Trusted Health Plan Formulary

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1 2017 Trusted Health Plan Formulary Version 9, Effective 10/5/2017

2 Introduction... 6 The Trusted Health Plan Pharmacy and Therapeutics Committee (P&T)... 6 Notice...6 Preface...6 Product Selection Criteria... 6 Formulary Components... 6 Generic Substitution...6 Covered Medications without Authorization...6 Non-Covered Benefits...7 Prior Authorization... 7 Step Therapy... 7 Specialty Medications... 7 Quantity Limits... 7 Benefit Exception...7 Pharmacy Benefit Management...7 Prior Authorization Information... 8 Acne Therapy...16 Agents for Narcotic Withdrawal...17 Alcoholism Treatment Agents Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic Analgesics - Narcotic Angina Therapy...22 Anorectal - Glucocorticoids Anorectal Combinations...23 Anterior Pituitary Hormones and Hormone Antagonists Anti-Infective - Immunologic Adjuvants...23 Antianxiety Agents Antiarrhythmics Antibacterial Agents...26 Anticoagulants Anticonvulsants...30 Antidepressants Antidiarrheals...35 Antiemetics Antifungals Antihemophilic Factor Agents Antihistamines...37 Antihyperlipidemics Antihypertensive Therapy Agents Antineoplastic - Alkylating Agents...42 Antineoplastic - Antibody/Antibody-Drug Complexes Antineoplastic - Antimetabolites...42 Antineoplastic - Hedgehog Pathway Inhibitor Antineoplastic - Hormone/Hormone Antagonist Agents...43 Antineoplastic - Immunomodulators...44 Antineoplastic - Mast Cell Stabilizers...44 Antineoplastic - Metal Complexes...44 Antineoplastic - Retinoids and Retinoid Receptor Agonists...44 Antineoplastic - Systemic Enzyme Inhibitors Antineoplastic - Topoisomerase Inhibitors Antiparasitics...45 Antiparkinson Therapy...45 Antiprotozoal-Antibacterial Agents...47 Antipsychotics (Neuroleptics)...47 Antitussives...49 Antivirals Appetite Stimulants...50 Asthma/COPD Therapy Agents Attention Deficit-Hyperact Disorder (ADHD) Therapy...52 Beta Adrenergic Blockers Bipolar Therapy Agents Blood Albumin and Plasma Proteins...55 Bradykinin B2 Receptor Antagonists Calcium and Bone Metabolism Regulators...55 Calcium Channel Blockers and Combinations...55 Cardiac Inotropes...56 Cardiovascular Sympathomimetics and Combinations

3 Chelating Agents...57 Chemotherapy Rescue-Antidote Agents...57 CNS Stimulants...57 Cognitive Disorder Therapy - Antidementia Colonic Acidifier (Ammonia Inhibitor)...58 Contraceptives Implant Contraceptives Injectable...58 Contraceptives Intravaginal Contraceptives Oral Contraceptives Transdermal...62 Corticosteroids...62 Cystic Fibrosis Therapy Agents Dental-Periodontal Products Dermatological - Anti-infectives Dermatological - Antineoplastic or Premalignant Lesions...64 Dermatological - Antiparasitics and Combinations Dermatological - Antipruritics Dermatological - Antipsoriatics Dermatological - Antiseborrheic Products and Combinations...65 Dermatological - Burn Products Dermatological - Emollients and Combinations Dermatological - Glucocorticoids and Combinations Dermatological - Immunomodulating Agents Dermatological - Immunosuppressive Agents Dermatological - Keratolytics-Antimitotics...67 Dermatological - NSAID s Dermatological - Rosacea Therapy Dermatological - Topical Local Anesthetics and Combinations Diabetic Therapy...68 Diagnostic Drugs - In Vivo Digestive Aids Diuretics...70 Emergency Contraceptives and Combinations...71 Estrogens and Combinations...71 Gallstone Solubilizing (Litholysis) Agents and Combinations Gastrointestinal Antispasmodics...72 Gastrointestinal Prokinetic Agents General Anesthetics...73 General Injectable Solutions and Diluents Genitourinary Irrigants Hematopoietic Agents...73 Hepatic Hormones (Hormones Secreted by the Liver) Hyperuricemia Therapy...74 Immunosuppressive - Calcineurin Inhibitors Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors Immunosuppressive - Mammalian Target of Rapamycin (mtor) Inhibitors Immunosuppressive - Purine Analogs Inflammatory Bowel Agents Interstitial Cystitis Agents...76 Irrigation Solutions Irritable Bowel Syndrome (IBS) Agents Laxatives...76 Local Anesthetics - Parenteral Medical Supplies and DME - Diabetic Supplies...77 Medical Supplies and DME - Respiratory Therapy Metabolic Disease Enzyme Replacement, Gaucher s Disease Migraine Therapy...80 Minerals and Electrolytes...80 Mouth and Throat - Anti-infectives Mouth and Throat - Glucocorticoids...81 Mouth and Throat - Local Anesthetics Mouth and Throat - Xerostomia Therapy Mucolytics Multiple Sclerosis Agent - Interferons Multiple Sclerosis Agent - Potassium Channel Blocker Musculoskeletal Therapy Agents Narcolepsy and Cataplexy Therapy Agents

4 Nasal Preparations Neuromuscular Therapy Agents Ophthalmic - Anti-allergy...83 Ophthalmic - Anti-infectives Ophthalmic - Anti-inflammatory...83 Ophthalmic - Intraocular Pressure Reducing Agents...84 Ophthalmic - Mydriatics and Cycloplegics Ophthalmic Combinations...84 Opiate/Narcotic Reversal Agents - Opiate Antagonists Otic - Anti-infectives Otic Combinations...85 Oxytocics Passive Immunizing Agents...85 Peptic Ulcer Therapy Pharmaceutical Adjuvants Phosphate Binders...86 Platelet Aggregation Inhibitors and Combinations Posterior Pituitary Hormones Progestins...87 Prostatic Hypertrophy Agents Pseudobulbar Affect (PBA) Agents...87 Respiratory Combinations...87 Sedative-Hypnotics...88 Sickle Cell Anemia Agents...88 Smoking Deterrents and Combinations Thyroid Therapy...88 Urinary Analgesics Urinary Anti-infectives Urinary Antispasmodics Urinary ph Modifiers Urinary Retention Therapy...91 Vaginal Anti-infectives...91 Vaginal Estrogens...92 Vitamin Combinations Vitamins Wound Care Therapy...98 Acne Therapy...99 Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic Anorectal - Hemorrhoidal Single Agents Other Anorectal Combinations Antacids and Combinations Antidiarrheals Antiemetics Antihistamines Antiseptic - Biguanides Antitussives Artificial Tears and Lubricants Chemicals - Solvents Dermatological - Anti-infectives Dermatological - Antiparasitics and Combinations Dermatological - Antipruritics Dermatological - Astringents and Combinations Dermatological - Emollients and Combinations Dermatological - Glucocorticoids and Combinations Dermatological - Irritants-Counter-Irritants Dermatological - Keratolytics-Antimitotics Diabetic Therapy Dietary Products Digestive Aids Emergency Contraceptives and Combinations Expectorants Gastrointestinal Antiflatulents and Combinations Irrigation Solutions Laxatives Medical Supplies and DME - Diabetic Supplies Medical Supplies and DME - GI-GU Ostomy and Irrigation Supplies Medical Supplies and DME - Thermometers

5 Minerals and Electrolytes Mouth and Throat - Non-Narcotic Antitussive - Local Anesthetic Combos Nasal Preparations Nutritional Product - Nutritional Therapy Ophthalmic - Anti-allergy Ophthalmic - Hyperosmolar Agents Peptic Ulcer Therapy Respiratory Combinations Sedative-Hypnotics Smoking Deterrents and Combinations Urinary Analgesics Vaginal Anti-infectives Vitamin Combinations Vitamins

6 Introduction Trusted Health Plan is pleased to provide an updated 2017 Medicaid Formulary as a reference and informational tool for physicians, pharmacists and patients. The Trusted Health Plan Formulary is designed to assist practitioners in selecting clinically appropriate and cost-effective products for their patients. The Trusted Health Plan Pharmacy and Therapeutics Committee (P&T) The medications on this formulary have been reviewed by the Trusted Health Plan Pharmacy P&T Committee. The Committee includes physicians, pharmacists and health professionals. The clinical information within the formulary is primarily derived from medical literature and is reviewed and approved by the P&T Committee. Notice The information contained in this formulary is provided by Trusted Health Plan, solely for the convenience of medical providers. This formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs. Trusted Health Plan assumes no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer s product literature or standard references for more detailed information. Preface The Trusted Health Plan formulary is organized by sections. Each section includes therapeutic groups identified by either drug class or disease state. Products are listed by generic name. Brand and common names are included as a reference to assist in product recognition. Trusted Health Plan will not cover prescription drugs that are prescribed for experimental, investigational or non FDA approved indications, dosages, or routes of administration. Trusted Health Plan does not cover any medication excluded by District of Columbia Medicaid ( downloads/providers/dcrx_pdl_listing.pdf). Product Selection Criteria The MeridianRx P&T Committee considers clinical information on new to market drugs that are typically included in an outpatient pharmacy benefit. The primary goal of the MeridianRx P&T Committee is to preserve and evaluate the Trusted Health Plan formulary based upon an objective analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient administration/compliance considerations and cost effectiveness. When a new drug is considered for formulary inclusion, it will be reviewed relative to similar drugs currently included in the Trusted Health Plan Formulary. Formulary decisions are communicated quarterly on the Trusted Health Plan website. Therapeutic substitution occurs when a preferred drug is approved for use because it has similar treatment effects but is not identical to a nonpreferred drug. Formulary Components The Trusted Health Plan Formulary contains the following components: Covered medications without authorization, medications that must meet Step Therapy Protocol, medications that require Prior Authorization, Specialty medications and medications that are subject to Quantity Limits. Members will not be charged a co-pay when Trusted Health Plan covers a medication. Generic Substitution Trusted Health Plan is a mandatory generic plan. The brand and common names listed in the formulary are for reference only. Generic medication will be dispensed where available. Covered Medications without Authorization Trusted Health Plan covers many medications without any authorization required. These medications include many prescription and over-the-counter medications (when ordered by a physician). 6

