2019 FORMULARY FORMULARIO

Transcription

1 2019 FORMULARY FORMULARIO

2 What is the Steward Health Choice Arizona Formulary/Preferred Drug List (PDL)? A Formulary / Preferred Drug List (PDL) is a list of drugs chosen by Steward Health Choice Arizona and a team of doctors and pharmacists. Health Choice will cover the drugs listed in our PDL as long as they are medically necessary and appropriate. All Health Choice member prescriptions must be filled at a Steward Health Choice Arizona network pharmacy, and other plan rules must be followed. The Steward Health Choice Complete formulary contains drugs used to treat physical conditions and behavioral health conditions. What if a drug is not on the Formulary/ PDL? If a drug you want to prescribe for your patient is not on this Formulary / PDL, the prescriber can: Prescribe a similar drug that is Formulary / PDL covered, or Ask Steward Health Choice Arizona to make an exception and cover the medically necessary, non-formulary drug through the prior authorization process. Can the Formulary / PDF change? Yes, Health Choice may add or take off drugs during the year. To get the latest information about covered drugs, go to our website at or call Steward Health Choice Member Services at or (outside Maricopa County). Product Selection Criteria The Steward Health Choice Arizona Pharmacy & Therapeutics Committee will consider and advise Health Choice on all new-to-market drugs and will continually review and evaluate existing market drugs for formulary/pdl inclusion. The committee s evaluation includes a current literature review. Expert external opinion may also be sought. Formal reviews are prepared that typically address the following information: Safety & Efficacy Comparison studies Approved indications Adverse effects Contraindications, warnings and precautions Pharmacokinetics Cost-effectiveness Patient administration and compliance considerations The Pharmacy & Therapeutics Committee reviews all AHCCCS drug coverage requirements as noted on the AHCCCS PDL lists and honors all requirements for preferred drug coverage. When a new drug is considered for formulary inclusion, an attempt will be made to examine the drug relative to similar drugs currently on formulary. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in deletion of one or more drugs in a particular i

3 therapeutic class in an effort to continually promote the most clinically useful and cost effective agents. Drug coverage within therapy classes is consistent with AHCCCS requirements for drug coverage. The entire formulary / PDL is reviewed and approved annually. Prior authorization (PA) is required for two groups of medications and for two clinical formulary/ PDL override conditions: 1. Medication roups Medications noted with a PA in the formulary / PDL. Steward Health Choice may require prior authorization for certain drugs on the Preferred Drug List. This means that your doctor will need to get approval from us before you can fill some of your prescriptions. If approval isn t given, Steward Health Choice will not cover the drug. All unlisted medications. 2. Clinical Override Conditions To override a Step Therapy (ST) edit. In some cases, Steward Health Choice requires you to try certain drugs first to treat your medical condition before we will cover another drug for that same condition. For example, if Drug A and Drug both treat your medical condition, Steward Health Choice may not cover Drug unless you try Drug A first. If Drug A does not work for you, we will then cover Drug. To override a Quantity Limit (QL) edit. For certain drugs, Steward Health Choice limits the amount of the drug it will cover. For example, we provide <XX> pills in <XX> days per prescription for <drug name>. Health Choice anticipates that requests for an unlisted medication will be infrequent and providers will be able to prescribe a formulary / PDL medication for the vast majority of therapeutic needs. Providers are encouraged to use this formulary / PDL when prescribing medications for Steward Health Choice Arizona members to avoid unnecessary delays in therapy. The AHCCCS Minimum Required Prescription Drug List is included in the Steward Health Choice Arizona Formulary. All AHCCCS Preferred drug are included in our formulary exactly as noted by AHCCCS. Off label drugs may be prior authorized when the use of the drug has proven to be the community standard. Steward Health Choice Arizona uses a four (4) day override process to ensure that members can access immediately needed, non-formulary or prior authorization required drugs. The Steward Health Choice network pharmacy can override the prior authorization requirement to provide the member with the immediately needed drug, such as an antibiotic or other emergent drug by calling us. Health Choice providers may formally request the Steward Health Choice Pharmacy & Therapeutics Committee consider a medication be considered for addition to the formulary / PDL. The instructions and required submission form(s) which indicate how to submit a formulary / PDL medication consideration request are detailed in the Health Choice Provider Manual. The instructions and materials are also available on the Health Choice website. ii

4 All the information in the Steward Health Choice Arizona formulary is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber. Formulary Product Descriptions To assist in understanding which specific strengths and dosage forms are on the formulary, examples are noted below. The general principles shown in the examples can then usually be extended to other entries in the book. Any exceptions are noted in the drug list. There may also be a statement associated with a drug list that gives additional information about which specific products or dosage forms are on formulary. eneric drugs are identified in lower case type, whereas brand drugs are identified in all caps allopurinol is a generic drug ULORIC is a brand drug The brand name products shown are for reference only; a different brand or a generic version may be dispensed. simvastatin ZOCOR Extended-release and delayed-release products require their own entry. Identified below, both propranolol and propranolol SR are on the formulary. propranolol propranolol SR INDERAL INDERAL LA Dose forms on formulary will be consistent with the category and usewhere listed. Identified below from Otic group, the otic solution and ophthalmic ointment are on the formulary, and the ophthalmic products and topical cream cannot be assumed to be on formulary unless there are entries for these products in the OPHTHALMIC and DERMATOLOY sections of the formulary. neomycin/polymyxin /hydrocortisone CORTISPORIN eneric Substitution AHCCCS health plans are required to utilize a mandatory generic drug substitution policy. eneric substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand name product. An important consideration for generic substitution is the knowledge that all approvals of generic drugs by the FDA since 1984, and many generic approvals prior to 1984, have a showing of bioequivalence between the generic versions and the reference brand name product. To gain FDA approval: iii

