Florida Healthy Kids Formulary Updates

Transcription

1 Florida Healthy Kids Formulary Updates March 2017 Drug/Product Inhaler Assist Devices Added w/ql of #1 spacer/365 days ACTIVE OB CAP Removed from formulary 03/16/2017 ADYNOVATE INJ 1500UNIT Added to formulary 03/17/2017 ADYNOVATE INJ 750UNIT Added to formulary 03/17/2017 ALAHIST DM LIQ Removed from formulary 03/16/2017 ALOSETRON TAB 0.5MG Added to formulary 03/17/2017 ALOSETRON TAB 1MG Added to formulary 03/10/2017 AMNESTEEM CAP 20MG Removed from formulary 03/16/2017 AMNESTEEM CAP 40MG Removed from formulary 03/16/2017 AQUADEKS CAP Removed from formulary 03/16/2017 ARBINOXA TAB 4MG Removed from formulary 03/08/2017 BENICAR TAB 20MG Removed from formulary 03/16/2017 BENICAR TAB 40MG Removed from formulary 03/16/2017 BP VIT 3 CAP PLUS Removed from formulary 03/16/2017 BRINTELLIX TAB 10MG Removed from formulary 03/16/2017 BRINTELLIX TAB 20MG Removed from formulary 03/16/2017 BRINTELLIX TAB 5MG Removed from formulary 03/16/2017 BUTALB/ACETA TAB MG Added to formulary 03/17/2017 CHERATUSSIN SOL DAC Removed from formulary 03/16/2017 DIHYDROERGOT INJ 1MG/ML Removed from formulary 03/08/2017 DONEPEZIL TAB HCL 23MG Removed from formulary 03/08/2017 ELDERCAPS CAP Removed from formulary 03/16/2017 ELOXATIN INJ 100MG Removed from formulary 03/16/2017 ELOXATIN INJ 50MG Removed from formulary 03/16/2017 ENJUVIA TAB 0.3MG Removed from formulary 03/16/2017 ENJUVIA TAB 0.45MG Removed from formulary 03/16/2017 ENJUVIA TAB 0.625MG Removed from formulary 03/16/2017 ENLYTE CAP Removed from formulary 03/08/2017 ERRIN TAB 0.35MG Removed from formulary 03/16/2017 FABB TAB Removed from formulary 03/16/2017 FUSION PAK SPRINKLE Added to formulary 03/10/2017 GILDESS TAB 1.5/30 Removed from formulary 03/16/2017 GILDESS TAB 1/20 Removed from formulary 03/16/2017 GILDESS 24 TAB FE 1/20 Removed from formulary 03/16/2017 GILDESS FE TAB 1.5/30 Removed from formulary 03/16/2017 Page 1 of 10

2 Drug/Product GILDESS FE TAB 1/20 Removed from formulary 03/16/2017 INATAL ULTRA TAB Removed from formulary 03/16/2017 INFANATE CAP BALANCE Removed from formulary 03/16/2017 IOPHEN C-NR LIQ /5 Removed from formulary 03/16/2017 ISTODAX INJ 10MG Removed from formulary 03/16/2017 IXINITY INJ 1000UNIT Removed from formulary 03/23/2017 IXINITY INJ 1500UNIT Removed from formulary 03/23/2017 IXINITY INJ 500UNIT Removed from formulary 03/23/2017 KOATE INJ 1000UNIT Added to formulary 03/10/2017 KOATE INJ 250UNIT Added to formulary 03/10/2017 KOATE INJ 500 UNIT Added to formulary 03/10/2017 LEVONORGESTR TAB 1.5MG Removed from formulary 03/16/2017 LINZESS CAP 145MCG Added to formulary 03/31/2017 LINZESS CAP 290MCG Added to formulary 03/31/2017 LINZESS CAP 72MCG Added to formulary 03/31/2017 LUPANETA KIT Added to formulary 03/31/2017 LUPANETA KIT Added to formulary 03/31/2017 MAPAP CHILD SUS 160/5ML Removed from formulary 03/16/2017 METHYLERGON TAB 0.2MG Removed from formulary 03/16/2017 MOVANTIK TAB 12.5MG Added to formulary 03/31/2017 MOVANTIK TAB 25MG Added