7 Non-Covered Benefits The following categories are not covered benefits: Medications used for cosmetic purposes, to promote fertility, for sexual dysfunction, for experimental or investigational purposes, or medications that are not licensed for use in the United States. Prior Authorization Drugs indicated with "PA" require Prior Authorization for coverage. Details of the PA criteria are listed next to the drug name. Please call the MeridianRx Help Desk at or fax a completed Prior Authorization form to All requests must be accompanied by pertinent clinical information and are reviewed within 72 hours. Step Therapy Drugs indicated with a "ST" require Step Therapy for coverage. The required step is listed next to the drug name. Step Therapy ensures clinically appropriate and cost-effective drugs are used before other alternatives. Specialty Medications All specialty medications noted as "SP" are handled by MeridianRx. To order a specialty medication by fax, send the prescription and a completed prior authorization form to or call MeridianRx s Help Desk at Quantity Limits Drugs indicated with a "QL" have a set quantity limit imposed. These limits are based on FDA recommended dosing guidelines. The quantity limit is listed next to the drug name. All medications are subject to a maximum of 30 days per prescription. Benefit Exception The process for requesting non formulary medication(s) requires faxing of a completed Formulary Exception form indicating the request for an exception to the formulary. This request will need to include pertinent clinical documentation showing trial and failure of all formulary agents. It should also contain information showing the medication is the standard of care for the indication provided (Peer reviewed journal articles may be required). Please call the MeridianRx Help Desk at or fax a completed Formulary Exception form to Pharmacy Benefit Management Trusted Health Plan utilizes MeridianRx to manage each member s pharmacy benefit. MeridianRx provides Trusted Health Plan with a pharmacy network, pharmacy claims management services, and claims adjudication. MeridianRx s Help Desk can be contacted at

8 Prior Authorization Information Agents for Narcotic Withdrawal SUBOXONE 12 MG-3 MG SL FILM SUBOXONE PA SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE PA SUBOXONE 4 MG-1 MG SL FILM SUBOXONE PA SUBOXONE 8 MG-2 MG SL FILM SUBOXONE PA Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic BENLYSTA 120 MG VIAL BENLYSTA PA BENLYSTA 400 MG VIAL BENLYSTA PA ENBREL 25 MG KIT ENBREL PA ENBREL 25 MG/0.5 ML SYRINGE ENBREL PA ENBREL 50 MG/ML SURECLICK SYR ENBREL PA ENBREL 50 MG/ML SYRINGE ENBREL PA HUMIRA 40 MG/0.8 ML PEN HUMIRA PEN PA HUMIRA PEN CROHN-UC-HS STARTER HUMIRA PEN PSORIASIS-UVEITIS STARTER HUMIRA PEN CROHN-UC-HS STARTER HUMIRA PEN PSORIASIS- UVEITIS KINERET 100 MG/0.67 ML SYRINGE KINERET PA PA PA Anterior Pituitary Hormones and Hormone Antagonists LUPRON DEPOT MG (LUPANETA) LUPRON DEPOT (LUPANETA) LUPRON DEPOT MG 3MO KIT LUPRON DEPOT PA LUPRON DEPOT 3.75 MG (LUPANETA) LUPRON DEPOT (LUPANETA) PA LUPRON DEPOT 3.75 MG KIT LUPRON DEPOT PA LUPRON DEPOT-PED MG 3MO KIT LUPRON DEPOT-PED LUPRON DEPOT-PED MG KIT LUPRON DEPOT-PED PA LUPRON DEPOT-PED 15 MG KIT LUPRON DEPOT-PED PA LUPRON DEPOT-PED 30 MG 3MO KIT LUPRON DEPOT-PED PA LUPRON DEPOT-PED 7.5 MG KIT LUPRON DEPOT-PED PA PA PA Anti-Infective - Immunologic Adjuvants ACTIMMUNE 100 MCG/0.5 ML VIAL ACTIMMUNE PA,SP Antibacterial Agents THALOMID 100 MG CAPSULE THALOMID PA THALOMID 150 MG CAPSULE THALOMID PA THALOMID 200 MG CAPSULE THALOMID PA THALOMID 50 MG CAPSULE THALOMID PA Anticonvulsants ONFI 10 MG TABLET ONFI PA ONFI 20 MG TABLET ONFI PA 8

9 Prior Authorization Information Antidepressants CYMBALTA 20 MG CAPSULE CYMBALTA PA,QL CYMBALTA 30 MG CAPSULE CYMBALTA PA,QL CYMBALTA 60 MG CAPSULE CYMBALTA PA,QL Antihemophilic Factor Agents ADVATE 2,401-3,600 UNIT VIAL ADVATE PA ALPHANATE 1, UNIT VIAL ALPHANATE PA ALPHANATE 1, UNIT VIAL ALPHANATE PA ALPHANATE UNIT VIAL ALPHANATE PA ALPHANATE UNIT VIAL ALPHANATE PA ALPHANINE SD 1,000 UNITS VIAL ALPHANINE SD PA ALPHANINE SD 1,500 UNITS VIAL ALPHANINE SD PA ALPHANINE SD 500 UNITS VIAL ALPHANINE SD PA BENEFIX 1,000 UNIT RANGE BENEFIX PA BENEFIX 2,000 UNIT RANGE BENEFIX PA BENEFIX 250 UNIT RANGE BENEFIX PA BENEFIX 3,000 UNIT RANGE BENEFIX PA BENEFIX 500 UNIT RANGE BENEFIX PA FEIBA NF 1,000 UNIT (NOMINAL) FEIBA NF PA FEIBA NF 2,500 UNIT (NOMINAL) FEIBA NF PA FEIBA NF 500 UNIT (NOMINAL) FEIBA NF PA HELIXATE FS 3,000 UNITS VIAL HELIXATE FS PA HEMOFIL M 1,000 UNIT NOMINAL HEMOFIL M PA HEMOFIL M 1,700 UNIT NOMINAL HEMOFIL M PA HEMOFIL M 250 UNIT NOMINAL HEMOFIL M PA HEMOFIL M 500 UNIT NOMINAL HEMOFIL M PA KOGENATE FS 3,000 UNIT-BIOSET KOGENATE FS PA KOGENATE FS 3,000 UNITS VIAL KOGENATE FS PA KOVALTRY 3,000 UNIT KIT KOVALTRY PA KOVALTRY 3,000 UNIT VIAL KOVALTRY PA MONONINE 1,000 UNIT VIAL MONONINE PA NOVOSEVEN RT 1 MG VIAL NOVOSEVEN RT PA NOVOSEVEN RT 2 MG VIAL NOVOSEVEN RT PA NOVOSEVEN RT 5 MG VIAL NOVOSEVEN RT PA NOVOSEVEN RT 8 MG VIAL NOVOSEVEN RT PA RECOMBINATE 1,241-1,800 UNIT V RECOMBINATE PA RECOMBINATE 1,801-2,400 UNIT V RECOMBINATE PA RECOMBINATE UNIT VIAL RECOMBINATE PA RECOMBINATE UNIT VIAL RECOMBINATE PA RECOMBINATE 801-1,240 UNIT VL RECOMBINATE PA RIXUBIS 1,000 UNIT NOMINAL RIXUBIS PA RIXUBIS 2,000 UNIT NOMINAL RIXUBIS PA RIXUBIS 250 UNIT NOMINAL RIXUBIS PA 9