5 1. The generic drug must contain the same active ingredient(s), be the same strength and the same dosage form as the brand name product. 2. The FDA has given the generic an "A" rating compared to the brand name product indicating bioequivalence, and has determined the generic is therapeutically equivalent to the reference brand name product. The ratings of generic drugs are available by referring to the FDA reference, Approved Drug Products with Therapeutic Equivalence Evaluations (Orange ook). When the above two criteria are met, a generic can be substituted with the full expectation that the substituted product will produce the same clinical effect and safety profile as the prescribed product. Drug products that have a narrow therapeutic index (NTI) can also be guided by these principles. It is not necessary for the healthcare practitioner to approach any one therapeutic class of drug products (e.g., NTI drugs) differently from any other class, when there has been a determination of therapeutic equivalence by the FDA for the drug products under consideration. Also, additional clinical tests or examinations by the practitioner are not needed when a therapeutically equivalent generic drug product is substituted for the brand name product. It is recommended that generic substitution not be exercised by the pharmacist with multisource products that appear in the Orange ook and carry a "" rating, indicating that these products cannot be considered therapeutically equivalent to other products in the group. It is also recommended that generic substitution not be undertaken for any unrated multisource products that might be considered narrow therapeutic index, or maintenance drugs where it is known that unrated products from different labelers are not bioequivalent. State law or regulations may dictate the ability to practice generic substitution for selected products or categories of drugs. Plan Exclusions The following drug categories are excluded from coverage under the outpatient pharmacy benefit and are not part of the formulary/pdl Anti-obesity agents Experimental / research drugs Cosmetic drugs Cosmetic drugs for hair growth Nutritional / diet supplements lood and blood plasma products Products to promote fertility Erectile dysfunction drugs Drugs from manufacturers that do not participate in the FFS Medicaid Drug Rebate Program Diagnostic products Medical supplies except: o Syringes o Needles o Lancets o Alcohol Swabs o Spacers o lood glucose meters and test strips Intrauterine Devices Pharmacy enefit Manager (PM) Health Choice Arizona uses Optum Rx to process our prescription drug claims iv

6 LEEND oldface PA QL ST PREFERED Indicates generic availability Over-the-Counter Prior Authorization Required Quantity Level Limit Step Therapy through prerequisite drug required AHCCCS Preferred Agent Contact Steward Health Choice Arizona Your comments and suggestions regarding the Steward Health Choice Arizona Formulary are encouraged. Your input is vital to this clinical formulary s continued success. All responses will be reviewed and considered. Please send comments to: Pharmacy Services Department Health Choice Arizona 410 N 44 th Street, Suite 405 Phoenix, AZ v

7 Table of Contents Analgesics - Drugs for Pain... 3 Analgesics - Drugs for Pain and Inflammation... 5 Anesthetics... 7 Anti-Addiction / Substance Abuse Treatment Agents... 7 Antibacterials... 8 Anticoagulants Anticonvulsants - Drugs for Seizures Antidementia Agents - Drugs for Alzheimer's Disease and Dementia Antidepressants Antiemetics - Drugs for Nausea and Vomiting Antifungals Antigout Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics - Drugs for Cancer Antiparasitics Antiparkinson Agents Antiplatelets Antipsychotics - Drugs for Mood Disorders Antivirals Anxiolytics - Drugs for Anxiety ipolar Agents - Drugs for Mood Disorders lood Products / Modifiers / Volume Expanders - Drugs for leeding Disorders Cardiovascular Agents - Drugs for Heart and Circulation Conditions Central Nervous System Agents - Drugs for Attention Deficit Disorder Central Nervous System Agents - Drugs for Multiple Sclerosis Central Nervous System Agents - Miscellaneous Dental and Oral Agents - Drugs for Mouth and Throat Conditions Dermatological Agents - Drugs for Skin Conditions Diabetes - Antidiabetic Agents Diabetes - lucose Monitoring Diabetes - lycemic Agents Diabetes - Insulins Electrolytes / Minerals / Metals / Vitamins astrointestinal Agents - Drugs for Acid Reflux and Ulcer

8 astrointestinal Agents - Drugs for owel, Intestine and Stomach Conditions enetic or Enzyme Disorder: Drugs for Replacement, Modifiers, Treatment enitourinary Agents - Drugs for ladder, enital and Kidney Conditions enitourinary Agents - Drugs for Prostate Conditions Hormonal Agents - Adrenal Hormonal Agents - Men's Health Hormonal Agents - Osteoporosis Hormonal Agents - Parathyroid Hormonal Agents - Pituitary Hormonal Agents - Sex Hormones and irth Control Hormonal Agents - Thyroid Immunological Agents - Drugs for Immune System Stimulation or Suppression Immunological Agents - Drugs for Vaccination Inflammatory owel Disease Agents Metabolic one Disease Agents - Drugs for Osteoporosis Miscellaneous Therapeutic Agents Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation Ophthalmic Agents - Drugs for laucoma Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions Otic Agents - Drugs for Ear Conditions Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm Sleep Disorder Agents

9 Analgesics - Drugs for Pain acetaminophen childrens oral tablet chewable Mapap Childrens acetaminophen er Midol acetaminophen extra strength oral liquid Chloraseptic Sore Throat acetaminophen oral liquid Little Remedies for Fever acetaminophen oral solution acetaminophen oral tablet Pharbetol acetaminophen rectal suppository 120 mg Acephen acetaminophen-codeine #2 acetaminophen-codeine #3 Tylenol with Codeine #3 acetaminophen-codeine #4 Tylenol with Codeine #4 acetaminophen-codeine oral solution acetaminophen-codeine oral tablet alfentanil hcl apap Medi-Tabs Childrens ascomp-codeine Ascomp-Codeine butalbital-acetaminophen oral tablet mg Tencon butalbital-apap Tencon butalbital-apap-caff-cod butalbital-apap-caffeine Esgic butalbital-asa-caff-codeine Ascomp-Codeine butalbital-asa-caffeine Fiorinal butalbital-aspirin-caffeine oral capsule Fiorinal butorphanol tartrate injection UTRANS PA capacet oral capsule mg Esgic childrens acetaminophen oral suspension Mapap Childrens 160 mg/5ml childrens acetaminophen oral tablet dispersible Mapap Childrens childrens apap Childrens Medi-Tabs childrens non-asa pain relief oral tablet Childrens Medi-Tabs chewable 80 mg childrens non-aspirin oral tablet chewable Childrens Medi-Tabs codeine sulfate oral tablet 30 mg, 60 mg duramorph 3

10 EMEDA PA; Preferred Drug endocet Endocet esgic oral capsule Esgic fentanyl transdermal patch 72 hour 100 mcg/hr Duragesic-100 PA; Preferred Drug fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 PA; Preferred Drug fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 PA; Preferred Drug fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 PA; Preferred Drug fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 PA; Preferred Drug headache relief ayer Migraine hydrocodone-acetaminophen oral solution hydrocodone-acetaminophen oral tablet Lorcet HD hydrocodone-ibuprofen hydromorphone hcl injection solution 2 mg/ml Dilaudid hydromorphone hcl oral tablet Dilaudid hydromorphone hcl pf ibudone oral tablet mg Ibudone infants pain reliever oral suspension 80 mg/0.8ml lorcet Lorcet lorcet hd Lorcet HD lorcet plus Lorcet Plus marten-tab oral tablet mg Tencon meperidine hcl oral tablet migraine relief ayer Migraine mitigo morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml morphine sulfate (pf) intravenous morphine sulfate er oral tablet extended release MS Contin PA; Preferred Drug 4

