Imperial Health Plan of California 2018 Formulary 1

Transcription

1 Imperial Health Plan of California 2018 Formulary 1

2 2018 Formulary (List of Covered Drugs) Imperial Health Plan of California Senior Value (HMO- SNP) Please Read: Document contains information about drugs covered in this plan. HPMS Approved Formulary File Submission ID 18497, Version Number 12. This formulary was updated on 03/20/2018. For more recent information or other questions, please contact Imperial Health Plan of California, Member Services Department at , (TTY/TDD: 711), Monday through Sunday, 8:00 am to 8:00 pm except holidays October 1 through February 14 and Monday through Friday 8:00 am to 5:00 pm February 15 through September 30 except holidays, or visit H5496_024 Drug Form SNP ENG Imperial Health Plan of California 2018 Formulary 2

3 Contents What is the Imperial Health Plan of California Formulary?... 4 Can the Formulary (drug list) change?... 4 How do I use the Formulary?... 5 What are generic drugs?... 5 Are there any restrictions on my coverage?... 5 How do I request an exception to the Imperial Health Plan of California?... 6 What do I do before I can talk to my doctor about changing my drugs or requesting an exception?... 7 For more information... 8 Imperial Health Plan of California... 9 Index of Drugs Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Imperial Health Plan of California. When it refers to plan or our plan, it means Imperial Health Plan of California. This document includes a list of the drugs (formulary) for our plan which is current as of 03/20/2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time during the year. Imperial Health Plan of California 2018 Formulary 3

4 What is the Imperial Health Plan of California Formulary? A formulary is a list of covered drugs selected by Imperial Health Plan of California in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Imperial Health Plan of California will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Imperial Health Plan of California network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same costsharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 03/20/2018. To get updated information about the drugs covered by Imperial Health Plan of California, please contact us. Our contact information appears on the front and back cover pages. In the event of non-maintenance changes to the formulary throughout the plan year, Imperial Health Plan of California may make changes via errata sheets mailed to you. Additionally, you may visit our website for a link to the errata sheet. Imperial Health Plan of California 2018 Formulary 4

5 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR. If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 143. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Imperial Health Plan of California covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Imperial Health Plan of California requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Imperial Health Plan of California before you fill your prescriptions. If you don t get approval, Imperial Health Plan of California may not cover the drug. Quantity : For certain drugs, Imperial Health Plan of California limits the amount of the drug that Imperial Health Plan of California will cover. For example, Imperial Health Plan of California 2018 Formulary 5

6 Imperial Health Plan of California provides 60 capsules per prescription for celecoxib. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Imperial Health Plan of California requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Imperial Health Plan of California may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Imperial Health Plan of California will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Imperial Health Plan of California to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to Imperial Health Plan of California? on page 6 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Imperial Health Plan of California does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Imperial Health Plan of California. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Imperial Health Plan of California. You can ask Imperial Health Plan of California to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Imperial Health Plan of California? You can ask Imperial Health Plan of California to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. Imperial Health Plan of California 2018 Formulary 6

7 You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Imperial Health Plan of California limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Imperial Health Plan of California will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for Imperial Health Plan of California 2018 Formulary 7

8 fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 91-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Exceptions are available for beneficiaries who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which beneficiaries would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows: 1. Beneficiary was discharged from the hospital and was provided a discharge list of medications based upon the formulary of the hospital. 2. Beneficiaries who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert back to their Part D plan formulary 3. Beneficiaries who give up Hospice Status to revert back to standard Medicare Part A and B benefits 4. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized. For more information For more detailed information about your Imperial Health Plan of California prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Imperial Health Plan of California, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Imperial Health Plan of California 2018 Formulary 8

9 Imperial Health Plan of California The formulary that begins on this page provides coverage information about the drugs covered by Imperial Health Plan of California. If you have trouble finding your drug in the list, turn to the Index that begins on page 143. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., HUMIRA) and generic drugs are listed in lower-case italics (e.g., celecoxib). The information in the column tells you if Imperial Health Plan of California has any special requirements for coverage of your drug. The following table describes the abbreviations used in ABBREVIATION ABBREVIATION MEANING LA QL PA NEW PA B/D PA ST This prescription may be available only at certain pharmacies. For more information please call hours a day-seven days a week. TTY/TDD users should call Quantity limitation. Followed by the limitation amount per days specified. This medication requires prior authorization. To obtain an exception please call hours a day-seven days a week. TTY/TDD users should call This medication requires prior authorization for new starts only. To obtain an exception please call hours a day-seven days a week. TTY/TDD users should call This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of drug to make the determination. Step therapy protocols apply. ANALGESICS Analgesics acetaminophen w/ codeine soln mg/5ml 2 You can find information on what the abbreviations on this table mean by going to the beginning of Imperial Health Plan of California 2018 Formulary 9 QL 4500 PER 30

10 acetaminophen w/ codeine tab mg 2 QL 400 PER 30 acetaminophen w/ codeine tab mg 2 QL 400 PER 30 acetaminophen w/ codeine tab mg 2 QL 400 PER 30 butalbital-acetaminophen tab mg 4 PA butalbital-acetaminophen tab mg 4 QL 180 PER 30 ; PA butalbital-acetaminophen-caff w/ cod cap mg 4 ; PA butalbital-acetaminophen-caff w/ cod cap mg 2 QL 360 PER 30 ; PA butalbital-acetaminophen-caffeine cap mg 4 PA butalbital-acetaminophen-caffeine cap mg 4 ; PA butalbital-acetaminophen-caffeine tab mg 4 ; PA butalbital-aspirin-caff w/ codeine cap mg 2 ; PA butalbital-aspirin-caffeine cap mg 4 QL 180 PER 30 ; PA diclofenac w/ misoprostol tab delayed release mg 2 diclofenac w/ misoprostol tab delayed release mg 2 ergotamine w/ caffeine tab mg 2 hydrocodone-acetaminophen soln mg/15ml 2 QL 3600 PER 30 hydrocodone-acetaminophen tab mg 2 hydrocodone-acetaminophen tab mg 2 hydrocodone-acetaminophen tab mg 2 hydrocodone-acetaminophen tab mg 2 hydrocodone-acetaminophen tab mg 2 hydrocodone-acetaminophen tab mg 2 QL 360 PER 30 hydrocodone-acetaminophen tab mg 2 Imperial Health Plan of California 2018 Formulary 10