to formulary 03/31/2017 MULTICHEW CHW Removed from formulary 03/16/2017 MULTIVITAMIN CAP PLS ZINC Removed from formulary 03/16/2017 MULTIVITAMIN CHW Removed from formulary 03/16/2017 MULTIVITAMIN DRO PEDIATRC Removed from formulary 03/16/2017 MULT-VIT/FL CHW 0.5MG Removed from formulary 03/16/2017 NALOXONE INJ 0.4MG/ML Added to formulary 03/10/2017 NALOXONE INJ 1MG/ML Added to formulary 03/10/2017 NARCAN SPR Added to formulary 03/10/2017 NECON TAB 1/35 Removed from formulary 03/16/2017 NORINYL TAB Removed from formulary 03/16/2017 NOR-QD TAB 0.35MG Removed from formulary 03/16/2017 PANCRELIPASE CAP 5000UNIT Removed from formulary 03/16/2017 PNV-TOTAL CAP Removed from formulary 03/16/2017 PREDNISOLONE SOL 10MG/5ML Added to formulary 03/24/2017 PREDNISOLONE SOL 20MG/5ML Added to formulary 03/17/2017 PRENAISSANCE CAP BALANCE Removed from formulary 03/16/2017 PRENAISSANCE TAB NEXT Removed from formulary 03/16/2017 Page 2 of 10

3 Drug/Product PRENAISSANCE TAB NEXT-B Removed from formulary 03/16/2017 PRIMSOL SOL 50MG/5ML Removed from formulary 03/16/2017 PURALOR CI TAB Removed from formulary 03/08/2017 SANDOSTATIN KIT LAR 10MG Removed from formulary 03/16/2017 SANDOSTATIN KIT LAR 20MG Removed from formulary 03/16/2017 SANDOSTATIN KIT LAR 30MG Removed from formulary 03/16/2017 SOD FLUORIDE CHW 0.25MG F Removed from formulary 03/16/2017 SOD FLUORIDE CHW 0.5MG F Removed from formulary 03/16/2017 SODIUM CHLOR INJ 0.9% Removed from formulary 03/16/2017 TREANDA INJ 180/2ML Removed from formulary 03/16/2017 TREANDA INJ 45/0.5ML Removed from formulary 03/16/2017 TRI-VIT/FLUO DRO 0.25MG Added to formulary 03/17/2017 VIRT NATE TAB 28-1MG Removed from formulary 03/16/2017 VIT A/C/D/FL DRO 0.25MG Removed from formulary 03/16/2017 VITAFOL TAB Removed from formulary 03/08/2017 VITEKTA TAB 150MG Removed from formulary 03/16/2017 VITEKTA TAB 85MG Removed from formulary 03/16/2017 VP-GSTN CAP Removed from formulary 03/16/2017 VP-HEME-OB TAB MG Removed from formulary 03/16/2017 WINRHO SDF INJ 15000UNT Removed from formulary 03/16/2017 WINRHO SDF INJ 1500UNIT Removed from formulary 03/16/2017 WINRHO SDF INJ 2500UNIT Removed from formulary 03/16/2017 WINRHO SDF INJ 5000UNIT Removed from formulary 03/16/2017 ZEOSA CHW Removed from formulary 03/16/2017 April 2017 Drug/Product ACTIGALL CAP 300MG Removed from formulary 04/20/2017 ANAPROX DS TAB 550MG Removed from formulary 04/27/2017 AUG BETAMET CRE 0.05% Added to formulary 04/21/2017 AZOR TAB Removed from formulary 04/20/2017 BETAMETH DIP CRE 0.05% Removed from formulary 04/20/2017 BETAMETH DIP LOT 0.05% Removed from formulary 04/20/2017 BROMFED DM SYP Removed from formulary 04/20/2017 BUPRENORPHIN SUB Added to formulary 03/31/2017 BUSULFAN INJ 6MG/ML Added to formulary 04/21/2017 CAPCOF SYP MG Removed from formulary 04/20/2017 CHERATUSSIN SYP /5 Removed from formulary 04/20/2017 CLINDAMYCIN GEL 1% Removed from formulary 04/20/2017 CLINDAMYCIN LOT 1% Removed from formulary 04/20/2017 Page 3 of 10