11 morphine sulfate injection solution 10 mg/ml, 15 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml morphine sulfate intramuscular morphine sulfate intravenous solution 1 mg/ml, 150 mg/30ml, 25 mg/ml, 50 mg/ml morphine sulfate oral solution morphine sulfate oral tablet morphine sulfate rectal suppository 30 mg nalbuphine hcl injection oxycodone hcl oral capsule oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution oxycodone hcl oral tablet oxycodone-acetaminophen oral solution mg/5ml oxycodone-acetaminophen oral tablet Endocet oxycodone-aspirin oxymorphone hcl Opana phrenilin forte Fioricet ra acetaminophen rapid melts oral tablet dispersible 160 mg sufentanil citrate intravenous tencon Tencon tramadol hcl er oral tablet extended release 24 hour tramadol hcl ir Ultram tramadol-acetaminophen Ultracet verdrocet Verdrocet vicodin Vicodin vicodin es Vicodin ES vicodin hp Vicodin HP 5 PA; Preferred Drug XTAMPZA ER PA; Preferred Drug xylon oral tablet mg Ibudone zebutal Esgic Analgesics - Drugs for Pain and Inflammation

12 advil junior strength aspirin childrens ayer Low Dose aspirin ec low dose Aspir-Low aspirin low dose oral tablet chewable ayer Low Dose ayer Advanced Aspirin aspirin oral tablet Reg St aspirin oral tablet delayed release 325 mg ayer Aspirin Regimen aspirin rectal ayer Advanced Aspirin bayer aspirin Reg St bayer aspirin ec low dose Aspir-Low buffered aspirin oral tablet 325 mg ufferin celecoxib oral CeleREX PA childrens ibuprofen oral suspension 40 mg/ml choline-mag trisalicylate diclofenac potassium diclofenac sodium er diclofenac sodium oral Infants Advil diclofenac sodium transdermal gel 1 % Voltaren PA diflunisal etodolac etodolac er fenoprofen calcium oral tablet Nalfon flurbiprofen oral gnp all day pain relief Aleve ibuprofen junior strength Advil Junior Strength ibuprofen oral capsule Advil ibuprofen oral suspension Childrens Advil ibuprofen oral tablet 200 mg Advil ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN indomethacin er indomethacin oral indomethacin sodium ketoprofen oral capsule 50 mg, 75 mg ketorolac tromethamine injection IU 6

13 ketorolac tromethamine intramuscular ketorolac tromethamine oral meloxicam oral Mobic nabumetone oral naproxen dr EC-Naprosyn naproxen oral Naprosyn naproxen sodium oral tablet 220 mg Aleve naproxen sodium oral tablet 275 mg naproxen sodium oral tablet 550 mg Anaprox DS oxaprozin Daypro piroxicam oral Feldene profeno Nalfon salsalate oral sulindac oral tri-buffered aspirin ufferin Anesthetics QL (20 EA per 30 glydo 7T Lido QL (2 ML per 1 day) lidocaine external cream 4 % AneCream ; QL (9.27 M per 1 day) PA; QL (50 M per 30 lidocaine external ointment lidocaine external patch Lidoderm QL (60 EA per 30 lidocaine hcl external gel 7T Lido QL (2 ML per 1 day) lidocaine hcl external solution PA; QL (50 M per 30 lidocaine pak lidocaine-prilocaine external cream QL (1 M per 1 day) premium lidocaine regenecare ha external gel 7T Lido Anti-Addiction / Substance Abuse Treatment Agents acamprosate calcium bupropion hcl er (smoking det) Zyban PA; QL (50 M per 30 ; QL (2 M per 1 day) QL (84 EA per 180 7

14 CHANTIX CHANTIX CONTINUIN MONTH PAK CHANTIX STARTIN MONTH PAK disulfiram oral Antabuse naloxone hcl injection solution naloxone hcl injection solution prefilled syringe naloxone hcl solution cartridge 0.4 mg/ml injection naloxone hcl solution cartridge 0.4 mg/ml injection 8 QL (84 EA per 180 QL (84 EA per 180 QL (84 EA per 180 Preferred Drug naltrexone hcl oral Preferred Drug NARCAN Preferred Drug NICORETTE MOUTH/THROAT UM 2 M KLS Quit2 nicotine polacrilex mouth/throat KLS Quit2 nicotine step 1 Nicoderm CQ nicotine step 2 Nicoderm CQ nicotine step 3 Nicoderm CQ NICOTROL NICOTROL NS SUOXONE SULINUAL FILM 12-3 M, 8-2 M SUOXONE SULINUAL FILM M, 4-1 M ; QL (84 EA per 180 ; QL (84 EA per 180 ; QL (84 EA per 180 ; QL (84 EA per 180 ; QL (84 EA per 180 QL (84 EA per 180 QL (84 ML per 180 Preferred Drug Preferred Drug VIVITROL Preferred Drug; SP ZYAN Zyban Antibacterials amikacin sulfate injection amoxicillin amoxicillin-potassium clavulanate er Augmentin XR QL (84 EA per 180

15 amoxicillin-potassium clavulanate oral Augmentin ampicillin ampicillin sodium ampicillin-sulbactam sodium injection Unasyn ampicillin-sulbactam sodium intravenous solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm AUMENTIN ORAL SUSPENSION RECONSTITUTED M/5ML AVELOX INTRAVENOUS avidoxy AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION 1 M/50ML, 2 M azithromycin intravenous Zithromax azithromycin oral Zithromax aztreonam Azactam baciim bacitracin external aciguent bacitracin intramuscular bacitracin zinc external ICILLIN C-R ICILLIN C-R 900/300 ICILLIN L-A cefaclor er cefaclor oral capsule cefadroxil cefazolin sodium injection cefazolin sodium intravenous solution reconstituted cefazolin sodium-dextrose intravenous solution 1-4 gm/50ml-% cefazolin sodium-dextrose intravenous solution reconstituted 1-4 gm-%, 2-3 gm- % cefdinir cefditoren pivoxil cefepime hcl Maxipime 9

