Scripps Health Formulary April 2016

Foreword Pharmacy and Therapeutics Committee. MedImpact approves such multi- This document represents the efforts of the MedImpact Healthcare Systems source drugs for addition to the MAC list based on the following criteria: Pharmacy and Therapeutics (P & T) and Formulary Committees to provide physicians • A multi-source drug product manufactured by at least one (1) nationally and pharmacists with a method to evaluate the safety, efficacy and cost-effectiveness marketed company. of commercially available drug products. A structured approach to the drug selection • At least one (1) of the generic manufacturer’s products must have an “A” process is essential in ensuring continuing patient access to rational drug therapies. rating or the generic product has been determined to be unassociated with The ultimate goal of the Portfolio Formulary is to provide a process and framework to efficacy, safety or bioequivalency concerns by the MedImpact P & T support the dynamic evolution of this document to guide prescribing decisions that Committee. reflect the most current clinical consensus associated with drug therapy decisions. • Drug product will be approved for generic substitution by the Med Impact P & T Committee. This is accomplished through the auspices of the MedImpact P & T and Formulary

Committees. These committees meet quarterly and more often as warranted to ensure This list is reviewed and updated periodically based on the clinical literature and clinical relevancy of the Formulary. To accommodate changes to this document, pharmacokinetic characteristics of currently available versions of these drug updates are made accessible as necessary. products.

As you use this Formulary, you are encouraged to review the information and provide If a member or physician requests a brand name product in lieu of an approved your input and comments to the MedImpact P & T and Formulary Committees. generic, the member, based upon their coverage, will typically be required to pay

the difference in cost between the brand and the generic. If a physician The MedImpact P & T and Formulary Committees use the following criteria in the determines that there is a documented medical need for the brand equivalent, a evaluation of drug selection for the Portfolio Formulary: request for coverage may be made using the request process. • Drug safety profile • Drug efficacy 2. Three Tier Benefit • Comparison of relevant therapeutic benefits to current formulary agents of The Formulary may be applied to a three tier benefit design, where the member similar use, and to minimize therapeutic duplication where possible shares the cost of prescription drug therapy at three levels of copayment. In • Cost-effectiveness relative to comparable therapies most instances, generically available drugs will be covered under the first or lowest copay tier, branded drugs listed on the Formulary will be covered under How to Use the Formulary the second copay tier, and branded drugs not on the Formulary will be covered The Formulary is a list of available to MedImpact members under their under the third or highest copay tier. pharmacy benefit. All drugs are listed by their generic names and most common 3. Medication Request Process proprietary (branded) name. The Formulary may be accessed by using the index, Depending upon plan benefit design, a medication request process may apply either by generic or proprietary name (in capital letters) and by therapeutic drug as follows: category. In situations where an FDA approved generic equivalent is available, brand A. Formulary Agents names are listed for reference purposes only, and do not denote coverage for the Drugs that are listed in the Formulary with associated Prior Authorization brand, unless specifically noted. Any drug not found in this Formulary listing, or any (PA) require evaluation, per MedImpact P & T Committee Prior Formulary updates published by Med shall be considered a Non-Formulary Impact Authorization guidelines prior to dispensing at a network pharmacy. Each drug. request will be reviewed on an individual patient need basis. If the request

does not meet the guidelines established by the P & T Committee, the All drugs are listed in each category in alphabetical order by generic name. Where an request will not be approved and alternative therapy may be FDA approved generic is available for the listed generic name, the generic name is recommended. bolded. B. Non-Formulary Agents For certain agents within the Formulary, a recommended prescribing guideline may Any drug not found in the Formulary listing, or any Formulary updates apply. These are denoted throughout the document using the following symbols: published by MedImpact, shall be considered a Non-Formulary drug. Coverage for non-formulary agents may be applied for in advance. When AGE Age Edit Coverage may depend on patient age a member gives a prescription order for a non-formulary drug to a CU Concurrent Coverage or lack thereof may depend upon pharmacist, the pharmacist will evaluate the patient’s drug history and Use Edit concurrent use of another drug contact the physician to determine if there is a reasonable medical need G Gender Edit Coverage may depend on patient gender for a non-formulary drug. Each request will be reviewed on an individual MD Physician Coverage may depend on prescribing physician’s patient need basis. Approval will be given if a documented medical need Specialty specialty or board certification exists. The following basic guidelines are used: Edit • The use of Formulary Drugs is contraindicated in the patient. PA Prior Requires specific physician request process • The patient has failed an appropriate trial of Formulary or related Authorization agents. • The choices available in the Formulary are not suited for the present QL Quantity Coverage may be limited to specific quantities patient care need, and the drug selected is required for patient Limit per prescription and/or time period safety. ST Step Coverage may depend on previous use of another • The use of a Formulary drug may provoke an underlying condition, Therapy drug which would be detrimental to patient care.

Please refer to the prescribing guideline appendix within this document for details If the request does not meet the guidelines established by the P & T regarding specific agents. Committee, the request will not be approved and alternative therapy may be recommended. Benefit Coverage and Limitations C. Obtaining Coverage This printed Formulary does not provide information regarding the specific coverage Coverage, questions or information regarding the medication request or and limitations an individual member may be subject to. Many members have specific formulary process may be obtained by: benefit inclusions, exclusions, copays, or a lack of coverage, which are not reflected in 1. Faxing a completed Medication Request Form to MedImpact at the Formulary. (858) 790-7100. 2. Contacting MedImpact at (800) 788-2949 and providing all The Formulary applies only to outpatient drugs provided to members, and does not necessary information requested. apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact their Plan Sponsor or MedImpact will provide an authorization number, specific for the medical MedImpact at (800) 788-2949. need, for all approved requests. Non-approved requests may be appealed. The prescriber must provide information to support the appeal Depending upon a member’s specific benefit parameters, the following topics on the basis of medical necessity. Prior Authorization is generally not may apply: available for drugs that are specifically excluded by benefit design. 1. Generic Substitution When available, FDA approved generic drugs are to be used in all situations, 4. General Exclusions regardless of the brand name indicated. The generic names are bolded in the A. Over the Counter (OTC) medications or their equivalents, unless otherwise formulary listing wherever an FDA approved generic drug product is available. specified in the Formulary listing. Greater economy is realized through the use of generic equivalents. This policy B. Nicotine Smoking Cessation products (i.e., transdermal nicotine, nicotine is not meant to preclude or supplant any state statutes that may exist. All drugs gum, nicotine inhaler). that are or become available generically are subject to review by MedImpact’s C. Drugs specifically listed as not covered.

804 Portfolio High Formulary – April 2016 i Scripps Health Formulary

D. Any drug products used for cosmetic purposes. E. Experimental drug products or any drug product used in an experimental manner. F. Replacement of lost or stolen medication. G. Non self-administered injectable drug products unless otherwise specified in the Formulary listing. H. Foreign sourced drugs or drugs not approved by the United States Food & Drug Administration.

The P & T and Formulary Committees recognize that not all medical needs can be met with this document and encourage inquiries about alternative therapies.

5. Pharmacist and Physician Communication The Formulary is a tool to promote cost-effective prescription drug use. The P & T and Formulary Committees have made every attempt to create a document that meets all therapeutic needs; however, the art of medicine makes this a formidable task. MedImpact welcomes the participation of physicians, pharmacists, and ancillary medical providers, in this dynamic process. Physicians and pharmacists are highly encouraged to direct any suggestions, comments or formulary additions to MedImpact at the following address:

Chairperson, Pharmacy & Therapeutics Committee MedImpact Healthcare Systems, Inc. 10181 Scripps Gateway Court San Diego, CA 92131