11 hydrocodone-ibuprofen tab mg 2 oxycodone w/ acetaminophen tab mg 2 oxycodone w/ acetaminophen tab mg 2 oxycodone w/ acetaminophen tab mg 2 oxycodone w/ acetaminophen tab mg 2 oxycodone-aspirin tab mg 2 oxycodone-ibuprofen tab mg 2 tramadol-acetaminophen tab mg 2 Imperial Health Plan of California 2018 Formulary 11 Nonsteroidal Anti-inflammatory Drugs diclofenac sodium gel 1% 2 diclofenac sodium soln 1.5% 4 indomethacin cap cr 75 mg 1 PA oxaprozin tab 600 mg 4 Opioid Analgesics, Long-acting buprenorphine hcl inj 0.3 mg/ml (base equiv) 3 BUTRANS DIS10MCG/HR 3 BUTRANS DIS15MCG/HR 3 BUTRANS DIS20MCG/HR 3 BUTRANS DIS5MCG/HR 3 BUTRANS DIS7.5/HR 3 fentanyl td patch 72hr 100 mcg/hr 2 fentanyl td patch 72hr 12 mcg/hr 2 fentanyl td patch 72hr 25 mcg/hr 2 QL 240 PER 30 QL 150 PER 30 ; B/D PA QL 4 PER 28 QL 4 PER 28 QL 4 PER 28 QL 4 PER 28 QL 4 PER 28

12 fentanyl td patch 72hr 37.5 mcg/hr 2 fentanyl td patch 72hr 50 mcg/hr 2 fentanyl td patch 72hr 62.5 mcg/hr 2 fentanyl td patch 72hr 75 mcg/hr 2 fentanyl td patch 72hr 87.5 mcg/hr 2 hydromorphone hcl tab er 24hr deter 12 mg 2 hydromorphone hcl tab er 24hr deter 16 mg 5 hydromorphone hcl tab er 24hr deter 32 mg 5 hydromorphone hcl tab er 24hr deter 8 mg 2 HYSINGLA ER TAB100 MG 3 HYSINGLA ER TAB120 MG 3 HYSINGLA ER TAB20 MG 3 HYSINGLA ER TAB30 MG 3 HYSINGLA ER TAB40 MG 3 HYSINGLA ER TAB60 MG 3 HYSINGLA ER TAB80 MG 3 levorphanol tartrate tab 2 mg 2 METHADONE INJ10MG/ML 4 methadone hcl soln 10 mg/5ml 2 methadone hcl soln 5 mg/5ml 2 methadone hcl tab 10 mg 2 methadone hcl tab 5 mg 2 ; B/D PA QL 600 PER 30 QL 1200 PER 30 Imperial Health Plan of California 2018 Formulary 12

13 morphine sulfate beads cap sr 24hr 120 mg 2 morphine sulfate beads cap sr 24hr 30 mg 2 morphine sulfate beads cap sr 24hr 45 mg 2 morphine sulfate beads cap sr 24hr 60 mg 2 morphine sulfate beads cap sr 24hr 75 mg 2 morphine sulfate beads cap sr 24hr 90 mg 2 morphine sulfate cap sr 24hr 10 mg 2 morphine sulfate cap sr 24hr 100 mg 5 morphine sulfate cap sr 24hr 20 mg 2 morphine sulfate cap sr 24hr 30 mg 2 morphine sulfate cap sr 24hr 50 mg 2 morphine sulfate cap sr 24hr 60 mg 2 morphine sulfate cap sr 24hr 80 mg 2 morphine sulfate oral soln 20 mg/5ml 4 QL 900 PER 30 morphine sulfate tab cr 100 mg 2 morphine sulfate tab cr 15 mg 2 morphine sulfate tab cr 200 mg 2 morphine sulfate tab cr 30 mg 2 morphine sulfate tab cr 60 mg 2 MORPHINE SULINJ10MG/ML 4 B/D PA MORPHINE SULINJ2MG/ML 4 QL 900 PER 30 ; B/D PA Imperial Health Plan of California 2018 Formulary 13

14 MORPHINE SULINJ4MG/ML 4 QL 450 PER 30 ; B/D PA MORPHINE SULINJ8MG/ML 4 B/D PA OXYCONTIN TAB10MG CR 3 QL 90 PER 30 OXYCONTIN TAB15MG CR 3 QL 90 PER 30 OXYCONTIN TAB20MG CR 3 QL 90 PER 30 OXYCONTIN TAB30MG CR 3 QL 90 PER 30 OXYCONTIN TAB40MG CR 3 QL 90 PER 30 OXYCONTIN TAB60MG CR 3 QL 90 PER 30 OXYCONTIN TAB80MG CR 3 tramadol hcl tab sr 24hr 100 mg 2 tramadol hcl tab sr 24hr 200 mg 2 tramadol hcl tab sr 24hr biphasic release 300 mg 2 Opioid Analgesics, Short-acting butorphanol tartrate nasal soln 10 mg/ml 2 fentanyl citrate lozenge on a handle 1200 mcg 5 fentanyl citrate lozenge on a handle 1600 mcg 5 fentanyl citrate lozenge on a handle 200 mcg 5 fentanyl citrate lozenge on a handle 400 mcg 5 fentanyl citrate lozenge on a handle 600 mcg 5 fentanyl citrate lozenge on a handle 800 mcg 5 hydromorphone hcl tab 2 mg 2 QL 10 PER 30 ; PA ; PA ; PA ; PA ; PA ; PA Imperial Health Plan of California 2018 Formulary 14

15 hydromorphone hcl tab 4 mg 2 hydromorphone hcl tab 8 mg 2 morphine sulfate inj pf 0.5 mg/ml 4 morphine sulfate inj pf 1 mg/ml 4 morphine sulfate oral soln 10 mg/5ml 4 morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 2 morphine sulfate tab 15 mg 2 morphine sulfate tab 30 mg 2 nalbuphine hcl inj 10 mg/ml 4 nalbuphine hcl inj 20 mg/ml 4 oxycodone hcl cap 5 mg 2 oxycodone hcl conc 100 mg/5ml (20 mg/ml) 2 oxycodone hcl soln 5 mg/5ml 2 oxycodone hcl tab 10 mg 2 oxycodone hcl tab 15 mg 2 oxycodone hcl tab 20 mg 2 oxycodone hcl tab 30 mg 2 oxycodone hcl tab 5 mg 2 tramadol hcl tab 50 mg 2 ANESTHETICS Local Anesthetics QL 180 PER 30 ; B/D PA QL 180 PER 30 ; B/D PA QL 1800 PER 30 QL 180 PER 30 ; B/D PA ; B/D PA QL 1800 PER 30 QL 240 PER 30 Imperial Health Plan of California 2018 Formulary 15

16 lidocaine hcl gel 2% 4 lidocaine hcl local preservative free (pf) inj 0.5% 4 B/D PA lidocaine hcl soln 4% 4 lidocaine hcl viscous soln 2% 2 QL 36 PER 30 lidocaine oint 5% 4 lidocaine patch 5% 4 lidocaine-prilocaine cream % 4 QL 90 PER 30 ; PA ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving acamprosate calcium tab delayed release 333 mg 2 disulfiram tab 250 mg 2 disulfiram tab 500 mg 2 naltrexone hcl tab 50 mg 2 Opioid Dependence Treatments buprenorphine hcl sl tab 2 mg (base equiv) 2 buprenorphine hcl sl tab 8 mg (base equiv) 2 buprenorphine hcl-naloxone hcl sl tab mg (base equiv) 2 ; PA buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 2 ; PA SUBOXONE MIS12-3MG 3 SUBOXONE MIS2-0.5MG 3 QL 90 PER 30 SUBOXONE MIS4-1MG 3 QL 45 PER 30 SUBOXONE MIS8-2MG 3 QL 90 PER 30 VIVITROL INJ380MG 5 PA Opioid Reversal Agents naloxone hcl soln prefilled syringe 2 mg/2ml 3 Smoking Cessation Agents bupropion hcl (smoking deterrent) tab sr 12hr 150 mg 2 QL 90 PER 30 Imperial Health Plan of California 2018 Formulary 16

