extended release beads cap sr (generic of TIAZAC) 10mg, 180mg, 0mg, 00mg, 60mg, 0mg diltiazem hcl extended release beads cap sr (generic of CARDIZEM CD) 180mg 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 5 NYMALIZE 5 taztia xt (generic of TIAZAC)

32 018 GENERIC STANDARD FORMULARY 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 1 verapamil hcl (generic of CALAN) TABS 1 80mg, 10mg verapamil hcl (generic of CALAN SR) TBCR verapamil tab er (generic of CALAN SR) DIGITALIS GLYCOSIDES digitek (generic of LANOXIN).5mg PA; PA if 65 years and older digitek (generic of LANOXIN).15mg QL (0 tabs / 0 days) digox (generic of LANOXIN) 15mcg QL (0 tabs / 0 days) digox (generic of LANOXIN) 50mcg PA; PA if 65 years and older digoxin (generic of LANOXIN) TABS QL (0 tabs / 0 days) 15mcg digoxin (generic of LANOXIN) TABS 50mcg PA; PA if 65 years and older digoxin inj (generic of LANOXIN) digoxin sol 50mcg/ml PA; PA if 65 years and older DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA TEKTURNA HCT DIURETICS acetazolamide CP1 acetazolamide TABS amiloride & hydrochlorothiazide amiloride hcl TABS bumetanide inj 0.5/ml bumetanide tab (generic of BUMEX) chlorothiazide tabs chlorthalidone furosemide SOLN furosemide (generic of LASIX) TABS 1 furosemide inj hydrochlorothiazide (generic of 1 MICROZIDE) CAPS hydrochlorothiazide TABS 1 indapamide

33 018 GENERIC STANDARD FORMULARY methazolamide (generic of NEPTAZANE) TABS 5mg methazolamide TABS 50mg methyclothiazide metolazone spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE) torsemide tabs 5mg, 100mg torsemide tabs (generic of DEMADEX) 10mg, 0mg triamterene & hydrochlorothiazide cap mg (generic of DYAZIDE) triamterene & hydrochlorothiazide tabs 1 (generic of MAXZIDE) triamterene & hydrochlorothiazide tabs 1 (generic of MAXZIDE-5) 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 5 hydralazine hcl SOLN hydralazine hcl TABS midodrine hcl minoxidil TABS NORTHERA 5 NM, LA, PA RANEXA NITRATES isosorb mononitrate tab isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg 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 5

34 018 GENERIC STANDARD FORMULARY nitroglycerin td patch.1mg/hr nitroglycerin td patch (generic of NITRO- DUR).mg/hr,.mg/hr,.6mg/hr PULMONARY ARTERIAL HYPERTENSION ADCIRCA 5 QL (60 tabs / 0 days), NM, PA ADEMPAS 5 QL (90 tabs / 0 days), NM, LA, PA LETAIRIS 5 QL (0 tabs / 0 days), NM, LA, PA OPSUMIT 5 QL (0 tabs / 0 days), NM, LA, PA REMODULIN 5 NM, LA, PA sildenafil citrate (pulmonary hypertension) QL (90 tabs / 0 days), (generic of REVATIO) TABS NM, PA TRACLEER TABS 6.5mg 5 QL (10 tabs / 0 days), NM, LA, PA TRACLEER TABS 15mg 5 QL (60 tabs / 0 days), NM, LA, PA VENTAVIS 5 NM, PA CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5mg (generic of XANAX) 1 QL (0 tabs / 0 days) alprazolam tab 0.5mg (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 (150 tabs / 0 days) buspirone hcl TABS 5mg, 7.5mg, 10mg, 15mg buspirone hcl TABS 0mg fluvoxamine maleate TABS 5mg, 50mg QL (5 tabs / 0 days) fluvoxamine maleate TABS 100mg lorazepam (generic of ATIVAN) SOLN lorazepam (generic of ATIVAN) TABS 1 QL (150 tabs / 0 days) lorazepam intensol QL (150 ml / 0 days) ANTICONVULSANTS APTIOM 00mg 5 QL (180 tabs / 0 days) APTIOM 00mg 5 QL (90 tabs / 0 days) APTIOM 600mg, 800mg 5 QL (60 tabs / 0 days) BANZEL SUS 0MG/ML 5 PA BANZEL TAB 00MG 5 PA BANZEL TAB 00MG 5 PA BRIVIACT SOLN 10mg/ml 5 PA BRIVIACT SOLN 50mg/5ml PA BRIVIACT TABS 5 PA 6

35 018 GENERIC STANDARD FORMULARY carbamazepine CHEW carbamazepine (generic of CARBATROL) CP1 carbamazepine (generic of TEGRETOL) SUSP carbamazepine (generic of TEGRETOL) TABS carbamazepine (generic of TEGRETOL-XR) TB1 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).5mg clonazepam TBDP 1mg QL (10 tabs / 0 days) clonazepam TBDP mg QL (00 tabs / 0 days) clonazepam TBDP.5mg QL (0 tabs / 0 days) clonazepam TBDP.5mg QL (80 tabs / 0 days) clonazepam TBDP.15mg QL (960 tabs / 0 days) clorazepate dipotassium.75mg QL (10 tabs / 0 days), PA; PA if 65 years and older clorazepate dipotassium (generic of TRANXENE T) 7.5mg QL (10 tabs / 0 days), PA; PA if 65 years and older clorazepate dipotassium 15mg QL (180 tabs / 0 days), PA; PA if 65 years and older DIASTAT ACUDIAL DIASTAT PEDIATRIC diazepam SOLN 1mg/ml QL (100 ml / 0 days), PA; PA if 65 years and older diazepam SOLN 5mg/ml diazepam (generic of VALIUM) TABS 1 QL (10 tabs / 0 days), PA; PA if 65 years and older diazepam gel diazepam intensol QL (0 ml / 0 days), PA; PA if 65 years and older DILANTIN DILANTIN-15 SUS 15/5ML 7

36 018 GENERIC STANDARD FORMULARY 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 5 felbamate (generic of FELBATOL) TABS FYCOMPA SUSP 5 QL (70 ml / 0 days), PA FYCOMPA TABS mg QL (180 tabs / 0 days), PA FYCOMPA TABS mg 5 QL (90 tabs / 0 days), PA FYCOMPA TABS 6mg 5 QL (60 tabs / 0 days), PA FYCOMPA TABS 8mg, 10mg, 1mg 5 QL (0 tabs / 0 days), PA gabapentin (generic of NEURONTIN) CAPS QL (1080 caps / 0 100mg days) gabapentin (generic of NEURONTIN) CAPS QL (60 caps / 0 days) 00mg gabapentin (generic of NEURONTIN) CAPS QL (70 caps / 0 days) 00mg gabapentin (generic of NEURONTIN) SOLN QL (160 ml / 0 days) gabapentin (generic of NEURONTIN) TABS QL (180 tabs / 0 days) 600mg gabapentin (generic of NEURONTIN) TABS QL (10 tabs / 0 days) 800mg GABITRIL 1mg, 16mg 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) 8

37 018 GENERIC STANDARD FORMULARY LYRICA CAPS 5mg, 50mg, 75mg, QL (10 caps / 0 days) 100mg, 150mg LYRICA CAPS 00mg QL (90 caps / 0 days) LYRICA CAPS 5mg, 00mg QL (60 caps / 0 days) LYRICA SOLN QL (96 ml / 0 days) ONFI 5 PA oxcarbazepine (generic of TRILEPTAL) SUSP oxcarbazepine (generic of TRILEPTAL) TABS PEGANONE phenobarbital ELIX; TABS PA; PA if 65 years and older PHENOBARBITAL SODIUM SOLN 65mg/ml PA; PA if 65 years and older phenobarbital sodium SOLN 10mg/ml PA; PA if 65 years and older PHENYTEK phenytoin (generic of DILANTIN INFATABS) CHEW phenytoin (generic of DILANTIN-15) 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) roweepra xr (generic of KEPPRA XR) SABRIL TABS 5 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) 9

38 018 GENERIC STANDARD FORMULARY vigabatrin powd pack 500mg (generic of SABRIL) 5 QL (180 packets / 0 days), NM, LA, PA VIMPAT SOLN 10mg/ml 5 QL (100 ml / 0 days) VIMPAT SOLN 00mg/0ml 5 VIMPAT TABS 50mg QL (180 tabs / 0 days) VIMPAT TABS 100mg, 150mg, 00mg 5 QL (60 tabs / 0 days) zonisamide (generic of ZONEGRAN) CAPS 5mg, 100mg zonisamide CAPS 50mg ANTIDEMENTIA donepezil hydrochloride (generic of QL (60 tabs / 0 days) ARICEPT) TABS 5mg donepezil hydrochloride (generic of ARICEPT) TABS 10mg donepezil hydrochloride (generic of ARICEPT) TABS mg donepezil hydrochloride TBDP 5mg 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) TABS PA; PA if < 0 yrs memantine hcl cp (generic of NAMENDA PA; PA if < 0 yrs XR) NAMENDA XR PA; PA if < 0 yrs NAMENDA XR TITRATION PACK PA; PA if < 0 yrs NAMZARIC rivastigmine tartrate rivastigmine td patch hr.6 mg/hr (generic of EXELON) QL (0 patches / 0 days) rivastigmine td patch hr 9.5 mg/hr (generic of EXELON) QL (0 patches / 0 days) rivastigmine td patch hr 1. mg/hr (generic of EXELON) ANTIDEPRESSANTS QL (0 patches / 0 days) 0

39 018 GENERIC STANDARD FORMULARY amitriptyline hcl TABS PA; PA if 65 years and older amoxapine bupropion hcl TABS bupropion hcl (generic of WELLBUTRIN SR) TB1 bupropion hcl (generic of WELLBUTRIN XL) QL (90 tabs / 0 days) TB 150mg bupropion hcl (generic of WELLBUTRIN XL) QL (0 tabs / 0 days) TB 00mg citalopram hydrobromide SOLN citalopram hydrobromide (generic of 1 QL (5 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) CAPS PA; PA if 65 years and older desipramine hcl (generic of NORPRAMIN) TABS 10mg, 5mg desipramine hcl TABS 50mg, 75mg, 100mg, 150mg desvenlafaxine succinate (generic of QL (0 tabs / 0 days) PRISTIQ) doxepin hcl CAPS; CONC PA; PA if 65 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 5 QL (0 patches / 0 days), PA escitalopram oxalate SOLN QL (600 ml / 0 days) escitalopram oxalate (generic of LEXAPRO) QL (5 tabs / 0 days) TABS 5mg, 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 1

40 018 GENERIC STANDARD FORMULARY imipramine hcl (generic of TOFRANIL) TABS PA; PA if 65 years and older maprotiline hcl MARPLAN TAB 10MG QL (180 tabs / 0 days) mirtazapine TABS 7.5mg QL (5 tabs / 0 days) mirtazapine (generic of REMERON) TABS QL (5 tabs / 0 days) 15mg mirtazapine (generic of REMERON) TABS 0mg, 5mg mirtazapine (generic of REMERON SOLTAB) QL (0 tabs / 0 days) TBDP 15mg mirtazapine (generic of REMERON SOLTAB) TBDP 0mg, 5mg nefazodone hcl nortriptyline hcl (generic of PAMELOR) 1 CAPS nortriptyline hcl SOLN paroxetine hcl tabs (generic of PAXIL) 1 QL (5 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 (5 tabs / 0 days) 5mg, 50mg sertraline hcl (generic of ZOLOFT) TABS 1 100mg tranylcypromine sulfate (generic of PARNATE) trazodone hcl TABS 50mg, 100mg, 150mg 1 trimipramine maleate (generic of SURMONTIL) CAPS 5mg trimipramine maleate (generic of SURMONTIL) CAPS 50mg trimipramine maleate (generic of SURMONTIL) CAPS 100mg QL (0 caps / 0 days), PA; PA if 65 years and older QL (10 caps / 0 days), PA; PA if 65 years and older QL (60 caps / 0 days), PA; PA if 65 years and older TRINTELLIX 5mg QL (10 tabs / 0 days) TRINTELLIX 10mg QL (60 tabs / 0 days) TRINTELLIX 0mg QL (0 tabs / 0 days)

41 018 GENERIC STANDARD FORMULARY venlafaxine hcl (generic of EFFEXOR XR) QL (0 caps / 0 days) CP 7.5mg, 75mg venlafaxine hcl (generic of EFFEXOR XR) QL (60 caps / 0 days) CP 150mg venlafaxine hcl TABS VIIBRYD STARTER PACK VIIBRYD TAB QL (0 tabs / 0 days) ANTIPARKINSONIAN AGENTS amantadine hcl CAPS QL (10 caps / 0 days) amantadine hcl SYRP amantadine hcl TABS APOKYN 5 NM, LA, PA benztropine mesylate (generic of COGENTIN) SOLN benztropine mesylate TABS PA; PA if 65 years and older bromocriptine mesylate (generic of PARLODEL) CAPS; TABS carbidopa-levodopa (generic of SINEMET) TABS carbidopa-levodopa (generic of SINEMET CR) TBCR carbidopa-levodopa TBDP carbidopa/levodopa/entacapone (generic of STALEVO 50) carbidopa/levodopa/entacapone (generic of STALEVO 75) carbidopa/levodopa/entacapone (generic of STALEVO 100) carbidopa/levodopa/entacapone (generic of STALEVO 15) carbidopa/levodopa/entacapone (generic of STALEVO 150) carbidopa/levodopa/entacapone (generic of STALEVO 00) entacapone (generic of COMTAN) NEUPRO pramipexole tab 0.5mg (generic of MIRAPEX) pramipexole tab 0.5mg (generic of MIRAPEX) pramipexole tab 0.75mg (generic of MIRAPEX) pramipexole tab 0.15mg (generic of MIRAPEX)

42 018 GENERIC STANDARD FORMULARY pramipexole tab 1.5mg (generic of MIRAPEX) pramipexole tab 1mg (generic of MIRAPEX) rasagiline mesylate (generic of AZILECT) TABS ropinirole tab 0.5mg (generic of REQUIP) ropinirole tab 0.5mg (generic of REQUIP) ropinirole tab 1mg (generic of REQUIP) ropinirole tab mg (generic of REQUIP) ropinirole tab mg (generic of REQUIP) ropinirole tab mg (generic of REQUIP) ropinirole tab 5mg (generic of REQUIP) selegiline hcl (generic of ELDEPRYL) CAPS selegiline hcl TABS trihexyphenidyl hcl PA; PA if 65 years and older ANTIPSYCHOTICS ABILIFY MAINTENA 5 QL (1 injection / 8 days) aripiprazole odt 5 QL (60 tabs / 0 days) aripiprazole oral solution 1 mg/ml 5 QL (900 ml / 0 days) aripiprazole tab (generic of ABILIFY) mg, QL (0 tabs / 0 days) 5mg, 10mg, 15mg aripiprazole tab (generic of ABILIFY) 5 QL (0 tabs / 0 days) 0mg, 0mg ARISTADA 1mg/1.6ml, 66mg/.ml, 88mg/.ml 5 QL (1 injection / 8 days) ARISTADA 106mg/.9ml 5 QL (1 injection / 56 days) chlorpromazine hcl TABS CHLORPROMAZINE INJ clozapine odt (generic of FAZACLO) PA 1.5mg, 5mg clozapine odt (generic of FAZACLO) 100mg QL (70 tabs / 0 days), PA clozapine odt (generic of FAZACLO) 150mg QL (180 tabs / 0 days), PA clozapine odt (generic of FAZACLO) 00mg 5 QL (15 tabs / 0 days), PA clozapine tab 5mg (generic of CLOZARIL) clozapine tab 50mg clozapine tab 100mg (generic of QL (70 tabs / 0 days) CLOZARIL) clozapine tab 00mg QL (15 tabs / 0 days) FANAPT QL (60 tabs / 0 days)

43 018 GENERIC STANDARD FORMULARY FANAPT TITRATION PACK fluphenazine decanoate SOLN fluphenazine hcl GEODON SOLR QL (6 ml / days) haloperidol TABS haloperidol conc mg/ml haloperidol decanoate (generic of HALDOL DECANOATE 50) SOLN 50mg/ml haloperidol decanoate (generic of HALDOL DECANOATE 100) SOLN 100mg/ml haloperidol inj 5mg/ml (generic of HALDOL) haloperidol lactate inj 5 mg/ml (generic of HALDOL) INVEGA SUST INJ 9 MG/0.5 ML QL (1 injection / 8 days) INVEGA SUST INJ 78 MG/0.5 ML 5 QL (1 injection / 8 days) INVEGA SUST INJ 117 MG/0.75 ML 5 QL (1 injection / 8 days) INVEGA SUST INJ 156MG/ML 5 QL (1 injection / 8 days) INVEGA SUST INJ MG/1.5 ML 5 QL (1 injection / 8 days) INVEGA TRINZA 5 QL (1 injection / 90 days) LATUDA 0mg QL (0 tabs / 0 days) LATUDA 0mg, 10mg QL (0 tabs / 0 days) LATUDA 60mg, 80mg QL (60 tabs / 0 days) loxapine succinate NUPLAZID 5 QL (60 tabs / 0 days), NM, LA, PA olanzapine (generic of ZYPREXA) SOLR QL ( vials / 1 day) olanzapine (generic of ZYPREXA) TABS QL (0 tabs / 0 days).5mg olanzapine (generic of ZYPREXA) TABS QL (10 tabs / 0 days) 5mg olanzapine (generic of ZYPREXA) TABS QL (0 tabs / 0 days) 7.5mg olanzapine (generic of ZYPREXA) TABS QL (60 tabs / 0 days) 10mg, 15mg, 0mg olanzapine (generic of ZYPREXA ZYDIS) QL (0 tabs / 0 days) TBDP 5mg olanzapine (generic of ZYPREXA ZYDIS) TBDP 10mg, 15mg, 0mg QL (60 tabs / 0 days) 5

44 018 GENERIC STANDARD FORMULARY paliperidone (generic of INVEGA) 1.5mg, 5 QL (0 tabs / 0 days) mg, 9mg paliperidone (generic of INVEGA) 6mg 5 QL (60 tabs / 0 days) perphenazine TABS pimozide (generic of ORAP) quetiapine fumarate (generic of SEROQUEL) TABS QL (90 tabs / 0 days) quetiapine fumarate (generic of SEROQUEL QL (10 tabs / 0 days) XR) TB 50mg quetiapine fumarate (generic of SEROQUEL QL (0 tabs / 0 days) XR) TB 150mg, 00mg quetiapine fumarate (generic of SEROQUEL QL (60 tabs / 0 days) XR) TB 00mg, 00mg REXULTI 1mg 5 QL (90 tabs / 0 days) REXULTI mg 5 QL (60 tabs / 0 days) REXULTI mg, mg 5 QL (0 tabs / 0 days) REXULTI.5mg 5 QL (180 tabs / 0 days) REXULTI.5mg 5 QL (60 tabs / 0 days) RISPERDAL INJ 1.5MG QL ( injections / 8 days) RISPERDAL INJ 5MG QL ( injections / 8 days) RISPERDAL INJ 7.5MG 5 QL ( injections / 8 days) RISPERDAL INJ 50MG 5 QL ( injections / 8 days) risperidone (generic of RISPERDAL) SOLN QL (0 ml / 0 days) risperidone (generic of RISPERDAL) TABS QL (60 tabs / 0 days) 1mg, mg, mg risperidone (generic of RISPERDAL) TABS QL (10 tabs / 0 days) mg risperidone (generic of RISPERDAL) TABS QL (90 tabs / 0 days).5mg,.5mg risperidone TBDP 1mg, mg, mg QL (60 tabs / 0 days) risperidone TBDP mg QL (10 tabs / 0 days) risperidone TBDP.5mg,.5mg QL (90 tabs / 0 days) SAPHRIS.5mg QL (0 tabs / 0 days) SAPHRIS 5mg QL (10 tabs / 0 days) SAPHRIS 10mg QL (60 tabs / 0 days) thioridazine hcl TABS PA; PA if 65 years and older thiothixene trifluoperazine hcl VERSACLOZ 5 QL (600 ml / 0 days), PA 6