16 cefepime-dextrose intravenous solution reconstituted 1 gm/50ml, 2 gm/50ml cefixime Suprax cefotaxime sodium cefotetan disodium Cefotan cefotetan disodium-dextrose intravenous solution reconstituted gm-%, gm-% cefoxitin sodium cefoxitin sodium-dextrose intravenous solution reconstituted 1-4 gm-%, gm-% cefpodoxime proxetil cefprozil ceftazidime injection Tazicef CEFTIN ORAL SUSPENSION RECONSTITUTED 125 M/5ML, 250 M/5ML ceftriaxone sodium in dextrose ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg ceftriaxone sodium intravenous ceftriaxone sodium-dextrose intravenous solution reconstituted gm-%, gm-% cefuroxime axetil cefuroxime sodium cephalexin Keflex chloramphenicol sod succinate ciprofloxacin hcl oral ciprofloxacin in d5w ciprofloxacin intravenous solution 200 mg/20ml, 400 mg/40ml clarithromycin er clarithromycin oral clindamycin hcl oral Cleocin clindamycin palmitate hcl Cleocin 10

17 clindamycin phosphate in d5w intravenous solution 600 mg/50ml, 900 mg/50ml clindamycin phosphate injection Cleocin Phosphate clindamycin phosphate intravenous Cleocin Phosphate clindamycin phosphate vaginal Cleocin colistimethate sodium (cba) Coly-Mycin M daptomycin intravenous solution reconstituted 500 mg Cubicin demeclocycline hcl PA dicloxacillin sodium DIFICID PA doxy 100 Doxy 100 doxycycline hyclate intravenous Doxy 100 doxycycline hyclate oral capsule Morgidox doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral suspension reconstituted doxycycline monohydrate oral tablet 100 mg ERYPED 400 erythrocin lactobionate gentamicin in saline gentamicin sulfate external gentamicin sulfate injection imipenem-cilastatin INVANZ INTRAVENOUS SOLUTION RECONSTITUTED 1 M levofloxacin in d5w levofloxacin intravenous Mondoxyne NL Vibramycin levofloxacin oral Levaquin linezolid oral Zyvox PA meropenem Merrem methenamine hippurate Hiprex methenamine mandelate oral tablet 1 gm 11

18 METRO INTRAVENOUS SOLUTION M/100ML-% metronidazole in nacl intravenous solution mg/ml-%, mg/100ml-% metronidazole oral Flagyl metronidazole vaginal Metroel-Vaginal minocycline hcl oral capsule Minocin mondoxyne nl oral capsule 100 mg, 50 mg Mondoxyne NL morgidox oral Morgidox mupirocin calcium actroban mupirocin external Centany nafcillin sodium injection solution reconstituted 1 gm, 2 gm nafcillin sodium intravenous neomycin sulfate oral nitrofurantoin Furadantin nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg Macrodantin nitrofurantoin monohydrate macrocrystals Macrobid ofloxacin oral tablet 400 mg oxacillin sodium paromomycin sulfate oral penicillin g potassium Pfizerpen penicillin g procaine penicillin g sodium penicillin v potassium pfizerpen injection solution reconstituted unit piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, ( ) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm poly bacitracin external ointment unit/gm polymyxin b sulfate injection Pfizerpen Zosyn Polysporin PRIMSOL Primsol silver sulfadiazine external Silvadene SIVEXTRO ORAL PA 12

19 ssd Silvadene streptomycin sulfate intramuscular sulfadiazine oral sulfamethoxazole-trimethoprim sulfatrim pediatric Sulfatrim Pediatric SUPRAX ORAL SUSPENSION RECONSTITUTED 500 M/5ML SYNERCID tazicef injection Tazicef tazicef intravenous solution reconstituted TEFLARO tinidazole oral Tindamax tobramycin sulfate injection trimethoprim oral TRIMPEX ORAL SOLUTION 50 M/5ML Primsol vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, mg/100ml-%, mg/150ml-% vancomycin hcl intravenous solution reconstituted 1 gm, 10 gm, 1000 mg, 500 mg, 5000 mg, 750 mg vancomycin hcl oral Vancocin HCl vandazole Metroel-Vaginal XIFAXAN PA Anticoagulants acd formula a ACD-A noclot-50 acd-a noclot-50 ACD-A noclot-50 ACTIVASE anticoagulant cit dext soln a ACD-A noclot-50 CATHFLO ACTIVASE Preferred Drug; QL (60 ELIQUIS ORAL TALET 2.5 M EA per 30 ELIQUIS ORAL TALET 5 M Preferred Drug ELIQUIS STARTER PACK Preferred Drug enoxaparin sodium Lovenox heparin (porcine) in d5w 13 Preferred Drug; SP; QL (60 ML per 30

20 heparin (porcine) in nacl injection heparin sod (porcine) in d5w intravenous solution 100 unit/ml, 40-5 unit/ml-% heparin sodium (porcine) injection heparin sodium (porcine) pf heparin sodium/d5w jantoven Coumadin Preferred Drug Preferred Drug; QL (60 PRADAXA EA per 30 warfarin sodium oral Coumadin Preferred Drug XARELTO ORAL TALET 10 M, 15 M, 20 M XARELTO STARTER PACK Anticonvulsants - Drugs for Seizures ANZEL PA carbamazepine er Carbatrol carbamazepine oral Preferred Drug; QL (60 EA per 30 Preferred Drug; QL (51 EA per 30 diazepam rectal gel 10 mg Diastat AcuDial QL (2 EA per 30 diazepam rectal gel 2.5 mg Diastat Pediatric QL (2 EA per 30 divalproex sodium er Depakote ER divalproex sodium oral Depakote epitol Epitol ethosuximide oral Zarontin felbamate Felbatol gabapentin oral Neurontin lamotrigine er LaMICtal XR lamotrigine oral tablet LaMICtal lamotrigine oral tablet chewable LaMICtal levetiracetam er Keppra XR levetiracetam oral Keppra oxcarbazepine Trileptal OXTELLAR XR phenobarbital oral phenytoin infatabs Dilantin Infatabs phenytoin oral Dilantin < 6 years 14

21 phenytoin sodium extended Dilantin primidone oral Mysoline roweepra Keppra roweepra xr Keppra XR subvenite LaMICtal tiagabine hcl abitril topiramate oral Topamax valproate sodium oral Depakene valproic acid Depakene VIMPAT ORAL PA zonisamide oral Zonegran Antidementia Agents - Drugs for Alzheimer's Disease and Dementia donepezil hcl Aricept PA galantamine hydrobromide er Razadyne ER PA galantamine hydrobromide oral tablet Razadyne PA memantine hcl oral tablet Namenda PA rivastigmine Exelon PA rivastigmine tartrate PA Antidepressants amitriptyline hcl oral amoxapine oral tablet 100 mg, 150 mg, 25 mg bupropion hcl er (sr) Wellbutrin SR bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg UPROPION HCL ER (XL) ORAL TALET EXTENDED RELEASE 24 HOUR 450 M bupropion hcl oral citalopram hydrobromide oral solution Wellbutrin XL Forfivo XL < 6 years < 6 years < 6 years; QL (60 EA per 30 < 6 years; QL (30 EA per 30 < 6 years < 6 years; QL (120 EA per 30 < 6 years; QL (600 ML per 30 15