17 CHANTIX PAK0.5& 1MG 3 CHANTIX TAB0.5MG 3 CHANTIX TAB1MG 3 NICOTROL NS SPR10MG/ML 3 ANTIBACTERIALS Imperial Health Plan of California 2018 Formulary 17 QL 40 PER 30 Aminoglycosides GENTAMICIN OIN0.1% 2 gentamicin sulfate cream 0.1% 2 gentamicin sulfate inj 40 mg/ml 2 B/D PA gentamicin sulfate iv soln 10 mg/ml 4 B/D PA gentamicin sulfate ophth oint 0.3% 2 gentamicin sulfate ophth soln 0.3% 2 neomycin sulfate tab 500 mg 2 paromomycin sulfate cap 250 mg 2 streptomycin sulfate for inj 1 gm 4 B/D PA TOBRADEX OIN % 4 tobramycin ophth soln 0.3% 2 tobramycin sulfate inj 10 mg/ml (base equivalent) 4 B/D PA tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv) 4 B/D PA Antibacterials colistimethate sodium for inj 150 mg 4 B/D PA neomycin-polymyxin b gu irrigation soln 2 SYNERCID INJ500MG 5 B/D PA Antibacterials, Other acetic acid otic soln 2% 2 bacitracin intramuscular for soln unit 4 bacitracin ophth oint 500 unit/gm 2 chloramphenicol sodium succinate for iv inj 1 gm 4 B/D PA clindamycin hcl cap 150 mg 2 clindamycin hcl cap 300 mg 2 clindamycin hcl cap 75 mg 2 clindamycin phosphate foam 1% 4

18 clindamycin phosphate gel 1% 4 clindamycin phosphate in d5w iv soln 300 mg/50ml 4 clindamycin phosphate in d5w iv soln 600 mg/50ml 4 clindamycin phosphate in d5w iv soln 900 mg/50ml 4 clindamycin phosphate inj 600 mg/4ml 4 B/D PA clindamycin phosphate lotion 1% 4 clindamycin phosphate soln 1% 4 clindamycin phosphate swab 1% 4 clindamycin phosphate vaginal cream 2% 2 clindamycin phosphate-tretinoin gel % 2 daptomycin for iv soln 500 mg 2 B/D PA linezolid for susp 100 mg/5ml 5 linezolid iv soln 600 mg/300ml (2 mg/ml) 5 PA QL 28 PER 14 linezolid tab 600 mg 5 ; PA methenamine hippurate tab 1 gm 2 metronidazole cap 375 mg 2 metronidazole cream 0.75% 4 metronidazole gel 0.75% 4 metronidazole gel 1% 4 metronidazole in nacl 0.79% iv soln 500 mg/100ml 4 B/D PA metronidazole lotion 0.75% 4 metronidazole tab 250 mg 2 metronidazole tab 500 mg 2 metronidazole vaginal gel 0.75% 2 mupirocin calcium cream 2% 4 mupirocin oint 2% 4 nitrofurantoin macrocrystalline cap 100 mg 2 PA nitrofurantoin macrocrystalline cap 25 mg 2 PA nitrofurantoin macrocrystalline cap 50 mg 4 PA nitrofurantoin monohydrate macrocrystalline cap 100 mg 2 nitrofurantoin susp 25 mg/5ml 2 PA SULFAMYLON CRE85MG/GM 4 TIGECYCLINE INJ50MG 2 PA tinidazole tab 250 mg 2 tinidazole tab 500 mg 2 trimethoprim tab 100 mg 2 Imperial Health Plan of California 2018 Formulary 18

19 TYGACIL INJ50MG 5 PA QL 40 PER 30 vancomycin hcl cap 125 mg 5 ; PA vancomycin hcl cap 250 mg 5 QL 80 PER 30 ; PA vancomycin hcl for inj 10 gm 4 PA vancomycin hcl for inj 1000 mg 4 PA vancomycin hcl for inj 500 mg 4 PA Beta-lactam, Cephalosporins cefaclor cap 250 mg 2 cefaclor cap 500 mg 2 cefaclor for susp 125 mg/5ml 2 cefaclor for susp 250 mg/5ml 2 cefaclor for susp 375 mg/5ml 2 cefaclor monohydrate tab sr 12hr 500 mg 2 cefadroxil cap 500 mg 2 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2 cefazolin sodium for inj 1 gm 4 B/D PA cefazolin sodium for inj 10 gm 4 B/D PA cefazolin sodium for inj 500 mg 4 B/D PA cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefepime hcl for inj 1 gm 4 B/D PA cefepime hcl for inj 2 gm 4 B/D PA cefixime for susp 100 mg/5ml 2 cefixime for susp 200 mg/5ml 2 cefoxitin sodium for inj 10 gm 4 B/D PA cefoxitin sodium for iv soln 1 gm 4 B/D PA cefoxitin sodium for iv soln 2 gm 4 B/D PA cefpodoxime proxetil for susp 100 mg/5ml 2 cefpodoxime proxetil for susp 50 mg/5ml 2 cefpodoxime proxetil tab 100 mg 2 cefpodoxime proxetil tab 200 mg 2 cefprozil for susp 125 mg/5ml 2 Imperial Health Plan of California 2018 Formulary 19

20 cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 ceftazidime for inj 1 gm 2 ceftazidime for inj 2 gm 2 ceftazidime for inj 6 gm 2 ceftriaxone sodium for inj 10 gm 4 ceftriaxone sodium for inj 250 mg 4 B/D PA ceftriaxone sodium for inj 500 mg 4 B/D PA ceftriaxone sodium for iv soln 1 gm 4 ceftriaxone sodium for iv soln 2 gm 4 B/D PA cefuroxime axetil tab 250 mg 2 cefuroxime axetil tab 500 mg 2 cefuroxime sodium for inj 1.5 gm 4 B/D PA cefuroxime sodium for inj 7.5 gm 4 B/D PA cefuroxime sodium for inj 750 mg 4 B/D PA cephalexin cap 250 mg 2 cephalexin cap 500 mg 2 cephalexin cap 750 mg 2 cephalexin for susp 125 mg/5ml 2 cephalexin for susp 250 mg/5ml 2 cephalexin tab 250 mg 2 cephalexin tab 500 mg 2 SUPRAX CAP400MG 4 TEFLARO INJ400MG 5 B/D PA TEFLARO INJ600MG 5 B/D PA Beta-lactam, Other AZACTAM/DEX INJ1GM 4 PA AZACTAM/DEX INJ2GM 4 PA aztreonam for inj 1 gm 4 LA; QL 84 PER 28 CAYSTON INH75MG 5 ; PA imipenem-cilastatin intravenous for soln 250 mg 2 B/D PA imipenem-cilastatin intravenous for soln 500 mg 2 B/D PA INVANZ INJ1GM 4 meropenem iv for soln 500 mg 4 B/D PA Imperial Health Plan of California 2018 Formulary 20