45 018 GENERIC STANDARD FORMULARY VRAYLAR 1.5mg 5 QL (10 caps / 0 days), PA VRAYLAR mg 5 QL (60 caps / 0 days), PA VRAYLAR.5mg, 6mg 5 QL (0 caps / 0 days), PA VRAYLAR THERAPY PACK PA ziprasidone hcl (generic of GEODON) QL (60 caps / 0 days) ZYPREXA RELPREVV 00mg 5 QL ( vials / 8 days), PA ZYPREXA RELPREVV 05mg 5 QL (1 vial / 8 days), PA ZYPREXA RELPREVV INJ 10MG QL ( vials / 8 days), PA ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap sr QL (90 caps / 0 days) hr 5 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine cap sr QL (90 caps / 0 days) hr 10 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine cap sr QL (0 caps / 0 days) hr 15 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine cap sr QL (0 caps / 0 days) hr 0 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine cap sr QL (0 caps / 0 days) hr 5 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine cap sr QL (0 caps / 0 days) hr 0 mg (generic of ADDERALL XR) amphetamine-dextroamphetamine tab 5 mg (generic of ADDERALL) QL (60 tabs / 0 days) amphetamine-dextroamphetamine tab 7.5 QL (0 tabs / 0 days) mg (generic of ADDERALL) amphetamine-dextroamphetamine tab 10 QL (180 tabs / 0 days) mg (generic of ADDERALL) amphetamine-dextroamphetamine tab QL (1 tabs / 0 days) 1.5 mg (generic of ADDERALL) amphetamine-dextroamphetamine tab 15 QL (10 tabs / 0 days) mg (generic of ADDERALL) amphetamine-dextroamphetamine tab 0 QL (90 tabs / 0 days) mg (generic of ADDERALL) amphetamine-dextroamphetamine tab 0 QL (60 tabs / 0 days) mg (generic of ADDERALL) atomoxetine hcl (generic of STRATTERA) QL (10 caps / 0 days) 10mg, 18mg, 5mg atomoxetine hcl (generic of STRATTERA) QL (60 caps / 0 days) 0mg atomoxetine hcl (generic of STRATTERA) 60mg, 80mg, 100mg QL (0 caps / 0 days) 7

46 018 GENERIC STANDARD FORMULARY guanfacine er (adhd) (generic of INTUNIV) PA; PA if 65 years and older metadate er tab 0mg QL (90 tabs / 0 days) methylphenidate hcl (generic of RITALIN) QL (180 tabs / 0 days) TABS 5mg, 10mg methylphenidate hcl (generic of RITALIN) QL (90 tabs / 0 days) TABS 0mg methylphenidate hcl oral soln (generic of QL (1800 ml / 0 days) METHYLIN) 5mg/5ml methylphenidate hcl oral soln (generic of QL (900 ml / 0 days) METHYLIN) 10mg/5ml methylphenidate tab 10mg er QL (90 tabs / 0 days) methylphenidate tab 0mg er QL (90 tabs / 0 days) HYPNOTICS HETLIOZ 5 NM, LA, PA SILENOR mg QL (60 tabs / 0 days) SILENOR 6mg QL (0 tabs / 0 days) temazepam (generic of RESTORIL) 7.5mg QL (0 caps / 0 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year temazepam (generic of RESTORIL) 15mg QL (60 caps / 0 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year zolpidem tartrate (generic of AMBIEN) TABS QL (0 tabs / 0 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year MIGRAINE dihydroergotamine mesylate 1mg/ml 5 (generic of D.H.E. 5) dihydroergotamine mesylate nasal 5 QL (8 ml / 0 days) eletriptan hydrobromide (generic of QL (1 tabs / 0 days) RELPAX) ergotamine w/ caffeine (generic of CAFERGOT) migergot 5 naratriptan hcl (generic of AMERGE) QL (1 tabs / 0 days) rizatriptan benzoate (generic of MAXALT) QL (18 tabs / 0 days) rizatriptan benzoate odt (generic of MAXALT-MLT) QL (18 tabs / 0 days) 8

47 018 GENERIC STANDARD FORMULARY sumatriptan (generic of IMITREX) SOLN 5mg/act QL ( inhalers / 0 days) sumatriptan (generic of IMITREX) SOLN 0mg/act QL (1 inhalers / 0 days) sumatriptan inj mg/0.5ml QL (18 injections / 0 days) sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE SYSTEM) SOAJ QL (1 injections / 0 days) sumatriptan inj 6mg/0.5ml (generic of IMITREX STATDOSE REFILL) SOCT QL (1 injections / 0 days) sumatriptan inj 6mg/0.5ml (generic of IMITREX) SOLN QL (1 injections / 0 days) sumatriptan inj 6mg/0.5ml SOSY QL (1 injections / 0 days) sumatriptan succinate (generic of QL (1 tabs / 0 days) IMITREX) TABS zolmitriptan (generic of ZOMIG) TABS QL (1 tabs / 0 days) zolmitriptan odt (generic of ZOMIG ZMT) QL (1 tabs / 0 days) MISCELLANEOUS AUSTEDO 6mg 5 QL (60 tabs / 0 days), NM, LA, PA AUSTEDO 9mg, 1mg 5 QL (10 tabs / 0 days), NM, LA, PA lithium carbonate CAPS 1 lithium carbonate TABS lithium carbonate er (generic of LITHOBID) 00mg lithium carbonate er 50mg LITHIUM SOLN 8MEQ/5ML NUEDEXTA PA pyridostigmine tab 60mg (generic of MESTINON) riluzole (generic of RILUTEK) tetrabenazine (generic of XENAZINE) 1.5mg 5 QL (0 tabs / 0 days), NM, PA tetrabenazine (generic of XENAZINE) 5mg 5 QL (10 tabs / 0 days), NM, PA MULTIPLE SCLEROSIS AGENTS AMPYRA 5 NM, LA, PA BETASERON 5 QL (1 syringes / 8 days), NM, PA GILENYA 5 QL (8 caps / 8 days), NM, PA glatiramer acetate 0mg/ml (generic of COPAXONE) 5 QL (0 syringes / 0 days), NM, PA 9

48 018 GENERIC STANDARD FORMULARY glatiramer acetate 0mg/ml (generic of COPAXONE) 5 QL (1 syringes / 8 days), NM, PA glatopa (generic of COPAXONE) 0mg/ml 5 QL (0 syringes / 0 days), NM, PA glatopa (generic of COPAXONE) 0mg/ml 5 QL (1 syringes / 8 days), NM, PA TYSABRI 5 NM, LA, PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 10mg, 0mg cyclobenzaprine hcl TABS 5mg, 10mg PA; PA if 65 years and older dantrolene sodium (generic of DANTRIUM) CAPS 5mg, 50mg dantrolene sodium CAPS 100mg tizanidine hcl TABS mg tizanidine hcl (generic of ZANAFLEX) TABS mg NARCOLEPSY/CATAPLEXY armodafinil (generic of NUVIGIL) 50mg QL (150 tabs / 0 days), PA armodafinil (generic of NUVIGIL) 150mg QL (60 tabs / 0 days), PA armodafinil (generic of NUVIGIL) 00mg, QL (0 tabs / 0 days), 50mg PA XYREM 5 QL (50 ml / 0 days), NM, LA, PA PSYCHOTHERAPEUTIC-MISC acamprosate calcium buprenorphine hcl SUBL PA buprenorphine hcl-naloxone hcl sl QL (10 tabs / 0 days), PA bupropion hcl (smoking deterrent) (generic of ZYBAN) CHANTIX PA CHANTIX CONTINUING MONTH PA CHANTIX STARTER PACK PA disulfiram (generic of ANTABUSE) TABS naloxone inj 0.mg/ml naloxone inj 1mg/ml naltrexone hcl TABS NARCAN NICOTROL INHALER NICOTROL NS SUBOXONE MIS -0.5MG QL (10 SL films / 0 days), PA 0

49 018 GENERIC STANDARD FORMULARY SUBOXONE MIS -1MG QL (10 SL films / 0 days), PA SUBOXONE MIS 8-MG QL (10 SL films / 0 days), PA SUBOXONE MIS 1-MG QL (60 SL films / 0 days), PA VIVITROL 5 NM ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 5 PA ANDRODERM QL (0 patches / 0 days), PA ANDROGEL 1.6% QL (150 grams / 0 days), PA ANDROGEL PUMP QL (150 grams / 0 days), PA oxandrolone tab.5mg PA oxandrolone tab 10mg (generic of PA OXANDRIN) testosterone GEL 1% QL (00 gm / 0 days), PA testosterone (generic of ANDROGEL) GEL QL (00 gm / 0 days), 5mg/.5gm, 50mg/5gm PA testosterone cypionate (generic of DEPO- PA TESTOSTERONE) SOLN testosterone enanthate SOLN PA ANTIDIABETICS, INJECTABLE ALCOHOL SWABS BASAGLAR KWIKPEN BYDUREON BCISE QL ( pens / 8 days) BYDUREON INJ QL ( vials / 8 days) BYDUREON PEN QL ( pens / 8 days) BYETTA QL (1 pen / 0 days) FIASP FIASP FLEXTOUCH GAUZE PADS " X " HUMULIN R INJ U B/D HUMULIN R U-500 KWIKPEN 5 INSULIN PEN NEEDLE INSULIN SAFETY NEEDLES INSULIN SYRINGE LEVEMIR LEVEMIR FLEXTOUCH 1

50 018 GENERIC STANDARD FORMULARY NOVOLIN 70/0 (brand RELION not covered) NOVOLIN N (brand RELION not covered) NOVOLIN R (brand RELION not covered) NOVOLOG NOVOLOG 70/0 FLEXPEN NOVOLOG FLEXPEN NOVOLOG MIX 70/0 NOVOLOG PENFILL OZEMPIC INJ 0.5 OR 0.5MG/DOSE QL (1 pen / 8 days) OZEMPIC INJ 1MG/DOSE QL ( pens / 8 days) SOLIQUA 100/ QL (10 pens / 0 days) TRESIBA FLEXTOUCH TRULICITY QL ( pens / 8 days) VICTOZA QL ( pens / 0 days) XULTOPHY 100/.6 QL (5 pens / 0 days) ANTIDIABETICS, ORAL acarbose (generic of PRECOSE) FARXIGA 5mg QL (60 tabs / 0 days) FARXIGA 10mg QL (0 tabs / 0 days) glimepiride (generic of AMARYL) 1mg 1 QL (0 tabs / 0 days) glimepiride (generic of AMARYL) mg 1 QL (10 tabs / 0 days) glimepiride (generic of AMARYL) mg 1 QL (60 tabs / 0 days) glip/metform tab.5-50mg 1 QL (0 tabs / 0 days) glip/metform tab.5-500mg 1 QL (10 tabs / 0 days) glip/metform tab 5-500mg 1 QL (10 tabs / 0 days) glipizide (generic of GLUCOTROL) TABS 1 QL (0 tabs / 0 days) 5mg glipizide (generic of GLUCOTROL) TABS 10mg 1 QL (10 tabs / 0 days) glipizide (generic of GLUCOTROL XL) TB 1 QL (0 tabs / 0 days).5mg glipizide (generic of GLUCOTROL XL) TB 1 QL (10 tabs / 0 days) 5mg glipizide (generic of GLUCOTROL XL) TB 1 QL (60 tabs / 0 days) 10mg glipizide xl (generic of GLUCOTROL XL) 1 QL (0 tabs / 0 days).5mg glipizide xl (generic of GLUCOTROL XL) 1 QL (10 tabs / 0 days) 5mg glipizide xl (generic of GLUCOTROL XL) 1 QL (60 tabs / 0 days) 10mg INVOKAMET TAB MG QL (10 tabs / 0 days)

51 018 GENERIC STANDARD FORMULARY INVOKAMET TAB MG QL (60 tabs / 0 days) INVOKAMET TAB MG QL (60 tabs / 0 days) INVOKAMET TAB MG QL (60 tabs / 0 days) INVOKAMET XR TAB MG QL (10 tabs / 0 days) INVOKAMET XR TAB MG QL (60 tabs / 0 days) INVOKAMET XR TAB MG QL (60 tabs / 0 days) INVOKAMET XR TAB MG QL (60 tabs / 0 days) INVOKANA 100mg QL (90 tabs / 0 days) INVOKANA 00mg QL (0 tabs / 0 days) JANUMET QL (60 tabs / 0 days) JANUMET XR TAB MG QL (60 tabs / 0 days) JANUMET XR TAB QL (60 tabs / 0 days) JANUMET XR TAB QL (0 tabs / 0 days) JANUVIA QL (0 tabs / 0 days) JENTADUETO QL (60 tabs / 0 days) JENTADUETO TAB XR MG QL (60 tabs / 0 days) JENTADUETO TAB XR MG QL (0 tabs / 0 days) metformin er (generic of GLUCOPHAGE XR) 500mg metformin er (generic of GLUCOPHAGE XR) 750mg 1 QL (10 tabs / 0 days); (generic of GLUCOPHAGE XR) 1 QL (60 tabs / 0 days); (generic of GLUCOPHAGE XR) metformin hcl (generic of GLUCOPHAGE) 1 QL (150 tabs / 0 days) TABS 500mg metformin hcl (generic of GLUCOPHAGE) 1 QL (90 tabs / 0 days) TABS 850mg metformin hcl (generic of GLUCOPHAGE) 1 QL (75 tabs / 0 days) TABS 1000mg nateglinide (generic of STARLIX) 1 QL (90 tabs / 0 days) pioglitazone hcl (generic of ACTOS) 1 QL (0 tabs / 0 days) repaglinide (generic of PRANDIN) 1mg 1 QL (10 tabs / 0 days) repaglinide (generic of PRANDIN) mg 1 QL (0 tabs / 0 days) repaglinide.5mg 1 QL (10 tabs / 0 days) TRADJENTA QL (0 tabs / 0 days) XIGDUO XR TAB MG QL (60 tabs / 0 days) XIGDUO XR TAB 5-500MG QL (60 tabs / 0 days) XIGDUO XR TAB MG QL (60 tabs / 0 days) XIGDUO XR TAB MG QL (0 tabs / 0 days) XIGDUO XR TAB MG QL (0 tabs / 0 days) BISPHOSPHONATES alendronate sodium TABS 5mg, 10mg, 1 0mg alendronate sodium TABS 5mg 1 QL ( tabs / 8 days)

52 018 GENERIC STANDARD FORMULARY alendronate sodium (generic of FOSAMAX) 1 QL ( tabs / 8 days) TABS 70mg PAMIDRONATE DISODIUM 6mg/ml B/D pamidronate disodium 0mg/10ml, B/D 90mg/10ml pamidronate inj 0mg B/D pamidronate inj 90mg B/D zoledronic acid (generic of RECLAST) B/D, NM 5mg/100ml zoledronic inj mg/5ml (generic of B/D, NM ZOMETA) CALCIUM RECEPTOR AGONISTS SENSIPAR 0mg, 90mg 5 B/D, QL (10 tabs / 0 days), NM SENSIPAR 60mg 5 B/D, QL (60 tabs / 0 days), NM CHELATING AGENTS CHEMET DEPEN TITRATABS 5 JADENU 5 NM, LA, PA JADENU SPRINKLE 5 NM, LA, PA kionex sus 15gm/60ml sodium polystyrene sulfonate sodium polystyrene sulfonate oral susp sps susp 15gm/60ml SYPRINE 5 trientine hcl (generic of SYPRINE) 5 CONTRACEPTIVES altavera tab alyacen 1/5 (generic of ORTHO-NOVUM 1/5) apri (generic of DESOGEN) aranelle (generic of TRI-NORINYL 8) aubra aviane balziva bekyree (generic of MIRCETTE) blisovi fe 1.5/0 (generic of LOESTRIN FE 1.5/0) blisovi fe 1/0 (generic of LOESTRIN FE 1/0) briellyn camila caziant pak

53 018 GENERIC STANDARD FORMULARY cryselle-8 cyclafem 1/5 (generic of ORTHO-NOVUM 1/5) cyclafem 7/7/7 (generic of ORTHO-NOVUM 7/7/7) cyred tab (generic of DESOGEN) dasetta 1/5 (generic of ORTHO-NOVUM 1/5) dasetta 7/7/7 (generic of ORTHO-NOVUM 7/7/7) deblitane delyla desogestrel & ethinyl estradiol (generic of DESOGEN) desogestrel-ethinyl estradiol (biphasic) (generic of MIRCETTE) drospirenone-ethinyl estradiol (generic of YASMIN 8) drospirenone-ethinyl estradiol (generic of YAZ) ELLA emoquette (generic of DESOGEN) enpresse-8 enskyce (generic of DESOGEN) errin (generic of ORTHO MICRONOR) estarylla tab (generic of ORTHO- CYCLEN) ethynodiol diacet & eth estrad ethynodiol tab 1-50 falmina femynor (generic of ORTHO-CYCLEN) gianvi tab -0.0mg (generic of YAZ) gildagia heather introvale isibloom (generic of DESOGEN) jolessa tab mg jolivette (generic of ORTHO MICRONOR) juleber (generic of DESOGEN) junel 1.5/0 (generic of LOESTRIN 1.5/0-1) junel 1/0 (generic of LOESTRIN 1/0-1) junel fe 1.5/0 (generic of LOESTRIN FE 1.5/0) 5

54 018 GENERIC STANDARD FORMULARY junel fe 1/0 (generic of LOESTRIN FE 1/0) kariva (generic of MIRCETTE) kelnor 1/5 kelnor 1/50 kimidess (generic of MIRCETTE) kurvelo larin 1.5/0 (generic of LOESTRIN 1.5/0-1) larin 1/0 (generic of LOESTRIN 1/0-1) larin fe 1.5/0 (generic of LOESTRIN FE 1.5/0) larin fe 1/0 (generic of LOESTRIN FE 1/0) larissia tab leena tab (generic of TRI-NORINYL 8) lessina levonest levonor/ethi tab levonorgestrel & eth estradiol levonorgestrel-ethinyl estradiol (91-day) levora 0.15/0-8 loryna (generic of YAZ) low-ogestrel lutera lyza marlissa medroxyprogesterone acetate (contraceptive) (generic of DEPO-PROVERA CONTRACEPTIV) microgestin 1.5/0 (generic of LOESTRIN 1.5/0-1) microgestin 1/0 (generic of LOESTRIN 1/0-1) microgestin fe 1.5/0 (generic of LOESTRIN FE 1.5/0) microgestin fe 1/0 (generic of LOESTRIN FE 1/0) mono-linyah tab (generic of ORTHO-CYCLEN) mononessa (generic of ORTHO-CYCLEN) myzilra necon 0.5/5-8 necon 1/50-8 6

55 018 GENERIC STANDARD FORMULARY necon 7/7/7 (generic of ORTHO-NOVUM 7/7/7) nikki (generic of YAZ) nora-be tab 0.5mg norethindrone (contraceptive) (generic of ORTHO MICRONOR) norethindrone acet & eth estra (generic of LOESTRIN 1/0-1) norgest/ethi tab 0.5/5 (generic of ORTHO-CYCLEN) norgestimate-ethinyl estradiol (triphasic) /0.15-5/0.5-5 mg-mcg (generic of ORTHO TRI-CYCLEN LO) norgestimate-ethinyl estradiol (triphasic) /0.15-5/0.5-5 mg-mcg (generic of ORTHO TRI-CYCLEN) norlyroc nortrel 0.5/5 (8) nortrel 1/5 (generic of ORTHO-NOVUM 1/5) nortrel 7/7/7 (generic of ORTHO-NOVUM 7/7/7) NUVARING ocella tab -0.0mg (generic of YASMIN 8) orsythia philith pimtrea (generic of MIRCETTE) pirmella 1/5 (generic of ORTHO-NOVUM 1/5) portia-8 previfem (generic of ORTHO-CYCLEN) quasense reclipsen (generic of DESOGEN) setlakin tab sharobel (generic of ORTHO MICRONOR) sprintec 8 (generic of ORTHO-CYCLEN) sronyx syeda (generic of YASMIN 8) tarina fe 1/0 (generic of LOESTRIN FE 1/0) tilia fe (generic of ESTROSTEP FE) tri-legest fe (generic of ESTROSTEP FE) tri-linyah (generic of ORTHO TRI-CYCLEN) 7