22 citalopram hydrobromide oral tablet 10 mg citalopram hydrobromide oral tablet 20 mg, 40 mg CeleXA CeleXA clomipramine hcl oral Anafranil desipramine hcl oral Norpramin desvenlafaxine succinate er Pristiq doxepin hcl oral capsule doxepin hcl oral concentrate duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg duloxetine hcl oral capsule delayed release particles 60 mg EMSAM escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg, 20 mg Cymbalta Cymbalta Lexapro escitalopram oxalate oral tablet 5 mg Lexapro fluoxetine hcl oral capsule 10 mg, 40 mg PROzac fluoxetine hcl oral capsule 20 mg PROzac fluoxetine hcl oral capsule delayed release < 6 years; QL (60 EA per 30 < 6 years; QL (30 EA per 30 < 6 years < 6 years < 6 years; QL (120 EA per 30 < 6 years; QL (90 EA per 30 < 6 years; QL (180 ML per 30 < 6 years; QL (120 EA per 30 < 6 years; QL (60 EA per 30 PA; PA Required for Ages < 6 years < 6 years; QL (600 ML per 30 < 6 years; QL (30 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (120 EA per 30 PA; PA Required for Ages < 6 years 16

23 fluoxetine hcl oral solution fluvoxamine maleate er oral capsule extended release 24 hour 100 mg fluvoxamine maleate er oral capsule extended release 24 hour 150 mg fluvoxamine maleate oral tablet 100 mg fluvoxamine maleate oral tablet 25 mg fluvoxamine maleate oral tablet 50 mg FORFIVO XL Forfivo XL imipramine hcl oral Tofranil imipramine pamoate maprotiline hcl MARPLAN mirtazapine oral Remeron nefazodone hcl oral tablet 100 mg, 250 mg, 50 mg nefazodone hcl oral tablet 150 mg nefazodone hcl oral tablet 200 mg nortriptyline hcl oral Pamelor paroxetine hcl er Paxil CR 17 < 6 years; QL (600 ML per 30 < 6 years; QL (90 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (90 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (180 EA per 30 < 6 years < 6 years < 6 years < 6 years < 6 years < 6 years; QL (30 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (120 EA per 30 < 6 years; QL (90 EA per 30 < 6 years < 6 years; QL (90 EA per 30

24 paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg Paxil paroxetine hcl oral tablet 40 mg Paxil PAXIL ORAL SUSPENSION PEXEVA phenelzine sulfate oral Nardil protriptyline hcl sertraline hcl oral concentrate sertraline hcl oral tablet 100 mg Zoloft sertraline hcl oral tablet 25 mg Zoloft sertraline hcl oral tablet 50 mg Zoloft tranylcypromine sulfate Parnate trazodone hcl oral tablet 100 mg trazodone hcl oral tablet 150 mg trazodone hcl oral tablet 300 mg trazodone hcl oral tablet 50 mg trimipramine maleate oral Surmontil < 6 years; QL (30 EA per 30 < 6 years; QL (45 EA per 30 < 6 years; QL (900 ML per 30 PA; PA Required for Ages < 6 years < 6 years < 6 years < 6 years; QL (300 ML per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (90 EA per 30 < 6 years; QL (120 EA per 30 < 6 years < 6 years; QL (120 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (30 EA per 30 < 6 years; QL (90 EA per 30 < 6 years 18

25 venlafaxine hcl er oral capsule extended release 24 hour 150 mg venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 37.5 mg, 50 mg Effexor XR Effexor XR 19 < 6 years; QL (30 EA per 30 < 6 years; QL (90 EA per 30 < 6 years; QL (90 EA per 30 venlafaxine hcl oral tablet 25 mg < 6 years; QL (120 EA per 30 venlafaxine hcl oral tablet 75 mg < 6 years; QL (150 EA per 30 PA; PA Required for VIIRYD Ages < 6 years PA; PA Required for VIIRYD STARTER PACK Ages < 6 years Antiemetics - Drugs for Nausea and Vomiting ANZEMET PA aprepitant oral capsule 125 mg Emend aprepitant oral capsule 40 mg, 80 mg Emend QL (6 EA per 30 aprepitant oral capsule 80 & 125 mg Emend Tri-Pack compro Compro granisetron hcl meclizine hcl oral tablet metoclopramide hcl injection metoclopramide hcl oral solution metoclopramide hcl oral tablet Reglan motion sickness relief oral tablet chewable ondansetron hcl injection ondansetron hcl oral solution Zofran ondansetron hcl oral tablet Zofran ondansetron odt perphenazine oral < 6 years QL (30 EA per 30 QL (30 EA per 30 < 6 years

26 prochlorperazine Compro < 6 years prochlorperazine maleate oral < 6 years travel sickness oral tablet chewable trimethobenzamide hcl oral Tigan Antifungals AELCET AMISOME amphotericin b injection antifungal external aerosol Tinactin AVC VAINAL ciclodan Ciclodan ciclopirox external solution Ciclodan ciclopirox olamine external Loprox clotrimazole 3 yne-lotrimin 3 clotrimazole external cream Clotrimazole Rx clotrimazole mouth/throat clotrimazole solution 1 % external (otc) clotrimazole solution 1 % external (rx) FungiCure Intensive/Nailuard FungiCure Intensive/Nailuard 20 clotrimazole vaginal cream 1 % yne-lotrimin fluconazole in dextrose fluconazole in sodium chloride fluconazole oral Diflucan flucytosine oral Ancobon PA griseofulvin microsize oral griseofulvin ultramicrosize itraconazole oral capsule Sporanox PA ketoconazole external cream ketoconazole external shampoo Nizoral ketoconazole oral lotrimin af external powder micaderm Carrington Antifungal miconazole 1 Monistat 1 Combo Pack miconazole 3 vaginal suppository