10 Prior Authorization Information Antihemophilic Factor Agents RIXUBIS 3,000 UNIT NOMINAL RIXUBIS PA RIXUBIS 500 UNIT NOMINAL RIXUBIS PA Antihyperlipidemics JUXTAPID 10 MG CAPSULE JUXTAPID PA JUXTAPID 20 MG CAPSULE JUXTAPID PA JUXTAPID 5 MG CAPSULE JUXTAPID PA Antihypertensive Therapy Agents LETAIRIS 10 MG TABLET LETAIRIS PA LETAIRIS 5 MG TABLET LETAIRIS PA Antineoplastic - Alkylating Agents TEMODAR 100 MG CAPSULE TEMODAR PA TEMODAR 140 MG CAPSULE TEMODAR PA,QL TEMODAR 180 MG CAPSULE TEMODAR PA,QL TEMODAR 20 MG CAPSULE TEMODAR PA,QL TEMODAR 250 MG CAPSULE TEMODAR PA,QL TEMODAR 5 MG CAPSULE TEMODAR PA,QL TEMOZOLOMIDE 100 MG CAPSULE TEMOZOLOMIDE PA TEMOZOLOMIDE 140 MG CAPSULE TEMOZOLOMIDE PA TEMOZOLOMIDE 180 MG CAPSULE TEMOZOLOMIDE PA TEMOZOLOMIDE 20 MG CAPSULE TEMOZOLOMIDE PA TEMOZOLOMIDE 250 MG CAPSULE TEMOZOLOMIDE PA TEMOZOLOMIDE 5 MG CAPSULE TEMOZOLOMIDE PA Antineoplastic - Antibody/Antibody-Drug Complexes PERJETA 420 MG/14 ML VIAL PERJETA PA Antineoplastic - Antimetabolites CAPECITABINE 150 MG TABLET CAPECITABINE PA CAPECITABINE 500 MG TABLET CAPECITABINE PA XELODA 150 MG TABLET XELODA PA XELODA 500 MG TABLET XELODA PA Antineoplastic - Hedgehog Pathway Inhibitor ERIVEDGE 150 MG CAPSULE ERIVEDGE PA Antineoplastic - Hormone/Hormone Antagonist Agents ELIGARD 22.5 MG SYRINGE B ELIGARD PA ELIGARD 22.5 MG SYRINGE KIT ELIGARD PA ELIGARD 30 MG SYRINGE B ELIGARD PA ELIGARD 30 MG SYRINGE KIT ELIGARD PA 10

11 Prior Authorization Information Antineoplastic - Hormone/Hormone Antagonist Agents ELIGARD 45 MG SYRINGE B ELIGARD PA ELIGARD 45 MG SYRINGE KIT ELIGARD PA ELIGARD 7.5 MG SYRINGE B ELIGARD PA ELIGARD 7.5 MG SYRINGE KIT ELIGARD PA LEUPROLIDE 1 MG/0.2 ML VIAL LEUPROLIDE ACETATE PA LEUPROLIDE 2WK 1 MG/0.2 ML KIT LEUPROLIDE ACETATE PA LEUPROLIDE 2WK 14 MG/2.8 ML KT LEUPROLIDE ACETATE PA LEUPROLIDE 2WK 14 MG/2.8 ML VL LEUPROLIDE ACETATE PA LUPRON DEPOT 22.5 MG 3MO KIT LUPRON DEPOT PA LUPRON DEPOT 45 MG 6MO KIT LUPRON DEPOT PA LUPRON DEPOT 7.5 MG KIT LUPRON DEPOT PA LUPRON DEPOT-4 MONTH KIT LUPRON DEPOT PA TRELSTAR MG SYRINGE TRELSTAR PA TRELSTAR MG VIAL TRELSTAR PA TRELSTAR 22.5 MG SYRINGE TRELSTAR PA TRELSTAR 22.5 MG VIAL TRELSTAR PA TRELSTAR 3.75 MG SYRINGE TRELSTAR PA TRELSTAR 3.75 MG VIAL TRELSTAR PA XTANDI 40 MG CAPSULE XTANDI PA ZOLADEX 10.8 MG IMPLANT SYRN ZOLADEX PA ZOLADEX 3.6 MG IMPLANT SYRN ZOLADEX PA Antineoplastic - Systemic Enzyme Inhibitors BOSULIF 100 MG TABLET BOSULIF PA BOSULIF 500 MG TABLET BOSULIF PA COMETRIQ 100 MG DAILY-DOSE PK COMETRIQ PA COMETRIQ 140 MG DAILY-DOSE PK COMETRIQ PA COMETRIQ 60 MG DAILY-DOSE PACK COMETRIQ PA GLEEVEC 100 MG TABLET GLEEVEC PA,QL GLEEVEC 400 MG TABLET GLEEVEC PA,QL ICLUSIG 15 MG TABLET ICLUSIG PA ICLUSIG 45 MG TABLET ICLUSIG PA IMATINIB MESYLATE 100 MG TAB IMATINIB MESYLATE PA,QL IMATINIB MESYLATE 400 MG TAB IMATINIB MESYLATE PA,QL JAKAFI 10 MG TABLET JAKAFI PA JAKAFI 15 MG TABLET JAKAFI PA JAKAFI 20 MG TABLET JAKAFI PA JAKAFI 25 MG TABLET JAKAFI PA JAKAFI 5 MG TABLET JAKAFI PA TARCEVA 100 MG TABLET TARCEVA PA,QL,SP Prior Authorization Required; Limited to 30 tablets per 30 days. 11

12 Prior Authorization Information Antineoplastic - Systemic Enzyme Inhibitors TARCEVA 150 MG TABLET TARCEVA PA,QL,SP Prior Authorization Required; Limited to 30 tablets per 30 days. TARCEVA 25 MG TABLET TARCEVA PA,QL,SP Prior Authorization Required; Limited to 90 tablets per 30 days. XALKORI 200 MG CAPSULE XALKORI PA XALKORI 250 MG CAPSULE XALKORI PA ZELBORAF 240 MG TABLET ZELBORAF PA Antineoplastic - Topoisomerase Inhibitors HYCAMTIN 0.25 MG CAPSULE HYCAMTIN PA HYCAMTIN 1 MG CAPSULE HYCAMTIN PA Antivirals APTIVUS 100 MG/ML SOLUTION APTIVUS PA APTIVUS 250 MG CAPSULE APTIVUS PA EPCLUSA 400 MG-100 MG TABLET EPCLUSA PA,SP HEPSERA 10 MG TABLET HEPSERA PA MAVYRET MG TABLET MAVYRET PA,SP Prior Authorization Required PEGASYS 180 MCG/0.5 ML SYRINGE PEGASYS PA PEGASYS 180 MCG/ML VIAL PEGASYS PA PEGASYS PROCLICK 135 MCG/0.5 ML PEGASYS PROCLICK PA PEGASYS PROCLICK 180 MCG/0.5 PEGASYS PROCLICK PA PEGINTRON 50 MCG KIT PEGINTRON REDIPEN PA PEGINTRON REDIPEN 120 MCG PEGINTRON REDIPEN PA PEGINTRON REDIPEN 150 MCG PEGINTRON REDIPEN PA PEGINTRON REDIPEN 50 MCG PEGINTRON REDIPEN PA REBETOL 40 MG/ML SOLUTION REBETOL PA RIBAVIRIN 200 MG CAPSULE RIBAVIRIN PA RIBAVIRIN 200 MG TABLET RIBAVIRIN PA RIBAVIRIN 6 GM INHALATION VIAL RIBAVIRIN PA TRUVADA 100 MG-150 MG TABLET TRUVADA PA,SP Prior Authorization Required TRUVADA 133 MG-200 MG TABLET TRUVADA PA,SP Prior Authorization Required TRUVADA 167 MG-250 MG TABLET TRUVADA PA,SP Prior Authorization Required TRUVADA 200 MG-300 MG TABLET TRUVADA PA,SP Prior Authorization Required Asthma/COPD Therapy Agents XOLAIR 150 MG VIAL XOLAIR PA Bipolar Therapy Agents ABILIFY 10 MG TABLET ABILIFY PA ABILIFY 15 MG TABLET ABILIFY PA ABILIFY 2 MG TABLET ABILIFY PA ABILIFY 20 MG TABLET ABILIFY PA 12

13 Prior Authorization Information Bipolar Therapy Agents ABILIFY 30 MG TABLET ABILIFY PA ABILIFY 5 MG TABLET ABILIFY PA Blood Albumin and Plasma Proteins CINRYZE 500 UNIT VIAL CINRYZE PA Bradykinin B2 Receptor Antagonists FIRAZYR 30 MG/3 ML SYRINGE FIRAZYR PA Calcium and Bone Metabolism Regulators FORTEO 600 MCG/2.4 ML PEN INJ FORTEO PA Chelating Agents EXJADE 125 MG TABLET EXJADE PA EXJADE 250 MG TABLET EXJADE PA EXJADE 500 MG TABLET EXJADE PA Cystic Fibrosis Therapy Agents KALYDECO 150 MG TABLET KALYDECO PA TOBI 300 MG/5 ML SOLUTION TOBI PA TOBI PODHALER 28 MG INHALE CAP TOBI PODHALER PA Diabetic Therapy BYDUREON 2 MG VIAL BYDUREON PA Hematopoietic Agents ARANESP 100 MCG/0.5 ML SYRINGE ARANESP PA ARANESP 100 MCG/ML VIAL ARANESP PA ARANESP 150 MCG/0.3 ML SYRINGE ARANESP PA ARANESP 150 MCG/0.75 ML VIAL ARANESP PA ARANESP 200 MCG/0.4 ML SYRINGE ARANESP PA ARANESP 200 MCG/ML VIAL ARANESP PA ARANESP 25 MCG/0.42 ML SYRING ARANESP PA ARANESP 25 MCG/ML VIAL ARANESP PA ARANESP 300 MCG/0.6 ML SYRINGE ARANESP PA ARANESP 300 MCG/ML VIAL ARANESP PA ARANESP 40 MCG/0.4 ML SYRINGE ARANESP PA ARANESP 40 MCG/ML VIAL ARANESP PA ARANESP 500 MCG/1 ML SYRINGE ARANESP PA ARANESP 60 MCG/0.3 ML SYRINGE ARANESP PA ARANESP 60 MCG/ML VIAL ARANESP PA EPOGEN 10,000 UNITS/ML VIAL EPOGEN PA EPOGEN 2,000 UNITS/ML VIAL EPOGEN PA 13