Portfolio High Formulary – April 2016 ii Scripps Health Formulary

Foreword ...... i Antihyperlipidemic - MTP Inhibitors ...... 8 1. Generic Substitution ...... i Bile Salt Sequestrants ...... 8 2. Three Tier Benefit ...... i Lipotropics ...... 9 3. Medication Request Process ...... i Niacin Preparations ...... 9 4. General Exclusions ...... i CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ...... 9 5. Pharmacist and Physician Communication ...... ii Adrenergic Vasopressor Agents ...... 9 ALLERGY ...... 6 Antianginal & Anti-Ischemic Agents, Non-Hemodynamic ...... 9 Allergenic extracts ...... 6 Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker Combinations ..... 9 2nd Geneneration Antihistamine & Decongestant Combinations ...... 6 Heart Rate Reducing, Selective I(F) Current Inhib...... 9 Antihistamines - 1st Generation ...... 6 CARDIOVASCULAR DISEASE - VASODILATION ...... 9 Antihistamines - 2nd Generation ...... 6 Vasodilators, Combination ...... 9 Nasal Anti-Inflammatory ...... 6 Vasodilators, Coronary ...... 9 Nasal Antihistamine ...... 6 CONTRACEPTION/OXYTOCICS ...... 9 ANTIEMESIS/ANTIVERTIGO ...... 6 Contraceptives, Intravaginal, Systemic ...... 9 Antiemetic/Antivertigo Agents ...... 6 Contraceptives, Oral ...... 9 ASTHMA ...... 6 Contraceptives, Transdermal ...... 9 Beta-Adrenergic Agents ...... 6 Oxytocics ...... 9 Beta-Adrenergic & Anticholinergic Combinations ...... 6 COUGH AND COLD ...... 9 Beta-Adrenergic & Combinations ...... 6 1st Generation Antihistamine & Decongestant Combinations...... 9 General Bronchodilator Agents ...... 6 Narcotic Antitussive-1st Geneneration Antihistamine-Decongestants ...... 9 Leukotriene Receptor Antagonists ...... 6 Narcotic Antitussive-1st Generation Antihistamines ...... 9 Mast Cell Stabilizers ...... 6 Narcotic Antitussive-Anticholinergic Comb...... 9 Oral Inhaled ...... 6 Non-Narcotic Antitussive-1st Generation Antihistamine Combinations ...... 9 Phosphodiesterase-4 (PDE4) Inhibitors ...... 6 DERMATOLOGY - ACNE ...... 9 Xanthines ...... 6 Acne Agents, Systemic ...... 9 AUTONOMIC NERVOUS SYSTEM DISORDERS ...... 6 Acne Agents, Topical ...... 9 Alzheimer's Therapy, Nmda Receptor Antagonists ...... 6 Keratolytic-Glucocorticoid Combinations ...... 9 Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines Inhibitors ...... 6 Keratolytics ...... 9 Cholinesterase Inhibitors ...... 6 Rosacea Agents, Topical ...... 9 BEHAVIORAL HEALTH - ANTIDEPRESSANTS ...... 6 Vitamin A Derivatives ...... 9 Alpha-2 Receptor Antagonist Antidepressants ...... 6 DERMATOLOGY - ANTIINFECTIVE ...... 9 Maois - Non-Selective & Irreversible ...... 6 Topical Antibiotics ...... 9 Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs) ...... 6 Topical Antifungals ...... 10 Selective Serotonin Reuptake Inhibitors (SSRIs) ...... 6 Topical Antiparasitics ...... 10 SSRI & Antipsycho, Atyp, Dopamine & Serotonin Antag Comb ...... 6 Topical Antivirals ...... 10 Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs)...... 6 Topical Sulfonamides ...... 10 Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) ...... 6 DERMATOLOGY - ANTIINFLAMMATORY ...... 10 Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib ...... 7 Topical Anti-Inflammatory Steroidal ...... 10 BEHAVIORAL HEALTH - OTHER ...... 7 Topical Anti-Inflammatory, NSAIDs ...... 10 Adrenergics, Aromatic, Non-Catecholamine ...... 7 Topical Antibiotics/Antiinflammatory, Steroidal ...... 10 Anti-Alcoholic Preparations ...... 7 DERMATOLOGY - MISCELLANEOUS ...... 10 Anti-Anxiety Drugs ...... 7 Antiperspirants ...... 10 Anti-Mania Drugs ...... 7 Antiseborrheic Agents ...... 10 Antipsychotics, Phenothiazines ...... 7 Topical Antineoplastic & Premalignant Lesion Agents ...... 10 Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed ...... 7 Topical Local Anesthetics ...... 10 Antipsychotics, Dopamine & Serotonin Antagonists ...... 7 DERMATOLOGY - PIGMENTATION DISORDERS ...... 10 Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists ...... 7 Topical Hyperpigmentation Agents ...... 10 Antipsychotics, Dopamine Antagonists, Thioxanthenes ...... 7 DERMATOLOGY - PSORIASIS/ECZEMA ...... 10 Antipsychotics, Dopamine Antagonists, Butyrophenones ...... 7 Antipsoriatic Agents, Systemic ...... 10 Barbiturates ...... 7 Antipsoriatics Agents ...... 10 Narcolepsy and Sleep Disorder Therapy Agents ...... 7 Topical Immunosuppressive Agents ...... 10 Narcotic Antagonists ...... 7 DIABETES ...... 10 Sedative-Hypnotics, Non-Barbiturate ...... 7 Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea) ...... 10 Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy ...... 7 Antihyperglycemic, Amylin Analog-Type ...... 10 Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type ...... 7 Antihyperglycemic, DPP-4 Inhibitors ...... 10 CARDIOVASCULAR DISEASE - ARRHYTHMIA ...... 7 Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations ...... 10 Antiarrhythmics ...... 7 Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists) ...... 10 CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS ...... 7 Antihyperglycemic, Insulin-Release Stimulant Type ...... 10 Digitalis Glycosides ...... 7 Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea) ...... 11 CARDIOVASCULAR DISEASE - HYPERTENSION ...... 7 Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) ...... 11 ACE Inhibitor/Calcium Channel Blocker Combinations ...... 7 Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations ...... 11 ACE Inhibitor/Thiazide & Thiazide-Like Diuretics ...... 7 Antihyperglycemic, Insulin-Response & Release Combinations ...... 11 Alpha-Adrenergic Blocking Agents ...... 8 Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations ...... 11 Alpha/Beta-Adrenergic Blocking Agents ...... 8 Antihyperglycemic- Blockers...... 11 Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors ...... 11 Combinations ...... 8 Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations ...... 8 Biguanide Combination ...... 11 Angiotensin Receptor Antagonist & Calcium Channel Blockers ...... 8 Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination ...... 11 Antihypertensives, ACE Inhibitors ...... 8 Diabetic Supplies ...... 11 Antihypertensives, Angiotensin Receptor Antagonist ...... 8 Diabetic Ulcer Preparations, Topical ...... 11 Antihypertensives, Sympatholytic ...... 8 Hyperglycemics ...... 11 Antihypertensives, Vasodilators ...... 8 Insulins ...... 11 Beta-Adrenergic Blocking Agents ...... 8 Syringes & Accessories ...... 11 Beta-Adrenergic Blocking Agents/Thiazide & Related ...... 8 EAR - GENERAL DISORDERS ...... 11 Calcium Channel Blocking Agents ...... 8 Ear Preparations, Misc. Anti-Infectives ...... 11 Loop Diuretics ...... 8 Ear Preparations, Antibiotics ...... 11 Potassium Sparing Diuretics ...... 8 Otic Preparations, Anti-Inflammatory-Antibiotics ...... 11 Potassium Sparing Diuretics in Combination ...... 8 Otic Preparations, Local anesthetics ...... 11 Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors ...... 8 ELECTROLYTE REGULATION ...... 11 Pulmonary Anti-HTN, Endothelin Receptor Antagonists ...... 8 Electrolyte Depleters ...... 11 Pulmonary Anti-HTN, Prostacyclin-Type ...... 8 Potassium Replacement ...... 11 Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators ...... 8 ENDOCRINE DISORDER - FERTILITY ...... 11 Thiazide & Related Diuretics ...... 8 Drugs to Treat Impotency ...... 11 CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ...... 8 Fertility Stimulating Preparations, Non-FSH ...... 11 Antihyperlipidemic - APO B-100 Synthesis Inhibitor ...... 8 Follicle Stimulating / Luteinizing Hormones ...... 11 Antihyperlipidemic - HMG CoA Reductase Inhibitors ...... 8 Pregnancy Facilitating/Maintaining Agents, Hormonal...... 11 Antihyperlipidemic - HMG CoA Reductase Inhibitors & Niacin ...... 8 ENDOCRINE DISORDER - OTHER ...... 11