27 miconazole 7 vaginal suppository miconazole nitrate external Carrington Antifungal MYCAMINE NOXAFIL ORAL SUSPENSION PA nyamyc Nyamyc nyata external powder unit/gm Nyamyc nystatin external nystatin mouth/throat nystatin oral nystop Nyamyc podactin external cream Carrington Antifungal terbinafine hcl external LamISIL AT terbinafine hcl oral LamISIL QL (90 EA per 365 terconazole Terazol 7 tgt clotrimazole Clotrimazole Rx tolnaftate external powder Odor Eaters Antifungal voriconazole intravenous Vfend IV PA voriconazole oral tablet Vfend PA Antigout Agents allopurinol oral Zyloprim colchicine oral capsule Mitigare COLCHICINE TALET 0.6 M ORAL Colcrys colchicine tablet 0.6 mg oral Colcrys colchicine-probenecid COLCRYS Colcrys probenecid ULORIC PA Antimigraine Agents CAFEROT MIEROT naratriptan hcl Amerge Preferred Drug; QL (9 EA per 30 rizatriptan benzoate QL (9 EA per 30 sumatriptan nasal Imitrex QL (6 EA per 30 sumatriptan succinate oral Imitrex QL (9 EA per 30 sumatriptan succinate refill Imitrex STATdose Refill QL (2 ML per 30 21

28 sumatriptan succinate subcutaneous Imitrex QL (2 ML per 30 solution sumatriptan succinate subcutaneous solution auto-injector sumatriptan succinate subcutaneous solution prefilled syringe Imitrex STATdose System zolmitriptan oral Zomig Antimyasthenic Agents pyridostigmine bromide er Mestinon pyridostigmine bromide oral Mestinon Antimycobacterials dapsone oral ethambutol hcl oral Myambutol isoniazid injection isoniazid oral pyrazinamide oral RIFAMATE rifampin intravenous Rifadin rifampin oral Rifadin SIRTURO Antineoplastics - Drugs for Cancer adriamycin Adriamycin SP adrucil intravenous solution 2.5 gm/50ml, 500 mg/10ml Adrucil SP AFINITOR PA; SP AFINITOR DISPERZ PA; SP anastrozole oral Arimidex PA bexarotene Targretin PA; SP bicalutamide Casodex CAPRELSA PA; SP cyclophosphamide injection SP cyclophosphamide oral PA cytarabine SP cytarabine (pf) injection solution 100 mg/ml doxorubicin hcl Adriamycin SP ETOPOPHOS SP 22 QL (2 ML per 30 QL (1 ML per 30 Preferred Drug; QL (9 EA per 30 SP

29 etoposide oral PA; SP exemestane Aromasin PA FARESTON PA fluorouracil intravenous solution 1 gm/20ml fluorouracil intravenous solution 2.5 gm/50ml, 500 mg/10ml flutamide 23 SP Adrucil SP LEOSTINE PA; SP HEXALEN ORAL CAPSULE 50 M PA hydroxyurea oral Hydrea PA; SP; QL (60 EA per ICLUSI 30 imatinib mesylate leevec PA; SP IMRUVICA PA; SP INLYTA PA; SP IRESSA PA; SP JAKAFI PA; SP letrozole oral Femara leucovorin calcium oral PA LEUKERAN LYSODREN MATULANE PA; SP mercaptopurine oral SP MYLERAN NEXAVAR PA; SP REVLIMID PA; SP SUTENT PA; SP TALOID SP tamoxifen citrate oral TARCEVA PA; SP TASINA PA; SP THALOMID PA; SP TYKER PA; SP VOTRIENT PA; SP XALKORI PA; SP ZELORAF PA; SP

30 ZOLINZA PA; SP Antiparasitics atovaquone oral Mepron atovaquone-proguanil hcl Malarone bedding spray lice treatment Licide chloroquine phosphate oral COARTEM EURAX EXTERNAL CREAM PA hydroxychloroquine sulfate oral Plaquenil ivermectin oral Stromectol PA lice killing Licide lice treatment external liquid Nix Creme Rinse lice treatment external lotion licemd external gel liceout licide Licide licide maximum strength Licide Maximum Strength lindane malathion Ovide medi-lice combing mefloquine hcl PENTAM permethrin external Elimite pinworm medicine praziquantel oral iltricide quinine sulfate oral Qualaquin RID ESSENTIAL LICE ELIMINATION EXTERNAL KIT % SKLICE PA spinosad Natroba PA 24 stop lice Licide stop lice maximum strength external liquid Licide Maximum Strength stop lice step 2 stop lice step 3 Licide Antiparkinson Agents amantadine hcl oral

31 benztropine mesylate oral bromocriptine mesylate oral Parlodel carbidopa-levodopa Sinemet carbidopa-levodopa er Sinemet CR carbidopa-levodopa-entacapone Stalevo 50 entacapone Comtan pramipexole dihydrochloride Mirapex ropinirole hcl Requip selegiline hcl oral trihexyphenidyl hcl Antiplatelets RILINTA PA cilostazol clopidogrel bisulfate oral Plavix dipyridamole oral Antipsychotics - Drugs for Mood Disorders AILIFY MAINTENA aripiprazole oral solution aripiprazole oral tablet Abilify aripiprazole oral tablet dispersible ARISTADA INITIO ARISTADA INTRAMUSCULAR PREFILLED SYRINE 1064 M/3.9ML < 18 years; Preferred Drug; QL (1 EA per 30 < 6 years; Preferred Drug; QL (150 ML per 30 < 6 years; Preferred Drug; QL (30 EA per 30 < 6 years; Preferred Drug; QL (30 EA per 30 < 18 years; Preferred Drug; QL (1 ML per 365 < 18 years; Preferred Drug; QL (1 ML per 60 25

32 ARISTADA INTRAMUSCULAR PREFILLED SYRINE 441 M/1.6ML, 662 M/2.4ML, 882 M/3.2ML chlorpromazine hcl injection chlorpromazine hcl oral clozapine oral tablet Clozaril clozapine oral tablet dispersible 100 mg, 25 mg clozapine oral tablet dispersible 150 mg, 200 mg FazaClo FazaClo clozapine tablet dispersible 12.5 mg oral FazaClo clozapine tablet dispersible 12.5 mg oral FazaClo fluphenazine decanoate injection fluphenazine hcl oral haloperidol decanoate intramuscular Haldol Decanoate haloperidol lactate oral haloperidol oral INVEA SUSTENNA INTRAMUSCULAR SUSPENSION 117 M/0.75ML INVEA SUSTENNA INTRAMUSCULAR SUSPENSION 156 M/ML, 234 M/1.5ML < 18 years; Preferred Drug; QL (1 ML per 30 < 6 years < 6 years < 18 years; Preferred Drug; QL (150 EA per 30 < 18 years; Preferred Drug; QL (150 EA per 30 PA required for Ages < 18 years; Preferred Drug; QL (150 EA per 30 < 18 years; Preferred Drug; QL (150 EA per 30 Preferred Drug; QL (150 EA per 30 PA required for Ages < 18 years < 6 years < 18 years < 6 years < 6 years < 18 years; Preferred Drug; QL (1 ML per 30 < 18 years; Preferred Drug; SP; QL (1 ML per 30 26