14 Prior Authorization Information Hematopoietic Agents EPOGEN 20,000 UNITS/2 ML VIAL EPOGEN PA EPOGEN 20,000 UNITS/ML VIAL EPOGEN PA EPOGEN 3,000 UNITS/ML VIAL EPOGEN PA EPOGEN 4,000 UNITS/ML VIAL EPOGEN PA NEULASTA 6 MG/0.6 ML SYRINGE NEULASTA PA NEUPOGEN 300 MCG/0.5 ML SYR NEUPOGEN PA NEUPOGEN 300 MCG/ML VIAL NEUPOGEN PA NEUPOGEN 480 MCG/0.8 ML SYR NEUPOGEN PA NEUPOGEN 480 MCG/1.6 ML VIAL NEUPOGEN PA NPLATE 250 MCG VIAL NPLATE PA NPLATE 500 MCG VIAL NPLATE PA PROCRIT 10,000 UNITS/ML VIAL PROCRIT PA PROCRIT 2,000 UNITS/ML VIAL PROCRIT PA PROCRIT 20,000 UNITS/ML VIAL PROCRIT PA PROCRIT 3,000 UNITS/ML VIAL PROCRIT PA PROCRIT 4,000 UNITS/ML VIAL PROCRIT PA PROCRIT 40,000 UNITS/ML VIAL PROCRIT PA Hepatic Hormones (Hormones Secreted by the Liver) INCRELEX 40 MG/4 ML VIAL INCRELEX PA Inflammatory Bowel Agents HUMIRA 20 MG/0.4 ML SYRINGE HUMIRA PA HUMIRA 40 MG/0.8 ML SYRINGE HUMIRA PA HUMIRA PEDIATRIC CROHN S START HUMIRA PEDIATRIC CROHN S PA REMICADE 100 MG VIAL REMICADE PA Metabolic Disease Enzyme Replacement, Gaucher s Disease CEREZYME 400 UNITS VIAL CEREZYME PA Mucolytics PULMOZYME 1 MG/ML AMPUL PULMOZYME PA Multiple Sclerosis Agent - Interferons BETASERON 0.3 MG KIT BETASERON PA BETASERON 0.3 MG VIAL BETASERON PA EXTAVIA 0.3 MG KIT EXTAVIA PA EXTAVIA 0.3 MG VIAL EXTAVIA PA REBIF 22 MCG/0.5 ML SYRINGE REBIF PA REBIF 44 MCG/0.5 ML SYRINGE REBIF PA REBIF REBIDOSE 22 MCG/0.5 ML REBIF REBIDOSE PA REBIF REBIDOSE 44 MCG/0.5 ML REBIF REBIDOSE PA REBIF REBIDOSE TITRATION PACK REBIF REBIDOSE PA 14

15 Prior Authorization Information Multiple Sclerosis Agent - Interferons REBIF TITRATION PACK REBIF PA Multiple Sclerosis Agent - Potassium Channel Blocker AMPYRA ER 10 MG TABLET AMPYRA PA Musculoskeletal Therapy Agents GENVISC MG/2.5 ML SYR GENVISC 850 PA HYALGAN 20 MG/2 ML SYRINGE HYALGAN PA HYALGAN 20 MG/2 ML VIAL HYALGAN PA SUPARTZ FX 25 MG/2.5 ML SYR SUPARTZ FX PA SYNVISC SYRINGE SYNVISC PA SYNVISC-ONE SYRINGE SYNVISC-ONE PA Passive Immunizing Agents CYTOGAM 2.5 GM/50 ML VIAL CYTOGAM PA HYPERRHO S-D 1500 UNITS SYR HYPERRHO S-D PA RHOGAM ULTRA-FILTERED PLUS SYR RHOGAM ULTRA-FILTERED PLUS SYNAGIS 100 MG/1 ML VIAL SYNAGIS PA SYNAGIS 50 MG/0.5 ML VIAL SYNAGIS PA PA Pseudobulbar Affect (PBA) Agents NUEDEXTA MG CAPSULE NUEDEXTA PA 15

16 2017 Trusted Health Plan Medicaid Formulary Acne Therapy ABSORICA 10 MG CAPSULE ABSORICA 20 MG CAPSULE ABSORICA 30 MG CAPSULE ABSORICA 40 MG CAPSULE ADAPALENE 0.1% CREAM ADAPALENE 0.1% GEL ADAPALENE 0.1% LOTION ADAPALENE 0.3% GEL ADAPALENE 0.3% GEL PUMP AMNESTEEM 10 MG CAPSULE AMNESTEEM 20 MG CAPSULE AMNESTEEM 40 MG CAPSULE BENZOYL PEROX 4% CREAMY WASH CLARAVIS 10 MG CAPSULE CLARAVIS 20 MG CAPSULE CLARAVIS 30 MG CAPSULE CLARAVIS 40 MG CAPSULE CLINDAMYCIN PH 1% GEL CLINDAMYCIN PH 1% SOLUTION CLINDAMYCIN PHOS 1% PLEDGET CLINDAMYCIN PHOSP 1% LOTION CLINDAMYCIN PHOSPHATE 1% FOAM ERYTHROMYCIN 2% GEL ERYTHROMYCIN 2% PLEDGETS ERYTHROMYCIN 2% SOLUTION METRONIDAZOLE 0.75% CREAM METRONIDAZOLE 0.75% LOTION MYORISAN 10 MG CAPSULE MYORISAN 20 MG CAPSULE MYORISAN 30 MG CAPSULE MYORISAN 40 MG CAPSULE NORITATE 1% CREAM SODIUM SULFACETAMIDE 10% LOTN SULFACETAMIDE SOD 10% TOP SUSP SULFACETAMIDE-SULFUR 8-4% SUSP TRETINOIN 0.01% GEL TRETINOIN 0.025% CREAM TRETINOIN 0.025% GEL TRETINOIN 0.05% CREAM TRETINOIN 0.05% GEL TRETINOIN 0.1% CREAM ABSORICA ABSORICA ABSORICA ABSORICA ADAPALENE ADAPALENE ADAPALENE ADAPALENE ADAPALENE AMNESTEEM AMNESTEEM AMNESTEEM BENZOYL PEROXIDE CLARAVIS CLARAVIS CLARAVIS CLARAVIS CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE CLINDAMYCIN PHOSPHATE ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN METRONIDAZOLE METRONIDAZOLE MYORISAN MYORISAN MYORISAN MYORISAN NORITATE SULFACETAMIDE SODIUM SULFACETAMIDE SODIUM SODIUM SULFACETAMIDE- SULFUR TRETINOIN TRETINOIN TRETINOIN TRETINOIN TRETINOIN TRETINOIN 16

17 2017 Trusted Health Plan Medicaid Formulary Acne Therapy ZENATANE 10 MG CAPSULE ZENATANE 20 MG CAPSULE ZENATANE 30 MG CAPSULE ZENATANE 40 MG CAPSULE ZENATANE ZENATANE ZENATANE ZENATANE Agents for Narcotic Withdrawal SUBOXONE 12 MG-3 MG SL FILM SUBOXONE PA SUBOXONE 2 MG-0.5 MG SL FILM SUBOXONE PA SUBOXONE 4 MG-1 MG SL FILM SUBOXONE PA SUBOXONE 8 MG-2 MG SL FILM SUBOXONE PA Alcoholism Treatment Agents DISULFIRAM 250 MG TABLET DISULFIRAM 500 MG TABLET DISULFIRAM DISULFIRAM Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic BENLYSTA 120 MG VIAL BENLYSTA PA BENLYSTA 400 MG VIAL BENLYSTA PA BUTALB-ACETAMIN-CAFF BUTALB-ASPIRIN-CAFFE CELEBREX 100 MG CAPSULE CELEBREX 200 MG CAPSULE CELEBREX 400 MG CAPSULE CELEBREX 50 MG CAPSULE CELECOXIB 100 MG CAPSULE CELECOXIB 200 MG CAPSULE CELECOXIB 400 MG CAPSULE CELECOXIB 50 MG CAPSULE DICLOFENAC SOD DR 25 MG TAB DICLOFENAC SOD DR 50 MG TAB DICLOFENAC SOD DR 75 MG TAB DICLOFENAC SOD EC 25 MG TAB DICLOFENAC SOD EC 50 MG TAB DICLOFENAC SOD EC 75 MG TAB DICLOFENAC SOD ER 100 MG TAB DIFLUNISAL 500 MG TABLET BUTALBITAL-ACETAMINOPHEN- CAFFE BUTALBITAL-ASPIRIN- CAFFEINE CELEBREX CELEBREX CELEBREX CELEBREX CELECOXIB CELECOXIB CELECOXIB CELECOXIB DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM DICLOFENAC SODIUM ER DIFLUNISAL ENBREL 25 MG KIT ENBREL PA ENBREL 25 MG/0.5 ML SYRINGE ENBREL PA ENBREL 50 MG/ML SURECLICK SYR ENBREL PA ENBREL 50 MG/ML SYRINGE ENBREL PA HUMIRA 40 MG/0.8 ML PEN HUMIRA PEN PA QL QL 17