21 Imperial Health Plan of California 2018 Formulary 21 Beta-lactam, Penicillins AMOX/K CLAV CHW200MG 2 amoxicillin & k clavulanate chew tab mg 2 amoxicillin & k clavulanate for susp mg/5ml 2 amoxicillin & k clavulanate for susp mg/5ml 2 amoxicillin & k clavulanate for susp mg/5ml 2 amoxicillin & k clavulanate for susp mg/5ml 2 amoxicillin & k clavulanate tab mg 2 amoxicillin & k clavulanate tab mg 2 amoxicillin & k clavulanate tab mg 2 amoxicillin & k clavulanate tab sr 12hr mg 2 amoxicillin (trihydrate) cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 125 mg 1 amoxicillin (trihydrate) chew tab 250 mg 1 amoxicillin (trihydrate) for susp 125 mg/5ml 1 amoxicillin (trihydrate) for susp 200 mg/5ml 1 amoxicillin (trihydrate) for susp 250 mg/5ml 1 amoxicillin (trihydrate) for susp 400 mg/5ml 1 amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 1 ampicillin & sulbactam sodium for inj 3 (2-1) gm 4 B/D PA ampicillin & sulbactam sodium for iv soln 15 (10-5) gm 4 B/D PA ampicillin cap 250 mg 2 ampicillin cap 500 mg 2 ampicillin for susp 125 mg/5ml 2 ampicillin for susp 250 mg/5ml 2 ampicillin sodium for inj 1 gm 4 B/D PA ampicillin sodium for inj 125 mg 4 B/D PA ampicillin sodium for iv soln 10 gm 4 B/D PA BICILLIN C-RINJ BICILLIN C-RINJ900/300 4 BICILLIN L-AINJ BICILLIN L-AINJ BICILLIN L-AINJ dicloxacillin sodium cap 250 mg 2

22 dicloxacillin sodium cap 500 mg 2 nafcillin sodium for inj 1 gm 4 B/D PA nafcillin sodium for inj 10 gm 5 B/D PA PENICILL GK/INJDEX 2MU 4 PENICILL GK/INJDEX 3MU 4 penicillin g potassium for inj unit 4 B/D PA penicillin g procaine intramuscular susp unit/ml 4 penicillin g sodium for inj unit 4 B/D PA penicillin v potassium for soln 125 mg/5ml 1 penicillin v potassium for soln 250 mg/5ml 1 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 1 piperacillin sod-tazobactam na for inj gm ( gm) 4 B/D PA piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 4 B/D PA piperacillin sod-tazobactam sod for inj 40.5 gm ( gm) 2 PA ZOSYN SOL2-0.25GM 4 PA ZOSYN SOL G 4 PA Macrolides AZASITE SOL1% 4 azithromycin for susp 100 mg/5ml 2 QL 30 PER 5 QL 90 PER 5 azithromycin for susp 200 mg/5ml 2 azithromycin iv for soln 500 mg 4 B/D PA azithromycin powd pack for susp 1 gm 2 azithromycin tab 250 mg 2 azithromycin tab 500 mg 2 azithromycin tab 600 mg 2 clarithromycin for susp 125 mg/5ml 2 clarithromycin for susp 250 mg/5ml 2 clarithromycin tab 250 mg 2 clarithromycin tab 500 mg 2 clarithromycin tab sr 24hr 500 mg 2 ERYTHROCIN INJ500MG 4 B/D PA ERYTHROM ETHTAB400MG 2 Imperial Health Plan of California 2018 Formulary 22

23 erythromycin ethylsuccinate tab 400 mg 2 erythromycin gel 2% 4 erythromycin ophth oint 5 mg/gm 2 erythromycin pads 2% 4 erythromycin soln 2% 4 erythromycin stearate tab 250 mg 4 erythromycin tab 250 mg 4 erythromycin tab 500 mg 4 erythromycin tab delayed release 250 mg 4 erythromycin tab delayed release 333 mg 4 erythromycin tab delayed release 500 mg 4 ZMAX SUS2GM 4 Quinolones ciprofloxacin 200 mg/100ml in d5w 4 ciprofloxacin hcl ophth soln 0.3% 2 ciprofloxacin hcl tab 100 mg (base equiv) 4 ciprofloxacin hcl tab 250 mg (base equiv) 2 ciprofloxacin hcl tab 500 mg (base equiv) 2 ciprofloxacin hcl tab 750 mg (base equiv) 2 ciprofloxacin iv soln 400 mg/40ml (1%) 4 B/D PA ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq) 2 ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq) 2 levofloxacin in d5w iv soln 500 mg/100ml 4 B/D PA levofloxacin iv soln 25 mg/ml 4 B/D PA levofloxacin ophth soln 0.5% 2 levofloxacin oral soln 25 mg/ml 2 levofloxacin tab 250 mg 2 QL 14 PER 14 levofloxacin tab 500 mg 2 levofloxacin tab 750 mg 2 MOXEZA SOL0.5% 3 ofloxacin ophth soln 0.3% 2 ofloxacin otic soln 0.3% 2 ofloxacin tab 300 mg 2 QL 14 PER 14 Imperial Health Plan of California 2018 Formulary 23

24 ofloxacin tab 400 mg 2 VIGAMOX DRO0.5% 3 Sulfonamides silver sulfadiazine cream 1% 1 SULFACET SODOIN10% OP 2 sulfacetamide sodium lotion 10% (acne) 2 sulfacetamide sodium ophth soln 10% 2 sulfadiazine tab 500 mg 2 sulfamethoxazole-trimethoprim iv soln mg/5ml 4 B/D PA sulfamethoxazole-trimethoprim susp mg/5ml 1 sulfamethoxazole-trimethoprim tab mg 1 sulfamethoxazole-trimethoprim tab mg 1 Tetracyclines demeclocycline hcl tab 150 mg 4 demeclocycline hcl tab 300 mg 4 doxycycline hyclate cap 100 mg 2 doxycycline hyclate cap 50 mg 2 doxycycline hyclate for inj 100 mg 4 B/D PA doxycycline hyclate tab 100 mg 2 doxycycline hyclate tab delayed release 100 mg 2 doxycycline hyclate tab delayed release 150 mg 2 doxycycline hyclate tab delayed release 50 mg 2 doxycycline hyclate tab delayed release 75 mg 2 doxycycline monohydrate cap 100 mg 2 doxycycline monohydrate cap 50 mg 2 doxycycline monohydrate cap 75 mg 2 doxycycline monohydrate for susp 25 mg/5ml 2 minocycline hcl cap 100 mg 2 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl tab 100 mg 4 minocycline hcl tab 50 mg 4 minocycline hcl tab 75 mg 4 minocycline hcl tab sr 24hr 135 mg 4 minocycline hcl tab sr 24hr 45 mg 4 minocycline hcl tab sr 24hr 90 mg 4 Imperial Health Plan of California 2018 Formulary 24