33 INVEA SUSTENNA INTRAMUSCULAR SUSPENSION 39 M/0.25ML INVEA SUSTENNA INTRAMUSCULAR SUSPENSION 78 M/0.5ML INVEA TRINZA INTRAMUSCULAR SUSPENSION 273 M/0.875ML INVEA TRINZA INTRAMUSCULAR SUSPENSION 410 M/1.315ML INVEA TRINZA INTRAMUSCULAR SUSPENSION 546 M/1.75ML INVEA TRINZA INTRAMUSCULAR SUSPENSION 819 M/2.625ML LATUDA loxapine succinate olanzapine oral tablet 10 mg, 5 mg ZyPREXA < 18 years; PA Required for Ages < 6 years; Preferred Drug; QL (0.25 ML per 26 < 18 years; PA Required for Ages < 6 years; Preferred Drug; QL (0.5 ML per 26 < 18 years; PA Required for Ages < 6 years; Preferred Drug; SP; QL (0.88 ML per 82 < 18 years; PA Required for Ages < 6 years; Preferred Drug; SP; QL (1.31 ML per 82 < 18 years; PA Required for Ages < 6 years; Preferred Drug; SP; QL (1.75 ML per 82 < 18 years; PA Required for Ages < 6 years; Preferred Drug; SP; QL (2.63 ML per 82 < 6 years; Preferred Drug; QL (30 EA per 30 < 6 years < 6 years; Preferred Drug; QL (60 EA per 30 27

34 olanzapine oral tablet 15 mg, 20 mg ZyPREXA < 6 years; Preferred Drug; QL (30 EA per 30 olanzapine oral tablet 2.5 mg, 7.5 mg ZyPREXA < 6 years; Preferred Drug olanzapine oral tablet dispersible 10 mg, 5 mg olanzapine oral tablet dispersible 15 mg, 20 mg ZyPREXA Zydis ZyPREXA Zydis quetiapine fumarate SEROquel RISPERDAL CONSTA risperidone oral solution RisperDAL risperidone oral tablet RisperDAL risperidone oral tablet dispersible 0.25 mg risperidone oral tablet dispersible 0.5 mg, 1 mg, 2 mg risperidone oral tablet dispersible 3 mg, 4 mg SAPHRIS RisperiDONE M-TA 28 < 6 years; Preferred Drug; QL (60 EA per 30 < 6 years; Preferred Drug; QL (30 EA per 30 < 6 years; Preferred Drug; QL (60 EA per 30 < 18 years; PA Required for Ages < 6 years; Preferred Drug; SP; QL (2 EA per 30 < 6 years; Preferred Drug; QL (240 ML per 28 < 6 years; Preferred Drug; QL (60 EA per 30 Preferred Drug; QL (60 EA per 30 < 6 years; Preferred Drug; QL (60 EA per 30 < 6 years; Preferred Drug; QL (60 EA per 30 < 6 years; Preferred Drug; QL (60 EA per 30

35 thioridazine hcl oral thiothixene trifluoperazine hcl ziprasidone hcl eodon Antivirals abacavir sulfate oral tablet Ziagen abacavir sulfate-lamivudine Epzicom abacavir-lamivudine-zidovudine Trizivir acyclovir external Zovirax acyclovir oral Zovirax acyclovir sodium intravenous solution reconstituted 500 mg adefovir dipivoxil Hepsera PA; SP APTIVUS atazanavir sulfate Reyataz ATRIPLA ARACLUDE ORAL SOLUTION PA; SP IKTARVY cidofovir intravenous COMPLERA CRIXIVAN DESCOVY didanosine Videx EC EDURANT efavirenz oral tablet Sustiva EMTRIVA entecavir araclude PA; SP EPIVIR HV ORAL SOLUTION SP EVOTAZ famciclovir oral FUZEON PA 29 < 6 years < 6 years < 6 years < 6 years; Preferred Drug; QL (60 EA per 30 QL (15 M per 30 QL (30 EA per 30

36 ganciclovir sodium intravenous solution reconstituted Cytovene ENVOYA INTELENCE INTRON A PA; SP INVIRASE ISENTRESS ORAL TALET ISENTRESS ORAL TALET CHEWALE KALETRA ORAL TALET lamivudine oral solution Epivir lamivudine oral tablet 100 mg Epivir HV SP lamivudine oral tablet 150 mg, 300 mg Epivir lamivudine-zidovudine Combivir LEXIVA ORAL SUSPENSION lopinavir-ritonavir Kaletra MAVYRET moderiba Moderiba nevirapine Viramune nevirapine er Viramune XR NORVIR ORAL CAPSULE 100 M NORVIR ORAL SOLUTION ODEFSEY oseltamivir phosphate oral capsule 30 mg Tamiflu oseltamivir phosphate oral capsule 45 mg, 75 mg oseltamivir phosphate oral suspension reconstituted PEASYS PEASYS PROCLICK PEINTRON PREZCOIX PREZISTA Tamiflu Tamiflu PA; Preferred Drug; SP PA; Preferred Drug; SP QL (20 EA per 180 QL (10 EA per 180 QL (60 ML per 180 PA; Preferred Drug; SP PA; Preferred Drug; SP PA; Preferred Drug; SP 30

37 RELENZA DISKHALER RESCRIPTOR ribasphere oral capsule Rebetol ribasphere oral tablet 200 mg Moderiba ribavirin oral Rebetol rimantadine hcl Flumadine ritonavir Norvir SELZENTRY ORAL TALET PA stavudine Zerit STRIILD tenofovir disoproxil fumarate Viread TIVICAY TRIUMEQ TRUVADA PA TYOST valacyclovir hcl oral Valtrex valganciclovir hcl Valcyte PA VIDEX VIRACEPT VIREAD ORAL TALET 150 M, 200 M, 250 M zidovudine Retrovir Anxiolytics - Drugs for Anxiety alprazolam er Xanax XR ALPRAZOLAM INTENSOL alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg Xanax alprazolam oral tablet 2 mg Xanax QL (10 EA per 365 PA; Preferred Drug; SP PA; Preferred Drug; SP PA; Preferred Drug; SP < 6 years; QL (30 EA per 30 < 6 years; QL (60 ML per 15 < 6 years; QL (120 EA per 30 < 6 years; QL (60 EA per 30 31