18 2017 Trusted Health Plan Medicaid Formulary Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic HUMIRA PEN CROHN-UC-HS STARTER HUMIRA PEN PSORIASIS-UVEITIS STARTER IBUPROFEN 100 MG/5 ML SUSP IBUPROFEN 400 MG TABLET IBUPROFEN 600 MG TABLET IBUPROFEN 800 MG TABLET KETOPROFEN 50 MG CAPSULE KETOPROFEN 75 MG CAPSULE KETOPROFEN ER 200 MG CAPSULE KETOROLAC 10 MG TABLET KETOROLAC 15 MG/ML CARPUJECT KETOROLAC 15 MG/ML ISECURE SYR KETOROLAC 15 MG/ML SYRINGE KETOROLAC 15 MG/ML VIAL KETOROLAC 30 MG/ML CARPUJECT KETOROLAC 30 MG/ML ISECURE SYR KETOROLAC 30 MG/ML SYRINGE KETOROLAC 30 MG/ML VIAL KETOROLAC 300 MG/10 ML VIAL KETOROLAC 60 MG/2 ML CARPUJECT KETOROLAC 60 MG/2 ML SYRINGE KETOROLAC 60 MG/2 ML VIAL HUMIRA PEN CROHN-UC-HS STARTER HUMIRA PEN PSORIASIS- UVEITIS IBUPROFEN IBUPROFEN IBUPROFEN IBUPROFEN KETOPROFEN KETOPROFEN KETOPROFEN KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KETOROLAC TROMETHAMINE KINERET 100 MG/0.67 ML SYRINGE KINERET PA LEFLUNOMIDE 10 MG TABLET LEFLUNOMIDE 20 MG TABLET MELOXICAM 15 MG TABLET MELOXICAM 7.5 MG TABLET MELOXICAM 7.5 MG/5 ML SUSP METHOTREXATE 2.5 MG TABLET NABUMETONE 500 MG TABLET NABUMETONE 750 MG TABLET NAPROXEN 125 MG/5 ML SUSPEN NAPROXEN 250 MG TABLET NAPROXEN 375 MG TABLET NAPROXEN 500 MG KIT NAPROXEN 500 MG TABLET NAPROXEN DR 375 MG TABLET NAPROXEN DR 500 MG TABLET NAPROXEN EC 375 MG TABLET NAPROXEN EC 500 MG TABLET NAPROXEN SOD CR 375 MG TABLET LEFLUNOMIDE LEFLUNOMIDE MELOXICAM MELOXICAM MELOXICAM METHOTREXATE NABUMETONE NABUMETONE NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN NAPROXEN SODIUM CR PA PA 18

19 2017 Trusted Health Plan Medicaid Formulary Analgesic, Anti-inflammatory or Antipyretic - Non-Narcotic NAPROXEN SOD CR 500 MG TABLET NAPROXEN SOD ER 375 MG TABLET NAPROXEN SOD ER 500 MG TABLET NAPROXEN SODIUM 275 MG TAB NAPROXEN SODIUM 550 MG TAB NAPROXEN SODIUM DS 550 MG TAB OXAPROZIN 600 MG CAPLET OXAPROZIN 600 MG TABLET SULINDAC 150 MG TABLET SULINDAC 200 MG TABLET NAPROXEN SODIUM CR NAPROXEN SODIUM ER NAPROXEN SODIUM ER NAPROXEN SODIUM NAPROXEN SODIUM NAPROXEN SODIUM DS OXAPROZIN OXAPROZIN SULINDAC SULINDAC Analgesics - Narcotic ACETAMINOPHEN-COD #2 TABLET ACETAMINOPHEN-CODEINE QL ACETAMINOPHEN-COD #3 TABLET ACETAMINOPHEN-CODEINE QL ACETAMINOPHEN-COD #4 TABLET ACETAMINOPHEN-CODEINE QL ACETAMINOPHEN-CODEINE 120 MG- 12 MG/5 ML SOLUTION ACETAMINOPHEN-CODEINE MG/5 ML ACETAMINOPHEN-CODEINE MG/10 ML ACETAMINOPHEN-CODEINE MG/12.5 ML ACETAMINOPHEN-CODEINE ACETAMINOPHEN-CODEINE ACETAMINOPHEN-CODEINE ACETAMINOPHEN-CODEINE ASCOMP WITH CODEINE CAPSULE ASCOMP WITH CODEINE QL BUTALB-ACETAMINOPH-CAFF- CODEIN BUTALB-ACETAMINOPH-CAFF- CODEIN FENTANYL 100 MCG/HR PATCH FENTANYL QL FENTANYL 12 MCG/HR PATCH FENTANYL QL FENTANYL 25 MCG/HR PATCH FENTANYL QL FENTANYL 50 MCG/HR PATCH FENTANYL QL FENTANYL 75 MCG/HR PATCH FENTANYL QL FIORINAL WITH CODEINE #3 CAP FIORINAL WITH CODEINE #3 QL FIORINAL-COD CAP FIORINAL WITH CODEINE #3 QL HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN MG TABLET HYDROCODONE-ACETAMINOPHEN TABLET HYDROMORPHONE 0.5 MG/0.5 ML HYDROMORPHONE 1 MG/ML CARPUJCT HYDROMORPHONE 1 MG/ML SOLUTION HYDROMORPHONE 1 MG/ML SYRINGE HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROCODONE- ACETAMINOPHEN HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL QL QL QL QL QL QL QL QL 19

20 2017 Trusted Health Plan Medicaid Formulary Analgesics - Narcotic HYDROMORPHONE 2 MG TABLET HYDROMORPHONE 2 MG/ML CARPUJCT HYDROMORPHONE 2 MG/ML ISECURE HYDROMORPHONE 2 MG/ML SYRINGE (CMPD-RX) HYDROMORPHONE 2 MG/ML VIAL HYDROMORPHONE 3 MG SUPPOS HYDROMORPHONE 4 MG TABLET HYDROMORPHONE 4 MG/ML CARPUJCT HYDROMORPHONE 5 MG/5 ML SOLN HYDROMORPHONE 8 MG TABLET HYDROMORPHONE HCL 110 MG/55 ML HYDROMORPHONE HCL 60 MG/30 ML HYDROMORPHONE HCL ER 12 MG TAB HYDROMORPHONE HCL ER 16 MG TAB HYDROMORPHONE HCL ER 32 MG TAB HYDROMORPHONE HCL ER 8 MG TAB HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE HCL HYDROMORPHONE ER HYDROMORPHONE ER HYDROMORPHONE ER HYDROMORPHONE ER LORCET MG TABLET LORCET QL LORTAB MG TABLET LORTAB QL MEPERIDINE 100 MG/ML VIAL MORPHINE 10 MG/ML CARPUJECT MORPHINE 10 MG/ML SYRINGE MORPHINE 15 MG/ML VIAL MORPHINE 2 MG/ML CARPUJECT MORPHINE 2 MG/ML SYRINGE MORPHINE 20 MG/ML ORAL SYRINGE MORPHINE 30 MG/30 ML SYRINGE MORPHINE 4 MG/ML CARPUJECT MORPHINE 4 MG/ML SYRINGE MORPHINE 5 MG/ML SYRINGE MORPHINE 8 MG/ML SYRINGE MORPHINE 8 MG/ML VIAL MORPHINE SULF 10 MG SUPPOS MORPHINE SULF 10 MG/0.7 ML SYR MORPHINE SULF 10 MG/5 ML SOLN MORPHINE SULF 100 MG/5 ML (20 MG/ ML) SOLUTION MORPHINE SULF 100 MG/5 ML SOLN MEPERIDINE HCL MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE 20