Portfolio High Formulary – April 2016 iii Scripps Health Formulary

Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants ...... 11 Antivirals, HIV-Specific, CCR5 Co-Receptor Antag...... 14 Antidiuretic & Vasopressor Hormones ...... 11 Antivirals, HIV-Specific, Fusion Inhibitors ...... 14 Bone Formation Stim. Agents - Parathyroid Hormone ...... 11 Antivirals, HIV-Specific, Non-Nucleoside, RTI ...... 14 Bone Resorption Inhibitor & Vitamin D Combinations ...... 11 Antivirals, HIV-Specific, Nucleoside Analog, RTI ...... 14 Bone Resorption Inhibitors ...... 11 Antivirals, HIV-Specific, Nucleotide Analog, RTI ...... 15 Growth Hormone Receptor Antagonists ...... 12 Antivirals, HIV-Specific, Protease Inhibitor Comb ...... 15 Growth Hormones ...... 12 Antivirals, HIV-Specific, Protease Inhibitors ...... 15 Hyperparathyroid Tx Agent, Vitamin D Analog-Type ...... 12 Antivirals, HIV-1 Integrase Strand Transfer Inhibtors...... 15 LHRH (GnRH) Antagonist, Pituitary Suppressant Agents ...... 12 Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI ...... 15 Luteinizing Hormone Releasing Hormone –LHRH (GnRH) ... Error! Bookmark Cytochrome P450 Inhibitors ...... 15 not defined. Hepatitis B Treatment Agents ...... 15 Pituitary Suppressive Agents ...... 12 Hepatitis C Combination Agents...... 15 ENDOCRINE DISORDER - THYROID ...... 12 Hepatitis C Treatment Agents ...... 15 Antithyroid Preparations ...... 12 INFLAMMATORY DISEASE ...... 15 Iodine Containing Agents ...... 12 Anti-Arthritic & Chelating Agents ...... 15 Thyroid Hormones ...... 12 Anti-Arthritic, Folate Antagonist Agents ...... 15 EYE - GENERAL DISORDERS ...... 12 Anti-Inflammatory Tumor Necrosis Factor Inhibitor ...... 15 Eye Antibiotic-Corticoid Combinations ...... 12 Anti-Inflammatory, Pyrimidine Synthesis Inhibitors ...... 15 Eye Antihistamines ...... 12 Bradykinin B2 Receptor Antagonists ...... 15 Eye Antiinflammatory Agents ...... 12 ...... 15 Eye Antivirals ...... 12 Mineralocorticoids ...... 15 Eye Sulfonamides ...... 12 Monoclonal antibody-human interleukin ...... 15 EYE - MISCELLANEOUS ...... 12 NSAIDs, Cyclooxygenase Inhibitor-Type ...... 15 Ophthalmic Cystine Delpleting Agents ...... 12 LOCAL ANESTHESIA ...... 15 Ophthalmic Anti-Inflammatory Immunomodulator-Type ...... 12 Local Anesthetics ...... 15 Ophthalmic Antibiotics ...... 12 LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT ...... 15 Ophthalmic Mast Cell Stabilizers ...... 12 Bowel Antiinflamatory Agents ...... 15 EYE - GLAUCOMA ...... 12 Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx ...... 15 Carbonic Anhydrase Inhibitors ...... 12 Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat ...... 15 Miotics/Other Intraoccula Pressure Reducers ...... 12 Hemorrhoidal Preparations ...... 15 Mydriatics ...... 12 Rectal Preparations ...... 15 GOUT AND RELATED DISEASES ...... 13 Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) ...... 15 Colchicine ...... 13 LOWER GASTROINTESTINAL DISORDERS - OTHER ...... 15 Hyperuricemia Treatment - Purine Inhibitors ...... 13 Ammonia Inhibitors ...... 15 Uricosuric Agents ...... 13 Antidiarrheals ...... 15 HEMATOLOGICAL DISORDERS ...... 13 Bile Salts ...... 15 Anticoagulants, Coumarin Type ...... 13 Laxatives & Cathartics ...... 16 Hematinics, Other ...... 13 Narcotic Antagonists, Peripherally-Acting ...... 16 Hemorrheologic Agents ...... 13 MISCELLANEOUS AGENTS ...... 16 Heparin & Related Preparations ...... 13 Anaphylaxis Therapy Agents ...... 16 Leukocyte (WBC) Stimulants ...... 13 Parasympathetic Agents ...... 16 Platelet Aggregation Inhibitors ...... 13 Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase...... 16 Platelet Reducing Agents ...... 13 NEOPLASTIC DISEASE ...... 16 Thrombopoietin Receptor Agonists ...... 13 Alkylating Agents...... 16 Vitamin K Preparations ...... 13 Antiandrogenic Agents ...... 16 HORMONAL DEFICIENCY...... 13 Antimetabolites ...... 16 Androgenic Agents ...... 13 Antineoplastic - Aromatase Inhibitors ...... 16 Estrogen/Androgen Combinations ...... 13 Antineoplastic – Hedgehog Pathway Inhibitors...... 16 Estrogenic Agents ...... 13 Antineoplastic – Janus Kinase (JAK) Inhibitors ...... 16 Progestational Agents ...... 13 Antineoplastic - MEK1 and MEK2 Kinase Inhibitors ...... 16 IMMUNOSUPPRESSION/MODULATION...... 13 Antineoplastic - Topoisomerase I Inhibitors ...... 16 Immunomodulators ...... 13 Antineoplastic - Immunomodulator Agents ...... 16 Immunosuppressives ...... 13 Antineoplastic - Systemic Enzyme Inhibitors ...... 16 INFECTIOUS DISEASE - BACTERIAL ...... 13 Antineoplastic, Histone Deacetylase Inhibitors, HDIS ...... 16 Absorbable Sulfonamides ...... 13 Antineoplastics, Miscellaneous ...... 16 Betalactams ...... 13 Chemotherapy Rescue/Antidote Agents ...... 16 Cephalosporins - 1st Generation ...... 13 Selective Estrogen Receptor Modulators (SERM) ...... 16 Cephalosporins - 2nd Generation ...... 13 Selective Retinoid X Receptor Agonists (RXR) ...... 16 Cephalosporins - 3rd Generation ...... 13 Antineoplastics ...... 16 Chemotherapeutics, Antibacterial, Miscellaneous ...... 13 NEUROLOGICAL DISEASE - MISCELLANEOUS ...... 16 Ketolides ...... 13 Agents to Treat Multiple Sclerosis ...... 16 Lincosamides ...... 13 Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor ...... 17 Macrolides ...... 13 Movement Disorders (Drug Therapy) ...... 17 Nitrofuran Derivatives ...... 14 ORAL/PHARYNGEAL DISORDERS ...... 17 Oxazolidinones ...... 14 Dental Aids & Preparations ...... 17 Penicillins ...... 14 Nose Preparations, Antibiotics ...... 17 Quinolones ...... 14 Nose Preparations, Miscellaneous (Rx) ...... 17 Tetracyclines ...... 14 OTHER DRUGS ...... 17 INFECTIOUS DISEASE - FUNGAL ...... 14 Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome ...... 17 Antifungal Agents ...... 14 General Inhalation Agents ...... 17 Antifungal Antibiotics ...... 14 Metabolic disease enzyme replace, hypophosphatasia ...... 17 INFECTIOUS DISEASE - MISCELLANEOUS ...... 14 Needles/Needleless Devices ...... 17 Aminoglycosides ...... 14 Somatostatic Agents ...... 17 Anti-Mycobacterium Agents ...... 14 OTHER RESPIRATORY DISORDERS ...... 17 Antileprotics ...... 14 Antifibrotic Therapy – Pyridone Analogs ...... 17 Antitubercular Antibiotics ...... 14 Cystic Fibrosis-Cftr Potentiator & Corrector Comb...... 17 Rifamycins and Related Derivative Antibiotics ...... 14 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiators Vancomycin & Derivatives ...... 14 ...... 17 INFECTIOUS DISEASE - PARASITIC ...... 14 Mucolytics ...... 17 Amebacides ...... 14 Pulmonary Fibrosis – Systemic Enzyme Inhibitors ...... 17 Anaerobic Antiprotozoal-Antibacterial Agents ...... 14 PAIN MANAGEMENT - ANALGESICS ...... 17 Anthelmintics ...... 14 Analgesic, Non-Salicylate & Barbiturate Combinations ...... 17 Antimalarial Drugs ...... 14 Analgesic, Salicylate, Barbiturate & Xanthine Combinations ...... 17 Antiprotozoal Drugs, Miscellaneous ...... 14 Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations ...... 17 INFECTIOUS DISEASE - VIRAL ...... 14 Analgesic/Antipyretics, Salicylates ...... 17 Antivirals, HIV-Spec, Non-Peptidic Protease Inhib ...... 14 Analgesics, Narcotics ...... 17 Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog ...... 14 Antimigraine Preparations ...... 17 Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb ...... 14 Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations . 17