38 alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg alprazolam oral tablet dispersible 2 mg alprazolam xr Xanax XR buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg buspirone hcl oral tablet 30 mg chlordiazepoxide hcl clonazepam oral tablet 0.5 mg, 1 mg KlonoPIN clonazepam oral tablet 2 mg KlonoPIN clonazepam oral tablet dispersible mg, 0.25 mg, 0.5 mg, 1 mg clonazepam oral tablet dispersible 2 mg clorazepate dipotassium oral tablet 15 mg clorazepate dipotassium oral tablet 3.75 mg clorazepate dipotassium oral tablet 7.5 mg diazepam injection Tranxene-T diazepam intensol Diazepam Intensol < 6 years; QL (120 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (30 EA per 30 < 6 years; QL (120 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (120 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (120 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (120 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (120 EA per 30 < 6 years < 6 years; QL (60 ML per 30 32

39 diazepam oral concentrate Diazepam Intensol < 6 years; QL (60 ML per 30 diazepam oral solution 1 mg/ml diazepam oral tablet Valium hydroxyzine hcl intramuscular hydroxyzine hcl oral syrup hydroxyzine hcl oral tablet hydroxyzine pamoate oral lorazepam injection Ativan lorazepam intensol LORazepam Intensol lorazepam oral concentrate LORazepam Intensol lorazepam oral tablet 0.5 mg, 1 mg Ativan lorazepam oral tablet 2 mg Ativan oxazepam ipolar Agents - Drugs for Mood Disorders lithium lithium carbonate er Lithobid lithium carbonate oral capsule lithium carbonate oral tablet 33 < 6 years; QL (300 EA per 30 < 6 years; QL (120 EA per 30 QL (300 ML per 30 QL (240 EA per 30 QL (120 EA per 30 < 6 years < 6 years; QL (60 ML per 30 < 6 years; QL (60 ML per 30 < 6 years; QL (120 EA per 30 < 6 years; QL (60 EA per 30 < 6 years; QL (60 EA per 30 < 6 years < 6 years; QL (30 EA per 30 < 6 years; QL (30 EA per 30 < 6 years

40 lood Products / Modifiers / Volume Expanders - Drugs for leeding Disorders ADVATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS SP ADVATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 2000 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 2000 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 250 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 250 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 3000 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 3000 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 4000 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 4000 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS ADVATE SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS Preferred Vendor; SP SP Preferred Vendor; SP SP Preferred Vendor; SP SP Preferred Vendor; SP SP Preferred Vendor; SP SP Preferred Vendor; SP SP Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP 34

41 ADYNOVATE SOLUTION RECONSTITUTED 2000 UNIT INTRAVENOUS PA; SP ADYNOVATE SOLUTION RECONSTITUTED 2000 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 250 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 250 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 3000 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 3000 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 750 UNIT INTRAVENOUS ADYNOVATE SOLUTION RECONSTITUTED 750 UNIT INTRAVENOUS AFSTYLA ALPHANATE/VWF COMPLEX/HUMAN SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS ALPHANATE/VWF COMPLEX/HUMAN SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS ALPHANATE/VWF COMPLEX/HUMAN SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS ALPHANATE/VWF COMPLEX/HUMAN SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; Preferred Vendor; SP SP Preferred Vendor; SP SP Preferred Vendor; SP 35

42 ALPHANATE/VWF COMPLEX/HUMAN SOLUTION RECONSTITUTED 2000 UNIT INTRAVENOUS SP ALPHANATE/VWF COMPLEX/HUMAN SOLUTION RECONSTITUTED 2000 UNIT INTRAVENOUS ALPHANATE/VWF COMPLEX/HUMAN SOLUTION RECONSTITUTED 250 UNIT INTRAVENOUS ALPHANATE/VWF COMPLEX/HUMAN SOLUTION RECONSTITUTED 250 UNIT INTRAVENOUS ALPHANATE/VWF COMPLEX/HUMAN SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS ALPHANATE/VWF COMPLEX/HUMAN SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS ALPHANINE SD SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS ALPHANINE SD SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS ALPHANINE SD SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS ALPHANINE SD SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS ALPHANINE SD SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS ALPHANINE SD SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT ALPROLIX SOLUTION RECONSTITUTED 250 UNIT INTRAVENOUS ALPROLIX SOLUTION RECONSTITUTED 250 UNIT INTRAVENOUS Preferred Vendor; SP SP Preferred Vendor; SP SP Preferred Vendor; SP SP Preferred Vendor; SP SP Preferred Vendor; SP SP Preferred Vendor; SP PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP 36

43 ALPROLIX SOLUTION RECONSTITUTED 4000 UNIT INTRAVENOUS PA; SP ALPROLIX SOLUTION RECONSTITUTED 4000 UNIT INTRAVENOUS AMICAR ORAL TALET anagrelide hcl Agrylin ARANESP (ALUMIN FREE) PA; SP EULIN INTRAVENOUS SOLUTION RECONSTITUTED UNIT 37 PA; Preferred Vendor; SP Preferred Vendor; SP ENEFIX Preferred Vendor; SP PA; Preferred Vendor; CEPROTIN SP CORIFACT Preferred Vendor; SP ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 4000 UNIT ELOCTATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 1500 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 2000 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 2000 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 250 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 250 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 3000 UNIT INTRAVENOUS PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; SP

44 ELOCTATE SOLUTION RECONSTITUTED 3000 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 500 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 5000 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 5000 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 6000 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 6000 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 750 UNIT INTRAVENOUS ELOCTATE SOLUTION RECONSTITUTED 750 UNIT INTRAVENOUS 38 PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; SP PA; Preferred Vendor; SP PA; SP EPOEN PA; SP PA; Preferred Vendor; SP FEIA Preferred Vendor; SP HELIXATE FS Preferred Vendor; SP HEMLIRA PA; SP hemofil m intravenous solution reconstituted 1000 unit, 250 unit, 500 unit Preferred Vendor; SP HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1700 UNIT Preferred Vendor; SP HUMATE-P Preferred Vendor; SP IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT PA; Preferred Vendor; SP IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 2000 UNIT, 250 UNIT, Ixinity Preferred Vendor; SP 3000 UNIT IXINITY SOLUTION RECONSTITUTED 1000 UNIT INTRAVENOUS Ixinity SP