21 2017 Trusted Health Plan Medicaid Formulary Analgesics - Narcotic MORPHINE SULF 20 MG SUPPOS MORPHINE SULF 20 MG/5 ML SOLN MORPHINE SULF 30 MG SUPPOS MORPHINE SULF 5 MG SUPPOS MORPHINE SULF CR 100 MG TABLET MORPHINE SULF CR 60 MG TABLET MORPHINE SULF ER 100 MG TABLET MORPHINE SULF ER 15 MG TABLET MORPHINE SULF ER 200 MG TABLET MORPHINE SULF ER 30 MG TABLET MORPHINE SULF ER 60 MG TABLET MORPHINE SULFATE 10 MG/ML VIAL MORPHINE SULFATE 25 MG/ML VIAL MORPHINE SULFATE 25 MG/ML VL MORPHINE SULFATE 50 MG/ML VIAL MORPHINE SULFATE ER 10 MG CAP MORPHINE SULFATE ER 100 MG CAP MORPHINE SULFATE ER 120 MG CAP MORPHINE SULFATE ER 20 MG CAP MORPHINE SULFATE ER 30 MG CAP MORPHINE SULFATE ER 45 MG CAP MORPHINE SULFATE ER 50 MG CAP MORPHINE SULFATE ER 60 MG CAP MORPHINE SULFATE ER 75 MG CAP MORPHINE SULFATE ER 80 MG CAP MORPHINE SULFATE ER 90 MG CAP MORPHINE SULFATE IR 15 MG TAB MORPHINE SULFATE IR 30 MG TAB MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE CR MORPHINE SULFATE CR MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE ER MORPHINE SULFATE MORPHINE SULFATE NORCO TABLET NORCO QL OXYCODONE HCL 10 MG TABLET OXYCODONE HCL QL OXYCODONE HCL 100 MG/5 ML SOLN OXYCODONE HCL QL OXYCODONE HCL 15 MG TABLET OXYCODONE HCL QL OXYCODONE HCL 20 MG TABLET OXYCODONE HCL OXYCODONE HCL 30 MG TABLET OXYCODONE HCL QL OXYCODONE HCL 5 MG CAPSULE OXYCODONE HCL QL OXYCODONE HCL 5 MG TABLET OXYCODONE HCL QL OXYCODONE HCL 5 MG/5 ML SOLN OXYCODONE HCL QL OXYCODONE-ACETAMINOPHEN MG TAB OXYCODONE-ACETAMINOPHEN MG TABLET OXYCODONE-ACETAMINOPHEN MG/5 ML SOLUTION OXYCODONE-ASPIRIN MG TABLET OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN OXYCODONE- ACETAMINOPHEN OXYCODONE HCL-ASPIRIN QL QL 21

22 2017 Trusted Health Plan Medicaid Formulary Analgesics - Narcotic TRAMADOL ER 100 MG TABLET TRAMADOL HCL ER QL TRAMADOL HCL 50 MG TABLET TRAMADOL HCL QL TRAMADOL HCL ER 100 MG CAPSULE TRAMADOL HCL ER TRAMADOL HCL ER 100 MG TABLET TRAMADOL HCL ER QL TRAMADOL HCL ER 200 MG TABLET TRAMADOL HCL ER QL TRAMADOL HCL ER 300 MG TABLET TRAMADOL HCL ER QL TRAMADOL-ACETAMINOPHEN MG TAB TRAMADOL HCL- ACETAMINOPHEN ULTRAM 50 MG TABLET ULTRAM QL ULTRAM ER 300 MG TABLET ULTRAM ER QL VICODIN MG TABLET VICODIN QL XODOL TABLET XODOL QL Angina Therapy ISOSORBIDE DN 10 MG TABLET ISOSORBIDE DN 20 MG TABLET ISOSORBIDE DN 30 MG TABLET ISOSORBIDE DN 5 MG TABLET ISOSORBIDE DN ER 40 MG TABLET ISOSORBIDE MN 10 MG TABLET ISOSORBIDE MN 20 MG TABLET ISOSORBIDE MN ER 120 MG TAB ISOSORBIDE MN ER 30 MG TABLET ISOSORBIDE MN ER 60 MG TABLET NITROGLYCERIN 0.1 MG/HR PATCH NITROGLYCERIN 0.2 MG/HR PATCH NITROGLYCERIN 0.3 MG TABLET SL NITROGLYCERIN 0.4 MG TABLET SL NITROGLYCERIN 0.4 MG/HR PATCH NITROGLYCERIN 0.6 MG TABLET SL NITROGLYCERIN 0.6 MG/HR PATCH NITROGLYCERIN 400 MCG SPRAY NITROGLYCERIN 5 MG/ML VIAL NITROGLYCERIN ER 2.5 MG CAP NITROGLYCERIN ER 6.5 MG CAP NITROGLYCERIN ER 9 MG CAPSULE NITROGLYCERIN LINGUAL 0.4 MG ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE ER ISOSORBIDE MONONITRATE ER NITROGLYCERIN PATCH NITROGLYCERIN PATCH NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN PATCH NITROGLYCERIN NITROGLYCERIN PATCH NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN NITROGLYCERIN QL Anorectal - Glucocorticoids ANUCORT-HC 25 MG SUPPOSITORY ANUSOL-HC 25 MG SUPPOSITORY ANUCORT-HC ANUSOL-HC 22

23 2017 Trusted Health Plan Medicaid Formulary HEMMOREX-HC 25 MG SUPPOSITORY Anorectal - Glucocorticoids HYDROCORTISONE 1% CREAM HYDROCORTISONE AC 25 MG SUPP HYDROCORTISONE AC 30 MG SUPP HEMMOREX-HC HYDROCORTISONE HYDROCORTISONE ACETATE HYDROCORTISONE ACETATE Anorectal Combinations LIDOCAINE-HC 3-1% CREAM KIT LIDOCAINE-HYDROCORTISONE Anterior Pituitary Hormones and Hormone Antagonists DANAZOL 100 MG CAPSULE DANAZOL 200 MG CAPSULE LUPRON DEPOT MG (LUPANETA) DANAZOL DANAZOL LUPRON DEPOT (LUPANETA) LUPRON DEPOT MG 3MO KIT LUPRON DEPOT PA LUPRON DEPOT 3.75 MG (LUPANETA) LUPRON DEPOT (LUPANETA) PA LUPRON DEPOT 3.75 MG KIT LUPRON DEPOT PA LUPRON DEPOT-PED MG 3MO KIT LUPRON DEPOT-PED LUPRON DEPOT-PED MG KIT LUPRON DEPOT-PED PA LUPRON DEPOT-PED 15 MG KIT LUPRON DEPOT-PED PA LUPRON DEPOT-PED 30 MG 3MO KIT LUPRON DEPOT-PED PA LUPRON DEPOT-PED 7.5 MG KIT LUPRON DEPOT-PED PA OCTREOTIDE 1,000 MCG/5 ML VIAL OCTREOTIDE 1,000 MCG/ML VIAL OCTREOTIDE 5,000 MCG/5 ML VIAL OCTREOTIDE ACET 100 MCG/ML AMP OCTREOTIDE ACET 200 MCG/ML VL OCTREOTIDE ACET 50 MCG/ML AMP OCTREOTIDE ACET 500 MCG/ML AMP SANDOSTATIN 0.05 MG/ML AMPUL SANDOSTATIN 0.1 MG/ML AMPUL SANDOSTATIN 0.2 MG/ML VIAL SANDOSTATIN 0.5 MG/ML AMPUL SANDOSTATIN 1 MG/ML VIAL OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE OCTREOTIDE ACETATE SANDOSTATIN SANDOSTATIN SANDOSTATIN SANDOSTATIN SANDOSTATIN PA PA Anti-Infective - Immunologic Adjuvants ACTIMMUNE 100 MCG/0.5 ML VIAL ACTIMMUNE PA,SP Antianxiety Agents ALPRAZOLAM 0.25 MG TABLET ALPRAZOLAM 0.5 MG TABLET ALPRAZOLAM 1 MG TABLET ALPRAZOLAM 2 MG TABLET ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM ALPRAZOLAM 23

24 2017 Trusted Health Plan Medicaid Formulary Antianxiety Agents BUSPIRONE HCL 10 MG TABLET BUSPIRONE HCL 15 MG TABLET BUSPIRONE HCL 30 MG TABLET BUSPIRONE HCL 5 MG TABLET BUSPIRONE HCL 7.5 MG TABLET CHLORDIAZEPOXIDE 10 MG CAPSULE CHLORDIAZEPOXIDE 25 MG CAPSULE CHLORDIAZEPOXIDE 5 MG CAPSULE CLONAZEPAM MG DIS TAB CLONAZEPAM MG ODT CLONAZEPAM 0.25 MG ODT CLONAZEPAM 0.5 MG DIS TABLET CLONAZEPAM 0.5 MG ODT CLONAZEPAM 0.5 MG TABLET CLONAZEPAM 1 MG DIS TABLET CLONAZEPAM 1 MG ODT CLONAZEPAM 1 MG TABLET CLONAZEPAM 2 MG ODT CLONAZEPAM 2 MG TABLET DIAZEPAM 10 MG TABLET DIAZEPAM 10 MG/2 ML CARPUJECT DIAZEPAM 10 MG/2 ML SYRINGE DIAZEPAM 2 MG TABLET DIAZEPAM 5 MG TABLET DIAZEPAM 5 MG/5 ML ORAL SOLN DIAZEPAM 5 MG/5 ML SOLUTION DIAZEPAM 5 MG/ML ORAL CONC DIAZEPAM 5 MG/ML VIAL DIAZEPAM 50 MG/10 ML VIAL HYDROXYZINE 10 MG/5 ML SOLN HYDROXYZINE 10 MG/5 ML SYRUP HYDROXYZINE 100 MG/2 ML VIAL HYDROXYZINE 25 MG/ML VIAL HYDROXYZINE 50 MG/ML VIAL HYDROXYZINE 500 MG/10 ML VIAL HYDROXYZINE HCL 10 MG TABLET HYDROXYZINE HCL 25 MG TABLET HYDROXYZINE HCL 50 MG TABLET LORAZEPAM 0.5 MG TABLET LORAZEPAM 1 MG TABLET LORAZEPAM 2 MG TABLET BUSPIRONE HCL BUSPIRONE HCL BUSPIRONE HCL BUSPIRONE HCL BUSPIRONE HCL CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL CHLORDIAZEPOXIDE HCL CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM CLONAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM DIAZEPAM HYDROXYZINE HCL HYDROXYZINE HCL SYRUP HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL HYDROXYZINE HCL LORAZEPAM LORAZEPAM LORAZEPAM 24