25 ANTICONVULSANTS Anticonvulsants, Other BRIVIACT INJ50MG/5ML 5 BRIVIACT SOL10MG/ML 5 BRIVIACT TAB100MG 5 BRIVIACT TAB10MG 5 BRIVIACT TAB25MG 5 BRIVIACT TAB50MG 5 Imperial Health Plan of California 2018 Formulary 25 QL 600 PER 30 QL 600 PER 30 QL 240 PER 30 QL 90 PER 30 BRIVIACT TAB75MG 5 levetiracetam inj 500 mg/5ml (100 mg/ml) 4 B/D PA levetiracetam oral soln 100 mg/ml 2 levetiracetam tab 1000 mg 2 levetiracetam tab 250 mg 2 levetiracetam tab 500 mg 2 levetiracetam tab 750 mg 2 levetiracetam tab sr 24hr 500 mg 2 levetiracetam tab sr 24hr 750 mg 2 ROWEEPRA TAB1000MG 2 ROWEEPRA TAB750MG 2 SPRITAM TAB1000MG 4 SPRITAM TAB250MG 4 SPRITAM TAB500MG 4 SPRITAM TAB750MG 5 Calcium Channel Modifying Agents CELONTIN CAP300MG 4 ethosuximide cap 250 mg 2 QL 180 PER 30 QL 90 PER 30 QL 360 PER 30 QL 180 PER 30

26 ethosuximide soln 250 mg/5ml 2 LYRICA CAP100MG 3 zonisamide cap 100 mg 2 zonisamide cap 25 mg 2 zonisamide cap 50 mg 2 QL 180 PER 30 Gamma-aminobutyric Acid (GABA) Augmenting Agents QL 1200 PER 30 clonazepam orally disintegrating tab 0.5 mg 4 QL 600 PER 30 clonazepam orally disintegrating tab 1 mg 4 QL 600 PER 30 clonazepam tab 1 mg 2 QL 40 PER 30 DIASTAT ACDLGEL DIASTAT ACDLGEL5-10MG 4 DIASTAT PED GEL2.5M GEL 4 QL 240 PER 30 diazepam conc 5 mg/ml 2 QL 1200 PER 30 diazepam oral soln 1 mg/ml 2 QL 180 PER 30 diazepam tab 10 mg 2 QL 90 PER 30 diazepam tab 2 mg 2 QL 240 PER 30 diazepam tab 5 mg 2 QL 360 PER 30 gabapentin cap 100 mg 2 QL 360 PER 30 gabapentin cap 300 mg 2 QL 270 PER 30 gabapentin cap 400 mg 2 QL 2160 PER 30 gabapentin oral soln 250 mg/5ml 2 QL 180 PER 30 gabapentin tab 600 mg 2 gabapentin tab 800 mg 2 Imperial Health Plan of California 2018 Formulary 26

27 GABITRIL TAB12MG 4 GABITRIL TAB16MG 5 ONFI SUS2.5MG/ML 5 ONFI TAB10MG 5 ONFI TAB20MG 5 PHENOBARB TAB100MG 2 PHENOBARB TAB15MG 2 PHENOBARB TAB30MG 2 PHENOBARB TAB60MG 2 phenobarbital elixir 20 mg/5ml 2 phenobarbital tab 16.2 mg 2 phenobarbital tab 32.4 mg 2 phenobarbital tab 64.8 mg 2 phenobarbital tab 97.2 mg 2 primidone tab 250 mg 2 primidone tab 50 mg 2 SABRIL POW500MG 5 Imperial Health Plan of California 2018 Formulary 27 QL 90 PER 30 QL 90 PER 30 QL 480 PER 30 QL 90 PER 30 QL 195 PER 30 QL 1500 PER 30 QL 360 PER 30 QL 180 PER 30 QL 90 PER 30 SABRIL TAB500MG 5 tiagabine hcl tab 2 mg 2 tiagabine hcl tab 4 mg 2 valproate sodium inj 100 mg/ml 4 B/D PA Glutamate Reducing Agents felbamate susp 600 mg/5ml 2 felbamate tab 400 mg 2 LA; QL 180 PER 30 LA; QL 180 PER 30

28 felbamate tab 600 mg 2 FYCOMPA SUS0.5MG/ML 5 FYCOMPA TAB10MG 4 FYCOMPA TAB12MG 5 FYCOMPA TAB2MG 4 FYCOMPA TAB4MG 4 FYCOMPA TAB6MG 4 FYCOMPA TAB8MG 4 lamotrigine orally disintegrating tab 100 mg 4 topiramate sprinkle cap 25 mg 2 TROKENDI XR CAP100MG 4 TROKENDI XR CAP200MG 5 TROKENDI XR CAP25MG 4 TROKENDI XR CAP50MG 4 QL 720 PER 30 QL 90 PER 30 Sodium Channel Agents QL 180 PER 30 APTIOM TAB200MG 5 QL 90 PER 30 APTIOM TAB400MG 5 APTIOM TAB600MG 5 QL 45 PER 30 APTIOM TAB800MG 5 QL 2400 PER 30 BANZEL SUS40MG/ML 5 QL 240 PER 30 BANZEL TAB200MG 5 QL 240 PER 30 BANZEL TAB400MG 5 carbamazepine tab 200 mg 2 carbamazepine tab sr 12hr 100 mg 2 carbamazepine tab sr 12hr 400 mg 2 DILANTIN CAP30MG 3 Imperial Health Plan of California 2018 Formulary 28

29 EQUETRO CAP300MG 4 QL 180 PER 30 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv) 4 B/D PA oxcarbazepine susp 300 mg/5ml (60 mg/ml) 4 oxcarbazepine tab 150 mg 2 oxcarbazepine tab 300 mg 2 oxcarbazepine tab 600 mg 2 OXTELLAR XR TAB150MG 4 QL 480 PER 30 OXTELLAR XR TAB300MG 4 QL 240 PER 30 OXTELLAR XR TAB600MG 4 PEGANONE TAB250MG 4 phenytoin chew tab 50 mg 1 phenytoin sodium extended cap 100 mg 1 phenytoin sodium extended cap 200 mg 1 phenytoin sodium extended cap 300 mg 1 phenytoin sodium inj 50 mg/ml 4 B/D PA phenytoin susp 125 mg/5ml 1 QL 1200 PER 30 VIMPAT INJ200MG/20 5 VIMPAT SOL10MG/ML 5 QL 1200 PER 30 VIMPAT TAB100MG 5 VIMPAT TAB150MG 5 VIMPAT TAB200MG 5 VIMPAT TAB50MG 4 ANTIDEMENTIA AGENTS Antidementia Agents, Other ergoloid mesylates tab 1 mg 2 Cholinesterase Inhibitors donepezil hydrochloride orally disintegrating tab 10 mg 4 Imperial Health Plan of California 2018 Formulary 29