4 CLINDAMYCIN LOT 10MG/ML Removed from formulary 04/20/2017 CLOBETASOL OIN 0.05% Removed from formulary 04/20/2017 CODEINE/GG SOL /5 Removed from formulary 04/20/2017 CORVITA TAB Added to formulary 04/21/2017 CORVITE TAB Added to formulary 04/21/2017 CORVITE FREE TAB Added to formulary 04/21/2017 CYKLOKAPRON INJ 100MG/ML Removed from formulary 04/06/2017 CYSTADANE POW Removed from formulary 04/20/2017 DIPHEN/ATROP LIQ 2.5/5 Removed from formulary 04/20/2017 ELOCTATE INJ 4000UNIT, 50000UNIT, 6000UNIT Added to formulary 04/07/2017 EPIPEN 2-PAK INJ 0.3MG Removed from formulary 04/27/2017 EPIPEN-JR INJ 2-PAK Removed from formulary 04/27/2017 ERYTHROMYCIN GEL 2% Removed from formulary 04/20/2017 ERYTHROMYCIN SOL 2% Removed from formulary 04/20/2017 FAYOSIM TAB Added to formulary 04/21/2017 FLOWTUSS SOL Removed from formulary 04/20/2017 FLUOCINONIDE CRE -E 0.05% Removed from formulary 04/20/2017 FLUOCINONIDE SOL 0.05% Removed from formulary 04/20/2017 FLUTICASONE OIN 0.005% Added to formulary 04/21/2017 FOSINOP/HCTZ TAB Added to formulary 04/21/2017 FOSINOPRIL TAB Added to formulary 04/21/2017 GG/CODEINE SOL /5 Removed from formulary 04/20/2017 GUAIATUSSIN SYP /5 Removed from formulary 04/20/2017 GUAIFENESIN SYP /5 Removed from formulary 04/20/2017 HC BUTYRATE SOL 0.1% Removed from formulary 04/20/2017 HC VALERATE CRE 0.2% Removed from formulary 04/20/2017 HC VALERATE OIN 0.2% Removed from formulary 04/20/2017 HISTEX-AC SYP Removed from formulary 04/20/2017 HYCOFENIX SOL Removed from formulary 04/20/2017 HYD POL/CPM SUS 10-8/5ML Removed from formulary 04/20/2017 HYDR/CPM/PSE LIQ MG Removed from formulary 04/20/2017 HYDRO/CHLOR/ LIQ MG Removed from formulary 04/20/2017 IMIPRAM PAM CAP Removed from formulary 04/20/2017 IRBESARTAN TAB Added to formulary 04/21/2017 ISOSORB DIN TAB 40MG ER Removed from formulary 04/20/2017 LAMIVUDINE SOL 10MG/ML Added to formulary 04/07/2017 LORTUSS EX LIQ Removed from formulary 04/20/2017 LUPRON DEPOT INJ 22.5MG, 30MG, 45MG, 7.5MG Added to formulary 04/28/2017 MAR-COF BP LIQ Removed from formulary 04/20/2017 MAR-COF CG LIQ Removed from formulary 04/20/2017 M-CLEAR WC LIQ Removed from formulary 04/20/2017 MEDIFIN 400 TAB 400MG Added to formulary 04/07/2017 M-END PE LIQ Removed from formulary 04/20/2017 METHSCOPOLAM TAB Removed from formulary 04/20/2017 MIBELAS 24 CHW FE Added to formulary 04/07/2017 MINOCYCLINE TAB Removed from formulary 04/20/2017 MOMETASONE OIN 0.1% Added to formulary 04/21/2017 MORPHINE SUL SOL 20MG/ML Added to formulary 04/21/2017 Page 4 of 10

5 NAPROSYN TAB 500MG Added to formulary 04/21/2017 NICOMIDE TAB Removed from formulary 04/20/2017 NINJACOF-XG LIQ 200-8/5 Removed from formulary 04/20/2017 NORETH/ETHIN CHW FE 1/20 Added to formulary 04/07/2017 PAIN RELIEVE SUS 160/5ML Removed from formulary 04/06/2017 PAREGORIC TIN 2MG/5ML Removed from formulary 04/20/2017 PFIZERPEN-G INJ Removed from formulary 04/20/2017 PHENHIST DH LIQ Removed from formulary 04/20/2017 POLY-TUSSIN LIQ Removed from formulary 04/20/2017 PREQUE 10 TAB Removed from formulary 04/27/2017 