25 2017 Trusted Health Plan Medicaid Formulary Antianxiety Agents OXAZEPAM 10 MG CAPSULE OXAZEPAM OXAZEPAM 15 MG CAPSULE OXAZEPAM OXAZEPAM 30 MG CAPSULE OXAZEPAM Antiarrhythmics AMIODARONE HCL 200 MG TABLET AMIODARONE HCL AMIODARONE HCL 400 MG TABLET AMIODARONE HCL BETAPACE 120 MG TABLET BETAPACE BETAPACE 160 MG TABLET BETAPACE BETAPACE 240 MG TABLET BETAPACE BETAPACE 80 MG TABLET BETAPACE BETAPACE AF 120 MG TABLET BETAPACE AF BETAPACE AF 160 MG TABLET BETAPACE AF BETAPACE AF 80 MG TABLET BETAPACE AF DILTIAZEM 125 MG/25 ML VIAL DILTIAZEM HCL DILTIAZEM 25 MG/5 ML VIAL DILTIAZEM HCL DILTIAZEM 50 MG/10 ML VIAL DILTIAZEM HCL DILTIAZEM HCL 100 MG VIAL DILTIAZEM HCL DISOPYRAMIDE 100 MG CAPSULE DISOPYRAMIDE PHOSPHATE DISOPYRAMIDE 150 MG CAPSULE DISOPYRAMIDE PHOSPHATE FLECAINIDE ACETATE 100 MG TAB FLECAINIDE ACETATE FLECAINIDE ACETATE 150 MG TAB FLECAINIDE ACETATE FLECAINIDE ACETATE 50 MG TAB FLECAINIDE ACETATE LIDOCAINE HCL 1% ABBOJECT LIDOCAINE HCL LIDOCAINE HCL 1% SYRINGE LIDOCAINE HCL LIDOCAINE HCL 2% ABBOJECT LIDOCAINE HCL LIDOCAINE HCL 2% LUER-JET LIDOCAINE HCL LIDOCAINE HCL 2% SYRINGE LIDOCAINE HCL LIDOCAINE HCL 2% VIAL LIDOCAINE HCL PHENYTOIN 100 MG/2 ML VIAL PHENYTOIN SODIUM PHENYTOIN 250 MG/5 ML VIAL PHENYTOIN SODIUM PHENYTOIN 50 MG/ML VIAL PHENYTOIN SODIUM PROPAFENONE HCL 150 MG TABLET PROPAFENONE HCL PROPAFENONE HCL 225 MG TAB PROPAFENONE HCL PROPAFENONE HCL 300 MG TAB PROPAFENONE HCL PROPAFENONE HCL ER 225 MG CAP PROPAFENONE HCL ER PROPAFENONE HCL ER 325 MG CAP PROPAFENONE HCL ER PROPAFENONE HCL ER 425 MG CAP PROPAFENONE HCL ER SORINE 120 MG TABLET SORINE SORINE 160 MG TABLET SORINE SORINE 240 MG TABLET SORINE SORINE 80 MG TABLET SORINE SOTALOL 120 MG TABLET SOTALOL 25

26 2017 Trusted Health Plan Medicaid Formulary Antiarrhythmics SOTALOL 160 MG TABLET SOTALOL 240 MG TABLET SOTALOL 80 MG TABLET SOTALOL AF 120 MG TABLET SOTALOL AF 160 MG TABLET SOTALOL AF 80 MG TABLET SOTALOL HCL 150 MG/10 ML VIAL VERAPAMIL 120 MG TABLET VERAPAMIL 2.5 MG/ML VIAL VERAPAMIL 40 MG TABLET VERAPAMIL 5 MG/2 ML VIAL VERAPAMIL 80 MG TABLET SOTALOL SOTALOL SOTALOL SOTALOL AF SOTALOL AF SOTALOL AF SOTALOL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL VERAPAMIL HCL Antibacterial Agents AMOX-CLAV MG TAB CHEW AMOX-CLAV MG/5 ML SUS AMOX-CLAV MG TABLET AMOX-CLAV MG/5 ML SUS AMOX-CLAV MG TAB CHEW AMOX-CLAV MG/5 ML SUSP AMOX-CLAV MG TABLET AMOX-CLAV MG/5 ML SUS AMOX-CLAV MG TABLET AMOXICILLIN 125 MG/5 ML SUSP AMOXICILLIN 200 MG/5 ML SUSP AMOXICILLIN 250 MG CAPSULE AMOXICILLIN 250 MG/5 ML SUSP AMOXICILLIN 400 MG/5 ML SUSP AMOXICILLIN 500 MG CAPSULE AMOXICILLIN 875 MG TABLET AMPICILLIN 125 MG/5 ML SUSP AMPICILLIN 250 MG CAPSULE AMPICILLIN 250 MG/5 ML SUSP AMPICILLIN 500 MG CAPSULE AZITHROMYCIN 1 GM PWD PACKET AZITHROMYCIN 100 MG/5 ML SUSP AMOXICILLIN-CLAVULANATE POTASS AMOXICILLIN-CLAVULANATE POTASS AMOXICILLIN-CLAVULANATE POTASS AMOXICILLIN-CLAVULANATE POTASS AMOXICILLIN-CLAVULANATE POTASS AMOXICILLIN-CLAVULANATE POTASS AMOXICILLIN-CLAVULANATE POTASS AMOXICILLIN-CLAVULANATE POTASS AMOXICILLIN-CLAVULANATE POTASS AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN AMOXICILLIN AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE AMPICILLIN TRIHYDRATE AZITHROMYCIN AZITHROMYCIN 26

27 2017 Trusted Health Plan Medicaid Formulary Antibacterial Agents AZITHROMYCIN 200 MG/5 ML SUSP AZITHROMYCIN AZITHROMYCIN 250 MG TABLET AZITHROMYCIN QL AZITHROMYCIN 500 MG TABLET AZITHROMYCIN QL AZITHROMYCIN 600 MG TABLET AZITHROMYCIN AZITHROMYCIN I.V. 500 MG VIAL AZITHROMYCIN BACITRACIN 50,000 UNIT VIAL BACITRACIN CEFACLOR 125 MG/5 ML SUSP CEFACLOR CEFACLOR 250 MG CAPSULE CEFACLOR CEFACLOR 250 MG/5 ML SUSP CEFACLOR CEFACLOR 375 MG/5 ML SUSPEN CEFACLOR CEFACLOR 500 MG CAPSULE CEFACLOR CEFADROXIL 1 GM TABLET CEFADROXIL CEFADROXIL 250 MG/5 ML SUSP CEFADROXIL CEFADROXIL 500 MG CAPSULE CEFADROXIL CEFADROXIL 500 MG/5 ML SUSP CEFADROXIL CEFDINIR 125 MG/5 ML SUSP CEFDINIR CEFDINIR 250 MG/5 ML SUSP CEFDINIR CEFDINIR 300 MG CAPSULE CEFDINIR CEFPROZIL 125 MG/5 ML SUSP CEFPROZIL CEFPROZIL 250 MG TABLET CEFPROZIL CEFPROZIL 250 MG/5 ML SUSP CEFPROZIL CEFPROZIL 500 MG TABLET CEFPROZIL CEFUROXIME 125 MG/5 ML SUSP CEFUROXIME AXETIL CEFUROXIME AXETIL 250 MG TAB CEFUROXIME CEFUROXIME AXETIL 500 MG TAB CEFUROXIME CEPHALEXIN 125 MG/5 ML SUSP CEPHALEXIN CEPHALEXIN 250 MG CAPSULE CEPHALEXIN CEPHALEXIN 250 MG/5 ML SUSP CEPHALEXIN CEPHALEXIN 500 MG CAPSULE CEPHALEXIN CIPRO 10% SUSPENSION CIPRO CIPRO 5% SUSPENSION CIPRO CIPROFLOXACIN HCL 100 MG TAB CIPROFLOXACIN HCL CIPROFLOXACIN HCL 250 MG TAB CIPROFLOXACIN HCL CIPROFLOXACIN HCL 500 MG TAB CIPROFLOXACIN HCL CIPROFLOXACIN HCL 750 MG TAB CIPROFLOXACIN HCL CLARITHROMYCIN 125 MG/5 ML SUS CLARITHROMYCIN CLARITHROMYCIN 250 MG TABLET CLARITHROMYCIN CLARITHROMYCIN 250 MG/5 ML SUS CLARITHROMYCIN CLARITHROMYCIN 500 MG TABLET CLARITHROMYCIN CLARITHROMYCIN ER 500 MG TAB CLARITHROMYCIN ER CLINDAMYCIN 75 MG/5 ML SOLN CLINDAMYCIN PALMITATE HCL CLINDAMYCIN HCL 150 MG CAPSULE CLINDAMYCIN HCL CLINDAMYCIN HCL 300 MG CAPSULE CLINDAMYCIN HCL 27