Portfolio High Formulary – April 2016 iv Scripps Health Formulary

Narcotic & Salicylate Analgesics, Barbiturates & Xanthines ...... 17 Narcotic Analgesic & Non-Salicylate Analgesic Combinations ...... 17 PARKINSON’S DISEASE ...... 17 Antiparkinsonism Drugs, Anticholinergic ...... 17 Antiparkinsonism Drugs, Other ...... 17 Decarboxylase Inhibitors ...... 18 SEIZURE DISORDER ...... 18 Anticonvulsants...... 18 SKELETAL MUSCLE DISORDER ...... 18 Agents To Treat Periodic Paralysis ...... 18 Skeletal Muscle Relaxants ...... 18 UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ...... 18 Pancreatic Enzymes ...... 18 UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE ...... 18 Anticholinergics/Antispasmodics ...... 18

Belladonna Alkaloids ...... 18 UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ...... 18 Anti-Ulcer Preparations ...... 18 Anti-Ulcer-H.pylori Agents ...... 18 Anticholinergics, Quaternary Ammonium ...... 18 Histamine H2-Receptor Inhibitors ...... 18 Intestinal Motility Stimulants ...... 18 Proton-Pump Inhibitors ...... 18 URINARY TRACT - FUNCTIONAL DISORDERS ...... 18 Benign Prostatic Hypertrophy/Micturition Agents ...... 18 Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag comb agents ...... 18 Kidney Stone Agents ...... 18 Overactive Bladder Agents, Beta-3 Adrenergic Recep ...... 18 Urinary Tract Analgesic Agents ...... 18 Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) ...... 18 Urinary Tract Antispasmodic, M(3) Selective Antagonists ...... 18 Urinary Tract Antispasmodic/Antiincontinence Agents ...... 18 VAGINAL DISORDERS ...... 18 Vaginal Antibiotics ...... 18 Vaginal Antifungals ...... 18 Vaginal Estrogen Preparations ...... 18 Vaginal Sulfonamides ...... 18 VITAMIN AND/OR MINERAL DEFICIENCY ...... 18 Fluoride Preparations ...... 18 Folic Acid Preparations ...... 19 Multivitamin Preparations ...... 19 Pediatric Vitamin Preparations ...... 19 Prenatal Vitamin Preparations ...... 19 Vitamin B Preparations ...... 19 Vitamin D Preparations ...... 19 SPECIALTY INJECTABLE CROSS REFERENCE LISTING ...... 19

Portfolio High Formulary – April 2016 v Scripps Health Formulary

ALLERGY QL ipratropium bromide ATROVENT HFA Allergenic extracts QL tiotropium bromide SPIRIVA PA 5-grass pollen extract ORALAIR QL tiotropium bromide SPIRIVA RESPIMAT PA short ragweed pollen extract RAGWITEK Leukotriene Receptor Antagonists PA timothy grass pollen extract GRASTEK montelukast sodium SINGULAIR 2nd Geneneration Antihistamine & Decongestant Combinations Mast Cell Stabilizers p-ephed hcl/cetirizine hcl (OTC) ZYRTEC-D (OTC) cromolyn sodium INTAL p-ephed sul/loratadine (OTC) CLARITIN-D 12 HOUR Oral Inhaled Corticosteroids (OTC) QL PULMICORT RESPULES CLARITIN-D 24 HOUR QL beclomethasone dipropionate QVAR (OTC) QL budesonide PULMICORT Antihistamines - 1st Generation FLEXHALER hydroxyzine hcl ATARAX QL furoate ASMANEX hydroxyzine pamoate VISTARIL QL ASMANEX HFA promethazine hcl PHENERGAN Phosphodiesterase-4 (PDE4) Inhibitors Antihistamines - 2nd Generation QL + roflumilast DALIRESP cetirizine hcl (OTC) ZYRTEC (OTC) ST levocetirizine dihydrochloride XYZAL TABS Xanthines loratadine (OTC) CLARITIN (OTC) aminophylline AMINOPHYLLIN Nasal Anti-Inflammatory Steroids theophylline anhydrous UNIPHYL QL NASAREL theophylline anhydrous THEO-24 QL propionate FLONASE AUTONOMIC NERVOUS SYSTEM DISORDERS QL acetonide NASACORT AQ Alzheimer's Therapy, Nmda Receptor Antagonists QL + dipropionate QNASL QL memantine hcl NAMENDA ST QL memantine hcl NAMENDA XR QL + QNASL CHILDREN Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines ST Inhibitors QL mometasone furoate NASONEX QL + memantine hcl/donepezil hcl NAMZARIC Nasal Antihistamine ST QL azelastine hcl ASTELIN Cholinesterase Inhibitors QL + ASTEPRO donepezil hcl ARICEPT ST ARICEPT ODT ANTIEMESIS/ANTIVERTIGO QL galantamine hydrobromide RAZADYNE Antiemetic/Antivertigo Agents QL RAZADYNE ER QL + dronabinol MARINOL pyridostigmine bromide MESTINON ST QL rivastigmine EXELON PATCH meclizine hcl ANTIVERT rivastigmine tartrate EXELON ondansetron ZOFRAN ODT neostigmine bromide PROSTIGMIN QL ondansetron hcl (QL on ZOFRAN BEHAVIORAL HEALTH - ANTIDEPRESSANTS solution) Alpha-2 Receptor Antagonist Antidepressants prochlorperazine maleate COMPAZINE mirtazapine REMERON promethazine hcl PHENERGAN Maois - Non-Selective & Irreversible QL netupitant/palonosetron hcl AKYNZEO tranylcypromine sulfate PARNATE QL aprepitant EMEND phenelzine sulfate NARDIL prochlorperazine edisylate COMPAZINE SYRUP Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs) ASTHMA bupropion hcl WELLBUTRIN Beta-Adrenergic Agents WELLBUTRIN SR albuterol sulfate ALBUTEROL SULFATE WELLBUTRIN XL metaproterenol sulfate ALUPENT Selective Serotonin Reuptake Inhibitors (SSRIs) terbutaline sulfate BRETHINE citalopram hydrobromide CELEXA albuterol sulfate PROAIR HFA escitalopram oxalate LEXAPRO PROAIR RESPICLICK fluoxetine hcl PROZAC VENTOLIN HFA fluoxetine er PROZAC WEEKLY QL formoterol fumarate PERFOROMIST paroxetine hcl PAXIL QL olodaterol hcl STRIVERDI RESPIMAT sertraline hcl ZOLOFT QL salmeterol xinafoate SEREVENT DISKUS SSRI & Antipsycho, Atyp, Dopamine & Serotonin Antag Comb Beta-Adrenergic & Anticholinergic Combinations QL olanzapine/fluoxetine SYMBYAX ipratropium/albuterol sulfate DUONEB Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs) ipratropium/albuterol sulfate COMBIVENT trazodone hcl DESYREL 300MG COMBIVENT RESPIMAT Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) QL tiotropium br/olodaterol hcl STIOLTO RESPIMAT QL duloxetine hcl CYMBALTA Beta-Adrenergic & Glucocorticoid Combinations venlafaxine hcl EFFEXOR QL fluticasone/salmeterol ADVAIR DISKUS EFFEXOR XR QL ADVAIR HFA QL + desvenlafaxine ER (Ranbaxy) DESVENLAFAXINE ER QL fluticasone/vilanterol BREO ELLIPTA ST (RANBAXY BRAND) QL mometasone/formoterol DULERA QL + desvenlafaxine succinate PRISTIQ General Bronchodilator Agents ST ipratropium bromide ATROVENT