PROMETH VC/ SYP CODEINE Removed from formulary 04/20/2017 PROMETH/COD SYP Removed from formulary 04/20/2017 PROMETH/PE/ SYP CODEINE Removed from formulary 04/20/2017 PROPAFENONE CAP 225MG ER Removed from formulary 04/13/2017 PRO-RED AC SYP 5-1-9/5 Removed from formulary 04/20/2017 PYLERA CAP Added to formulary 04/21/2017 QNAPRIL/HCTZ TAB Added to formulary 04/21/2017 Q-TUSSIN SOL 100/5ML Removed from formulary 04/20/2017 RELCOF C SOL Removed from formulary 04/20/2017 RIVELSA TAB Added to formulary 04/21/2017 RYDEX LIQ Removed from formulary 04/20/2017 SB CGH CONTR SYP 100/5ML Removed from formulary 04/06/2017 SB COUGHTAB TAB 200MG Removed from formulary 04/06/2017 TRIAMCIN ACE INJ 10MG/ML Removed from formulary 04/20/2017 TUSNEL C SYP Removed from formulary 04/20/2017 TUSSICAPS CAP Removed from formulary 04/20/2017 TUSSIONEX SUS 10-8/5ML Removed from formulary 04/20/2017 UDAMIN SP TAB Removed from formulary 04/20/2017 VENLAFAXINE TAB ER Removed from formulary 04/27/2017 VIRTUSSIN SOL DAC Removed from formulary 04/20/2017 VIRTUSSIN AC SOL /5 Removed from formulary 04/20/2017 VYVANSE CHW Removed from formulary 04/27/2017 XELODA TAB Removed from formulary 04/06/2017 ZARXIO INJ Added to formulary 04/28/2017 ZUTRIPRO LIQ MG Removed from formulary 04/20/2017 ZYCLARA CRE 3.75% Removed from formulary 04/20/2017 ZYCLARA PUMP CRE Removed from formulary 04/20/2017 May 2017 Drug/Product ACETAMIN SOL 160/5ML Removed from formulary 05/16/2017 DOCETAXEL INJ 200/10 Added to formulary 05/19/2017 FE C PLUS TAB Removed from formulary 05/25/2017 HALOPERIDOL INJ 50/10ML Added to formulary 05/12/2017 HALOPERIDOL INJ 5MG/ML Added to formulary 05/12/2017 HALOPERIDOL INJ 5MG/ML Added to formulary 05/12/2017 Page 5 of 10

6 HYDROCO/APAP SOL Removed from formulary 05/04/2017 HYDROCODONE SOL MG Removed from formulary 05/04/2017 HYDROCODONE SOL MG Removed from formulary 05/11/2017 KOATE-DVI INJ 250UNIT Removed from formulary 05/04/2017 KOATE-DVI INJ 500UNIT Removed from formulary 05/04/2017 LEVOCARNITIN INJ 200MG/ML Removed from formulary 05/11/2017 LEVOCARNITIN INJ 200MG/ML Removed from formulary 05/11/2017 M.V.I-12 W/O INJ VIT K Removed from formulary 05/25/2017 METFORMIN ER TAB 1000MG Removed from formulary 05/18/2017 METFORMIN ER TAB 1000MG Removed from formulary 05/18/2017 METFORMIN ER TAB 1000MG Removed from formulary 05/18/2017 METFORMIN ER TAB 1000MG Removed from formulary 05/18/2017 METFORMIN ER TAB 1000MG Removed from formulary 05/18/2017 MY WAY TAB 1.5MG Removed from formulary 05/04/2017 PEG-INTRON KIT 120 RP Removed from formulary 05/25/2017 PRENAT PLUS TAB 27-1MG Removed from formulary 05/25/2017 PRENAT PLUS TAB 27-1MG Removed from formulary 05/25/2017 ROWEEPRA TAB 1000MG Added to formulary 05/26/2017 ROWEEPRA TAB 750MG Added to formulary 05/26/2017 UREA LOT 45% Added to formulary 05/26/2017 June 2017 Drug/Product ABRAXANE INJ 100MG Removed from formulary 06/22/2017 ACETAMIN SOL 160/5ML Removed from formulary 06/08/2017 ANDROGEL GEL PUMP 1% Removed from formulary 06/15/2017 