28 2017 Trusted Health Plan Medicaid Formulary Antibacterial Agents CLINDAMYCIN HCL 75 MG CAPSULE CLINDAMYCIN PEDIATR 75 MG/5 ML CLINDAMYCIN PEDIATRIC 75 MG/5 ML DAPSONE 100 MG TABLET DAPSONE 25 MG TABLET DICLOXACILLIN 250 MG CAPSULE DOXYCYCLINE HYC 100 MG VIAL DOXYCYCLINE HYC DR 100 MG TAB DOXYCYCLINE HYC DR 150 MG TAB DOXYCYCLINE HYC DR 200 MG TAB DOXYCYCLINE HYC DR 75 MG TAB DOXYCYCLINE HYCLATE 100 MG CAP DOXYCYCLINE HYCLATE 100 MG TAB DOXYCYCLINE HYCLATE 50 MG CAP ERYTHROMYCIN 200 MG/5 ML GRAN ERYTHROMYCIN 250 MG FILMTAB ERYTHROMYCIN 500 MG FILMTAB ERYTHROMYCIN DR 250 MG CAP ERYTHROMYCIN EC 250 MG CAP ERYTHROMYCIN ES 400 MG TAB ERYTHROMYCIN ST 250 MG TAB ETHAMBUTOL HCL 100 MG TABLET ETHAMBUTOL HCL 400 MG TABLET GENTAMICIN 10 MG/ML VIAL GENTAMICIN 20 MG/2 ML VIAL GENTAMICIN 40 MG/ML VIAL GENTAMICIN 80 MG/2 ML VIAL GENTAMICIN 800 MG/20 ML VIAL ISONIAZID 100 MG TABLET ISONIAZID 100 MG/ML VIAL ISONIAZID 300 MG TABLET ISONIAZID 50 MG/5 ML SOLUTION LEVOFLOXACIN 250 MG TABLET LEVOFLOXACIN 500 MG TABLET LEVOFLOXACIN 750 MG TABLET MINOCYCLINE 100 MG CAPSULE MINOCYCLINE 50 MG CAPSULE MINOCYCLINE 75 MG CAPSULE MINOCYCLINE ER 135 MG TABLET MINOCYCLINE ER 45 MG TABLET MINOCYCLINE ER 90 MG TABLET CLINDAMYCIN HCL CLINDAMYCIN PEDIATRIC CLINDAMYCIN PEDIATRIC DAPSONE DAPSONE DICLOXACILLIN SODIUM DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE DOXYCYCLINE HYCLATE ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN ERYTHROMYCIN ETHYLSUCCINATE ERYTHROMYCIN STEARATE ETHAMBUTOL HCL ETHAMBUTOL HCL GENTAMICIN SULFATE GENTAMICIN SULFATE GENTAMICIN SULFATE GENTAMICIN SULFATE GENTAMICIN SULFATE ISONIAZID ISONIAZID ISONIAZID ISONIAZID LEVOFLOXACIN LEVOFLOXACIN LEVOFLOXACIN MINOCYCLINE HCL MINOCYCLINE HCL MINOCYCLINE HCL MINOCYCLINE HCL ER MINOCYCLINE HCL ER MINOCYCLINE HCL ER 28

29 2017 Trusted Health Plan Medicaid Formulary Antibacterial Agents MINOCYCLINE HCL 100 MG TABLET MINOCYCLINE HCL 50 MG TABLET MINOCYCLINE HCL 75 MG TABLET OFLOXACIN 300 MG TABLET OFLOXACIN 400 MG TABLET PEN G 1.2 MILLION UNIT/2 ML PENICILLIN G 600,000 UNIT/1 ML PENICILLIN G K 5 MILLION UNIT PENICILLIN G NA 5 MILLION UNIT PENICILLIN VK 125 MG/5 ML SOLN PENICILLIN VK 250 MG TABLET PENICILLIN VK 250 MG/5 ML SOLN PENICILLIN VK 250 MG/5 ML SUS PENICILLIN VK 500 MG TABLET PYRAZINAMIDE 500 MG TABLET RIFAMPIN 150 MG CAPSULE RIFAMPIN 300 MG CAPSULE RIFAMPIN IV 600 MG VIAL SULFAMETHOXAZOLE-TMP DS TABLET SULFAMETHOXAZOLE-TMP INJ VIAL SULFAMETHOXAZOLE-TMP SS TABLET SULFAMETHOXAZOLE-TMP SUSP TETRACYCLINE 250 MG CAPSULE TETRACYCLINE 500 MG CAPSULE MINOCYCLINE HCL MINOCYCLINE HCL MINOCYCLINE HCL OFLOXACIN OFLOXACIN PENICILLIN G PROCAINE PENICILLIN G PROCAINE PENICILLIN G POTASSIUM PENICILLIN G SODIUM PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM PENICILLIN V POTASSIUM PYRAZINAMIDE RIFAMPIN RIFAMPIN RIFAMPIN SULFAMETHOXAZOLE- TRIMETHOPRIM SULFAMETHOXAZOLE- TRIMETHOPRIM SULFAMETHOXAZOLE- TRIMETHOPRIM SULFAMETHOXAZOLE- TRIMETHOPRIM TETRACYCLINE HCL TETRACYCLINE HCL THALOMID 100 MG CAPSULE THALOMID PA THALOMID 150 MG CAPSULE THALOMID PA THALOMID 200 MG CAPSULE THALOMID PA THALOMID 50 MG CAPSULE THALOMID PA TRIMETHOPRIM 100 MG TABLET VANCOMYCIN 1 GM VIAL VANCOMYCIN 125 MG/2.5 ML ORAL SYRINGE (CMPD-RX) VANCOMYCIN 500 MG VIAL ZITHROMAX 500 MG TABLET ZITHROMAX TRI-PAK 500 MG TAB TRIMETHOPRIM VANCOMYCIN HCL VANCOMYCIN HCL VANCOMYCIN HCL ZITHROMAX ZITHROMAX TRI-PAK Anticoagulants ENOXAPARIN 100 MG/ML SYRINGE ENOXAPARIN SODIUM QL ENOXAPARIN 120 MG/0.8 ML SYR ENOXAPARIN SODIUM QL ENOXAPARIN 150 MG/ML SYRINGE ENOXAPARIN SODIUM QL 29

30 2017 Trusted Health Plan Medicaid Formulary Anticoagulants ENOXAPARIN 30 MG/0.3 ML SYR ENOXAPARIN SODIUM QL ENOXAPARIN 300 MG/3 ML VIAL ENOXAPARIN SODIUM QL ENOXAPARIN 40 MG/0.4 ML SYR ENOXAPARIN SODIUM QL ENOXAPARIN 60 MG/0.6 ML SYR ENOXAPARIN SODIUM QL ENOXAPARIN 80 MG/0.8 ML SYR ENOXAPARIN SODIUM QL PRADAXA 150 MG CAPSULE PRADAXA WARFARIN SODIUM 1 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 10 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 2 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 2.5 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 3 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 4 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 5 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 6 MG TABLET WARFARIN SODIUM WARFARIN SODIUM 7.5 MG TABLET WARFARIN SODIUM XARELTO 10 MG TABLET XARELTO QL XARELTO 15 MG TABLET XARELTO QL XARELTO 20 MG TABLET XARELTO QL Anticonvulsants CARBAMAZEPINE 100 MG TAB CHEW CARBAMAZEPINE CARBAMAZEPINE 100 MG/5 ML SUSP CARBAMAZEPINE CARBAMAZEPINE 200 MG TABLET CARBAMAZEPINE CARBAMAZEPINE ER 100 MG TABLET CARBAMAZEPINE ER DIAZEPAM 10 MG RECTAL GEL SYST DIAZEPAM DIAZEPAM 2.5 MG RECTAL GEL SYS DIAZEPAM DIAZEPAM 20 MG RECTAL GEL SYST DIAZEPAM DIVALPROEX DR 125 MG CAP SPRNK DIVALPROEX SODIUM DIVALPROEX SOD DR 125 MG TAB DIVALPROEX SODIUM DIVALPROEX SOD DR 250 MG TAB DIVALPROEX SODIUM DIVALPROEX SOD DR 500 MG TAB DIVALPROEX SODIUM DIVALPROEX SOD ER 250 MG TAB DIVALPROEX SODIUM ER DIVALPROEX SOD ER 500 MG TAB DIVALPROEX SODIUM ER ETHOSUXIMIDE 250 MG CAPSULE ETHOSUXIMIDE ETHOSUXIMIDE 250 MG/5 ML SOLN ETHOSUXIMIDE GABAPENTIN 100 MG CAPSULE GABAPENTIN GABAPENTIN 250 MG/5 ML SOLN GABAPENTIN GABAPENTIN 300 MG CAPSULE GABAPENTIN GABAPENTIN 300 MG/6 ML SOLN GABAPENTIN GABAPENTIN 400 MG CAPSULE GABAPENTIN GABAPENTIN 600 MG TABLET GABAPENTIN GABAPENTIN 800 MG TABLET GABAPENTIN LAMOTRIGINE 100 MG TABLET LAMOTRIGINE 30

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