Portfolio High Formulary – April 2016 6 Scripps Health Formulary

Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib Antipsychotics, Dopamine Antagonists, Thioxanthenes amitriptyline hcl ELAVIL thiothixene NAVANE amoxapine ASENDIN Antipsychotics, Dopamine Antagonists, Butyrophenones clomipramine hcl ANAFRANIL haloperidol HALDOL desipramine hcl NORPRAMIN haloperidol lactate HALDOL ORAL CONC. doxepin hcl SINEQUAN Barbiturates imipramine hcl TOFRANIL phenobarbital PHENOBARBITAL maprotiline hcl LUDIOMIL Narcolepsy and Sleep Disorder Therapy Agents nortriptyline hcl PAMELOR PA modafinil PROVIGIL BEHAVIORAL HEALTH - OTHER Narcotic Antagonists Adrenergics, Aromatic, Non-Catecholamine naltrexone hcl REVIA QL amphet asp/amphet/d-amphet ADDERALL QL naloxone hcl NARCAN NASAL QL ADDERALL XR Sedative-Hypnotics, Non-Barbiturate QL dextroamphetamine sulfate DEXEDRINE chloral hydrate NOCTEC QL dextroamphetamine capsule DEXEDRINE SPANSULE estazolam PROSOM QL dextroamphetamine tablet (5mg, ZENZEDI QL eszopiclone LUNESTA 10mg) flurazepam hcl DALMANE QL + dextroamphetamine tablet (2.5mg, ZENZEDI ST 7.5mg) temazepam RESTORIL QL dextroamphetamine tablet (15mg, ZENZEDI triazolam HALCION 20mg, 30mg) QL zaleplon SONATA QL + lisdexamfetamine dimesylate VYVANSE QL zolpidem tartrate AMBIEN ST QL + AMBIEN CR ST Anti-Alcoholic Preparations disulfiram ANTABUSE Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy QL FOCALIN Anti-Anxiety Drugs dexmethylphenidate hcl QL FOCALIN XR alprazolam XANAX ALPRAZOLAM QL + methylphenidate hcl CONCERTA INTENSOL AGE QL METADATE CD BUSPAR buspirone hcl QL + METADATE ER VANSPAR AGE chlordiazepoxide hcl LIBRIUM QL+ METHYLIN CHEW TAB clorazepate dipotassium TRANXENE T-TAB AGE METHYLIN SOLN diazepam VALIUM QL RITALIN lorazepam ATIVAN QL+ RITALIN LA LORAZEPAM INTENSOL AGE RITALIN SR meprobamate MILTOWN oxazepam SERAX QL + methylphenidate ER Susp QUILLIVANT XR ST Anti-Mania Drugs Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type lithium carbonate ESKALITH LITHOBID QL atomoxetine hcl STRATTERA lithium citrate CIBALITH-S CARDIOVASCULAR DISEASE - ARRHYTHMIA Antipsychotics, Phenothiazines Antiarrhythmics chlorpromazine hcl THORAZINE amiodarone hcl CORDARONE fluphenazine hcl PROLIXIN disopyramide phosphate NORPACE perphenazine TRILAFON flecainide acetate TAMBOCOR thioridazine hcl MELLARIL mexiletine hcl MEXITIL trifluoperazine hcl STELAZINE procainamide hcl PRONESTYL Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed propafenone hcl RYTHMOL ST + aripiprazole ABILIFY SOLUTION quinidine gluconate QUINAGLUTE QL quinidine sulfate QUINIDEX ST + ABILIFY TABLET disopyramide phosphate NORPACE CR QL dofetilide TIKOSYN ST + aripiprazole ABILIFY DISCMELT dronedarone hcl MULTAQ QL propafenone hcl RYTHMOL SR Antipsychotics, Dopamine & Serotonin Antagonists CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS loxapine succinate LOXITANE Digitalis Glycosides Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists digoxin LANOXIN QL clozapine CLOZARIL DIGOXIN ORAL SOLN. QL olanzapine ZYPREXA CARDIOVASCULAR DISEASE - HYPERTENSION QL olanzapine ODT ZYPREXA ZYDIS ACE Inhibitor/Calcium Channel Blocker Combinations QL quetiapine fumarate SEROQUEL amlodipine besylate/benazepril LOTREL QL risperidone RISPERDAL ACE Inhibitor/Thiazide & Thiazide-Like Diuretics QL risperidone ODT RISPERDAL M-TAB benazepril/hydrochlorothiazide LOTENSIN HCT QL ziprasidone hcl GEODON captopril/hydrochlorothiazide CAPOZIDE enalapril/hydrochlorothiazide VASERETIC fosinopril/hydrochlorothiazide MONOPRIL HCT lisinopril/hydrochlorothiazide PRINZIDE ZESTORETIC

Portfolio High Formulary – April 2016 7 Scripps Health Formulary

moexipril/hydrochlorothiazide UNIRETIC diltiazem hcl CARDIZEM quinapril/hydrochlorothiazide ACCURETIC CARDIZEM CD Alpha-Adrenergic Blocking Agents DILACOR XR TIAZAC doxazosin mesylate CARDURA felodipine PLENDIL phenoxybenzamine hcl DIBENZYLINE isradipine IR capsules DYNACIRC prazosin hcl MINIPRESS nicardipine hcl CARDENE terazosin hcl HYTRIN nifedipine ADALAT CC Alpha/Beta-Adrenergic Blocking Agents PROCARDIA carvedilol COREG PROCARDIA XL labetalol hcl TRANDATE nimodipine NIMOTOP carvedilol phosphate COREG CR

Angiotensin Receptor Antagonist/Calcium Channel verapamil hcl CALAN Blocker/Thiazide Combinations VERELAN ST EXFORGE HCT amlodipine/valsartan/hctz verapamil hcl ER CALAN SR ST olmesartan/amlodipin/hcthiazid TRIBENZOR VERELAN PM Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations Loop Diuretics irbesartan/hydrochlorithiazide AVALIDE bumetanide BUMEX losartan/hydrochlorothiazide HYZAAR furosemide LASIX valsartan/hydrochlorothiazide DIOVAN HCT torsemide DEMADEX ST olmesartan/hydrochlorothiazide BENICAR HCT Potassium Sparing Diuretics Angiotensin Receptor Antagonist & Calcium Channel Blockers eplerenone INSPRA ST amlodipine/valsartan EXFORGE ALDACTONE ST amlodipine bes/olmesartan med AZOR Potassium Sparing Diuretics in Combination Antihypertensives, ACE Inhibitors triamterene/hydrochlorothiazide DYAZIDE benazepril hcl LOTENSIN MAXZIDE captopril CAPOTEN MAXZIDE-25MG enalapril maleate VASOTEC Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 fosinopril sodium MONOPRIL Inhibitors lisinopril PRINIVIL PA sildenafil citrate REVATIO TABLET ZESTRIL PA tadalafil ADCIRCA moexipril hcl UNIVASC Pulmonary Anti-HTN, Endothelin Receptor Antagonists quinapril hcl ACCUPRIL PA ambrisentan LETAIRIS ramipril ALTACE PA bosentan TRACLEER trandolapril MAVIK PA macitentan OPSUMIT Antihypertensives, Angiotensin Receptor Antagonist Pulmonary Anti-HTN, Prostacyclin-Type irbesartan AVAPRO PA selexipag UPTRAVI losartan potassium COZAAR Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators valsartan DIOVAN PA riociguat ADEMPAS ST olmesartan medoxomil BENICAR Thiazide & Related Diuretics Antihypertensives, Sympatholytic chlorthalidone HYGROTON clonidine hcl CATAPRES hydrochlorothiazide MICROZIDE guanfacine hcl TENEX indapamide LOZOL methyldopa ALDOMET metolazone ZAROXOLYN reserpine SERPASIL chlorthalidone THALITONE Antihypertensives, Vasodilators CARDIOVASCULAR DISEASE - LIPID IRREGULARITY hydralazine hcl APRESOLINE Antihyperlipidemic - APO B-100 Synthesis Inhibitor Beta-Adrenergic Blocking Agents PA mipomersen sodium KYNAMRO acebutolol hcl SECTRAL Antihyperlipidemic - HMG CoA Reductase Inhibitors atenolol TENORMIN atorvastatin calcium LIPITOR bisoprolol fumarate ZEBETA lovastatin MEVACOR metoprolol succinate TOPROL XL pravastatin sodium PRAVACHOL metoprolol tartrate LOPRESSOR simvastatin ZOCOR nadolol CORGARD ST simvastatin (80mg only) pindolol VISKEN QL + rosuvastatin calcium CRESTOR propranolol hcl INDERAL LA ST sotalol hcl BETAPACE Antihyperlipidemic - HMG CoA Reductase Inhibitors & Niacin BETAPACE AF QL + niacin/simvastatin SIMCOR timolol maleate BLOCADREN ST nebivolol hcl BYSTOLIC Antihyperlipidemic - MTP Inhibitors PA + lomitapide JUXTAPID Beta-Adrenergic Blocking Agents/Thiazide & Related atenolol/chlorthalidone TENORETIC 100 QL TENORETIC 50 Bile Salt Sequestrants bisoprolol fumarate/hctz ZIAC cholestyramine/aspartame QUESTRAN LIGHT metoprolol/hctz LOPRESSOR HCT cholestyramine/sucrose QUESTRAN propranolol/hydrochlorothiazide INDERIDE-40/25 colesevelam hcl WELCHOL Calcium Channel Blocking Agents WELCHOL POWDER PACKETS amlodipine besylate NORVASC colestipol COLESTID