ATOMOXETINE CAP 100MG Added to formulary 06/23/2017 ATOMOXETINE CAP 10MG Added to formulary 06/23/2017 ATOMOXETINE CAP 18MG Added to formulary 06/23/2017 ATOMOXETINE CAP 25MG Added to formulary 06/23/2017 ATOMOXETINE CAP 40MG Added to formulary 06/23/2017 ATOMOXETINE CAP 60MG Added to formulary 06/23/2017 ATOMOXETINE CAP 80MG Added to formulary 06/23/2017 AVASTIN INJ Removed from formulary 06/22/2017 AVASTIN INJ 400/16ML Removed from formulary 06/22/2017 AZOR TAB 10-20MG Removed from formulary 06/01/2017 AZOR TAB 10-40MG Removed from formulary 06/01/2017 AZOR TAB 5-40MG Removed from formulary 06/01/2017 BUPRENORPHIN DIS 10MCG/HR Added to formulary 06/23/2017 BUPRENORPHIN DIS 15MCG/HR Added to formulary 06/23/2017 BUPRENORPHIN DIS 20MCG/HR Added to formulary 06/23/2017 BUPRENORPHIN DIS 5MCG/HR Added to formulary 06/23/2017 CAMPTOSAR INJ 300/15ML Removed from formulary 06/22/2017 DIAZEPAM GEL 10MG Removed from formulary 06/29/2017 Page 6 of 10

7 DIAZEPAM GEL 2.5MG Removed from formulary 06/29/2017 DIAZEPAM GEL 20MG Removed from formulary 06/29/2017 DIPHENHYDRAM LIQ 12.5/5ML Added to formulary 06/23/2017 DOXIL INJ 2MG/ML Removed from formulary 06/22/2017 ENEMEEZ MINI ENE Added to formulary 06/09/2017 ENEMEEZ PLUS ENE Added to formulary 06/09/2017 ERBITUX INJ 100MG Removed from formulary 06/22/2017 ERBITUX INJ 200MG Removed from formulary 06/22/2017 ETOPOPHOS INJ 100MG Removed from formulary 06/22/2017 FEMCON FE CHW Removed from formulary 06/29/2017 FERROUS SULF TAB 325MG FC Removed from formulary 06/15/2017 GENTAMICIN OIN 0.3% OP Removed from formulary 06/29/2017 GUAIFENESIN SOL 300/15ML Removed from formulary 06/15/2017 GUAIFENESIN TAB 600MG ER Removed from formulary 06/29/2017 ISTODAX OVR INJ 10MG Removed from formulary 06/22/2017 JEVTANA INJ 60/1.5ML Removed from formulary 06/22/2017 LIPODOX INJ 2MG/ML Removed from formulary 06/22/2017 LIPODOX 50 INJ 2MG/ML Removed from formulary 06/22/2017 MACNATAL CN CAP DHA Removed from formulary 06/08/2017 MAPAP CHW 160MG Added to formulary 06/23/2017 MYCOPHENOLAT INJ 500MG Added to formulary 06/23/2017 NORLYDA TAB 0.35MG Added to formulary 06/23/2017 NP THYROID TAB 120MG Added to formulary 06/23/2017 SULFATRIM PD SUS /5 Added to formulary 06/09/2017 TRANEX ACID INJ 1000MG Added to formulary 06/23/2017 TRI FEMYNOR TAB Added to formulary 06/02/2017 UNITUXIN INJ Removed from formulary 06/22/2017 VINCASAR PFS INJ 1MG/ML Removed from formulary 06/22/2017 YONDELIS INJ 1MG Removed from formulary 06/22/2017 ZANOSAR INJ 1GM Removed from formulary 06/22/2017 July 2017 Drug/Product A-HYDROCORT INJ 100MG Removed from formulary 07/27/2017 AMPICILLIN CAP 250MG Removed from formulary 07/06/2017 AMPICILLIN CAP 250MG Removed from formulary 07/13/2017 AMPICILLIN CAP 250MG Removed from formulary 07/13/2017 AMPICILLIN SUS 125/5ML Removed from formulary 07/13/2017 AMPICILLIN SUS 250/5ML Removed from formulary 07/13/2017 ARRANON INJ 5MG/ML Removed from formulary 07/27/2017 ARRANON INJ 5MG/ML Removed from formulary 07/27/2017 BAL-CARE MIS DHA Removed from formulary 07/27/2017 BAL-CARE DHA MIS ESSNTIAL Removed from formulary 07/27/2017 BELLA ALK/PB TAB 16.2MG Added to formulary 07/14/2017 Page 7 of 10