30 donepezil hydrochloride orally disintegrating tab 5 mg 4 donepezil hydrochloride tab 10 mg 2 donepezil hydrochloride tab 23 mg 2 donepezil hydrochloride tab 5 mg 2 galantamine hydrobromide cap sr 24hr 16 mg 4 galantamine hydrobromide cap sr 24hr 24 mg 4 galantamine hydrobromide cap sr 24hr 8 mg 4 galantamine hydrobromide oral soln 4 mg/ml 4 galantamine hydrobromide tab 12 mg 4 galantamine hydrobromide tab 4 mg 4 galantamine hydrobromide tab 8 mg 4 rivastigmine tartrate cap 1.5 mg 4 rivastigmine tartrate cap 3 mg 4 rivastigmine tartrate cap 4.5 mg 4 rivastigmine tartrate cap 6 mg 4 rivastigmine td patch 24hr 13.3 mg/24hr 2 rivastigmine td patch 24hr 4.6 mg/24hr 2 rivastigmine td patch 24hr 9.5 mg/24hr 2 N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl oral solution 2 mg/ml 2 memantine hcl tab 10 mg 1 QL 180 PER 30 QL 360 PER 30 Imperial Health Plan of California 2018 Formulary 30

31 memantine hcl tab 5 mg 1 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak 4 NAMZARIC CAP 3 NAMZARIC CAP14-10MG 3 NAMZARIC CAP21-10MG 3 NAMZARIC CAP28-10MG 3 NAMZARIC CAP7-10MG 3 ANTIDEPRESSANTS Antidepressants olanzapine-fluoxetine hcl cap mg 4 olanzapine-fluoxetine hcl cap mg 4 olanzapine-fluoxetine hcl cap 3-25 mg 4 olanzapine-fluoxetine hcl cap 6-25 mg 4 olanzapine-fluoxetine hcl cap 6-50 mg 4 perphenazine-amitriptyline tab 2-10 mg 4 perphenazine-amitriptyline tab 2-25 mg 4 perphenazine-amitriptyline tab 4-10 mg 4 perphenazine-amitriptyline tab 4-25 mg 4 perphenazine-amitriptyline tab 4-50 mg 4 Antidepressants, Other QL 3.9 PER 56 ARISTADA INJ1064MG 5 bupropion hcl tab 100 mg 2 QL 180 PER 30 bupropion hcl tab 75 mg 2 bupropion hcl tab sr 12hr 100 mg 2 QL 90 PER 30 bupropion hcl tab sr 12hr 150 mg 2 bupropion hcl tab sr 12hr 200 mg 2 Imperial Health Plan of California 2018 Formulary 31 QL 90 PER 30 QL 90 PER 30

32 bupropion hcl tab sr 24hr 150 mg 2 bupropion hcl tab sr 24hr 300 mg 2 FORFIVO XL TAB450MG 4 mirtazapine orally disintegrating tab 15 mg 2 mirtazapine orally disintegrating tab 30 mg 2 mirtazapine orally disintegrating tab 45 mg 2 mirtazapine tab 15 mg 2 mirtazapine tab 30 mg 2 mirtazapine tab 45 mg 2 mirtazapine tab 7.5 mg 2 QUETIAPINE TAB300MG ER 3 QUETIAPINE TAB50MG ER 3 quetiapine fumarate tab 300 mg 2 quetiapine fumarate tab 400 mg 2 SEROQUEL XR TAB300MG 3 SEROQUEL XR TAB50MG 3 Monoamine Oxidase Inhibitors EMSAM DIS12MG/24H 5 EMSAM DIS6MG/24HR 5 EMSAM DIS9MG/24HR 5 MARPLAN TAB10MG 4 phenelzine sulfate tab 15 mg 2 Imperial Health Plan of California 2018 Formulary 32 QL 45 PER 30 QL 90 PER 30

33 tranylcypromine sulfate tab 10 mg 2 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin Norepinephrine Reuptake Inhibitors) QL 600 PER 30 citalopram hydrobromide oral soln 10 mg/5ml 1 citalopram hydrobromide tab 10 mg (base equiv) 1 citalopram hydrobromide tab 20 mg (base equiv) 1 citalopram hydrobromide tab 40 mg (base equiv) 1 DESVENLAFAX TAB100MG ER 2 DESVENLAFAX TAB100MG ER 4 DESVENLAFAX TAB25MG ER 2 QL 240 PER 30 DESVENLAFAX TAB50MG ER 4 QL 240 PER 30 DESVENLAFAX TAB50MG ER 2 QL 240 PER 30 duloxetine hcl enteric coated pellets cap 40 mg 2 QL 90 PER 30 FETZIMA CAP120MG 4 FETZIMA CAP20MG 4 QL 180 PER 30 FETZIMA CAP40MG 4 FETZIMA CAP80MG 4 FETZIMA CAPTITRATIO 4 QL 28 PER 28 fluoxetine hcl cap 10 mg 2 fluoxetine hcl cap 20 mg 2 fluoxetine hcl cap 40 mg 2 QL 5 PER 30 fluoxetine hcl cap delayed release 90 mg 1 Imperial Health Plan of California 2018 Formulary 33

34 fluoxetine hcl solution 20 mg/5ml 1 fluoxetine hcl tab 10 mg 1 fluoxetine hcl tab 20 mg 1 fluvoxamine maleate cap sr 24hr 100 mg 2 fluvoxamine maleate cap sr 24hr 150 mg 2 fluvoxamine maleate tab 100 mg 2 fluvoxamine maleate tab 25 mg 2 fluvoxamine maleate tab 50 mg 2 KHEDEZLA TAB100MG ER 4 KHEDEZLA TAB50MG ER 4 maprotiline hcl tab 25 mg 2 maprotiline hcl tab 50 mg 2 maprotiline hcl tab 75 mg 2 nefazodone hcl tab 100 mg 2 nefazodone hcl tab 150 mg 2 nefazodone hcl tab 200 mg 2 nefazodone hcl tab 250 mg 2 nefazodone hcl tab 50 mg 2 PRISTIQ TAB100MG 4 trazodone hcl tab 100 mg 2 trazodone hcl tab 150 mg 2 trazodone hcl tab 300 mg 2 trazodone hcl tab 50 mg 2 Imperial Health Plan of California 2018 Formulary 34 QL 600 PER 30 QL 240 PER 30 QL 90 PER 30 QL 360 PER 30 QL 180 PER 30 QL 240 PER 30 QL 270 PER 30 QL 135 PER 30 QL 180 PER 30 QL 90 PER 30 QL 72 PER 30 QL 360 PER 30