Portfolio High Formulary – April 2016 8 Scripps Health Formulary

COLESTID GRANULES ORTHO MICRONOR Lipotropics norethindrone a-e estradiol LOESTRIN ST fenofibrate FENOGLIDE norethindrone-ethinyl estrad NORINYL 1+35 LOFIBRA TABS ORTHO-NOVUM fenofibrate, micronized LOFIBRA CAPS TRI-NORINYL fenofibrate nanocrystallized TRICOR norethindrone-mestranol NORINYL 1+50 gemfibrozil LOPID -ethinyl estradiol ORTHO TRI-CYCLEN ST niacin NIASPAN ORTHO-CYCLEN QL omega-3 acid ethyl esters LOVAZA -ethinyl estradiol LO-OVRAL-28 QL ezetimibe ZETIA norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO ST fenofibrate TRIGLIDE ST noreth a-et estra/fe fumarate LO LOESTRIN FE QL icosapent ethyl VASCEPA Contraceptives, Transdermal Niacin Preparations ST + /ethin.estradiol ORTHO EVRA QL niacin SLO-NIACIN Oxytocics CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS methylergonovine maleate METHERGINE Adrenergic Vasopressor Agents COUGH AND COLD midodrine hcl PROAMATINE 1st Generation Antihistamine & Decongestant Combinations Antianginal & Anti-Ischemic Agents, Non-Hemodynamic PHENERGAN VC QL ranolazine RANEXA phenylephrine hcl/prometh hcl Narcotic Antitussive-1st Geneneration Antihistamine- Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker Decongestants Combinations phenylephrine hcl/cod/prometh PHENERGAN VC QL amlodipine/atorvastatin CADUET W/CODEINE Heart Rate Reducing, Selective I(F) Current Inhib. Narcotic Antitussive-1st Generation Antihistamines PA + ivabradine hcl CORLANOR PHENERGAN QL codeine/promethazine hcl W/CODEINE CARDIOVASCULAR DISEASE - VASODILATION hydrocodone/chlorphen p-stirex TUSSIONEX Vasodilators, Combination Narcotic Antitussive-Anticholinergic Comb. isosorb dinit/hydralazine hcl BIDIL hydrocodone/homatrop me-br HYCODAN Vasodilators, Coronary Non-Narcotic Antitussive-1st Generation Antihistamine isosorbide dinitrate ISOCHRON Combinations ISORDIL d-methorphan hb/prometh hcl PHENERGAN W/ ISORDIL TITRADOSE DEXTROMETHORPHAN isosorbide mononitrate IMDUR DERMATOLOGY - ACNE ISMO Acne Agents, Systemic MONOKET isotretinoin AMNESTEEM nitroglycerin NITRO-DUR CLARAVIS NITROLINGUAL MYORISAN nitroglycerin NITRO-BID SOTRET NITROSTAT ZENATANE CONTRACEPTION/OXYTOCICS Acne Agents, Topical Contraceptives, Intravaginal, Systemic clindamycin phos/benzoyl perox BENZACLIN QL + /ethinyl estradiol NUVARING sulfacetamide sodium KLARON ST clindamycin phos/benzoyl perox ACANYA Contraceptives, Oral clindamycin/tretinoin ZIANA MIRCETTE desog-et estra/ethin estra Keratolytic-Glucocorticoid Combinations -ethinyl estradiol CYCLESSA benzoyl peroxide/hydrocortison VANOXIDE-HC DESOGEN ORTHO-CEPT Keratolytics benzoyl peroxide BREVOXYL-4 ST ethinyl estradiol/ GIANVI BREVOXYL-8 ST LORYNA TRIAZ ST OCELLA ST SYEDA podofilox CONDYLOX ST VESTURA Rosacea Agents, Topical ST YASMIN 28 metronidazole METROCREAM ST YAZ METROLOTION ST ZARAH Vitamin A Derivatives ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 AGE adapalene DIFFERIN AFTERA AGE tazorotene foam FABIOR PLAN B ONE-STEP DERMATOLOGY - ANTIINFECTIVE TAKE ACTION Topical Antibiotics levonorgestrel-eth estra NORDETTE-28 clindamycin phosphate CLEOCIN T QL SEASONALE AVIANE-28 erythromycin base/benz per BENZAMYCIN LESSINA erythromycin base/ethanol EMGEL LUTERA ERYGEL ORSYTHIA gentamicin sulfate GARAMYCIN SRONYX mupirocin ointment BACTROBAN ST noreth a-et estra/fe fumarate LOESTRIN FE CENTANY LOESTRIN FE24 norethindrone NOR-Q-D

Portfolio High Formulary – April 2016 9 Scripps Health Formulary

mupirocin calcium cream BACTROBAN Topical Anti-Inflammatory, NSAIDs clindamycin phosphate EVOCLIN diclofenac sodium VOLTAREN GEL erythromycin base/benz per BENZAMYCIN PAK Topical Antibiotics/Antiinflammatory, Steroidal Topical Antifungals neomy sulf/polymyx b sulf/hc CORTISPORIN CREAM ciclopirox olamine LOPROX neomycin/bacitra/polymyxin/hc CORTISPORIN OINT ciclopirox 8% solution CICLODAN DERMATOLOGY - MISCELLANEOUS clotrimazole/betamet diprop LOTRISONE Antiperspirants KURIC aluminum chloride DRYSOL NIZORAL Antiseborrheic Agents naftifine hcl 1% cream NAFTIN selenium sulfide SELSUN RX naftifine hcl 1% gel, 2% NAFTIN sulfacetamide sodium OVACE PLUS SUSP cream/gel Topical Antineoplastic & Premalignant Lesion Agents nystatin MYCOSTATIN fluorouracil EFUDEX nystatin/triamcin MYCOLOG II PA bexarotene TARGRETIN sulconazole nitrate EXELDERM QL ingenol PICATO terbinafine hcl LAMISIL PA mechlorethamine gel VALCHLOR Topical Antiparasitics Topical Local Anesthetics lindane KWELL hc acetate/pramoxine hcl PRAMOSONE malathion OVIDE DERMATOLOGY - PIGMENTATION DISORDERS permethrin ELIMITE Topical Hyperpigmentation Agents crotamiton EURAX methoxsalen OXSORALEN Topical Antivirals DERMATOLOGY - PSORIASIS/ECZEMA acyclovir ZOVIRAX OINTMENT Antipsoriatic Agents, Systemic acyclovir ZOVIRAX CREAM acitretin SORIATANE Topical Sulfonamides methoxsalen, rapid OXSORALEN-ULTRA silver sulfadiazine SILVADENE methoxsalen 8-MOP THERMAZENE PA secukinumab COSENTYX DERMATOLOGY - ANTIINFLAMMATORY Antipsoriatics Agents Topical Anti-Inflammatory Steroidal ST calcipotriene DOVONEX ACLOVATE dipropionate anthralin DRITHO-SCALP CYCLOCORT ST anthralin DRITHOCREME HP DIPROLENE betamet diprop/prop gly tazarotene TAZORAC DIPROLENE AF Topical Immunosuppressive Agents betamethasone dipropionate DEL-BETA DIPROSONE AGE tacrolimus PROTOPIC + ST VALISONE DIABETES propionate CLOBEX Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non- OLUX Sulfonylurea) TEMOVATE acarbose PRECOSE clobetasol propionate/emoll TEMOVATE EMOLLIENT Antihyperglycemic, Amylin Analog-Type DESOWEN TRIDESILON pramlintide acetate SYMLIN SYMLINPEN 120 TOPICORT SYMLINPEN 60 TOPICORT LP Antihyperglycemic, DPP-4 Inhibitors diacetate APEXICON QL linagliptin TRADJENTA acetonide SYNALAR QL sitagliptin phosphate JANUVIA LIDEX VANOS Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations fluocinonide/emollient LIDEX-E QL linagliptin/metformin hcl JENTADUETO CUTIVATE QL sitagliptin phos/metformin hcl JANUMET QL sitagliptin phos/metformin hcl JANUMET XR halobetasol propionate ULTRAVATE LACTICARE-HC Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists) REDERM QL + dulaglutide TRULICITY SCALACORT ST /urea CARMOL HC QL + liraglutide VICTOZA ST LOCOID WESTCORT Antihyperglycemic, Insulin-Release Stimulant Type mometasone furoate ELOCON chlorpropamide DIABINESE KENALOG glimepiride AMARYL TRIDERM glipizide GLUCOTROL /emoll APEXICON E GLUCOTROL XL flurandrenolide CORDRAN glipizide/metformin hcl METAGLIP CORDRAN SP glyburide MICRONASE hydrocort/sal acid/sulf/shmp#1 SCALACORT DK nateglinide STARLIX hydrocortisone TEXACORT repaglinide PRANDIN hydrocortisone butyrate/emoll LOCOID LIPOCREAM tolazamide TOLINASE hydrocortisone probutate PANDEL tolbutamide ORINASE glyburide DIABETA