8 BUSULFAN INJ 6MG/ML Removed from formulary 07/27/2017 BUSULFAN INJ 6MG/ML Removed from formulary 07/27/2017 BUSULFAN INJ 6MG/ML Removed from formulary 07/27/2017 CALCIUM PNV CAP Removed from formulary 07/27/2017 CITRANATAL MIS 90 DHA Removed from formulary 07/27/2017 CITRANATAL PAK ASSURE Removed from formulary 07/27/2017 CITRANATAL TAB RX Removed from formulary 07/27/2017 CLOZARIL TAB 100MG Removed from formulary 07/06/2017 C-NATE DHA CAP Removed from formulary 07/27/2017 CUVPOSA SOL 1MG/5ML Added to formulary 07/21/2017 ELITE-OB TAB Removed from formulary 07/27/2017 ENBRACE HR CAP Removed from formulary 07/27/2017 ENLYTE CAP Removed from formulary 07/27/2017 EPIVIR HBV TAB 100MG Removed from formulary 07/27/2017 EPOGEN INJ 10000/ML Added to formulary 07/28/2017 EPOGEN INJ 10000/ML Added to formulary 07/28/2017 EPOGEN INJ 2000/ML Added to formulary 07/28/2017 EPOGEN INJ 2000/ML Added to formulary 07/28/2017 EPOGEN INJ 20000/ML Added to formulary 07/28/2017 EPOGEN INJ 20000/ML Added to formulary 07/28/2017 EPOGEN INJ 3000/ML Added to formulary 07/28/2017 EPOGEN INJ 3000/ML Added to formulary 07/28/2017 EPOGEN INJ 4000/ML Added to formulary 07/28/2017 EPOGEN INJ 4000/ML Added to formulary 07/28/2017 EXTRA-VIRT CAP PLUS DHA Removed from formulary 07/27/2017 FAMOTIDINE SUS 40MG/5ML Removed from formulary 07/27/2017 FAMOTIDINE SUS 40MG/5ML Removed from formulary 07/27/2017 FOCALGIN 90 MIS DHA Removed from formulary 07/27/2017 FOCALGIN CA MIS Removed from formulary 07/27/2017 FOLOTYN INJ 20MG/ML Removed from formulary 07/27/2017 FOLOTYN INJ 40MG/2ML Removed from formulary 07/27/2017 IMURAN TAB 50MG Removed from formulary 07/27/2017 ISENTRESS HD TAB 600MG Added to formulary 07/14/2017 LAMIVUDINE TAB 100MG Added to formulary 07/28/2017 LAMIVUDINE TAB 100MG Added to formulary 07/28/2017 LAMIVUDINE TAB 100MG Added to formulary 07/28/2017 LAMIVUDINE TAB 100MG Added to formulary 07/28/2017 MARNATAL-F CAP Removed from formulary 07/27/2017 MELPHALAN TAB 2MG Added to formulary 07/14/2017 NATELLE ONE CAP Removed from formulary 07/27/2017 NESTABS TAB Removed from formulary 07/27/2017 NESTABS ABC MIS Removed from formulary 07/27/2017 NESTABS DHA PAK Removed from formulary 07/27/2017 NEWGEN TAB 32-1MG Removed from formulary 07/27/2017 NEXA PLUS CAP Removed from formulary 07/27/2017 NORINYL TAB 1/35 Removed from formulary 07/20/2017 Page 8 of 10

9 OB COMPLETE CAP GOLD Removed from formulary 07/27/2017 OB COMPLETE CAP ONE Removed from formulary 07/27/2017 OB COMPLETE CAP PETITE Removed from formulary 07/27/2017 OB COMPLETE TAB Removed from formulary 07/27/2017 OB COMPLETE TAB PREMIER Removed from formulary 07/27/2017 OB COMPLETE/ CAP DHA Removed from formulary 07/27/2017 O-CAL TAB PRENATAL Removed from formulary 07/27/2017 O-CAL FA TAB Removed from formulary 07/27/2017 PNV OB+DHA PAK Removed from formulary 