56 018 GENERIC STANDARD FORMULARY tri-lo marzia (generic of ORTHO TRI- CYCLEN LO) tri-lo-estarylla (generic of ORTHO TRI- CYCLEN LO) tri-lo-sprintec (generic of ORTHO TRI- CYCLEN LO) tri-previfem (generic of ORTHO TRI- CYCLEN) tri-sprintec (generic of ORTHO TRI- CYCLEN) tri-vylibra (generic of ORTHO TRI-CYCLEN) trinessa (generic of ORTHO TRI-CYCLEN) trinessa lo (generic of ORTHO TRI-CYCLEN LO) trivora-8 velivet vestura (generic of YAZ) vienva viorele (generic of MIRCETTE) vyfemla vylibra (generic of ORTHO-CYCLEN) xulane dis zarah (generic of YASMIN 8) zenchent zovia 1/5e zovia 1/50e ENDOMETRIOSIS danazol CAPS SYNAREL 5 ENZYME REPLACEMENTS ADAGEN 5 NM, LA, PA ALDURAZYME 5 NM, LA, PA CARBAGLU 5 NM, LA, PA CERDELGA 5 NM, PA CEREZYME 5 NM, LA, PA CYSTADANE 5 NM, LA CYSTAGON NM, LA, PA FABRAZYME 5 NM, LA, PA KUVAN 5 NM, LA, PA levocarnitine (metabolic modifiers) B/D (generic of CARNITOR) SOLN 1gm/10ml levocarnitine (metabolic modifiers) SOLN 00mg/ml B/D 8

57 018 GENERIC STANDARD FORMULARY levocarnitine (metabolic modifiers) B/D (generic of CARNITOR) TABS LUMIZYME 5 NM, LA, PA miglustat 5 NM, PA NAGLAZYME 5 NM, LA, PA ORFADIN 5 NM, LA, PA sodium phenylbutyrate (generic of 5 NM, PA BUPHENYL) ZAVESCA 5 NM, LA, PA ESTROGENS DELESTROGEN 10mg/ml estradiol (generic of CLIMARA) PTWK PA; PA if 65 years and older estradiol (generic of ESTRACE) TABS PA; PA if 65 years and older estradiol vaginal cream (generic of ESTRACE) estradiol vaginal tab (generic of VAGIFEM) estradiol valerate inj (generic of DELESTROGEN) fyavolv tab 1-5mg PA; PA if 65 years and older jinteli PA; PA if 65 years and older norethindrone acetate-ethinyl estradiol tab PA; PA if 65 years and 1 mg-5 mcg older yuvafem vaginal tablet 10 mcg (generic of VAGIFEM) GLUCOCORTICOIDS cortisone acetate TABS DEXAMETHASONE CONC dexamethasone ELIX; SOLN dexamethasone TABS dexamethasone sodium phosphate fludrocortisone acetate TABS hydrocortisone (generic of CORTEF) TABS methylpr ace inj 0mg/ml (generic of B/D DEPO-MEDROL) methylpr ace inj 80mg/ml (generic of B/D DEPO-MEDROL) methylpr ss inj 1gm (generic of SOLU- B/D MEDROL) methylpr ss inj 0mg (generic of SOLU- MEDROL) B/D 9

58 018 GENERIC STANDARD FORMULARY methylpr ss inj 15mg (generic of SOLU- B/D MEDROL) methylpred pak mg (generic of MEDROL DOSEPAK) methylpred tab mg (generic of MEDROL) B/D methylpred tab 8mg (generic of MEDROL) B/D methylpred tab 16mg (generic of MEDROL) B/D methylpred tab mg (generic of MEDROL) B/D pred sod pho sol 5mg/5ml B/D prednisolone sodium phosphate SOLN B/D 15mg/5ml prednisolone sol 15mg/5ml B/D prednisolone sol 5mg/5ml B/D PREDNISONE CON 5MG/ML B/D prednisone pak 5mg prednisone pak 10mg prednisone sol 5mg/5ml B/D prednisone tab 1mg 1 B/D prednisone tab.5mg 1 B/D prednisone tab 5mg 1 B/D prednisone tab 10mg 1 B/D prednisone tab 0mg 1 B/D prednisone tab 50mg 1 B/D SOLU-CORTEF 50mg GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT PROGLYCEM SUS 50MG/ML HUMAN GROWTH HORMONES NORDITROPIN FLEXPRO 5 NM, PA MISCELLANEOUS cabergoline calcitonin (salmon) (generic of MIACALCIN) B/D FORTEO 5 NM, PA INCRELEX 5 NM, LA, PA KORLYM 5 NM, LA, PA LUPRON DEP-PED INJ 7.5MG 5 NM, PA LUPRON DEP-PED INJ 11.5MG 5 NM, PA LUPRON DEP-PED INJ 11.5MG (-MONTH)5 NM, PA LUPRON DEP-PED INJ 15MG 5 NM, PA LUPRON DEP-PED INJ 0MG (-MONTH) 5 NM, PA MIACALCIN 5 B/D NATPARA 5 NM, PA 50

59 018 GENERIC STANDARD FORMULARY octreotide acetate (generic of NM, PA SANDOSTATIN) 50mcg/ml, 100mcg/ml octreotide acetate 00mcg/ml NM, PA octreotide acetate (generic of 5 NM, PA SANDOSTATIN) 500mcg/ml octreotide acetate 1000mcg/ml 5 NM, PA PROLIA QL (1 injection / 180 days), NM raloxifene tab 60mg (generic of EVISTA) SANDOSTATIN LAR DEPOT 5 NM, PA SIGNIFOR 5 NM, LA, PA SOMATULINE DEPOT 5 NM, PA SOMAVERT 5 NM, LA, PA XGEVA 5 NM, PA PHOSPHATE BINDER AGENTS AURYXIA 5 QL (60 tabs / 0 days) calcium acetate (phosphate binder) (generic of PHOSLO) CAPS QL (60 caps / 0 days) calcium acetate (phosphate binder) TABS QL (60 tabs / 0 days) sevelamer carbonate (generic of RENVELA) QL (180 packs / 0 PACK.gm days) sevelamer carbonate (generic of RENVELA) QL (50 packs / 0 PACK.8gm days) sevelamer carbonate (generic of RENVELA) QL (50 tabs / 0 days) TABS PROGESTINS medroxyprogesterone acetate tab (generic 1 of PROVERA) norethindrone acetate (generic of AYGESTIN) TABS THYROID AGENTS levo-t (generic of SYNTHROID) levothyroxine sodium (generic of SYNTHROID) TABS levoxyl (generic of SYNTHROID) liothyronine sodium (generic of CYTOMEL) TABS methimazole (generic of TAPAZOLE) TABS propylthiouracil TABS SYNTHROID unithroid (generic of SYNTHROID) VASOPRESSINS desmopressin acetate spray (generic of DDAVP) 51

60 018 GENERIC STANDARD FORMULARY desmopressin acetate spray refrigerated desmopressin acetate tabs (generic of DDAVP) desmopressin inj mcg/ml (generic of DDAVP) desmopressin sol 0.01% STIMATE 5 NM GASTROINTESTINAL ANTIEMETICS aprepitant (generic of EMEND) B/D aprepitant pak 80mg & 15mg B/D compro supp dronabinol (generic of MARINOL) B/D, QL (60 caps / 0 days) EMEND SUSR B/D granisetron hcl SOLN granisetron hcl TABS B/D meclizine hcl TABS metoclopramide hcl SOLN metoclopramide hcl (generic of REGLAN) 1 TABS metoclopramide inj ondansetron hcl (generic of ZOFRAN) B/D TABS mg, 8mg ondansetron hcl TABS mg B/D ondansetron hcl inj ondansetron hcl oral soln (generic of ZOFRAN) B/D ondansetron odt (generic of ZOFRAN ODT) B/D prochlorperazine inj prochlorperazine maleate TABS prochlorperazine supp promethazine hcl (generic of PHENERGAN) PA; PA if 65 years and SOLN older promethazine hcl SYRP; TABS PA; PA if 65 years and older scopolamine patch (generic of TRANSDERM-SCOP) QL (10 patches / 0 days), PA; PA if 65 years and older ANTISPASMODICS dicyclomine hcl (generic of BENTYL) CAPS 1 dicyclomine hcl SOLN 10mg/5ml dicyclomine hcl TABS 1 5

61 018 GENERIC STANDARD FORMULARY glycopyrrolate (generic of ROBINUL) TABS 1mg glycopyrrolate (generic of ROBINUL FORTE) TABS mg glycopyrrolate inj (generic of ROBINUL) H-RECEPTOR ANTAGONISTS famotidine (generic of PEPCID) SUSR famotidine (generic of PEPCID) TABS 1 0mg, 0mg famotidine inj ranitidine hcl (generic of ZANTAC) TABS 1 ranitidine hcl inj (generic of ZANTAC) ranitidine syrup INFLAMMATORY BOWEL DISEASE APRISO balsalazide disodium (generic of COLAZAL) budesonide ec (generic of ENTOCORT EC) 5 CANASA colocort (generic of CORTENEMA) DELZICOL hydrocortisone (enema) (generic of CORTENEMA) mesalamine ENEM mesalamine (generic of ASACOL HD) TBEC 800mg mesalamine w/ cleanser (generic of ROWASA) sulfasalazine (generic of AZULFIDINE) TABS sulfasalazine ec (generic of AZULFIDINE EN-TABS) LAXATIVES constulose enulose gavilyte-c (generic of COLYTE-FLAVOR PACKS) gavilyte-g (generic of GOLYTELY) gavilyte-n/flavor pack (generic of NULYTELY/FLAVOR PACKS) generlac GOLYTELY lactulose lactulose (encephalopathy) MOVIPREP 5

62 018 GENERIC STANDARD FORMULARY NULYTELY/FLAVOR PACKS peg 50-kcl-sod bicarb-sod chloride-sod sulfate (generic of GOLYTELY) peg 50-potassium chloride-sod bicarbonate-sod chloride (generic of NULYTELY/FLAVOR PACKS) peg 50/electrolytes (generic of COLYTE- FLAVOR PACKS) polyethylene glycol 50 PACK polyethylene glycol 50 POWD SUPREP BOWEL PREP KIT trilyte (generic of NULYTELY/FLAVOR PACKS) MISCELLANEOUS alosetron hcl (generic of LOTRONEX) 5 PA AMITIZA CAP 8MCG QL (180 caps / 0 days) AMITIZA CAP MCG QL (60 caps / 0 days) cromolyn sodium (mastocytosis) (generic 5 of GASTROCROM) diphenoxylate w/ atropine LIQD diphenoxylate w/ atropine (generic of LOMOTIL) TABS GATTEX 5 NM, LA, PA LINZESS 7mcg, 90mcg QL (0 caps / 0 days) LINZESS 15mcg QL (60 caps / 0 days) loperamide hcl CAPS misoprostol (generic of CYTOTEC) TABS MOVANTIK 1.5mg QL (60 tabs / 0 days) MOVANTIK 5mg QL (0 tabs / 0 days) RELISTOR SOLN 5 PA sucralfate (generic of CARAFATE) TABS ursodiol (generic of ACTIGALL) CAPS ursodiol (generic of URSO 50) TABS 50mg ursodiol (generic of URSO FORTE) TABS 500mg XIFAXAN 550mg 5 PA PANCREATIC ENZYMES CREON ZENPEP PROTON PUMP INHIBITORS DEXILANT QL (0 caps / 0 days) esomeprazole magnesium (generic of NEXIUM) QL (0 caps / 0 days) 5

63 018 GENERIC STANDARD FORMULARY esomeprazole sodium inj 0mg esomeprazole sodium inj (generic of NEXIUM I.V.) 0mg omeprazole cap 10mg 1 QL (0 caps / 0 days) omeprazole cap 0mg 1 QL (60 caps / 0 days) omeprazole cap 0mg 1 QL (0 caps / 0 days) pantoprazole sodium tbec (generic of PROTONIX) QL (0 tabs / 0 days) GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of UROXATRAL) QL (0 tabs / 0 days) dutasteride (generic of AVODART) CAPS QL (0 caps / 0 days) dutasteride-tamsulosin hcl (generic of QL (0 caps / 0 days) JALYN) finasteride (generic of PROSCAR) TABS 5mg tamsulosin hcl (generic of FLOMAX) MISCELLANEOUS bethanechol chloride (generic of URECHOLINE) TABS potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 15) 15meq potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 5) 50mg potassium citrate (alkalinizer) er tabs (generic of UROCIT-K 10) 1080mg URINARY ANTISPASMODICS MYRBETRIQ 5mg QL (60 tabs / 0 days) MYRBETRIQ 50mg QL (0 tabs / 0 days) oxybutynin chloride SYRP 1 oxybutynin chloride TABS oxybutynin chloride (generic of DITROPAN QL (0 tabs / 0 days) XL) TB 5mg oxybutynin chloride (generic of DITROPAN QL (60 tabs / 0 days) XL) TB 10mg, 15mg tolterodine tartrate (generic of DETROL LA) QL (0 caps / 0 days) CP tolterodine tartrate (generic of DETROL) TABS TOVIAZ QL (0 tabs / 0 days) trospium chloride TABS QL (60 tabs / 0 days) VESICARE QL (0 tabs / 0 days) VAGINAL ANTI-INFECTIVES 55

64 018 GENERIC STANDARD FORMULARY clindamycin phosphate vaginal (generic of CLEOCIN) metronidazole vaginal (generic of METROGEL-VAGINAL) terconazole vaginal (generic of TERAZOL 7) CREA.% terconazole vaginal CREA.8% terconazole vaginal SUPP vandazole HEMATOLOGIC ANTICOAGULANTS COUMADIN ELIQUIS ELIQUIS STARTER PACK enoxaparin sodium (generic of LOVENOX) fondaparinux sodium (generic of ARIXTRA).5mg/0.5ml fondaparinux sodium (generic of ARIXTRA) 5 5mg/0.ml, 7.5mg/0.6ml, 10mg/0.8ml heparin sod (porcine) in d5w heparin sod inj 1000/ml B/D heparin sod inj 5000/ml B/D heparin sod inj 10000/ml B/D heparin sod inj 0000/ml B/D heparin sodium/d5w HEPARIN SODIUM/NACL 0.5% jantoven (generic of COUMADIN) 1 PRADAXA warfarin sodium (generic of COUMADIN) 1 XARELTO XARELTO STARTER PACK HEMATOPOIETIC GROWTH FACTORS GRANIX 5 NM, PA MOZOBIL 5 NM, PA NEUPOGEN 5 NM, PA PROCRIT 000unit/ml, 000unit/ml, NM, PA 000unit/ml, 10000unit/ml PROCRIT 0000unit/ml, 0000unit/ml 5 NM, PA MISCELLANEOUS anagrelide hcl 1mg anagrelide hcl (generic of AGRYLIN).5mg cilostazol CINRYZE 5 QL (0 vials / 0 days), NM, LA, PA 56

65 018 GENERIC STANDARD FORMULARY ENDARI 5 NM, LA, PA FIRAZYR 5 QL (9 syringes / 0 days), NM, PA HAEGARDA 000unit 5 QL (0 vials / 0 days), NM, LA, PA HAEGARDA 000unit 5 QL (0 vials / 0 days), NM, LA, PA pentoxifylline TBCR PROMACTA 1.5mg 5 QL (60 tabs / 0 days), NM, LA, PA PROMACTA 5mg 5 QL (180 tabs / 0 days), NM, LA, PA PROMACTA 50mg 5 QL (90 tabs / 0 days), NM, LA, PA PROMACTA 75mg 5 QL (60 tabs / 0 days), NM, LA, PA tranexamic acid (generic of CYKLOKAPRON) SOLN tranexamic acid (generic of LYSTEDA) TABS PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole (generic of AGGRENOX) BRILINTA clopidogrel tab 75mg (generic of PLAVIX) 1 prasugrel hcl (generic of EFFIENT) ZONTIVITY IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) HUMIRA 10mg/0.1ml, 0mg/0.ml 5 QL ( syringes / 8 days), NM, PA HUMIRA 0mg/0.ml 5 QL (6 syringes / 8 days), NM, PA HUMIRA INJ 10MG/0.ML 5 QL ( syringes / 8 days), NM, PA HUMIRA KIT 0MG/0.ML 5 QL ( syringes / 8 days), NM, PA HUMIRA KIT 0MG/0.8ML 5 QL (6 syringes / 8 days), NM, PA HUMIRA PEDIATRIC CROHNS DISEASE 5 NM, PA HUMIRA PEN 5 QL (6 pens / 8 days), NM, PA HUMIRA PEN-CROHNS DISEASE 5 NM, PA HUMIRA PEN-PSORIASIS 5 NM, PA 57

66 018 GENERIC STANDARD FORMULARY hydroxychloroquine sulfate (generic of PLAQUENIL) leflunomide (generic of ARAVA) TABS methotrexate sodium tabs REMICADE 5 NM, PA XATMEP B/D XELJANZ 5 QL (60 tabs / 0 days), NM, PA XELJANZ XR 5 QL (0 tabs / 0 days), NM, PA IMMUNOGLOBULINS BIVIGAM 5 NM, PA CARIMUNE NANOFILTERED 5 NM, PA FLEBOGAMMA DIF 5 NM, PA GAMASTAN S/D B/D, NM GAMMAGARD LIQUID 5 NM, PA GAMMAGARD S/D 5 NM, PA GAMMAKED 5 NM, PA GAMMAPLEX 5 NM, PA GAMMAPLEX 10GM/100ML 5 NM, PA GAMUNEX-C 5 NM, PA OCTAGAM 5 NM, PA PRIVIGEN 5 NM, PA IMMUNOMODULATORS ACTIMMUNE 5 NM, LA, PA ARCALYST 5 NM, PA INTRON-A INJ 10MU 5 B/D, NM INTRON-A INJ 18MU 5 B/D, NM INTRON-A INJ 5MU 5 B/D, NM INTRON-A INJ 50MU 5 B/D, NM IMMUNOSUPPRESSANTS AZATHIOPRINE SOLR B/D azathioprine (generic of IMURAN) TABS B/D BENLYSTA 5 NM, PA cyclosporine (generic of SANDIMMUNE) CAPS; SOLN B/D, NM cyclosporine modified (for microemulsion) B/D, NM (generic of NEORAL) CAPS 5mg, 100mg cyclosporine modified (for microemulsion) B/D, NM CAPS 50mg cyclosporine modified (for microemulsion) B/D, NM (generic of NEORAL) SOLN gengraf (generic of NEORAL) B/D, NM 58

67 018 GENERIC STANDARD FORMULARY mycophenolate mofetil (generic of B/D, NM CELLCEPT) CAPS; TABS mycophenolate mofetil (generic of 5 B/D, NM CELLCEPT) SUSR mycophenolate sodium (generic of B/D, NM MYFORTIC) NULOJIX 5 B/D, NM RAPAMUNE SOLN 5 B/D, NM SANDIMMUNE SOLN 100mg/ml B/D, NM sirolimus (generic of RAPAMUNE) TABS 5 B/D, NM mg sirolimus (generic of RAPAMUNE) TABS B/D, NM.5mg, 1mg tacrolimus (generic of PROGRAF) CAPS B/D, NM ZORTRESS TAB 0.5MG 5 B/D, NM ZORTRESS TAB 0.5MG 5 B/D, NM ZORTRESS TAB 0.75MG 5 B/D, NM VACCINES ACTHIB ADACEL BCG VACCINE BEXSERO BOOSTRIX DAPTACEL DIPHTHERIA/TETANUS TOXOID B/D ENGERIX-B SUSP B/D GARDASIL 9 HAVRIX HIBERIX IMOVAX RABIES (H.D.C.V.) INFANRIX IPOL INACTIVATED IPV IXIARO KINRIX M-M-R II MENACTRA MENVEO PEDIARIX PEDVAX HIB PENTACEL PROQUAD QUADRACEL RABAVERT RECOMBIVAX HB B/D 59

68 018 GENERIC STANDARD FORMULARY ROTARIX ROTATEQ SHINGRIX QL ( vials per lifetime) SYNAGIS 5 NM TENIVAC B/D TETANUS/DIPHTHERIA TOXOID B/D TRUMENBA TWINRIX INJ TYPHIM VI VAQTA VARIVAX YF-VAX ZOSTAVAX QL (1 vial per lifetime) NUTRITIONAL/SUPPLEMENTS ELECTROLYTES klor-con 8 klor-con 10 klor-con m10 KLOR-CON M15 klor-con m0 klor-con pak 0meq klor-con spr cap 8meq (generic of MICRO- K) klor-con spr cap 10meq (generic of MICRO- K) MAGNESIUM SULFATE SOLN gm/50ml, gm/100ml, gm/50ml, 0gm/500ml, 0gm/1000ml magnesium sulfate (generic of MAGNESIUM SULFATE) SOLN gm/50ml, gm/100ml, gm/50ml, 0gm/500ml, 0gm/1000ml magnesium sulfate SOLN 50% MAGNESIUM SULFATE IN D5W magnesium sulfate in dextrose (generic of MAGNESIUM SULFATE IN D5W) potassium chloride (generic of MICRO-K) CPCR potassium chloride PACK potassium chloride SOLN 10%, 0% potassium chloride TBCR potassium chloride microencapsulated crystals er potassium chloride tab cr 10 meq 60