Portfolio High Formulary – April 2016 10 Scripps Health Formulary

Antihyperglycemic, Insulin-Response Enhancer (Non- QL HUMALOG MIX 75-25 Sulfonylurea) QL insulin regular, human HUMULIN R pioglitazone hcl ACTOS Syringes & Accessories Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) syringes & needles ALL COMMERCIALLY metformin hcl GLUCOPHAGE AVAILABLE SYRINGES GLUCOPHAGE XR AND NEEDLES metformin hcl RIOMET EAR - GENERAL DISORDERS Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations Ear Preparations, Misc. Anti-Infectives glyburide, micro/metformin hcl GLUCOVANCE acetic acid VOSOL repaglinide/metformin hcl PRANDIMET acetic acid/aluminum acetate DOMEBORO Antihyperglycemic, Insulin-Response & Release Combinations acetic acid/hydrocortisone VOSOL HC ST pioglitazone/glimepiride DUETACT Ear Preparations, Antibiotics Antihyperglycemic Insul-Resp. Enhancer & Biguanide neomy sulf/polymyx b sulf/hc CORTISPORIN OTIC Combinations OTICIN HC ST pioglitazone hcl/metformin hcl ACTOPLUS MET ofloxacin FLOXIN ST pioglitazone hcl/metformin hcl ACTOPLUS MET XR Otic Preparations, Anti-Inflammatory-Antibiotics Antihyperglycemic-Glucocorticoid Receptor Blockers ciprofloxacin hcl/dexameth CIPRODEX PA KORLYM Otic Preparations, Local anesthetics Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors antipyrine/benzocaine otic BENZOTIC QL + canagliflozin INVOKANA ELECTROLYTE REGULATION ST Electrolyte Depleters QL + empagliflozin JARDIANCE calcium acetate PHOSLO ST sodium polystyrene sulfonate KAYEXALATE Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) sevelamer carbonate RENVELA Inhibitor and Biguanide Combination sevelamer hcl RENAGEL QL + canagliflozin/metformin hcl INVOKAMET ST Potassium Replacement K-DUR QL + empagliflozin/metformin hcl SYNJARDY potassium chloride ST K-TAB MICRO-K Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination QL + empagliflozin/linagliptin GLYXAMBI ENDOCRINE DISORDER - FERTILITY ST Drugs to Treat Impotency Diabetic Supplies G + sildenafil citrate VIAGRA blood-glucose calib. control ALL ABBOTT CONTROL QL PRODUCTS (e.g., G + tadalafil CIALIS FREESTYLE, QL PRECISION) Fertility Stimulating Preparations, Non-FSH clomiphene citrate CLOMID ALL LIFESCAN SEROPHENE CONTROL PRODUCTS Follicle Stimulating / Luteinizing Hormones (e.g., ONETOUCH) follitropin alpha, recomb GONAL-F blood-glucose meter ALL ABBOTT GONAL-F RFF METERS(e.g., follitropin beta, recomb FOLLISTIM AQ FREESTYLE, gonadotropin,chorionic, human NOVAREL PRECISION) PREGNYL

PROFASI ALL LIFESCAN METERS (e.g., ONETOUCH) hcg alpha, recombinant OVIDREL blood sugar diagnostics ALL ABBOTT TEST menotropins MENOPUR STRIPS (e.g., REPRONEX FREESTYLE, urofollitropin (fsh) BRAVELLE PRECISION) FERTINEX Pregnancy Facilitating/Maintaining Agents, Hormonal ALL LIFESCAN TEST , micronized CRINONE STRIPS (e.g., ENDOMETRIN ONETOUCH) PROCHIEVE lancing device/lancets ALL ABBOTT AND ENDOCRINE DISORDER - OTHER LIFESCAN (e.g., Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants ONETOUCH) LANCETS PA leuprolide ELIGARD Diabetic Ulcer Preparations, Topical Antidiuretic & Vasopressor Hormones becaplermin REGRANEX desmopressin (nonrefrigerated) DDAVP Hyperglycemics Bone Formation Stim. Agents - Parathyroid Hormone glucagon,human recombinant GLUCAGON QL teriparatide FORTEO EMERGENCY KIT Bone Resorption Inhibitor & Vitamin D Combinations Insulins alendronate sodium/vitamin d3 FOSAMAX PLUS D QL insulin glargine,hum.rec.anlog LANTUS QL TOUJEO Bone Resorption Inhibitors QL insulin lispro HUMALOG alendronate sodium tablet FOSAMAX QL insulin nph hum/reg insulin hm HUMULIN 70-30 QL alendronate sodium solution FOSAMAX SOLUTION QL insulin nph human isophane HUMULIN N etidronate disodium DIDRONEL QL insulin npl/insulin lispro HUMALOG MIX 50-50 ibandronate BONIVA QL raloxifene hcl EVISTA