07/27/2017 PNV-OMEGA CAP Removed from formulary 07/27/2017 PREFERA OB TAB Removed from formulary 07/27/2017 PREFERAOB CAP ONE Removed from formulary 07/27/2017 PREFERAOB MIS +DHA Removed from formulary 07/27/2017 PRENAISSANCE CAP Removed from formulary 07/27/2017 PRENAISSANCE CAP PLUS Removed from formulary 07/27/2017 PRENATA CHW 29-1MG Removed from formulary 07/27/2017 PRENATE CAP ENHANCE Removed from formulary 07/27/2017 PRENATE CAP PIXIE Removed from formulary 07/27/2017 PRENATE CAP RESTORE Removed from formulary 07/27/2017 PRENATE CHW Removed from formulary 07/27/2017 PRENATE AM TAB 1MG Removed from formulary 07/27/2017 PRENATE DHA CAP Removed from formulary 07/27/2017 PRENATE STAR TAB 20-1MG Removed from formulary 07/27/2017 PRIMACARE CAP Removed from formulary 07/27/2017 PROPRAN/HCTZ TAB 40/25 Removed from formulary 07/27/2017 PROPRAN/HCTZ TAB 80/25 Removed from formulary 07/27/2017 PUREFE CAP PLUS Removed from formulary 07/27/2017 PUREFE OB CAP PLUS Removed from formulary 07/27/2017 Q-PAP LIQ 160/5ML Removed from formulary 07/13/2017 Q-PAP LIQ 160/5ML Removed from formulary 07/13/2017 Q-PAP LIQ 160/5ML Removed from formulary 07/13/2017 Q-PAP CHILD SUS 160/5ML Removed from formulary 07/13/2017 Q-PAP CHILD SUS 160/5ML Removed from formulary 07/13/2017 Q-PAP CHILD SUS 160/5ML Removed from formulary 07/13/2017 RELNATE DHA CAP Removed from formulary 07/27/2017 ROWEEPRA TAB 500MG Added to formulary 07/14/2017 RULAVITE DHA CAP Removed from formulary 07/27/2017 SELZENTRY SOL 20MG/ML Added to formulary 07/14/2017 TARON-PREX CAP Removed from formulary 07/27/2017 TRANSDERM-SC DIS 1MG Removed from formulary 07/27/2017 TRANSDERM-SC DIS 1MG Removed from formulary 07/27/2017 TRANSDERM-SC DIS 1MG Removed from formulary 07/27/2017 TRICARE CHW PRENATAL Removed from formulary 07/27/2017 TRICARE PAK PRENATAL Removed from formulary 07/13/2017 TRICARE TAB PRENATAL Removed from formulary 07/27/2017 TRICARE PRE CAP Removed from formulary 07/27/2017 Page 9 of 10

10 TRISTART DHA CAP Removed from formulary 07/27/2017 TRI-TABS DHA MIS Removed from formulary 07/27/2017 ULTIMATECARE CAP ONE Removed from formulary 07/27/2017 ULTIMATECARE CAP ONE NF Removed from formulary 07/27/2017 VINATE DHA CAP Removed from formulary 07/27/2017 VIRT-NATE CAP DHA Removed from formulary 07/27/2017 VIRT-PN TAB Removed from formulary 07/27/2017 VIRT-PN DHA CAP Removed from formulary 07/27/2017 VIRT-PN PLUS CAP Removed from formulary 07/27/2017 VIRT-SELECT CAP Removed from formulary 07/27/2017 VITAFOL-OB PAK +DHA Removed from formulary 07/27/2017 VITAFOL-OB TAB 65-1MG Removed from formulary 07/27/2017 VP-CH PLUS CAP Removed from formulary 07/27/2017 VP-CH-PNV CAP Removed from formulary 07/27/2017 VP-HEME OB TAB Removed from formulary 07/27/2017 VP-HEME ONE CAP Removed from formulary 07/27/2017 VP-PNV-DHA CAP Removed from formulary 07/27/2017 ZATEAN-CH CAP Removed from formulary 07/27/2017 ZATEAN-PN CAP DHA Removed from formulary 07/27/2017 ZATEAN-PN CAP PLUS Removed from formulary 07/27/2017 Page 10 of 10