69 018 GENERIC STANDARD FORMULARY sodium chloride SOLN.5meq/ml sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln tpn electrolytes B/D IV NUTRITION AMINOSYN B/D AMINOSYN 7%/ELECTROLYTES B/D aminosyn 8.5%/electrolyte B/D aminosyn ii 8.5%/electrol B/D AMINOSYN II INJ 8.5% B/D AMINOSYN II INJ 10% B/D AMINOSYN M B/D AMINOSYN-HBC B/D AMINOSYN-PF 7% B/D AMINOSYN-PF INJ 10% B/D AMINOSYN-RF B/D CLINIMIX.75%/DEXTROSE 5% B/D CLINIMIX.5%/DEXTROSE 5% B/D CLINIMIX.5%/DEXTROSE 5% B/D CLINIMIX 5%/DEXTROSE 15% B/D CLINIMIX 5%/DEXTROSE 0% B/D CLINIMIX 5%/DEXTROSE 5% B/D CLINIMIX INJ.5/D10 B/D CLINIMIX INJ.5/D0 B/D FREAMINE HBC 6.9% B/D FREAMINE III B/D hepatamine B/D INTRALIPID 0% B/D intralipid inj 0% B/D NEPHRAMINE B/D nutrilipid inj 0% B/D premasol 6% B/D PREMASOL 10% B/D PROCALAMINE B/D PROSOL B/D TRAVASOL B/D TROPHAMINE INJ 10% B/D IV REPLACEMENT SOLUTIONS dextrose.5%/nacl 0.5% dextrose 5% DEXTROSE 5% /ELECTROLYTE dextrose 5%/lactated ring dextrose 5%/nacl 0.% 61

70 018 GENERIC STANDARD FORMULARY DEXTROSE 5%/NACL 0.% dextrose 5%/nacl 0.9% dextrose 5%/nacl 0.% dextrose 5%/nacl 0.5% dextrose 5%/nacl 0.5% dextrose 5%/potassium chl dextrose 10% flex contain DEXTROSE 10%/NACL 0.% dextrose 10%/nacl 0.5% dextrose 50% dextrose inj 70% IONOSOL-MB/DEXTROSE 5% ISOLYTE P ISOLYTE S kcl0.15%/d5w/nacl0.% KCL 0.%/D5W/NACL 0.9% kcl 0.%/d5w/nacl 0.5% kcl 0.15%/d5w/nacl 0.9% KCL 0.15%/D5W/NACL 0.5% kcl 0.075%/d5w/nacl 0.5% kcl/d5w inj 0.% kcl/d5w/nacl inj 0.%/0.5% kcl/d5w/nacl inj.15/.% kcl/d5w/nacl inj.15/.5% kcl/nacl inj kcl/nacl inj 0.15%-0.9% lactated ringer's inj NORMOSOL-M IN D5W NORMOSOL-R NORMOSOL-R IN D5W PLASMA-LYTE A PLASMA-LYTE-18 pot chloride inj meq/ml potassium chloride SOLN.meq/ml, meq/ml, 10meq/100ml, 10meq/50ml, 0meq/100ml, 0meq/100ml potassium chloride in nacl ringer's sodium chloride SOLN %, 5% sodium chloride 0.5% sodium chloride inj 0.9% VITAMINS calcitriol (generic of ROCALTROL) CAPS B/D calcitriol inj B/D 6

71 018 GENERIC STANDARD FORMULARY calcitriol oral soln 1 mcg/ml (generic of B/D ROCALTROL) paricalcitol (generic of ZEMPLAR) CAPS B/D 1mcg, mcg paricalcitol CAPS mcg B/D prenatal vitamin/folic acid > 0.8 mg (generic) RAYALDEE 5 OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc BLEPHAMIDE OINT neomycin-polymy-dexameth (generic of MAXITROL) neomycin-polymyxin-hc (ophth) sulfacetamide sod-prednisolone TOBRADEX OINT TOBRADEX ST tobramycin-dexamethasone (generic of TOBRADEX) ZYLET ANTI-INFECTIVES bacitracin (ophthalmic) bacitracin-polymyxin b (ophth) BESIVANCE CILOXAN OINT ciprofloxacin hcl (ophth) (generic of CILOXAN) erythromycin (ophth) gatifloxacin (ophth) (generic of ZYMAXID) gentak gentamicin sulfate soln (ophth) MOXEZA moxifloxacin hcl (ophth) (generic of VIGAMOX) NATACYN neomycin-bacitracin zn-polymyxin neomycin-polymyxin-gramicidin (generic of NEOSPORIN) ofloxacin (ophth) (generic of OCUFLOX) polymyxin b-trimethoprim (generic of POLYTRIM) sulfacet sod oin 10% op 6

72 018 GENERIC STANDARD FORMULARY sulfacetamide sodium (ophth) (generic of BLEPH-10) tobramycin (ophth) (generic of TOBREX) trifluridine (generic of VIROPTIC) SOLN ZIRGAN ANTI-INFLAMMATORIES ALREX bromfenac sodium (ophth) BROMSITE dexamethasone sodium phosphate (ophth) diclofenac sodium (ophth) DUREZOL fluorometholone flurbiprofen sodium ILEVRO ketorolac tromethamine (ophth) (generic of ACULAR LS).% ketorolac tromethamine (ophth) (generic of ACULAR).5% LOTEMAX prednisolone acetate (ophth) (generic of OMNIPRED) PREDNISOLONE SODIUM PHOSPHATE (OPHTH) PROLENSA ANTIALLERGICS azelastine drop 0.05% BEPREVE cromolyn sodium (ophth) 1 LASTACAFT olopatadine hcl 0.% (generic of PATADAY) PAZEO ANTIGLAUCOMA ALPHAGAN P SOL 0.1% AZOPT betaxolol hcl (ophth) BETOPTIC-S brimonidine sol 0.% brimonidine sol 0.15% (generic of ALPHAGAN P) carteolol hcl (ophth) COMBIGAN dorzolamide hcl (generic of TRUSOPT) 6

73 018 GENERIC STANDARD FORMULARY dorzolamide hcl-timolol maleate (generic of COSOPT) latanoprost (generic of XALATAN) SOLN levobunolol hcl (generic of BETAGAN) LUMIGAN metipranolol PHOSPHOLINE IODIDE pilocarpine hcl (generic of ISOPTO CARPINE) SOLN SIMBRINZA timolol maleate (ophth) soln (generic of 1 TIMOPTIC) timolol maleate gel (generic of TIMOPTIC- XE) timolol maleate ophth soln 0.5% (oncedaily) (generic of ISTALOL) TRAVATAN Z MISCELLANEOUS CYSTARAN 5 NM, LA, PA proparacaine hcl (generic of ALCAINE) SOLN RESTASIS QL (6 single use vials / 0 days) RESTASIS MULTIDOSE QL (1 bottle / 0 days) RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA QL (60 blisters / 0 days) BEVESPI AEROSPHERE QL (1 inhaler / 0 days) COMBIVENT RESPIMAT QL ( inhalers / 0 days) ipratropium-albuterol nebu B/D TRELEGY ELLIPTA QL (60 blisters / 0 days) ANTICHOLINERGICS ATROVENT HFA QL ( inhalers / 0 days) INCRUSE ELLIPTA QL (0 blisters / 0 days) ipratropium bromide SOLN B/D ipratropium bromide (nasal) ANTIHISTAMINES azelastine spr 0.1% azelastine spr 0.15% (generic of ASTEPRO) 65

74 018 GENERIC STANDARD FORMULARY cetirizine syrup cyproheptadine hcl SYRP; TABS PA; PA if 65 years and older diphenhydramine hcl inj hydroxyzine hcl SOLN; SYRP; TABS PA; PA if 65 years and older hydroxyzine pamoate (generic of VISTARIL) CAPS 5mg, 50mg PA; PA if 65 years and older levocetirizine dihydrochloride SOLN levocetirizine dihydrochloride TABS BETA AGONISTS albuterol sulfate NEBU B/D albuterol sulfate SYRP 1 albuterol sulfate TABS; TB1 levalbuterol hcl (generic of XOPENEX) B/D NEBU 1.5mg/ml levalbuterol hcl soln nebu conc 1.5 B/D mg/0.5ml (generic of XOPENEX CONCENTRATE) levalbuterol tartrate hfa QL ( inhalers / 0 days) SEREVENT DISKUS QL (60 inhalations / 0 days) terbutaline sulfate TABS VENTOLIN HFA QL ( inhalers / 0 days) LEUKOTRIENE MODULATORS montelukast sodium (generic of SINGULAIR) CHEW montelukast sodium (generic of SINGULAIR) PACK montelukast sodium (generic of SINGULAIR) TABS zafirlukast (generic of ACCOLATE) MAST CELL STABILIZERS cromolyn sod neb 0mg/ml B/D MISCELLANEOUS acetylcysteine SOLN 10%, 0% B/D ARALAST NP 5 NM, LA, PA DALIRESP epinephrine (anaphylaxis).15mg/0.15ml, (generic of Adrenaclick).mg/0.ml ESBRIET 5 NM, PA KALYDECO 5 NM, PA 66

75 018 GENERIC STANDARD FORMULARY OFEV 5 NM, PA ORKAMBI 5 NM, PA PROLASTIN-C 5 NM, LA, PA PULMOZYME 5 NM, PA SYMDEKO 5 NM, LA, PA XOLAIR 5 NM, LA, PA ZEMAIRA 5 NM, LA, PA NASAL STEROIDS flunisolide (nasal) QL ( bottles / 0 days) fluticasone propionate (nasal) (generic of QL (1 bottle / 0 days) FLONASE) STEROID INHALANTS ARNUITY ELLIPTA 100mcg/act, 00mcg/act QL (0 inhalations / 0 days) budesonide (inhalation) (generic of B/D PULMICORT).5mg/ml,.5mg/ml FLOVENT DISKUS 50mcg/blist, 100mcg/blist QL (10 inhalations / 0 days) FLOVENT DISKUS 50mcg/blist QL (0 inhalations / 0 days) FLOVENT HFA QL ( inhalers / 0 days) PULMICORT FLEXHALER QL ( inhalers / 0 days) STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS QL (60 inhalations / 0 days) ADVAIR HFA QL (1 inhaler / 0 days) BREO ELLIPTA QL (60 blisters / 0 days) SYMBICORT QL (1 inhaler / 0 days) XANTHINES aminophylline inj THEO- theophylline SOLN theophylline TB1; TB TOPICAL DERMATOLOGY, ACNE amnesteem PA avita (generic of RETIN-A) CREA PA avita GEL PA benzoyl peroxide-erythromycin (generic of BENZAMYCIN) claravis PA 67

76 018 GENERIC STANDARD FORMULARY clindacin-p (generic of CLEOCIN-T) clindamycin phosphate (topical) (generic of CLEOCIN-T) GEL; SOLN; SWAB clindamycin phosphate (topical) (generic of CLEOCIN-T) LOTN ery pad % erythromycin (acne aid) (generic of ERYGEL) GEL erythromycin (acne aid) SOLN isotretinoin CAPS PA myorisan PA sulfacetamide sodium (acne) (generic of KLARON) tretinoin (generic of RETIN-A) CREA PA tretinoin (generic of RETIN-A) GEL.01%, PA.05% zenatane PA DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) mafenide acetate (generic of SULFAMYLON) PACK mupirocin OINT silver sulfadiazine (generic of SILVADENE) CREA ssd (generic of SILVADENE) SULFAMYLON CREA SULFAMYLON PACK 5 DERMATOLOGY, ANTIFUNGALS ciclopirox (generic of LOPROX) CREA; SUSP ciclopirox GEL ciclopirox shampoo 1% (generic of LOPROX SHAMPOO) clotrimazole (topical) ketoconazole cream nyamyc nystatin (topical) nystop DERMATOLOGY, ANTIPSORIATICS acitretin (generic of SORIATANE) 5 PA calcipotriene (generic of DOVONEX) CREA calcipotriene SOLN tazarotene (generic of TAZORAC) CREA PA TAZORAC CREA.05% PA 68

77 018 GENERIC STANDARD FORMULARY DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo (generic of NIZORAL) selenium sulfide LOTN DERMATOLOGY, CORTICOSTEROIDS ala-cort 1 alclometasone dipropionate betamethasone dipropionate (topical) betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA betamethasone dipropionate augmented GEL betamethasone dipropionate augmented (generic of DIPROLENE) LOTN; OINT betamethasone valerate CREA; LOTN; OINT desoximetasone (generic of TOPICORT) CREA; GEL; OINT fluocinolone acetonide CREA.01% fluocinolone acetonide (generic of SYNALAR) CREA.05% fluocinolone acetonide (generic of DERMA- SMOOTHE/FS BODY) OIL fluocinolone acetonide (generic of SYNALAR) OINT fluocinolone acetonide (generic of SYNALAR) SOLN fluocinolone acetonide oil body (generic of DERMA-SMOOTHE/FS SCALP) fluocinonide CREA.05% fluocinonide GEL fluocinonide SOLN fluocinonide emulsified base fluticasone propionate CREA; OINT halobetasol propionate (generic of ULTRAVATE) hydrocortisone (topical) CREA 1 hydrocortisone (topical) LOTN hydrocortisone (topical) OINT hydrocortisone butyrate cream 0.1% (generic of LOCOID) hydrocortisone butyrate oint 0.1% (generic of LOCOID) hydrocortisone butyrate soln 0.1% (generic of LOCOID) 69

78 018 GENERIC STANDARD FORMULARY hydrocortisone valerate mometasone furoate (generic of ELOCON) CREA mometasone furoate (generic of ELOCON) OINT mometasone furoate SOLN TEXACORT SOLN.5% triamcinolone acetonide (topical) CREA; OINT triamcinolone acetonide (topical) LOTN DERMATOLOGY, LOCAL ANESTHETICS glydo QL (0 ml / 0 days), PA lidocaine (generic of LIDODERM) PTCH QL ( patches / 1 day), PA lidocaine hcl GEL QL (0 ml / 0 days), PA lidocaine hcl (generic of XYLOCAINE) SOLN % QL (50 ml / 0 days), PA lidocaine oint 5% QL (50 gm / 0 days), PA lidocaine-prilocaine QL (0 gm / 0 days), PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate (generic of LAC- HYDRIN) CREA ammonium lactate LOTN diclofenac sodium (topical) 1% gel (generic PA of VOLTAREN) doxepin hcl (antipruritic) fluorouracil (topical) (generic of EFUDEX) CREA 5% fluorouracil (topical) SOLN imiquimod (generic of ALDARA) CREA metronidazole (topical) (generic of METROCREAM) CREA metronidazole (topical) (generic of METROLOTION) LOTN metronidazole gel 0.75% PANRETIN 5 PICATO podofilox SOLN procto-med hc (generic of ANUSOL-HC) procto-pak 70

79 018 GENERIC STANDARD FORMULARY proctosol hc cre.5% (generic of ANUSOL- HC) proctozone-hc (generic of ANUSOL-HC) rosadan cre 0.75% (generic of METROCREAM) tacrolimus (topical) (generic of PROTOPIC) TARGRETIN GEL 5 NM, PA VALCHLOR 5 NM, LA, PA DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion (generic of OVIDE) permethrin cre 5% (generic of ELIMITE) DERMATOLOGY, WOUND CARE AGENTS acetic acid.5% REGRANEX 5 PA SANTYL sodium chlor sol 0.9% irr sterile water irrigation MOUTH/THROAT/DENTAL AGENTS cevimeline hcl (generic of EVOXAC) chlorhexidine gluconate (mouth-throat) 1 (generic of PERIDEX) clotrimazole LOZG lidocaine hcl (mouth-throat) nystatin (mouth-throat) paroex sol 0.1% (generic of PERIDEX) 1 periogard (generic of PERIDEX) 1 pilocarpine hcl (oral) (generic of SALAGEN) triamcinolone acetonide (mouth) OTIC acetic acid (otic) CIPRODEX fluocinolone acetonide (otic) (generic of DERMOTIC) neomycin-polymyxin-hc (otic) ofloxacin (otic) (generic of FLOXIN OTIC) 71

80 018 GENERIC STANDARD FORMULARY Index A abacavir sulfate... 6 abacavir sulfate-lamivudine... 8 abacavir sulfate-lamivudine-zidovudine 8 ABELCET... 6 ABILIFY see aripiprazole tab... ABILIFY MAINTENA... ABRAXANE...1 acamprosate calcium...0 acarbose... ACCOLATE see zafirlukast...66 ACCUPRIL see quinapril hcl...19 ACCURETIC see quinapril-hydrochlorothiazide...19 acebutolol hcl... acetaminophen w/ codeine... acetazolamide... acetic acid...71 acetic acid (otic)...71 acetylcysteine...66 acitretin...68 ACTHIB...59 ACTIGALL see ursodiol...5 ACTIMMUNE...58 ACTIQ see fentanyl citrate... ACTOS see pioglitazone hcl... ACULAR see ketorolac tromethamine (ophth).6 ACULAR LS see ketorolac tromethamine (ophth).6 acyclovir... 9 acyclovir sodium... 9 ADACEL...59 ADAGEN...8 ADALAT CC see afeditab cr... see nifedipine er... ADCIRCA... 6 ADDERALL see amphetamine-dextroamphetamine tab 10 mg... 7 see amphetamine-dextroamphetamine tab 1.5 mg... 7 see amphetamine-dextroamphetamine tab 15 mg... 7 see amphetamine-dextroamphetamine tab 0 mg... 7 see amphetamine-dextroamphetamine tab 0 mg... 7 see amphetamine-dextroamphetamine tab 5 mg... 7 see amphetamine-dextroamphetamine tab 7.5 mg... 7 ADDERALL XR see amphetamine-dextroamphetamine cap sr hr 10 mg... 7 see amphetamine-dextroamphetamine cap sr hr 15 mg... 7 see amphetamine-dextroamphetamine cap sr hr 0 mg... 7 see amphetamine-dextroamphetamine cap sr hr 5 mg... 7 see amphetamine-dextroamphetamine cap sr hr 0 mg... 7 see amphetamine-dextroamphetamine cap sr hr 5 mg... 7 adefovir dipivoxil... 9 ADEMPAS... 6 adriamycin... 1 adrucil... 1 adrucil inj... 1 ADVAIR DISKUS ADVAIR HFA afeditab cr... AFINITOR AFINITOR DISPERZ AGGRENOX see aspirin-dipyridamole AGRYLIN see anagrelide hcl

81 018 GENERIC STANDARD FORMULARY ala-cort...69 ALBENZA... albuterol sulfate...66 ALCAINE see proparacaine hcl...65 alclometasone dipropionate...69 ALCOHOL SWABS...1 ALDACTAZIDE see spironolactone & hydrochlorothiazide...5 ALDACTONE see spironolactone...0 ALDARA see imiquimod...70 ALDURAZYME...8 ALECENSA...16 alendronate sodium..., alfuzosin hcl...55 ALIMTA...1 ALINIA... ALKERAN see melphalan hcl...1 allopurinol tab... 1 alosetron hcl...5 ALPHAGAN P see brimonidine sol 0.15%...6 ALPHAGAN P SOL 0.1%...6 alprazolam tab 0.5mg...6 alprazolam tab 0.5mg...6 alprazolam tab 1mg...6 alprazolam tab mg...6 ALREX...6 ALTACE see ramipril...19 altavera tab... ALUNBRIG...16 alyacen 1/5... amantadine hcl... AMARYL see glimepiride... AMBIEN see zolpidem tartrate...8 AMBISOME... 6 AMERGE see naratriptan hcl...8 amikacin sulfate... amiloride & hydrochlorothiazide... amiloride hcl... aminophylline inj AMINOSYN AMINOSYN 7%/ELECTROLYTES aminosyn 8.5%/electrolyte aminosyn ii 8.5%/electrol AMINOSYN II INJ 10% AMINOSYN II INJ 8.5% AMINOSYN M AMINOSYN-HBC AMINOSYN-PF 7% AMINOSYN-PF INJ 10% AMINOSYN-RF amiodarone hcl... 0 AMITIZA CAP MCG... 5 AMITIZA CAP 8MCG... 5 amitriptyline hcl... 1 amlodipine besylate... amlodipine besylate-benazepril hcl cap 10-0 mg amlodipine besylate-benazepril hcl cap 10-0 mg amlodipine besylate-benazepril hcl cap.5-10 mg amlodipine besylate-benazepril hcl cap 5-10 mg amlodipine besylate-benazepril hcl cap 5-0 mg amlodipine besylate-benazepril hcl cap 5-0 mg amlodipine besylate-olmesartan medoxomil... 0 amlodipine besylate-valsartan tab... 0 amlodipine-valsartan-hydrochlorothiazide tab... 0 ammonium lactate amnesteem amoxapine... 1 amoxicillin... 1 amoxicillin & pot clavulanate... 1 amphetamine-dextroamphetamine cap sr hr 10 mg... 7 amphetamine-dextroamphetamine cap sr hr 15 mg... 7 amphetamine-dextroamphetamine cap sr 7