35 TRINTELLIX TAB10MG 4 TRINTELLIX TAB20MG 4 TRINTELLIX TAB5MG 4 venlafaxine hcl cap sr 24hr 150 mg (base equivalent) 2 venlafaxine hcl cap sr 24hr 75 mg (base equivalent) 2 venlafaxine hcl tab 100 mg 2 venlafaxine hcl tab 75 mg 2 venlafaxine hcl tab sr 24hr 75 mg (base equivalent) 4 VIIBRYD KITSTARTER 4 VIIBRYD TAB10MG 4 VIIBRYD TAB20MG 4 VIIBRYD TAB40MG 4 Tricyclics amitriptyline hcl tab 10 mg 2 amitriptyline hcl tab 100 mg 2 amitriptyline hcl tab 150 mg 2 amitriptyline hcl tab 25 mg 2 amitriptyline hcl tab 50 mg 2 amitriptyline hcl tab 75 mg 2 amoxapine tab 100 mg 2 amoxapine tab 150 mg 2 amoxapine tab 25 mg 2 amoxapine tab 50 mg 2 clomipramine hcl cap 25 mg 2 clomipramine hcl cap 50 mg 2 clomipramine hcl cap 75 mg 2 desipramine hcl tab 10 mg 4 desipramine hcl tab 100 mg 4 Imperial Health Plan of California 2018 Formulary 35 QL 90 PER 30 QL 90 PER 30 QL 150 PER 30 QL 90 PER 30

36 desipramine hcl tab 150 mg 4 desipramine hcl tab 25 mg 4 desipramine hcl tab 50 mg 4 desipramine hcl tab 75 mg 4 doxepin hcl cap 25 mg 2 imipramine hcl tab 10 mg 2 imipramine hcl tab 25 mg 2 imipramine hcl tab 50 mg 2 nortriptyline hcl cap 10 mg 2 nortriptyline hcl cap 25 mg 2 nortriptyline hcl cap 50 mg 2 nortriptyline hcl cap 75 mg 2 nortriptyline hcl soln 10 mg/5ml 2 protriptyline hcl tab 10 mg 2 protriptyline hcl tab 5 mg 2 trimipramine maleate cap 100 mg 4 trimipramine maleate cap 25 mg 4 trimipramine maleate cap 50 mg 4 ANTIEMETICS Antiemetics, Other chlorpromazine hcl inj 50 mg/2ml 4 B/D PA meclizine hcl tab 12.5 mg 2 meclizine hcl tab 25 mg 2 prochlorperazine suppos 25 mg 2 Emetogenic Therapy Adjuncts ALOXI INJ0.25MG/5 5 B/D PA QL 4 PER 30 aprepitant capsule 125 mg 2 ; B/D PA aprepitant capsule 40 mg 2 ; B/D PA aprepitant capsule 80 mg 2 QL 4 PER 30 ; B/D PA aprepitant capsule therapy pack 80 & 125 mg 2 ; B/D PA dronabinol cap 10 mg 5 ; B/D PA Imperial Health Plan of California 2018 Formulary 36

37 dronabinol cap 2.5 mg 2 ; B/D PA dronabinol cap 5 mg 2 ; B/D PA EMEND SUS125MG 4 B/D PA granisetron hcl tab 1 mg 4 ; B/D PA ondansetron hcl inj 4 mg/2ml (2 mg/ml) 4 ondansetron hcl oral soln 4 mg/5ml 2 B/D PA ondansetron hcl tab 24 mg 2 ; B/D PA ondansetron hcl tab 4 mg 2 ; B/D PA ondansetron hcl tab 8 mg 2 ; B/D PA ondansetron orally disintegrating tab 4 mg 2 B/D PA ondansetron orally disintegrating tab 8 mg 2 B/D PA ANTIFUNGALS Antifungals ABELCET INJ5MG/ML 5 PA AMBISOME INJ50MG 5 B/D PA amphotericin b for inj 50 mg 4 PA CANCIDAS INJ50MG 5 B/D PA CANCIDAS INJ70MG 5 B/D PA ciclopirox gel 0.77% 4 ciclopirox olamine cream 0.77% (base equiv) 4 ciclopirox olamine susp 0.77% (base equiv) 4 ciclopirox shampoo 1% 4 ciclopirox solution 8% 4 clotrimazole cream 1% 2 clotrimazole soln 1% 2 clotrimazole troche 10 mg 4 econazole nitrate cream 1% 4 ERAXIS INJ100MG 5 PA EXELDERM CRE1% 4 EXELDERM SOL1% 4 fluconazole for susp 10 mg/ml 2 Imperial Health Plan of California 2018 Formulary 37

38 fluconazole for susp 40 mg/ml 2 fluconazole in nacl 0.9% inj 200 mg/100ml 4 B/D PA fluconazole in nacl 0.9% inj 400 mg/200ml 4 B/D PA fluconazole tab 100 mg 2 fluconazole tab 150 mg 2 fluconazole tab 200 mg 2 fluconazole tab 50 mg 2 flucytosine cap 250 mg 5 flucytosine cap 500 mg 5 griseofulvin microsize susp 125 mg/5ml 2 griseofulvin microsize tab 500 mg 2 griseofulvin ultramicrosize tab 125 mg 2 griseofulvin ultramicrosize tab 250 mg 2 itraconazole cap 100 mg 2 ketoconazole cream 2% 2 ketoconazole shampoo 2% 4 ketoconazole tab 200 mg 2 miconazole nitrate vaginal suppos 200 mg 4 QL 3 PER 3 naftifine hcl cream 2% 2 NATACYN SUS5% OP 4 NOXAFIL SUS40MG/ML 5 NOXAFIL TAB100MG 5 nystatin cream unit/gm 2 nystatin oint unit/gm 2 nystatin susp unit/ml 4 nystatin tab unit 2 nystatin topical powder unit/gm 2 nystatin-triamcinolone cream unit/gm-% 4 nystatin-triamcinolone oint unit/gm-% 4 oxiconazole nitrate cream 1% 2 terbinafine hcl tab 250 mg 2 terconazole vaginal cream 0.4% 4 terconazole vaginal cream 0.8% 4 terconazole vaginal suppos 80 mg 4 voriconazole for inj 200 mg 4 PA QL 630 PER 30 Imperial Health Plan of California 2018 Formulary 38

39 voriconazole for susp 40 mg/ml 5 voriconazole tab 200 mg 5 voriconazole tab 50 mg 5 ANTIGOUT AGENTS Antigout Agents allopurinol tab 300 mg 2 COLCHICINE TAB0.6MG 4 colchicine w/ probenecid tab mg 2 COLCRYS TAB0.6MG 4 probenecid tab 500 mg 2 ANTI-INFLAMMATORY AGENTS Nonsteroidal Anti-inflammatory Drugs celecoxib cap 100 mg 4 celecoxib cap 200 mg 4 celecoxib cap 400 mg 4 celecoxib cap 50 mg 4 diclofenac potassium tab 50 mg 2 diclofenac sodium tab delayed release 25 mg 2 diclofenac sodium tab delayed release 50 mg 2 diclofenac sodium tab delayed release 75 mg 2 diclofenac sodium tab sr 24hr 100 mg 2 diflunisal tab 500 mg 2 etodolac cap 200 mg 4 etodolac cap 300 mg 4 etodolac tab 400 mg 4 etodolac tab 500 mg 4 etodolac tab sr 24hr 400 mg 4 etodolac tab sr 24hr 500 mg 4 QL 300 PER 30 ; PA ; PA ; PA Imperial Health Plan of California 2018 Formulary 39