82 018 GENERIC STANDARD FORMULARY hr 0 mg...7 amphetamine-dextroamphetamine cap sr hr 5 mg...7 amphetamine-dextroamphetamine cap sr hr 0 mg...7 amphetamine-dextroamphetamine cap sr hr 5 mg...7 amphetamine-dextroamphetamine tab 10 mg...7 amphetamine-dextroamphetamine tab 1.5 mg...7 amphetamine-dextroamphetamine tab 15 mg...7 amphetamine-dextroamphetamine tab 0 mg...7 amphetamine-dextroamphetamine tab 0 mg...7 amphetamine-dextroamphetamine tab 5 mg...7 amphetamine-dextroamphetamine tab 7.5 mg...7 amphotericin b... 6 ampicillin & sulbactam sodium...1 ampicillin cap 50mg...1 ampicillin cap 500mg...1 ampicillin inj...1 ampicillin sodium...1 ampicillin susp...1 AMPYRA...9 ANADROL ANAFRANIL see clomipramine hcl...1 anagrelide hcl...56 ANAPROX DS see naproxen sodium... 1 anastrozole...15 ANCOBON see flucytosine... 6 ANDRODERM...1 ANDROGEL see testosterone...1 ANDROGEL 1.6%...1 ANDROGEL PUMP...1 ANORO ELLIPTA...65 ANTABUSE see disulfiram...0 ANUSOL-HC see procto-med hc see proctosol hc cre.5% see proctozone-hc APOKYN... aprepitant... 5 aprepitant pak 80mg & 15mg... 5 apri... APRISO... 5 APTIOM... 6 APTIVUS... 6 ARALAST NP aranelle... ARAVA see leflunomide ARCALYST ARICEPT see donepezil hydrochloride... 0 ARIMIDEX see anastrozole aripiprazole odt... aripiprazole oral solution 1 mg/ml... aripiprazole tab... ARISTADA... ARIXTRA see fondaparinux sodium armodafinil... 0 ARNUITY ELLIPTA AROMASIN see exemestane ASACOL HD see mesalamine... 5 aspirin-dipyridamole ASTEPRO see azelastine spr 0.15% atazanavir sulfate... 7 atenolol... atenolol & chlorthalidone... ATIVAN see lorazepam... 6 atomoxetine hcl... 7 atorvastatin calcium... 1 atovaquone... atovaquone-proguanil hcl... 6 ATRIPLA... 8 ATROVENT HFA

83 018 GENERIC STANDARD FORMULARY aubra... AUGMENTIN see amoxicillin & pot clavulanate...1 AUGMENTIN ES-600 see amoxicillin & pot clavulanate...1 AUGMENTIN XR see amoxicillin & pot clavulanate...1 AURYXIA...51 AUSTEDO...9 AVALIDE see irbesartan-hydrochlorothiazide...0 AVAPRO see irbesartan...0 AVASTIN...15 aviane... avita...67 AVODART see dutasteride...55 AYGESTIN see norethindrone acetate...51 azacitidine...1 AZACTAM see aztreonam... AZACTAM IN ISO-OSMOTIC DE... AZACTAM/DEX INJ... azathioprine...58 AZATHIOPRINE...58 azelastine drop 0.05%...6 azelastine spr 0.1%...65 azelastine spr 0.15%...65 AZILECT see rasagiline mesylate... azithromycin...11 AZOPT...6 AZOR see amlodipine besylate-olmesartan medoxomil...0 aztreonam... AZULFIDINE see sulfasalazine...5 AZULFIDINE EN-TABS see sulfasalazine ec...5 B bacitracin (ophthalmic)...6 bacitracin-polymyxin b (ophth)...6 bacitracin-poly-neomycin-hc...6 baclofen... 0 BACTRIM see sulfamethoxazole-trimethoprim... 5 BACTRIM DS see sulfamethoxazole-trimethop ds... 5 balsalazide disodium... 5 balziva... BANZEL SUS 0MG/ML... 6 BANZEL TAB 00MG... 6 BANZEL TAB 00MG... 6 BARACLUDE... 9 see entecavir... 9 BASAGLAR KWIKPEN... 1 BCG VACCINE bekyree... BELEODAQ benazepril & hydrochlorothiazide benazepril hcl BENDEKA... 1 BENICAR see olmesartan medoxomil... 0 BENICAR HCT see olmesartan medoxomilhydrochlorothiazide... 0 BENLYSTA BENTYL see dicyclomine hcl... 5 BENZAMYCIN see benzoyl peroxide-erythromycin. 67 benzoyl peroxide-erythromycin benztropine mesylate... BEPREVE... 6 BESIVANCE... 6 BETAGAN see levobunolol hcl betamethasone dipropionate (topical). 69 betamethasone dipropionate augmented betamethasone valerate BETAPACE see sorine... 1 see sotalol hcl... 1 BETAPACE AF see sotalol hcl (afib/afl)... 1 BETASERON... 9 betaxolol hcl (ophth)

84 018 GENERIC STANDARD FORMULARY bethanechol chloride...55 BETOPTIC-S...6 BEVESPI AEROSPHERE...65 bexarotene...18 BEXSERO...59 BIAXIN see clarithromycin...11 BIAXIN XL see clarithromycin er...11 bicalutamide...15 BICILLIN L-A...1 BIKTARVY... 8 BILTRICIDE... see praziquantel... 5 bisoprolol & hydrochlorothiazide... bisoprolol fumarate... BIVIGAM...58 bleomycin sulfate...1 BLEPH-10 see sulfacetamide sodium (ophth)...6 BLEPHAMIDE...6 blisovi fe 1.5/0... blisovi fe 1/0... BOOSTRIX...59 BORTEZOMIB...15 BOSULIF...16 BREO ELLIPTA...67 briellyn... BRILINTA...57 brimonidine sol 0.15%...6 brimonidine sol 0.%...6 BRIVIACT...6 bromfenac sodium (ophth)...6 bromocriptine mesylate... BROMSITE...6 budesonide (inhalation)...67 budesonide ec...5 bumetanide inj 0.5/ml... bumetanide tab... BUMEX see bumetanide tab... BUPHENYL see sodium phenylbutyrate...9 buprenorphine hcl...0 buprenorphine hcl-naloxone hcl sl...0 bupropion hcl...1 bupropion hcl (smoking deterrent)... 0 buspirone hcl... 6 busulfan... 1 BUSULFEX see busulfan... 1 butorphanol tartrate... BYDUREON BCISE... 1 BYDUREON INJ... 1 BYDUREON PEN... 1 BYETTA... 1 BYSTOLIC... C cabergoline CABOMETYX CAFERGOT see ergotamine w/ caffeine... 8 CALAN see verapamil hcl... CALAN SR see verapamil hcl... see verapamil tab er... calcipotriene calcitonin (salmon) calcitriol... 6 calcitriol inj... 6 calcitriol oral soln 1 mcg/ml... 6 calcium acetate (phosphate binder) CALQUENCE camila... CAMPTOSAR see irinotecan hcl CANASA... 5 CANCIDAS... 6 CAPASTAT SULFATE... 9 CAPRELSA captopril captopril & hydrochlorothiazide CARAFATE see sucralfate... 5 CARBAGLU... 8 carbamazepine... 7 CARBATROL see carbamazepine... 7 carbidopa/levodopa/entacapone... carbidopa-levodopa... carboplatin

85 018 GENERIC STANDARD FORMULARY CARDIZEM see diltiazem hcl... CARDIZEM CD see cartia xt... see diltiazem cap 10mg cd... see diltiazem cap 180mg cd... see diltiazem cap 0mg cd... see diltiazem cap 60mg cd... see diltiazem hcl coated beads cap sr hr... see diltiazem hcl extended release beads cap sr... CARDURA see doxazosin mesylate...0 CARIMUNE NANOFILTERED...58 CARNITOR see levocarnitine (metabolic modifiers)... 8, 9 carteolol hcl (ophth)...6 cartia xt... carvedilol... CASODEX see bicalutamide...15 caspofungin acetate... 6 CASPOFUNGIN ACETATE... 6 CATAPRES see clonidine hcl...5 CATAPRES-TTS-1 see clonidine hcl...5 CATAPRES-TTS- see clonidine hcl...5 CATAPRES-TTS- see clonidine hcl...5 CAYSTON... caziant pak... cefaclor...10 CEFACLOR ER TAB 500MG...10 cefadroxil...10 CEFAZOLIN IN DEXTROSE GM/100ML- %...10 cefazolin inj...10 cefazolin sodium...10 CEFAZOLIN SODIUM 1 GM/50ML...10 cefdinir...10 cefepime for inj...10 cefixime...10 cefotaxime sodium cefoxitin for inj cefpodoxime proxetil cefprozil ceftazidime CEFTAZIDIME/DEXTROSE ceftriaxone sodium...10, 11 cefuroxime axetil cefuroxime sodium CELEBREX see celecoxib... 1 celecoxib... 1 CELEXA see citalopram hydrobromide... 1 CELLCEPT see mycophenolate mofetil CELONTIN... 7 cephalexin CERDELGA... 8 CEREZYME... 8 cetirizine syrup cevimeline hcl CHANTIX... 0 CHANTIX CONTINUING MONTH... 0 CHANTIX STARTER PACK... 0 CHEMET... chlorhexidine gluconate (mouth-throat) chloroquine phosphate... 6 chlorothiazide tabs... chlorpromazine hcl... CHLORPROMAZINE INJ... chlorthalidone... cholestyramine... 1 cholestyramine light... 1 ciclopirox ciclopirox shampoo 1% cilostazol CILOXAN... 6 see ciprofloxacin hcl (ophth)... 6 CINRYZE CIPRO see ciprofloxacin see ciprofloxacin hcl tab CIPRO I.V.-IN D5W see ciprofloxacin in d5w

86 018 GENERIC STANDARD FORMULARY CIPRODEX...71 ciprofloxacin...11 ciprofloxacin hcl (ophth)...6 ciprofloxacin hcl tab...11 ciprofloxacin in d5w...11 ciprofloxacin inj...11 cisplatin...18 citalopram hydrobromide...1 cladribine...1 claravis...67 clarithromycin...11 clarithromycin er...11 clarithromycin for susp...11 CLEOCIN see clindamycin cap 00 mg... see clindamycin cap 75mg... see clindamycin hcl cap 150 mg... see clindamycin phosphate vaginal...56 CLEOCIN IN D5W see clindamycin phosphate in d5w... CLEOCIN PEDIATRIC GRANULE see clindamycin soln 75mg/5ml... 5 CLEOCIN PHOSPHATE see clindamycin phosphate inj... 5 CLEOCIN-T see clindacin-p...68 see clindamycin phosphate (topical).68 CLIMARA see estradiol...9 clindacin-p...68 clindamycin cap 00 mg... clindamycin cap 75mg... clindamycin hcl cap 150 mg... clindamycin phosphate (topical)...68 clindamycin phosphate in d5w... CLINDAMYCIN PHOSPHATE IN NACL... clindamycin phosphate inj... 5 clindamycin phosphate vaginal...56 clindamycin soln 75mg/5ml... 5 CLINIMIX.75%/DEXTROSE 5%...61 CLINIMIX.5%/DEXTROSE 5%...61 CLINIMIX.5%/DEXTROSE 5%...61 CLINIMIX 5%/DEXTROSE 15%...61 CLINIMIX 5%/DEXTROSE 0%...61 CLINIMIX 5%/DEXTROSE 5%...61 CLINIMIX INJ.5/D CLINIMIX INJ.5/D clomipramine hcl... 1 clonazepam... 7 clonidine hcl... 5 clopidogrel tab 75mg clorazepate dipotassium... 7 clotrimazole clotrimazole (topical) clozapine odt... clozapine tab 100mg... clozapine tab 00mg... clozapine tab 5mg... clozapine tab 50mg... CLOZARIL see clozapine tab 100mg... see clozapine tab 5mg... COARTEM... 6 COGENTIN see benztropine mesylate... COLAZAL see balsalazide disodium... 5 colchicine w/ probenecid... 1 COLCRYS... 1 colesevelam hcl... 1 COLESTID see colestipol hcl gran... 1 see colestipol hcl pack... 1 see colestipol hcl tabs... 1 colestipol hcl gran... 1 colestipol hcl pack... 1 colestipol hcl tabs... 1 colistimethate sodium... 5 colocort... 5 COLY-MYCIN M see colistimethate sodium... 5 COLYTE-FLAVOR PACKS see gavilyte-c... 5 see peg 50/electrolytes... 5 COMBIGAN... 6 COMBIVENT RESPIMAT COMBIVIR see lamivudine-zidovudine... 8 COMETRIQ COMPLERA... 8 compro supp... 5 COMTAN 78

87 018 GENERIC STANDARD FORMULARY see entacapone... constulose...5 COPAXONE see glatiramer acetate 0mg/ml...9 see glatiramer acetate 0mg/ml...0 see glatopa...0 COREG see carvedilol... CORGARD see nadolol... CORLANOR...5 CORTEF see hydrocortisone...9 CORTENEMA see colocort...5 see hydrocortisone (enema)...5 cortisone acetate...9 COSOPT see dorzolamide hcl-timolol maleate.65 COTELLIC...17 COUMADIN...56 see jantoven...56 see warfarin sodium...56 COZAAR see losartan potassium...0 CREON...5 CRESTOR see rosuvastatin calcium...1 CRIXIVAN... 7 cromolyn sod neb 0mg/ml...66 cromolyn sodium (mastocytosis)...5 cromolyn sodium (ophth)...6 cryselle CUBICIN see daptomycin... 5 cyclafem 1/5...5 cyclafem 7/7/7...5 cyclobenzaprine hcl...0 cyclophosphamide...1 CYCLOPHOSPHAMIDE...1 see cyclophosphamide...1 cycloserine... 9 cyclosporine...58 cyclosporine modified (for microemulsion)...58 CYKLOKAPRON see tranexamic acid CYMBALTA see duloxetine hcl... 1 cyproheptadine hcl cyred tab... 5 CYSTADANE... 8 CYSTAGON... 8 CYSTARAN cytarabine... 1 CYTOMEL see liothyronine sodium CYTOTEC see misoprostol... 5 CYTOVENE see ganciclovir inj 500mg... 9 D D.H.E. 5 see dihydroergotamine mesylate 1mg/ml... 8 dacarbazine... 1 DAKLINZA... 9 DALIRESP danazol... 8 DANTRIUM see dantrolene sodium... 0 dantrolene sodium... 0 dapsone... 5 DAPTACEL daptomycin... 5 dasetta 1/ dasetta 7/7/ DDAVP see desmopressin acetate spray see desmopressin acetate tabs... 5 see desmopressin inj mcg/ml... 5 deblitane... 5 DELESTROGEN... 9 see estradiol valerate inj... 9 delyla... 5 DELZICOL... 5 DEMADEX see torsemide tabs... 5 DEMSER... 5 DEPACON see valproate sodium soln 100mg/ml9 DEPAKENE 79

88 018 GENERIC STANDARD FORMULARY see valproate sodium oral soln...9 see valproic acid...9 DEPAKOTE see divalproex sodium...8 DEPAKOTE ER see divalproex sodium...8 DEPAKOTE SPRINKLES see divalproex sodium...8 DEPEN TITRATABS... DEPO-MEDROL see methylpr ace inj 0mg/ml...9 see methylpr ace inj 80mg/ml...9 DEPO-PROVERA CONTRACEPTIV see medroxyprogesterone acetate (contraceptive)...6 DEPO-PROVERA INJ 00/ML...15 DEPO-TESTOSTERONE see testosterone cypionate...1 DERMA-SMOOTHE/FS BODY see fluocinolone acetonide...69 DERMA-SMOOTHE/FS SCALP see fluocinolone acetonide oil body...69 DERMOTIC see fluocinolone acetonide (otic)...71 DESCOVY... 8 desipramine hcl...1 desmopressin acetate spray...51 desmopressin acetate spray refrigerated...5 desmopressin acetate tabs...5 desmopressin inj mcg/ml...5 desmopressin sol 0.01%...5 DESOGEN see apri... see cyred tab...5 see desogestrel & ethinyl estradiol...5 see emoquette...5 see enskyce...5 see isibloom...5 see juleber...5 see reclipsen...7 desogestrel & ethinyl estradiol...5 desogestrel-ethinyl estradiol (biphasic)5 desoximetasone...69 desvenlafaxine succinate...1 DETROL see tolterodine tartrate DETROL LA see tolterodine tartrate dexamethasone... 9 DEXAMETHASONE... 9 dexamethasone sodium phosphate... 9 dexamethasone sodium phosphate (ophth)... 6 DEXILANT... 5 dexrazoxane dextrose 10% flex contain... 6 DEXTROSE 10%/NACL 0.%... 6 dextrose 10%/nacl 0.5%... 6 dextrose.5%/nacl 0.5% dextrose 5% DEXTROSE 5% /ELECTROLYTE dextrose 5%/lactated ring dextrose 5%/nacl 0.% dextrose 5%/nacl 0.5%... 6 DEXTROSE 5%/NACL 0.%... 6 dextrose 5%/nacl 0.%... 6 dextrose 5%/nacl 0.5%... 6 dextrose 5%/nacl 0.9%... 6 dextrose 5%/potassium chl... 6 dextrose 50%... 6 dextrose inj 70%... 6 DIASTAT ACUDIAL... 7 DIASTAT PEDIATRIC... 7 diazepam... 7 diazepam gel... 7 diazepam intensol... 7 diclofenac potassium... 1 diclofenac sodium... 1 diclofenac sodium (ophth)... 6 diclofenac sodium (topical) 1% gel dicloxacillin sodium... 1 dicyclomine hcl... 5 didanosine... 7 DIFICID DIFLUCAN see fluconazole... 6 diflunisal... 1 digitek... digox... digoxin... digoxin inj... 80

89 018 GENERIC STANDARD FORMULARY digoxin sol 50mcg/ml... dihydroergotamine mesylate 1mg/ml..8 dihydroergotamine mesylate nasal...8 DILANTIN...7 see phenytoin sodium extended...9 DILANTIN INFATABS see phenytoin...9 DILANTIN-15 see phenytoin...9 DILANTIN-15 SUS 15/5ML...7 DILAUDID see hydromorphone hcl... diltiazem cap 10mg cd... diltiazem cap 180mg cd... diltiazem cap 0mg cd... diltiazem cap 00mg cd... diltiazem cap 60mg cd... diltiazem cap er/1hr... diltiazem hcl... diltiazem hcl cap sr hr... diltiazem hcl coated beads cap sr hr diltiazem hcl extended release beads cap sr... diltiazem inj... dilt-xr cap... DIOVAN see valsartan...0 DIOVAN HCT see valsartan-hydrochlorothiazide...0 diphenhydramine hcl inj...66 diphenoxylate w/ atropine...5 DIPHTHERIA/TETANUS TOXOID...59 DIPROLENE see betamethasone dipropionate augmented...69 DIPROLENE AF see betamethasone dipropionate augmented...69 disopyramide phosphate...0 disulfiram...0 DITROPAN XL see oxybutynin chloride...55 divalproex sodium...8 docetaxel...1 DOCETAXEL...1 see docetaxel...1 dofetilide... 0 DOLOPHINE see methadone hcl 10mg... see methadone hcl 5mg... donepezil hydrochloride... 0 dorzolamide hcl... 6 dorzolamide hcl-timolol maleate DOVONEX see calcipotriene doxazosin mesylate... 0 doxepin hcl... 1 doxepin hcl (antipruritic) DOXIL see doxorubicin hcl liposomal inj mg/ml... 1 doxorubicin hcl... 1 doxorubicin hcl liposomal inj mg/ml.. 1 doxorubicin hcl soln mg/ml... 1 doxy doxycycline (monohydrate)... 1 doxycycline hyclate... 1 doxycycline hyclate 100 mg... 1 doxycycline hyclate 0 mg... 1 dronabinol... 5 drospirenone-ethinyl estradiol... 5 DROXIA duloxetine hcl... 1 DURAGESIC see fentanyl patch 100 mcg/hr... see fentanyl patch 1 mcg/hr... see fentanyl patch 5 mcg/hr... see fentanyl patch 50 mcg/hr... see fentanyl patch 75 mcg/hr... DUREZOL... 6 dutasteride dutasteride-tamsulosin hcl DYAZIDE see triamterene & hydrochlorothiazide cap mg... 5 E e.e.s EC-NAPROSYN see naproxen dr... 1 EDURANT... 7 efavirenz... 7 EFFEXOR XR 81

90 018 GENERIC STANDARD FORMULARY see venlafaxine hcl... EFFIENT see prasugrel hcl...57 EFUDEX see fluorouracil (topical)...70 ELDEPRYL see selegiline hcl... eletriptan hydrobromide...8 ELIMITE see permethrin cre 5%...71 ELIQUIS...56 ELIQUIS STARTER PACK...56 ELITEK...18 ELLA...5 ELLENCE see epirubicin hcl...1 ELOCON see mometasone furoate...70 EMCYT...1 EMEND...5 see aprepitant...5 emoquette...5 EMSAM...1 EMTRIVA... 7 EMVERM... 5 enalapril maleate...19 enalapril maleate & hydrochlorothiazide...19 ENDARI...57 endocet... ENGERIX-B...59 enoxaparin sodium...56 enpresse enskyce...5 entacapone... entecavir... 9 ENTOCORT EC see budesonide ec...5 ENTRESTO...0 enulose...5 EPCLUSA... 9 epinephrine (anaphylaxis)...66 epirubicin hcl...1 epitol...8 EPIVIR see lamivudine... 7 EPIVIR HBV... 9 see lamivudine (hbv)... 9 eplerenone... 0 EPZICOM see abacavir sulfate-lamivudine... 8 ergotamine w/ caffeine... 8 ERIVEDGE ERLEADA errin... 5 ery pad % ERYGEL see erythromycin (acne aid) ery-tab ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin (acne aid) erythromycin (ophth)... 6 erythromycin base erythromycin cap 50mg ec erythromycin ethylsuccinate ESBRIET escitalopram oxalate... 1 esomeprazole magnesium... 5 esomeprazole sodium inj estarylla tab ESTRACE see estradiol... 9 see estradiol vaginal cream... 9 estradiol... 9 estradiol vaginal cream... 9 estradiol vaginal tab... 9 estradiol valerate inj... 9 ESTROSTEP FE see tilia fe... 7 see tri-legest fe... 7 ethambutol hcl... 9 ethosuximide... 8 ethynodiol diacet & eth estrad... 5 ethynodiol tab etodolac... 1 etoposide EVISTA see raloxifene tab 60mg EVOTAZ... 8 EVOXAC see cevimeline hcl

91 018 GENERIC STANDARD FORMULARY EXELON see rivastigmine td patch hr 1. mg/hr...0 see rivastigmine td patch hr.6 mg/hr...0 see rivastigmine td patch hr 9.5 mg/hr...0 exemestane...15 EXFORGE see amlodipine besylate-valsartan tab...0 EXFORGE HCT see amlodipine-valsartanhydrochlorothiazide tab...0 ezetimibe...1 F FABRAZYME...8 falmina...5 famciclovir... 9 famotidine...5 famotidine inj...5 FANAPT... FANAPT TITRATION PACK...5 FARESTON...15 FARXIGA... FARYDAK...15 FASLODEX...15 FAZACLO see clozapine odt... felbamate...8 FELBATOL see felbamate...8 FELDENE see piroxicam... 1 felodipine... FEMARA see letrozole...16 femynor...5 fenofibrate...1 fenofibrate micronized...1 fentanyl citrate... fentanyl patch 100 mcg/hr... fentanyl patch 1 mcg/hr... fentanyl patch 5 mcg/hr... fentanyl patch 50 mcg/hr... fentanyl patch 75 mcg/hr... FENTORA... FETZIMA... 1 FETZIMA TITRATION PACK... 1 FIASP... 1 FIASP FLEXTOUCH... 1 finasteride FIRAZYR FLAGYL see metronidazole... 5 FLEBOGAMMA DIF flecainide acetate... 0 FLOMAX see tamsulosin hcl FLONASE see fluticasone propionate (nasal) FLOVENT DISKUS FLOVENT HFA FLOXIN OTIC see ofloxacin (otic) fluconazole... 6 fluconazole in dextrose... 6 FLUCONAZOLE INJ NACL fluconazole inj nacl fluconazole inj nacl flucytosine... 6 fludarabine phosphate... 1 fludrocortisone acetate... 9 FLUMADINE see rimantadine hydrochloride flunisolide (nasal) fluocinolone acetonide fluocinolone acetonide (otic) fluocinolone acetonide oil body fluocinonide fluocinonide emulsified base fluorometholone... 6 fluorouracil... 1 fluorouracil (topical) fluoxetine cap 10mg... 1 fluoxetine cap 0mg... 1 fluoxetine cap 0mg... 1 fluoxetine hcl... 1 fluphenazine decanoate... 5 fluphenazine hcl... 5 flurbiprofen... 1 flurbiprofen sodium

92 018 GENERIC STANDARD FORMULARY flutamide...15 fluticasone propionate...69 fluticasone propionate (nasal)...67 fluvoxamine maleate...6 fondaparinux sodium...56 FORTEO...50 FOSAMAX see alendronate sodium... fosamprenavir tab 700 mg... 7 fosinopril sodium...19 fosinopril sodium & hydrochlorothiazide...19 FREAMINE HBC 6.9%...61 FREAMINE III...61 furosemide... furosemide inj... FUSILEV see levoleucovorin calcium 50mg...18 FUZEON... 7 fyavolv tab 1-5mg...9 FYCOMPA...8 G gabapentin...8 GABITRIL...8 see tiagabine hcl...9 galantamine hydrobromide...0 galantamine hydrobromide er...0 GAMASTAN S/D...58 GAMMAGARD LIQUID...58 GAMMAGARD S/D...58 GAMMAKED...58 GAMMAPLEX...58 GAMMAPLEX 10GM/100ML...58 GAMUNEX-C...58 ganciclovir inj 500mg... 9 GANCICLOVIR INJ 500MG/10ML... 9 GARDASIL GASTROCROM see cromolyn sodium (mastocytosis) 5 gatifloxacin (ophth)...6 GATTEX...5 GAUZE PADS...1 gavilyte-c...5 gavilyte-g...5 gavilyte-n/flavor pack...5 gemcitabine inj soln...1 gemcitabine inj solr... 1 gemfibrozil... GEMZAR see gemcitabine inj solr... 1 generlac... 5 gengraf gentak... 6 gentamicin in saline... gentamicin sulfate... gentamicin sulfate (topical) gentamicin sulfate soln (ophth)... 6 GENVOYA... 8 GEODON... 5 see ziprasidone hcl... 7 gianvi tab -0.0mg... 5 gildagia... 5 GILENYA... 9 GILOTRIF TAB 0MG GILOTRIF TAB 0MG GILOTRIF TAB 0MG glatiramer acetate 0mg/ml... 9 glatiramer acetate 0mg/ml... 0 glatopa... 0 GLEEVEC see imatinib mesylate GLEOSTINE... 1 glimepiride... glip/metform tab.5-50mg... glip/metform tab.5-500mg... glip/metform tab 5-500mg... glipizide... glipizide xl... GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUCOPHAGE see metformin hcl... GLUCOPHAGE XR see metformin er... GLUCOTROL see glipizide... GLUCOTROL XL see glipizide... see glipizide xl... glycopyrrolate... 5 glycopyrrolate inj... 5 glydo

93 018 GENERIC STANDARD FORMULARY GOLYTELY...5 see gavilyte-g...5 see peg 50-kcl-sod bicarb-sod chloride-sod sulfate...5 granisetron hcl...5 GRANIX...56 griseofulvin microsize... 6 griseofulvin ultramicrosize... 6 guanfacine er (adhd)...8 H HAEGARDA...57 HALDOL see haloperidol inj 5mg/ml...5 see haloperidol lactate inj 5 mg/ml...5 HALDOL DECANOATE 100 see haloperidol decanoate...5 HALDOL DECANOATE 50 see haloperidol decanoate...5 halobetasol propionate...69 haloperidol...5 haloperidol conc mg/ml...5 haloperidol decanoate...5 haloperidol inj 5mg/ml...5 haloperidol lactate inj 5 mg/ml...5 HARVONI... 9 HAVRIX...59 heather...5 heparin sod (porcine) in d5w...56 heparin sod inj 1000/ml...56 heparin sod inj 10000/ml...56 heparin sod inj 0000/ml...56 heparin sod inj 5000/ml...56 heparin sodium/d5w...56 HEPARIN SODIUM/NACL 0.5%...56 hepatamine...61 HEPSERA see adefovir dipivoxil... 9 HERCEPTIN...15 HETLIOZ...8 HEXALEN...1 HIBERIX...59 HIPREX see methenamine hippurate... 5 HUMIRA...57 HUMIRA INJ 10MG/0.ML...57 HUMIRA KIT 0MG/0.ML...57 HUMIRA KIT 0MG/0.8ML HUMIRA PEDIATRIC CROHNS DISEASE57 HUMIRA PEN HUMIRA PEN-CROHNS DISEASE HUMIRA PEN-PSORIASIS HUMULIN R INJ U HUMULIN R U-500 KWIKPEN... 1 HYCAMTIN see topotecan inj mg hydralazine hcl... 5 HYDREA see hydroxyurea hydrochlorothiazide... hydroco/apap tab 10-5mg... hydroco/apap tab 5-5mg... hydroco/apap tab hydrocodone-acetaminophen mg/15ml... hydrocodone-ibuprofen tab mg hydrocortisone... 9 hydrocortisone (enema)... 5 hydrocortisone (topical) hydrocortisone butyrate cream 0.1%.. 69 hydrocortisone butyrate oint 0.1% hydrocortisone butyrate soln 0.1% hydrocortisone valerate hydromorphone hcl... hydroxychloroquine sulfate hydroxyprogesterone caproate (antineoplastic) hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYSINGLA ER..., HYZAAR see losartan-hydrochlorothiazide... 0 I IBRANCE ibu tabs 600mg... 1 ibu tabs 800mg... 1 ibuprofen... 1 ICLUSIG IDHIFA IFEX see ifosfamide inj 1gm... 1 IFEX INJ GM

94 018 GENERIC STANDARD FORMULARY ifosfamide inj 1gm...1 ifosfamide inj 1gm/0ml...1 IFOSFAMIDE INJ GM...1 ifosfamide inj gm/60ml...1 ILEVRO...6 imatinib mesylate...17 IMBRUVICA...17 imipenem-cilastatin... 5 imipramine hcl... imiquimod...70 IMITREX see sumatriptan...9 see sumatriptan inj 6mg/0.5ml...9 see sumatriptan succinate...9 IMITREX STATDOSE REFILL see sumatriptan inj 6mg/0.5ml...9 IMITREX STATDOSE SYSTEM see sumatriptan inj 6mg/0.5ml...9 IMOVAX RABIES (H.D.C.V.)...59 IMURAN see azathioprine...58 INCRELEX...50 INCRUSE ELLIPTA...65 indapamide... INDERAL LA see propranolol cap er... INFANRIX...59 INLYTA...17 INSPRA see eplerenone...0 INSULIN PEN NEEDLE...1 INSULIN SAFETY NEEDLES...1 INSULIN SYRINGE...1 INTELENCE... 7 INTRALIPID 0%...61 intralipid inj 0%...61 INTRON-A INJ 10MU...58 INTRON-A INJ 18MU...58 INTRON-A INJ 5MU...58 INTRON-A INJ 50MU...58 introvale...5 INTUNIV see guanfacine er (adhd)...8 INVANZ... 5 INVEGA see paliperidone...6 INVEGA SUST INJ 117 MG/0.75 ML... 5 INVEGA SUST INJ 156MG/ML... 5 INVEGA SUST INJ MG/1.5 ML... 5 INVEGA SUST INJ 9 MG/0.5 ML... 5 INVEGA SUST INJ 78 MG/0.5 ML... 5 INVEGA TRINZA... 5 INVIRASE... 7 INVOKAMET TAB MG... INVOKAMET TAB MG... INVOKAMET TAB MG... INVOKAMET TAB MG... INVOKAMET XR TAB MG... INVOKAMET XR TAB MG... INVOKAMET XR TAB MG... INVOKAMET XR TAB MG... INVOKANA... IONOSOL-MB/DEXTROSE 5%... 6 IPOL INACTIVATED IPV ipratropium bromide ipratropium bromide (nasal) ipratropium-albuterol nebu irbesartan... 0 irbesartan-hydrochlorothiazide... 0 IRESSA irinotecan hcl ISENTRESS... 7 ISENTRESS HD... 7 isibloom... 5 ISOLYTE P... 6 ISOLYTE S... 6 isoniazid... 9 isoniazid inj 100 mg/ml... 9 isoniazid syp 50mg/5ml... 9 ISOPTO CARPINE see pilocarpine hcl ISORDIL TITRADOSE see isosorbide dinitrate... 5 isosorb mononitrate tab... 5 isosorbide dinitrate... 5 isosorbide dinitrate er... 5 isosorbide mononitrate er... 5 isotretinoin isradipine... ISTALOL see timolol maleate ophth soln 0.5% (once-daily)

95 018 GENERIC STANDARD FORMULARY itraconazole... 6 ivermectin... 5 IXIARO...59 J JADENU... JADENU SPRINKLE... JAKAFI...17 JALYN see dutasteride-tamsulosin hcl...55 jantoven...56 JANUMET... JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG... JANUVIA... JENTADUETO... JENTADUETO TAB XR MG... JENTADUETO TAB XR MG... jinteli...9 jolessa tab mg...5 jolivette...5 juleber...5 JULUCA... 8 junel 1.5/0...5 junel 1/0...5 junel fe 1.5/0...5 junel fe 1/0...6 JUXTAPID... K KADCYLA...15 KALETRA see lopinavir-ritonavir... 8 KALETRA TAB 100-5MG... 8 KALETRA TAB 00-50MG... 8 KALYDECO...66 kariva...6 kcl 0.075%/d5w/nacl 0.5%...6 KCL 0.15%/D5W/NACL 0.5%...6 kcl 0.15%/d5w/nacl 0.9%...6 kcl 0.%/d5w/nacl 0.5%...6 KCL 0.%/D5W/NACL 0.9%...6 kcl/d5w inj 0.%...6 kcl/d5w/nacl inj.15/.%...6 kcl/d5w/nacl inj.15/.5%...6 kcl/d5w/nacl inj 0.%/0.5%...6 kcl/nacl inj 0.15%-0.9%...6 kcl/nacl inj kcl0.15%/d5w/nacl0.%... 6 KEFLEX see cephalexin kelnor 1/ kelnor 1/ KEPPRA see levetiracetam... 8 see levetiracetam inj... 8 see levetiracetam oral soln 100 mg/ml... 8 see roweepra... 9 KEPPRA XR see levetiracetam... 8 see roweepra xr... 9 ketoconazole... 6 ketoconazole cream ketoconazole shampoo ketoprofen cap 50mg... 1 ketoprofen cap 75mg... 1 ketorolac tromethamine (ophth)... 6 KEYTRUDA kimidess... 6 KINRIX kionex sus 15gm/60ml... KISQALI KISQALI FEMARA 00 DOSE KISQALI FEMARA 00 DOSE KISQALI FEMARA 600 DOSE KITABIS PAK see tobramycin... KLARON see sulfacetamide sodium (acne) KLONOPIN see clonazepam... 7 klor-con klor-con klor-con m KLOR-CON M klor-con m klor-con pak 0meq klor-con spr cap 10meq klor-con spr cap 8meq KORLYM kurvelo... 6 KUVAN

96 018 GENERIC STANDARD FORMULARY KYNAMRO... L labetalol hcl... LAC-HYDRIN see ammonium lactate...70 lactated ringer's inj...6 lactulose...5 lactulose (encephalopathy)...5 LAMICTAL see lamotrigine...8 LAMICTAL CHEWABLE DISPERS see lamotrigine...8 LAMICTAL XR see lamotrigine...8 LAMISIL see terbinafine hcl... 6 lamivudine... 7 lamivudine (hbv)... 9 lamivudine-zidovudine... 8 lamotrigine...8 LANOXIN see digitek... see digox... see digoxin... see digoxin inj... larin 1.5/0...6 larin 1/0...6 larin fe 1.5/0...6 larin fe 1/0...6 larissia tab...6 LASIX see furosemide... LASTACAFT...6 latanoprost...65 LATUDA...5 leena tab...6 leflunomide...58 LENVIMA 10 MG DAILY DOSE...17 LENVIMA 1 MG DAILY DOSE...17 LENVIMA 18 MG DAILY DOSE...17 LENVIMA 0 MG DAILY DOSE...17 LENVIMA MG DAILY DOSE...17 LENVIMA 8 MG DAILY DOSE...17 lessina...6 LETAIRIS...6 letrozole...16 leucovorin calcium LEUKERAN... 1 leuprolide inj 1mg/ levalbuterol hcl levalbuterol hcl soln nebu conc 1.5 mg/0.5ml levalbuterol tartrate hfa LEVAQUIN see levofloxacin LEVEMIR... 1 LEVEMIR FLEXTOUCH... 1 levetiracetam... 8 LEVETIRACETAM see levetiracetam in sodium chloride 8 levetiracetam in sodium chloride... 8 levetiracetam inj... 8 levetiracetam oral soln 100 mg/ml... 8 levobunolol hcl levocarnitine (metabolic modifiers) 8, 9 levocetirizine dihydrochloride levofloxacin levofloxacin in d5w... 1 levofloxacin inj 5mg/ml... 1 levofloxacin oral soln 5 mg/ml... 1 levoleucovorin calcium LEVOLEUCOVORIN CALCIUM LEVOLEUCOVORIN CALCIUM 175MG levoleucovorin calcium 50mg levonest... 6 levonor/ethi tab... 6 levonorgestrel & eth estradiol... 6 levonorgestrel-ethinyl estradiol (91-day)... 6 levora 0.15/ levo-t levothyroxine sodium levoxyl LEXAPRO see escitalopram oxalate... 1 LEXIVA... 7 see fosamprenavir tab 700 mg... 7 lidocaine lidocaine hcl lidocaine hcl (mouth-throat) lidocaine inj 0.5%... lidocaine inj 0.5% preservative free (pf) 88

97 018 GENERIC STANDARD FORMULARY lidocaine inj 1%... lidocaine inj 1% preservative free (pf).. lidocaine inj 1.5% preservative free (pf) lidocaine inj %... lidocaine oint 5%...70 lidocaine-prilocaine...70 LIDODERM see lidocaine...70 linezolid... 5 linezolid in sodium chloride... 5 LINZESS...5 liothyronine sodium...51 LIPITOR see atorvastatin calcium...1 lisinopril...19 lisinopril & hydrochlorothiazide...19 lithium carbonate...9 lithium carbonate er...9 LITHIUM SOLN 8MEQ/5ML...9 LITHOBID see lithium carbonate er...9 LOCOID see hydrocortisone butyrate cream 0.1%...69 see hydrocortisone butyrate oint 0.1%...69 see hydrocortisone butyrate soln 0.1%...69 LODINE see etodolac... 1 LOESTRIN 1.5/0-1 see junel 1.5/0...5 see larin 1.5/0...6 see microgestin 1.5/0...6 LOESTRIN 1/0-1 see junel 1/0...5 see larin 1/0...6 see microgestin 1/0...6 see norethindrone acet & eth estra...7 LOESTRIN FE 1.5/0 see blisovi fe 1.5/0... see junel fe 1.5/0...5 see larin fe 1.5/0...6 see microgestin fe 1.5/0...6 LOESTRIN FE 1/0 see blisovi fe 1/0... see junel fe 1/ see larin fe 1/ see microgestin fe 1/ see tarina fe 1/ LOMOTIL see diphenoxylate w/ atropine... 5 LONSURF loperamide hcl... 5 LOPID see gemfibrozil... lopinavir-ritonavir... 8 LOPRESSOR see metoprolol tartrate... LOPRESSOR HCT see metoprolol & hydrochlorothiazide... LOPROX see ciclopirox LOPROX SHAMPOO see ciclopirox shampoo 1% lorazepam... 6 lorazepam intensol... 6 lorcet hd tab 10-5mg... lorcet plus tab loryna... 6 losartan potassium... 0 losartan-hydrochlorothiazide... 0 LOTEMAX... 6 LOTENSIN see benazepril hcl LOTENSIN HCT see benazepril & hydrochlorothiazide 19 LOTREL see amlodipine besylate-benazepril hcl cap 10-0 mg see amlodipine besylate-benazepril hcl cap 10-0 mg see amlodipine besylate-benazepril hcl cap 5-10 mg see amlodipine besylate-benazepril hcl cap 5-0 mg LOTRONEX see alosetron hcl... 5 lovastatin... 1 LOVAZA see omega--acid ethyl esters... 89