40 etodolac tab sr 24hr 600 mg 4 fenoprofen calcium tab 600 mg 2 FLECTOR DIS1.3% 4 flurbiprofen tab 100 mg 2 flurbiprofen tab 50 mg 2 ibuprofen susp 100 mg/5ml 2 ibuprofen tab 400 mg 2 ibuprofen tab 600 mg 2 ibuprofen tab 800 mg 2 indomethacin cap 25 mg 1 PA indomethacin cap 50 mg 1 PA meclofenamate sodium cap 100 mg 2 meclofenamate sodium cap 50 mg 2 meloxicam tab 15 mg 2 meloxicam tab 7.5 mg 2 nabumetone tab 500 mg 2 nabumetone tab 750 mg 2 naproxen sodium tab 275 mg 4 naproxen sodium tab 550 mg 4 naproxen sodium tab sr 24hr 375 mg (base equiv) 2 naproxen sodium tab sr 24hr 500 mg (base equiv) 4 naproxen susp 125 mg/5ml 4 naproxen tab 250 mg 2 naproxen tab 375 mg 2 naproxen tab 500 mg 2 naproxen tab ec 375 mg 4 naproxen tab ec 500 mg 4 piroxicam cap 10 mg 2 piroxicam cap 20 mg 2 sulindac tab 150 mg 2 sulindac tab 200 mg 2 TOLMETIN SODCAP400MG 2 tolmetin sodium tab 600 mg 2 ANTIMIGRAINE AGENTS ; PA Imperial Health Plan of California 2018 Formulary 40

41 Antimigraine Agents ergotamine w/ caffeine suppos mg 4 Ergot Alkaloids dihydroergotamine mesylate inj 1 mg/ml 3 DIHYDROERGOTSPR4MG/ML 5 ergotamine w/ caffeine tab mg 4 Prophylactic divalproex sodium tab delayed release 125 mg 2 timolol maleate tab 10 mg 2 timolol maleate tab 5 mg 2 topiramate sprinkle cap 15 mg 2 topiramate tab 100 mg 2 topiramate tab 200 mg 2 topiramate tab 25 mg 2 topiramate tab 50 mg 2 Serotonin (5-HT) 1b/1d Receptor Agonists almotriptan malate tab 12.5 mg 2 almotriptan malate tab 6.25 mg 2 frovatriptan succinate tab 2.5 mg (base equivalent) 2 naratriptan hcl tab 1 mg (base equiv) 2 naratriptan hcl tab 2.5 mg (base equiv) 2 sumatriptan nasal spray 20 mg/act 2 sumatriptan nasal spray 5 mg/act 2 sumatriptan succinate inj 6 mg/0.5ml 4 sumatriptan succinate tab 100 mg 2 sumatriptan succinate tab 25 mg 2 Imperial Health Plan of California 2018 Formulary 41 QL 8 PER 30 QL 480 PER 30 QL 240 PER 30 QL 1920 PER 30 QL 960 PER 30 QL 12 PER 30 QL 12 PER 30 QL 12 PER 30 QL 9 PER 30 QL 9 PER 30 QL 6 PER 30 QL 9 PER 30 QL 9 PER 30

42 sumatriptan succinate tab 50 mg 2 ANTIMYASTHENIC AGENTS Parasympathomimetics GUANIDINE TAB125MG 4 MESTINON SYP60MG/5ML 4 pyridostigmine bromide tab 60 mg 2 pyridostigmine bromide tab cr 180 mg 2 ANTIMYCOBACTERIALS Antimycobacterials aminosalicylic acid cr granules packet 4 gm 2 RIFAMATE CAP 4 Antimycobacterials, Other dapsone tab 100 mg 2 dapsone tab 25 mg 2 rifabutin cap 150 mg 4 Imperial Health Plan of California 2018 Formulary 42 QL 9 PER 30 Antituberculars CAPASTAT SULINJ1GM 4 B/D PA ethambutol hcl tab 100 mg 2 ethambutol hcl tab 400 mg 2 isoniazid inj 100 mg/ml 4 isoniazid syrup 50 mg/5ml 2 isoniazid tab 100 mg 2 isoniazid tab 300 mg 2 PRIFTIN TAB150MG 4 pyrazinamide tab 500 mg 2 rifampin cap 150 mg 2 rifampin cap 300 mg 2 rifampin for inj 600 mg 4 B/D PA RIFATER TAB 5 SIRTURO TAB100MG 5 QL 68 PER 28 ; PA TRECATOR TAB250MG 4 ANTINEOPLASTICS

43 Imperial Health Plan of California 2018 Formulary 43 Alkylating Agents BUSULFAN INJ6MG/ML 5 B/D PA CYCLOPHOSPH CAP25MG 4 B/D PA CYCLOPHOSPH CAP50MG 4 B/D PA GLEOSTINE CAP100MG 4 GLEOSTINE CAP10MG 4 GLEOSTINE CAP40MG 4 GLEOSTINE CAP5MG 4 HEXALEN CAP50MG 5 ifosfamide for inj 1 gm 4 B/D PA LEUKERAN TAB2MG 3 MATULANE CAP50MG 5 LA melphalan hcl for inj 50 mg (base equiv) 4 B/D PA MUSTARGEN INJ10MG 5 B/D PA TREANDA INJ25MG 5 B/D PA TREANDA INJ100MG 5 B/D PA VALCHLOR GEL0.016% 5 YONDELIS INJ1MG 5 LA; B/D PA Antiandrogens bicalutamide tab 50 mg 2 flutamide cap 125 mg 2 nilutamide tab 150 mg 2 XTANDI CAP40MG 5 ZYTIGA TAB250MG 5 Antiangiogenic Agents POMALYST CAP1MG 5 POMALYST CAP2MG 5 POMALYST CAP3MG 5 POMALYST CAP4MG 5 LA; LA; LA; LA; LA; LA;

44 REVLIMID CAP10MG 5 REVLIMID CAP15MG 5 REVLIMID CAP2.5MG 5 REVLIMID CAP20MG 5 REVLIMID CAP25MG 5 REVLIMID CAP5MG 5 THALOMID CAP100MG 5 THALOMID CAP150MG 5 THALOMID CAP200MG 5 THALOMID CAP50MG 5 Antiestrogens/Modifiers EMCYT CAP140MG 5 FARESTON TAB60MG 5 SOLTAMOX SOL10MG/5ML 5 tamoxifen citrate tab 10 mg (base equivalent) 2 tamoxifen citrate tab 20 mg (base equivalent) 2 Antineoplastics ABRAXANE INJ100MG 5 B/D PA ALIMTA INJ500MG 5 B/D PA ARRANON INJ5MG/ML 5 B/D PA AVASTIN INJ 5 LA; B/D PA Imperial Health Plan of California 2018 Formulary 44 Antimetabolites DROXIA CAP200MG 4 DROXIA CAP300MG 4 DROXIA CAP400MG 4 hydroxyurea cap 500 mg 2 PURIXAN SUS20MG/ML 5 LA TABLOID TAB40MG 5 LA; LA; LA; LA; LA; LA; QL 150 PER 30