98 018 GENERIC STANDARD FORMULARY LOVENOX see enoxaparin sodium...56 low-ogestrel...6 loxapine succinate...5 LUMIGAN...65 LUMIZYME...9 LUPRON DEPOT (1-MONTH)...16 LUPRON DEPOT INJ 11.5MG (-MONTH)...16 LUPRON DEP-PED INJ 11.5MG...50 LUPRON DEP-PED INJ 11.5MG (- MONTH)...50 LUPRON DEP-PED INJ 15MG...50 LUPRON DEP-PED INJ 0MG (-MONTH)...50 LUPRON DEP-PED INJ 7.5MG...50 lutera...6 LYNPARZA...15 LYRICA...9 LYSODREN...16 LYSTEDA see tranexamic acid...57 lyza...6 M MACROBID see nitrofurantoin monohyd macro... 5 MACRODANTIN see nitrofurantoin macrocrystal... 5 mafenide acetate...68 magnesium sulfate...60 MAGNESIUM SULFATE...60 see magnesium sulfate...60 MAGNESIUM SULFATE IN D5W...60 see magnesium sulfate in dextrose...60 magnesium sulfate in dextrose...60 MALARONE see atovaquone-proguanil hcl... 6 malathion...71 maprotiline hcl... MARINOL see dronabinol...5 marlissa...6 MARPLAN TAB 10MG... MATULANE...18 MAVIK see trandolapril...19 MAVYRET... 9 MAXALT see rizatriptan benzoate... 8 MAXALT-MLT see rizatriptan benzoate odt... 8 MAXIPIME see cefepime for inj MAXITROL see neomycin-polymy-dexameth... 6 MAXZIDE see triamterene & hydrochlorothiazide tabs... 5 MAXZIDE-5 see triamterene & hydrochlorothiazide tabs... 5 meclizine hcl... 5 MEDROL see methylpred tab 16mg see methylpred tab mg see methylpred tab mg see methylpred tab 8mg MEDROL DOSEPAK see methylpred pak mg medroxyprogesterone acetate (contraceptive)... 6 medroxyprogesterone acetate tab mefloquine hcl... 6 MEGACE ES see megestrol sus 65mg/5ml megestrol ac sus 0mg/ml megestrol ac tab 0mg megestrol ac tab 0mg megestrol sus 65mg/5ml MEKINIST meloxicam... 1 melphalan hcl... 1 memantine hcl... 0 memantine hcl cp... 0 MENACTRA MENVEO MEPRON see atovaquone... mercaptopurine... 1 meropenem... 5 MERREM see meropenem

99 018 GENERIC STANDARD FORMULARY mesalamine...5 mesalamine w/ cleanser...5 mesna...18 MESNEX...18 see mesna...18 MESTINON see pyridostigmine tab 60mg...9 metadate er tab 0mg...8 metformin er... metformin hcl... methadone hcl... methadone hcl 10mg... methadone hcl 5mg... methadone hcl intensol... METHADOSE see methadone hcl intensol... methazolamide...5 methenamine hippurate... 5 methimazole...51 methotrexate sodium inj...1 methotrexate sodium tabs...58 methyclothiazide...5 METHYLIN see methylphenidate hcl oral soln...8 methylphenidate hcl...8 methylphenidate hcl oral soln...8 methylphenidate tab 10mg er...8 methylphenidate tab 0mg er...8 methylpr ace inj 0mg/ml...9 methylpr ace inj 80mg/ml...9 methylpr ss inj 15mg...50 methylpr ss inj 1gm...9 methylpr ss inj 0mg...9 methylpred pak mg...50 methylpred tab 16mg...50 methylpred tab mg...50 methylpred tab mg...50 methylpred tab 8mg...50 metipranolol...65 metoclopramide hcl...5 metoclopramide inj...5 metolazone...5 metoprolol & hydrochlorothiazide... metoprolol succinate... metoprolol tartrate... METROCREAM see metronidazole (topical) see rosadan cre 0.75% METROGEL-VAGINAL see metronidazole vaginal METROLOTION see metronidazole (topical) metronidazole... 5 metronidazole (topical) metronidazole gel 0.75% metronidazole in nacl... 5 metronidazole vaginal MEVACOR see lovastatin... 1 mexiletine hcl... 0 MIACALCIN see calcitonin (salmon) microgestin 1.5/ microgestin 1/ microgestin fe 1.5/ microgestin fe 1/ MICRO-K see klor-con spr cap 10meq see klor-con spr cap 8meq see potassium chloride MICROZIDE see hydrochlorothiazide... midodrine hcl... 5 migergot... 8 miglustat... 9 MINIPRESS see prazosin hcl... 0 minitran... 5 MINOCIN see minocycline hcl... 1 minocycline hcl... 1 minoxidil... 5 MIRAPEX see pramipexole tab 0.15mg... see pramipexole tab 0.5mg... see pramipexole tab 0.5mg... see pramipexole tab 0.75mg... see pramipexole tab 1.5mg... see pramipexole tab 1mg... MIRCETTE see bekyree... see desogestrel-ethinyl estradiol 91

100 018 GENERIC STANDARD FORMULARY (biphasic)...5 see kariva...6 see kimidess...6 see pimtrea...7 see viorele...8 mirtazapine... misoprostol...5 MITIGARE... 1 mitomycin...1 mitoxantrone hcl...18 M-M-R II...59 MOBIC see meloxicam... 1 moderiba tab 00mg... 9 moexipril hcl...19 moexipril-hydrochlorothiazide...19 mometasone furoate...70 mono-linyah tab mononessa...6 montelukast sodium...66 morgidox cap 1x50mg...1 morphine ext-rel tab... morphine sul inj 10mg/ml... morphine sul inj 1mg/ml... MORPHINE SUL INJ MG/ML... morphine sulfate... MORPHINE SULFATE... see morphine sul inj 10mg/ml... see morphine sulfate... morphine sulfate oral sol... MOVANTIK...5 MOVIPREP...5 MOXEZA...6 moxifloxacin hcl (ophth)...6 MOZOBIL...56 MS CONTIN see morphine ext-rel tab... MULTAQ...0 mupirocin...68 MUSTARGEN...1 MYAMBUTOL see ethambutol hcl... 9 MYCAMINE... 6 MYCOBUTIN see rifabutin... 9 mycophenolate mofetil...59 mycophenolate sodium MYFORTIC see mycophenolate sodium MYLOTARG myorisan MYRBETRIQ MYSOLINE see primidone... 9 myzilra... 6 N nabumetone... 1 nadolol... nafcillin sodium for inj... 1 NAGLAZYME... 9 nalbuphine hcl... naloxone inj 0.mg/ml... 0 naloxone inj 1mg/ml... 0 naltrexone hcl... 0 NAMENDA see memantine hcl... 0 NAMENDA XR... 0 see memantine hcl cp... 0 NAMENDA XR TITRATION PACK... 0 NAMZARIC... 0 NAPROSYN see naproxen... 1 naproxen... 1 naproxen dr... 1 naproxen sodium... 1 naratriptan hcl... 8 NARCAN... 0 NARDIL see phenelzine sulfate... NATACYN... 6 nateglinide... NATPARA NAVELBINE see vinorelbine tartrate NEBUPENT... 5 necon 0.5/ necon 1/ necon 7/7/ nefazodone hcl... neomycin sulfate... neomycin-bacitracin zn-polymyxin... 6 neomycin-polymy-dexameth

101 018 GENERIC STANDARD FORMULARY neomycin-polymyxin-gramicidin...6 neomycin-polymyxin-hc (ophth)...6 neomycin-polymyxin-hc (otic)...71 NEORAL see cyclosporine modified (for microemulsion)...58 see gengraf...58 NEOSPORIN see neomycin-polymyxin-gramicidin.6 NEPHRAMINE...61 NEPTAZANE see methazolamide...5 NERLYNX...17 NEUPOGEN...56 NEUPRO... NEURONTIN see gabapentin...8 nevirapine tab 00mg... 7 nevirapine tb... 7 NEXAVAR...17 NEXIUM see esomeprazole magnesium...5 NEXIUM I.V. see esomeprazole sodium inj...55 niacin er (antihyperlipidemic)... niacor... NIASPAN see niacin er (antihyperlipidemic)... nicardipine hcl... NICOTROL INHALER...0 NICOTROL NS...0 nifedical xl... nifedipine... nifedipine er... nikki...7 NILANDRON see nilutamide...16 nilutamide...16 nimodipine... NINLARO...15 NIPENT...1 NITRO-BID...5 NITRO-DUR see minitran...5 see nitroglycerin td patch...6 NITRO-DUR DIS 0.MG/HR...5 NITRO-DUR DIS 0.8MG/HR... 5 nitrofurantoin macrocrystal... 5 nitrofurantoin monohyd macro... 5 nitroglycerin... 5 nitroglycerin td patch... 6 NITROSTAT see nitroglycerin... 5 NIZORAL see ketoconazole shampoo nora-be tab 0.5mg... 7 NORCO see hydroco/apap tab 10-5mg... see hydroco/apap tab 5-5mg... see hydroco/apap tab see lorcet hd tab 10-5mg... see lorcet plus tab NORDITROPIN FLEXPRO norethindrone (contraceptive)... 7 norethindrone acet & eth estra... 7 norethindrone acetate norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg... 9 norgest/ethi tab 0.5/ norgestimate-ethinyl estradiol (triphasic) /0.15-5/0.5-5 mg-mcg... 7 norgestimate-ethinyl estradiol (triphasic) /0.15-5/0.5-5 mg-mcg... 7 norlyroc... 7 NORMOSOL-M IN D5W... 6 NORMOSOL-R... 6 NORMOSOL-R IN D5W... 6 NORPACE see disopyramide phosphate... 0 NORPACE CR... 1 NORPRAMIN see desipramine hcl... 1 NORTHERA... 5 nortrel 0.5/5 (8)... 7 nortrel 1/ nortrel 7/7/ nortriptyline hcl... NORVASC see amlodipine besylate... NORVIR... 7 see ritonavir... 7 NOVOLIN 70/0... 9

102 018 GENERIC STANDARD FORMULARY NOVOLIN N... NOVOLIN R... NOVOLOG... NOVOLOG 70/0 FLEXPEN... NOVOLOG FLEXPEN... NOVOLOG MIX 70/0... NOVOLOG PENFILL... NOXAFIL... 6 NUCYNTA ER... NUEDEXTA...9 NULOJIX...59 NULYTELY/FLAVOR PACKS...5 see gavilyte-n/flavor pack...5 see peg 50-potassium chloride-sod bicarbonate-sod chloride...5 see trilyte...5 NUPLAZID...5 nutrilipid inj 0%...61 NUVARING...7 NUVIGIL see armodafinil...0 nyamyc...68 NYMALIZE... nystatin... 6 nystatin (mouth-throat)...71 nystatin (topical)...68 nystop...68 O ocella tab -0.0mg...7 OCTAGAM...58 octreotide acetate...51 OCUFLOX see ofloxacin (ophth)...6 ODEFSEY... 8 ODOMZO...15 OFEV...67 ofloxacin (ophth)...6 ofloxacin (otic)...71 olanzapine...5 olmesartan medoxomil...0 olmesartan medoxomil-amlodipinehydrochlorothiazide...0 olmesartan medoxomilhydrochlorothiazide...0 olopatadine hcl 0.%...6 omega--acid ethyl esters... omeprazole cap 10mg omeprazole cap 0mg omeprazole cap 0mg OMNIPRED see prednisolone acetate (ophth)... 6 ondansetron hcl... 5 ondansetron hcl inj... 5 ondansetron hcl oral soln... 5 ondansetron odt... 5 ONFI... 9 OPSUMIT... 6 ORAP see pimozide... 6 ORFADIN... 9 ORKAMBI orsythia... 7 ORTHO MICRONOR see errin... 5 see jolivette... 5 see norethindrone (contraceptive)... 7 see sharobel... 7 ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic) /0.15-5/0.5-5 mg-mcg... 7 see tri-linyah... 7 see trinessa... 8 see tri-previfem... 8 see tri-sprintec... 8 see tri-vylibra... 8 ORTHO TRI-CYCLEN LO see norgestimate-ethinyl estradiol (triphasic) /0.15-5/0.5-5 mg-mcg... 7 see tri-lo marzia... 8 see tri-lo-estarylla... 8 see tri-lo-sprintec... 8 see trinessa lo... 8 ORTHO-CYCLEN see estarylla tab see femynor... 5 see mono-linyah tab see mononessa... 6 see norgest/ethi tab 0.5/ see previfem... 7 see sprintec

103 018 GENERIC STANDARD FORMULARY see vylibra...8 ORTHO-NOVUM 1/5 see alyacen 1/5... see cyclafem 1/5...5 see dasetta 1/5...5 see nortrel 1/5...7 see pirmella 1/5...7 ORTHO-NOVUM 7/7/7 see cyclafem 7/7/7...5 see dasetta 7/7/7...5 see necon 7/7/7...7 see nortrel 7/7/7...7 oseltamivir phosphate...9, 10 OVIDE see malathion...71 oxacillin sodium...1 oxaliplatin inj 100mg...18 oxaliplatin inj 100mg/0ml...18 oxaliplatin inj 50mg...18 oxaliplatin inj 50mg/10ml...18 OXANDRIN see oxandrolone tab 10mg...1 oxandrolone tab 10mg...1 oxandrolone tab.5mg...1 oxcarbazepine...9 oxybutynin chloride...55 oxycodone hcl... oxycodone w/ acetaminophen 10-5mg... oxycodone w/ acetaminophen.5-5mg... oxycodone w/ acetaminophen 5-5mg oxycodone w/ acetaminophen 7.5-5mg... OZEMPIC INJ 0.5 OR 0.5MG/DOSE... OZEMPIC INJ 1MG/DOSE... P pacerone...1 paclitaxel...1 paliperidone...6 PAMELOR see nortriptyline hcl... pamidronate disodium... PAMIDRONATE DISODIUM... pamidronate inj 0mg... pamidronate inj 90mg... PANRETIN pantoprazole sodium tbec paricalcitol... 6 PARLODEL see bromocriptine mesylate... PARNATE see tranylcypromine sulfate... paroex sol 0.1% paromomycin sulfate... paroxetine hcl tabs... PASER D/R... 9 PATADAY see olopatadine hcl 0.%... 6 PAXIL... see paroxetine hcl tabs... PAZEO... 6 PEDIARIX PEDVAX HIB peg 50/electrolytes... 5 peg 50-kcl-sod bicarb-sod chloride-sod sulfate... 5 peg 50-potassium chloride-sod bicarbonate-sod chloride... 5 PEGANONE... 9 PEGASYS PEGASYS PROCLICK PENICILLIN G POT IN DEXTROSE MU 1 PENICILLIN G POT IN DEXTROSE MU 1 PENICILLIN G PROCAINE... 1 penicillin g sodium... 1 penicillin v potassium... 1 penicilln gk inj 0mu... 1 penicilln gk inj 5mu... 1 PENTACEL PENTAM pentoxifylline PEPCID see famotidine... 5 PERCOCET see endocet... see oxycodone w/ acetaminophen 10-5mg... see oxycodone w/ acetaminophen.5-5mg... see oxycodone w/ acetaminophen 5-5mg... 95

104 018 GENERIC STANDARD FORMULARY see oxycodone w/ acetaminophen 7.5-5mg... PERIDEX see chlorhexidine gluconate (mouththroat)...71 see paroex sol 0.1%...71 see periogard...71 perindopril erbumine...19 periogard...71 permethrin cre 5%...71 perphenazine...6 pfizerpen-g inj 0mu...1 pfizerpen-g inj 5mu...1 phenelzine sulfate... PHENERGAN see promethazine hcl...5 phenobarbital...9 phenobarbital sodium...9 PHENOBARBITAL SODIUM...9 PHENYTEK...9 see phenytoin sodium extended...9 phenytoin...9 phenytoin sodium...9 phenytoin sodium extended...9 philith...7 PHOSLO see calcium acetate (phosphate binder)...51 PHOSPHOLINE IODIDE...65 PICATO...70 pilocarpine hcl...65 pilocarpine hcl (oral)...71 pimozide...6 pimtrea...7 pindolol... pioglitazone hcl... PIPER/TAZOBA INJ 1-1.5GM...1 piper/tazoba inj -0.5gm...1 piper/tazoba inj -0.75gm...1 piper/tazoba inj 6-.5gm...1 piper/tazoba inj -0.5gm...1 pirmella 1/5...7 piroxicam... 1 PLAQUENIL see hydroxychloroquine sulfate...58 PLASMA-LYTE A...6 PLASMA-LYTE PLAVIX see clopidogrel tab 75mg podofilox polyethylene glycol polymyxin b-trimethoprim... 6 POLYTRIM see polymyxin b-trimethoprim... 6 POMALYST portia pot chloride inj meq/ml... 6 potassium chloride...60, 6 potassium chloride in nacl... 6 potassium chloride microencapsulated crystals er potassium chloride tab cr 10 meq potassium citrate (alkalinizer) er tabs. 55 PRADAXA PRALUENT... pramipexole tab 0.15mg... pramipexole tab 0.5mg... pramipexole tab 0.5mg... pramipexole tab 0.75mg... pramipexole tab 1.5mg... pramipexole tab 1mg... PRANDIN see repaglinide... prasugrel hcl PRAVACHOL see pravastatin sodium... 1 pravastatin sodium... 1 praziquantel... 5 prazosin hcl... 0 PRECOSE see acarbose... pred sod pho sol 5mg/5ml prednisolone acetate (ophth)... 6 prednisolone sodium phosphate PREDNISOLONE SODIUM PHOSPHATE (OPHTH)... 6 prednisolone sol 15mg/5ml prednisolone sol 5mg/5ml PREDNISONE CON 5MG/ML prednisone pak 10mg prednisone pak 5mg prednisone sol 5mg/5ml

105 018 GENERIC STANDARD FORMULARY prednisone tab 10mg...50 prednisone tab 1mg...50 prednisone tab.5mg...50 prednisone tab 0mg...50 prednisone tab 50mg...50 prednisone tab 5mg...50 PREMASOL 10%...61 premasol 6%...61 prenatal vitamin/folic acid > 0.8 mg (generic)...6 prevalite... previfem...7 PREZCOBIX... 8 PREZISTA... 7 PRIFTIN... 9 PRIMAQUINE PHOSPHATE... 6 PRIMAXIN IV see imipenem-cilastatin... 5 primidone...9 PRINIVIL see lisinopril...19 PRISTIQ see desvenlafaxine succinate...1 PRIVIGEN...58 probenecid... 1 PROCALAMINE...61 PROCARDIA XL see nifedical xl... see nifedipine... prochlorperazine inj...5 prochlorperazine maleate...5 prochlorperazine supp...5 PROCRIT...56 procto-med hc...70 procto-pak...70 proctosol hc cre.5%...71 proctozone-hc...71 PROGLYCEM SUS 50MG/ML...50 PROGRAF see tacrolimus...59 PROLASTIN-C...67 PROLENSA...6 PROLIA...51 PROMACTA...57 promethazine hcl...5 propafenone hcl...1 propafenone hcl 1hr... 1 proparacaine hcl propranolol & hydrochlorothiazide... propranolol cap er... propranolol hcl... propranolol oral sol... propylthiouracil PROQUAD PROSCAR see finasteride PROSOL PROTONIX see pantoprazole sodium tbec PROTOPIC see tacrolimus (topical) protriptyline hcl... PROVERA see medroxyprogesterone acetate tab PROZAC see fluoxetine cap 10mg... 1 see fluoxetine cap 0mg... 1 see fluoxetine cap 0mg... 1 PULMICORT see budesonide (inhalation) PULMICORT FLEXHALER PULMOZYME PURIXAN... 1 pyrazinamide... 9 pyridostigmine tab 60mg... 9 Q QUADRACEL QUALAQUIN see quinine sulfate... 6 quasense... 7 QUESTRAN see cholestyramine... 1 QUESTRAN LIGHT see cholestyramine light... 1 see prevalite... quetiapine fumarate... 6 quinapril hcl quinapril-hydrochlorothiazide quinidine gluconate... 1 quinidine sulfate... 1 quinine sulfate

106 018 GENERIC STANDARD FORMULARY R RABAVERT...59 raloxifene tab 60mg...51 ramipril...19 RANEXA...5 ranitidine hcl...5 ranitidine hcl inj...5 ranitidine syrup...5 RAPAMUNE...59 see sirolimus...59 rasagiline mesylate... RAYALDEE...6 RAZADYNE see galantamine hydrobromide...0 RAZADYNE ER see galantamine hydrobromide er...0 REBETOL see ribasphere...10 see ribavirin cap 00mg...10 REBETOL SOLN...10 RECLAST see zoledronic acid... reclipsen...7 RECOMBIVAX HB...59 REGLAN see metoclopramide hcl...5 REGRANEX...71 RELENZA DISKHALER...10 RELISTOR...5 RELPAX see eletriptan hydrobromide...8 REMERON see mirtazapine... REMERON SOLTAB see mirtazapine... REMICADE...58 REMODULIN...6 RENVELA see sevelamer carbonate...51 repaglinide... REQUIP see ropinirole tab 0.5mg... see ropinirole tab 0.5mg... see ropinirole tab 1mg... see ropinirole tab mg... see ropinirole tab mg... see ropinirole tab mg... see ropinirole tab 5mg... RESCRIPTOR... 7 RESTASIS RESTASIS MULTIDOSE RESTORIL see temazepam... 8 RETIN-A see avita see tretinoin RETROVIR see zidovudine cap 100mg... 8 see zidovudine syp 50mg/5ml... 8 RETROVIR IV INFUSION... 7 REVATIO see sildenafil citrate (pulmonary hypertension)... 6 REVLIMID REXULTI... 6 REYATAZ... 7 see atazanavir sulfate... 7 ribasphere ribavirin cap 00mg ribavirin tab 00mg rifabutin... 9 RIFADIN see rifampin... 9 rifampin... 9 RIFATER... 9 RILUTEK see riluzole... 9 riluzole... 9 rimantadine hydrochloride ringer's... 6 RISPERDAL see risperidone... 6 RISPERDAL INJ 1.5MG... 6 RISPERDAL INJ 5MG... 6 RISPERDAL INJ 7.5MG... 6 RISPERDAL INJ 50MG... 6 risperidone... 6 RITALIN see methylphenidate hcl... 8 ritonavir... 7 RITUXAN RITUXAN HYCELA

107 018 GENERIC STANDARD FORMULARY rivastigmine tartrate...0 rivastigmine td patch hr 1. mg/hr...0 rivastigmine td patch hr.6 mg/hr...0 rivastigmine td patch hr 9.5 mg/hr...0 rizatriptan benzoate...8 rizatriptan benzoate odt...8 ROBINUL see glycopyrrolate...5 see glycopyrrolate inj...5 ROBINUL FORTE see glycopyrrolate...5 ROCALTROL see calcitriol...6 see calcitriol oral soln 1 mcg/ml...6 ROCEPHIN see ceftriaxone sodium...10 ropinirole tab 0.5mg... ropinirole tab 0.5mg... ropinirole tab 1mg... ropinirole tab mg... ropinirole tab mg... ropinirole tab mg... ropinirole tab 5mg... rosadan cre 0.75%...71 rosuvastatin calcium...1 ROTARIX...60 ROTATEQ...60 ROWASA see mesalamine w/ cleanser...5 roweepra...9 roweepra xr...9 ROXICODONE see oxycodone hcl... RUBRACA...15 RYDAPT...17 RYTHMOL SR see propafenone hcl 1hr...1 S SABRIL...9 see vigabatrin powd pack 500mg...0 SALAGEN see pilocarpine hcl (oral)...71 SANDIMMUNE...59 see cyclosporine SANDOSTATIN see octreotide acetate SANDOSTATIN LAR DEPOT SANTYL SAPHRIS... 6 scopolamine patch... 5 selegiline hcl... selenium sulfide SELZENTRY... 7 SENSIPAR... SEREVENT DISKUS SEROQUEL see quetiapine fumarate... 6 SEROQUEL XR see quetiapine fumarate... 6 sertraline hcl... setlakin tab... 7 sevelamer carbonate sharobel... 7 SHINGRIX SIGNIFOR sildenafil citrate (pulmonary hypertension)... 6 SILENOR... 8 SILVADENE see silver sulfadiazine see ssd silver sulfadiazine SIMBRINZA simvastatin... 1 SINEMET see carbidopa-levodopa... SINEMET CR see carbidopa-levodopa... SINGULAIR see montelukast sodium sirolimus SIRTURO... 9 SIVEXTRO... 5 sodium chlor sol 0.9% irr sodium chloride...61, 6 sodium chloride 0.5%... 6 sodium chloride inj 0.9%... 6 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

108 018 GENERIC STANDARD FORMULARY sodium phenylbutyrate...9 sodium polystyrene sulfonate... sodium polystyrene sulfonate oral susp SOLIQUA 100/... SOLTAMOX...16 SOLU-CORTEF...50 SOLU-MEDROL see methylpr ss inj 15mg...50 see methylpr ss inj 1gm...9 see methylpr ss inj 0mg...9 SOMATULINE DEPOT...51 SOMAVERT...51 SORIATANE see acitretin...68 sorine...1 sotalol hcl...1 sotalol hcl (afib/afl)...1 SOVALDI...10 spironolactone...0 spironolactone & hydrochlorothiazide..5 SPORANOX see itraconazole... 6 sprintec SPRITAM...9 SPRYCEL...17 sps susp 15gm/60ml... sronyx...7 ssd...68 STALEVO 100 see carbidopa/levodopa/entacapone. STALEVO 15 see carbidopa/levodopa/entacapone. STALEVO 150 see carbidopa/levodopa/entacapone. STALEVO 00 see carbidopa/levodopa/entacapone. STALEVO 50 see carbidopa/levodopa/entacapone. STALEVO 75 see carbidopa/levodopa/entacapone. STARLIX see nateglinide... stavudine... 8 sterile water irrigation...71 STIMATE...5 STIVARGA...17 STRATTERA see atomoxetine hcl... 7 streptomycin sulfate... STRIBILD... 8 STROMECTOL see ivermectin... 5 SUBOXONE MIS 1-MG... 1 SUBOXONE MIS -0.5MG... 0 SUBOXONE MIS -1MG... 1 SUBOXONE MIS 8-MG... 1 sucralfate... 5 sulfacet sod oin 10% op... 6 sulfacetamide sodium (acne) sulfacetamide sodium (ophth)... 6 sulfacetamide sod-prednisolone... 6 SULFADIAZINE... sulfamethoxazole-trimethop ds... 5 sulfamethoxazole-trimethoprim... 5 sulfamethoxazole-trimethoprim inj... 5 SULFAMYLON see mafenide acetate sulfasalazine... 5 sulfasalazine ec... 5 sulindac... 1 sumatriptan... 9 sumatriptan inj mg/0.5ml... 9 sumatriptan inj 6mg/0.5ml... 9 sumatriptan succinate... 9 SUPRAX see cefixime SUPREP BOWEL PREP KIT... 5 SURMONTIL see trimipramine maleate... SUSTIVA... 8 see efavirenz... 7 SUTENT syeda... 7 SYLATRON KIT 00MCG SYLATRON KIT 00MCG SYLATRON KIT 600MCG SYMBICORT SYMDEKO SYMFI LO... 8 SYNAGIS SYNALAR see fluocinolone acetonide

109 018 GENERIC STANDARD FORMULARY SYNAREL...8 SYNERCID... 5 SYNRIBO...18 SYNTHROID...51 see levo-t...51 see levothyroxine sodium...51 see levoxyl...51 see unithroid...51 SYPRINE... see trientine hcl... T TABLOID...1 tacrolimus...59 tacrolimus (topical)...71 TAFINLAR...17 TAGRISSO...17 TAMIFLU see oseltamivir phosphate...9, 10 tamoxifen citrate...16 tamsulosin hcl...55 TAPAZOLE see methimazole...51 TARCEVA...17 TARGRETIN...71 see bexarotene...18 tarina fe 1/0...7 TASIGNA...17 TAXOTERE...1 see docetaxel...1 tazarotene...68 tazicef...11 TAZORAC...68 see tazarotene...68 taztia xt... TECENTRIQ...15 TEFLARO...11 TEGRETOL...9 see carbamazepine...7 see epitol...8 TEGRETOL-XR...9 see carbamazepine...7 TEKTURNA... TEKTURNA HCT... temazepam...8 TENIVAC...60 tenofovir disoproxil fumarate... 8 TENORMIN see atenolol... TERAZOL 7 see terconazole vaginal terazosin hcl... 0 terbinafine hcl... 6 terbutaline sulfate terconazole vaginal testosterone... 1 testosterone cypionate... 1 testosterone enanthate... 1 TETANUS/DIPHTHERIA TOXOID tetrabenazine... 9 TEXACORT SOLN.5% THALOMID THEO theophylline thioridazine hcl... 6 thiothixene... 6 tiagabine hcl... 9 TIAZAC see diltiazem hcl extended release beads cap sr... see taztia xt... tigecycline... 5 TIGECYCLINE... 5 TIKOSYN see dofetilide... 0 tilia fe... 7 timolol maleate... timolol maleate (ophth) soln timolol maleate gel timolol maleate ophth soln 0.5% (oncedaily) TIMOPTIC see timolol maleate (ophth) soln TIMOPTIC-XE see timolol maleate gel TIVICAY... 8 tizanidine hcl... 0 TOBRADEX... 6 see tobramycin-dexamethasone... 6 TOBRADEX ST... 6 tobramycin... tobramycin (ophth)... 6 tobramycin inj 1. gm/0ml

110 018 GENERIC STANDARD FORMULARY tobramycin inj 1.gm... tobramycin inj 10mg/ml... tobramycin inj 0mg/ml... tobramycin inj 80mg/ml... tobramycin-dexamethasone...6 TOBREX see tobramycin (ophth)...6 TOFRANIL see imipramine hcl... tolterodine tartrate...55 TOPAMAX see topiramate...9 TOPAMAX SPRINKLE see topiramate...9 TOPICORT see desoximetasone...69 topiramate...9 toposar...18 TOPOTECAN HCL see topotecan inj mg...18 topotecan inj mg...18 TOPOTECAN INJ MG/ML...18 TOPROL XL see metoprolol succinate... torsemide tabs...5 TOVIAZ...55 tpn electrolytes...61 TRACLEER...6 TRADJENTA... tramadol hcl... tramadol-acetaminophen... trandolapril...19 tranexamic acid...57 TRANSDERM-SCOP see scopolamine patch...5 TRANXENE T see clorazepate dipotassium...7 tranylcypromine sulfate... TRAVASOL...61 TRAVATAN Z...65 trazodone hcl... TRECATOR... 9 TRELEGY ELLIPTA...65 TRELSTAR DEP INJ.75MG...16 TRELSTAR LA INJ 11.5MG...16 TRESIBA FLEXTOUCH... tretinoin tretinoin (chemotherapy) triamcinolone acetonide (mouth) triamcinolone acetonide (topical) triamterene & hydrochlorothiazide cap mg... 5 triamterene & hydrochlorothiazide tabs5 TRIBENZOR see olmesartan medoxomil-amlodipinehydrochlorothiazide... 0 TRICOR see fenofibrate... 1 trientine hcl... trifluoperazine hcl... 6 trifluridine... 6 trihexyphenidyl hcl... tri-legest fe... 7 TRILEPTAL see oxcarbazepine... 9 tri-linyah... 7 tri-lo marzia... 8 tri-lo-estarylla... 8 tri-lo-sprintec... 8 trilyte... 5 trimethoprim... 5 trimipramine maleate... trinessa... 8 trinessa lo... 8 TRI-NORINYL 8 see aranelle... see leena tab... 6 TRINTELLIX... tri-previfem... 8 TRISENOX tri-sprintec... 8 TRIUMEQ... 8 trivora tri-vylibra... 8 TRIZIVIR see abacavir sulfate-lamivudinezidovudine... 8 TROGARZO... 8 TROPHAMINE INJ 10% trospium chloride TRULICITY... TRUMENBA

111 018 GENERIC STANDARD FORMULARY TRUSOPT see dorzolamide hcl...6 TRUVADA TAB TRUVADA TAB TRUVADA TAB TRUVADA TAB TWINRIX INJ...60 TYBOST... 8 TYGACIL see tigecycline... 5 TYKERB...17 TYLENOL/CODEINE # see acetaminophen w/ codeine... TYLENOL/CODEINE # see acetaminophen w/ codeine... TYPHIM VI...60 TYSABRI...0 U ULORIC... 1 ULTRACET see tramadol-acetaminophen... ULTRAM see tramadol hcl... ULTRAVATE see halobetasol propionate...69 UNASYN see ampicillin & sulbactam sodium...1 UNASYN BULK PACK see ampicillin & sulbactam sodium...1 unithroid...51 URECHOLINE see bethanechol chloride...55 UROCIT-K 10 see potassium citrate (alkalinizer) er tabs...55 UROCIT-K 15 see potassium citrate (alkalinizer) er tabs...55 UROCIT-K 5 see potassium citrate (alkalinizer) er tabs...55 UROXATRAL see alfuzosin hcl...55 URSO 50 see ursodiol...5 URSO FORTE see ursodiol... 5 ursodiol... 5 V VAGIFEM see estradiol vaginal tab... 9 see yuvafem vaginal tablet 10 mcg.. 9 valacyclovir hcl VALCHLOR VALCYTE see valganciclovir hcl valganciclovir hcl VALIUM see diazepam... 7 valproate sodium oral soln... 9 valproate sodium soln 100mg/ml... 9 valproic acid... 9 valsartan... 0 valsartan-hydrochlorothiazide... 0 VALTREX see valacyclovir hcl VANCOCIN HCL see vancomycin hcl... 6 vancomycin hcl... 6 VANCOMYCIN IN NACL... 6 vandazole VAQTA VARIVAX VASCEPA... VASERETIC see enalapril maleate & hydrochlorothiazide VASOTEC see enalapril maleate VELCADE velivet... 8 VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl... VENTAVIS... 6 VENTOLIN HFA verapamil cap er... verapamil hcl... verapamil tab er... VERELAN see verapamil cap er... 10

112 018 GENERIC STANDARD FORMULARY VERELAN PM see verapamil cap er... VERSACLOZ...6 VERZENIO...15 VESICARE...55 vestura...8 VFEND see voriconazole... 6 VFEND IV see voriconazole... 6 VIBRAMYCIN see doxycycline hyclate...1 VICTOZA... VIDAZA see azacitidine...1 VIDEX EC... 8 see didanosine... 7 VIDEX PEDIATRIC... 8 vienva...8 vigabatrin powd pack 500mg...0 VIGAMOX see moxifloxacin hcl (ophth)...6 VIIBRYD STARTER PACK... VIIBRYD TAB... VIMPAT...0 vinblastine sulfate...1 vincasar pfs...1 vincristine sulfate...1 vinorelbine tartrate...15 viorele...8 VIRACEPT... 8 VIRAMUNE... 8 see nevirapine tab 00mg... 7 VIRAMUNE XR see nevirapine tb... 7 VIREAD... 8 see tenofovir disoproxil fumarate... 8 VIROPTIC see trifluridine...6 VISTARIL see hydroxyzine pamoate...66 VIVITROL...1 VOLTAREN see diclofenac sodium (topical) 1% gel...70 voriconazole... 6 VOSEVI VOTRIENT VRAYLAR... 7 VRAYLAR THERAPY PACK... 7 vyfemla... 8 vylibra... 8 W warfarin sodium WELCHOL... WELLBUTRIN SR see bupropion hcl... 1 WELLBUTRIN XL see bupropion hcl... 1 X XALATAN see latanoprost XALKORI XANAX see alprazolam tab 0.5mg... 6 see alprazolam tab 0.5mg... 6 see alprazolam tab 1mg... 6 see alprazolam tab mg... 6 XARELTO XARELTO STARTER PACK XATMEP XELJANZ XELJANZ XR XENAZINE see tetrabenazine... 9 XGEVA XIFAXAN... 5 XIGDUO XR TAB MG... XIGDUO XR TAB MG... XIGDUO XR TAB MG... XIGDUO XR TAB MG... XIGDUO XR TAB 5-500MG... XOLAIR XOPENEX see levalbuterol hcl XOPENEX CONCENTRATE see levalbuterol hcl soln nebu conc 1.5 mg/0.5ml XTANDI xulane dis XULTOPHY 100/.6... XYLOCAINE 10

113 018 GENERIC STANDARD FORMULARY see lidocaine hcl...70 see lidocaine inj 0.5%... see lidocaine inj 1%... see lidocaine inj %... XYLOCAINE-MPF see lidocaine inj 0.5% preservative free (pf)... see lidocaine inj 1% preservative free (pf)... see lidocaine inj 1.5% preservative free (pf)... XYREM...0 Y YASMIN 8 see drospirenone-ethinyl estradiol...5 see ocella tab -0.0mg...7 see syeda...7 see zarah...8 YAZ see drospirenone-ethinyl estradiol...5 see gianvi tab -0.0mg...5 see loryna...6 see nikki...7 see vestura...8 YERVOY...15 YF-VAX...60 yuvafem vaginal tablet 10 mcg...9 Z zafirlukast...66 ZANAFLEX see tizanidine hcl...0 ZANTAC see ranitidine hcl...5 see ranitidine hcl inj...5 zarah...8 ZARONTIN see ethosuximide...8 ZAVESCA...9 ZEJULA...15 ZELBORAF...17 ZEMAIRA...67 ZEMPLAR see paricalcitol...6 zenatane...68 zenchent...8 ZENPEP...5 ZEPATIER ZERIT... 8 see stavudine... 8 ZESTORETIC see lisinopril & hydrochlorothiazide.. 19 ZESTRIL see lisinopril ZETIA see ezetimibe... 1 ZIAC see bisoprolol & hydrochlorothiazide ZIAGEN see abacavir sulfate... 6 zidovudine cap 100mg... 8 zidovudine syp 50mg/5ml... 8 zidovudine tab 00mg... 8 ZINECARD see dexrazoxane ziprasidone hcl... 7 ZIRGAN... 6 ZITHROMAX see azithromycin ZOCOR see simvastatin... 1 ZOFRAN see ondansetron hcl... 5 see ondansetron hcl oral soln... 5 ZOFRAN ODT see ondansetron odt... 5 zoledronic acid... zoledronic inj mg/5ml... ZOLINZA zolmitriptan... 9 zolmitriptan odt... 9 ZOLOFT see sertraline hcl... zolpidem tartrate... 8 ZOMETA see zoledronic inj mg/5ml... ZOMIG see zolmitriptan... 9 ZOMIG ZMT see zolmitriptan odt... 9 ZONEGRAN see zonisamide... 0 zonisamide

114 018 GENERIC STANDARD FORMULARY ZONTIVITY...57 ZORTRESS TAB 0.5MG...59 ZORTRESS TAB 0.5MG...59 ZORTRESS TAB 0.75MG...59 ZOSTAVAX...60 ZOSYN see piper/tazoba inj -0.5gm...1 see piper/tazoba inj -0.75gm...1 see piper/tazoba inj 6-.5gm...1 see piper/tazoba inj -0.5gm...1 zovia 1/5e...8 zovia 1/50e...8 ZOVIRAX see acyclovir... 9 ZYBAN see bupropion hcl (smoking deterrent)...0 ZYDELIG ZYKADIA ZYLET... 6 ZYLOPRIM see allopurinol tab... 1 ZYMAXID see gatifloxacin (ophth)... 6 ZYPREXA see olanzapine... 5 ZYPREXA RELPREVV... 7 ZYPREXA RELPREVV INJ 10MG... 7 ZYPREXA ZYDIS see olanzapine... 5 ZYTIGA ZYVOX see linezolid

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