Portfolio High Formulary – April 2016 11 Scripps Health Formulary

Growth Hormone Receptor Antagonists Eye Antivirals pegvisomant SOMAVERT trifluridine VIROPTIC Growth Hormones ganciclovir ZIRGAN PA somatropin NORDITROPIN Eye Sulfonamides NORDITROPIN na sulfacetm/prednis sp VASOCIDIN FLEXPRO sulfacetamide sodium SULFAC NORDITROPIN na sulfacetm/prednisol ac BLEPHAMIDE NORDIFLEX BLEPHAMIDE S.O.P. PA somatropin OMNITROPE EYE - MISCELLANEOUS Hyperparathyroid Tx Agent, Vitamin D Analog-Type Ophthalmic Cystine Delpleting Agents paricalcitol ZEMPLAR PA cysteamine CYSTARAN LHRH (GnRH) Antagonist, Pituitary Suppressant Agents Ophthalmic Anti-Inflammatory Immunomodulator-Type cetrorelix acetate CETROTIDE QL cyclosporine RESTASIS ganirelix acetate GANIRELIX ACETATE Ophthalmic Antibiotics bacitracin AK-TRACIN bacitracin/polymyxin b sulfate POLYCIN-B Pituitary Suppressive Agents ciprofloxacin hcl CILOXAN cabergoline DOSTINEX erythromycin base ROMYCIN DANOCRINE gatifloxacin ZYMAXID ENDOCRINE DISORDER - THYROID gentamicin sulfate GARAMYCIN Antithyroid Preparations neomycin/bacitracin/polymyxin NEOSPORIN OPHTH methimazole TAPAZOLE OINTMENT propylthiouracil PROPYLTHIOURACIL neomycin/polymyxn NEOSPORIN OPHTH Iodine Containing Agents b/gramicidin DROPS potassium iodide POTASSIUM IODIDE ofloxacin OCUFLOX Thyroid Hormones polymyxin b sulfate/tmp POLYTRIM levothyroxine sodium LEVOTHROID tobramycin sulfate TOBREX LEVOXYL besifloxacin hcl drops susp 0.6% BESIVANCE SYNTHROID moxifloxacin hcl VIGAMOX liothyronine sodium CYTOMEL Ophthalmic Mast Cell Stabilizers thyroid, pork ARMOUR THYROID cromolyn sodium OPTICROM NATURE-THROID lodoxamide tromethamine ALOMIDE WESTHROID nedocromil sodium ALOCRIL EYE - GENERAL DISORDERS pemirolast potassium ALAMAST Eye Antibiotic-Corticoid Combinations EYE - GLAUCOMA neo/polymyx b sulf/dexameth MAXITROL Carbonic Anhydrase Inhibitors neomy sulf/bacitrac zn/poly/hc CORTISPORIN OPHTH acetazolamide DIAMOX SEQUELS OINTMENT methazolamide NEPTAZANE neomy sulf/polymyx b sulf/hc CORTISPORIN OPHTH SUSPENSION Miotics/Other Intraoccula Pressure Reducers BETOPTIC neomycin sulfate/dex na ph NEODECADRON betaxolol hcl QL LUMIGAN tobramycin sulfate/dexameth TOBRADEX bimatoprost 0.03% neomy sulf/polymyx b sulf/pred POLY-PRED brimonidine tartrate ALPHAGAN P tobramycin/lotepred etab ZYLET carteolol hcl OCUPRESS TRUSOPT Eye Antihistamines dorzolamide hcl COSOPT azelastine hcl OPTIVAR dorzolamide hcl/timolol maleat XALATAN ketotifen fumarate (OTC) ALAWAY (OTC) latanoprost BETAGAN QL olopatadine hcl PATADAY levobunolol hcl PATANOL metipranolol OPTIPRANOLOL Eye Antiinflammatory Agents pilocarpine hcl ISOPTO CARPINE diclofenac sodium VOLTAREN timolol maleate TIMOPTIC (Except Ocudose) FML TIMOPTIC-XE flurbiprofen sodium OCUFEN QL travoprost (benzalkonium) TRAVATAN ketorolac tromethamine ACULAR ACULAR LS betaxolol hcl BETOPTIC S QL bimatoprost 0.01% LUMIGAN acetate OMNIPRED PRED FORTE bimonidine/timolol COMBIGAN prednisolone sod phosphate PREDNISOL brinzolamide AZOPT DUREZOL brinzolamide/brimonidine SIMBRINZA fluorometholone FML FORTE carbachol ISOPTO CARBACHOL FML S.O.P. timolol BETIMOL fluorometholone acetate FLAREX QL travoprost TRAVATAN Z etabonate ALREX Mydriatics LOTEMAX atropine sulfate ISOPTO ATROPINE nepafenac ILEVRO cyclopentolate hcl CYCLOGYL NEVANAC homatropine hbr ISOPTO HOMATROPINE PRED MILD dipivefrin hcl PROPINE

Portfolio High Formulary – April 2016 12 Scripps Health Formulary

ESTRADERM GOUT AND RELATED DISEASES QL estradiol/noreth ac COMBIPATCH Colchicine estrogens, conj/bazedoxifene DUAVEE QL colchicine COLCRYS estrogen, con/m-progest acet PREMPHASE colchicine/probenecid COL-BENEMID PREMPRO Hyperuricemia Treatment - Purine Inhibitors estrogens, conjugated PREMARIN allopurinol ZYLOPRIM estrogens, esterified MENEST QL + febuxostat ULORIC Progestational Agents ST acet PROVERA Uricosuric Agents norethindrone acetate AYGESTIN probenecid BENEMID progesterone, micronized PROMETRIUM HEMATOLOGICAL DISORDERS IMMUNOSUPPRESSION/MODULATION Anticoagulants, Coumarin Type Immunomodulators warfarin sodium COUMADIN PA imiquimod ALDARA Direct Factor XA Inhibitors PA interferon alfa-2b, recomb. INTRON A QL apixaban ELIQUIS Immunosuppressives QL rivaroxaban XARELTO azathioprine IMURAN Hematinics, Other cyclosporine SANDIMMUNE PA epoetin alfa PROCRIT cyclosporine, modified NEORAL Hemorrheologic Agents mycophenolate mofetil CELLCEPT pentoxifylline TRENTAL sirolimus RAPAMUNE Heparin & Related Preparations tacrolimus anhydrous PROGRAF QL enoxaparin sodium LOVENOX everolimus ZORTRESS heparin sodium, porcine HEP-LOCK INFECTIOUS DISEASE - BACTERIAL HEPARIN LOCK Absorbable Sulfonamides heparin sodium, porcine/pf HEP-LOCK sulfadiazine SULFADIAZINE QL dalteparin sodium, porcine FRAGMIN sulfamethoxazole/trimethoprim BACTRIM DS QL fondaparinux sodium ARIXTRA SEPTRA Leukocyte (WBC) Stimulants SEPTRA DS PA filgrastim NEUPOGEN sulfisoxazole acetyl GANTRISIN PA pegfilgrastim NEULASTA Betalactams PA sargramostim LEUKINE PA aztreonam lysine CAYSTON Platelet Aggregation Inhibitors Cephalosporins - 1st Generation cilostazol PLETAL cefadroxil hydrate DURICEF clopidogrel bisulfate PLAVIX 75MG cephalexin monohydrate KEFLEX QL clopidogrel bisulfate 300mg PLAVIX 300MG Cephalosporins - 2nd Generation dipyridamole PERSANTINE cefaclor CECLOR QL prasugrel hcl EFFIENT cefprozil CEFZIL QL ticagrelor BRILINTA cefuroxime axetil CEFTIN Platelet Reducing Agents Cephalosporins - 3rd Generation anagrelide hcl AGRYLIN cefdinir OMNICEF Thrombopoietin Receptor Agonists cefpodoxime proxetil VANTIN PA + eltrombopag olamine PROMACTA cefixime SUPRAX QL Chemotherapeutics, Antibacterial, Miscellaneous Vitamin K Preparations trimethoprim PROLOPRIM phytonadione MEPHYTON meth/meth blue/ba/salicy/hyos PROSED-DS HORMONAL DEFICIENCY mth/me blue/salicy/na phos/hyo URETRON D-S Androgenic Agents URIN D.S. QL ANDROXY trimethoprim PRIMSOL methyltestosterone ANDROID Ketolides telithromycin KETEK PA testosterone 1% ANDROGEL Lincosamides PA + testosterone cypionate DEPO-TESTOSTERONE clindamycin hcl capsules CLEOCIN HCL QL clindamycin palmitate CLEOCIN PALMITATE PA testosterone enanthate DELATESTRYL Macrolides methyltestosterone azithromycin ZITHROMAX METHITEST ZITHROMAX TRI-PAK PA testosterone gel 1.62% ANDROGEL clarithromycin BIAXIN PA testosterone solution AXIRON BIAXIN XL Estrogen/Androgen Combinations ery e-succ/sulfisoxazole PEDIAZOLE estrogen, ester/me-testosterone ESTRATEST H.S. erythromycin base ERYC Estrogenic Agents erythromycin ethylsuccinate ERYPED 200 estradiol CLIMARA erythromycin stearate ERYTHROCIN ESTRACE STEARATE QL VIVELLE-DOT azithromycin ZMAX estropipate OGEN ZMAX PEDIATRIC norethindrone ac-eth estradiol FEMHRT erythromycin base ERY-TAB estradiol ALORA PCE

Portfolio High Formulary – April 2016 13 Scripps Health Formulary

erythromycin ethylsuccinate ERYPED 200 Vancomycin & Derivatives ERYPED 400 QL vancomycin hcl VANCOCIN HCL QL + fidaxomicin DIFICID INFECTIOUS DISEASE - PARASITIC ST Amebacides Nitrofuran Derivatives paromomycin sulfate HUMATIN nitrofurantoin macrocrystal MACRODANTIN iodoquinol YODOXIN nitrofurantoin/nitrofuran mac MACROBID Anaerobic Antiprotozoal-Antibacterial Agents furazolidone FUROXONE metronidazole FLAGYL nitrofurantoin FURADANTIN metronidazole FLAGYL ER Oxazolidinones Anthelmintics PA linezolid ZYVOX mebendazole VERMOX PA tedizolid phosphate tablet SIVEXTRO TABLET praziquantel BILTRICIDE Penicillins Antimalarial Drugs amox tr/potassium clavulanate AUGMENTIN chloroquine phosphate ARALEN PHOSPHATE AUGMENTIN ES-600 hydroxychloroquine sulfate PLAQUENIL AUGMENTIN XR mefloquine hcl LARIAM amoxicillin trihydrate AMOXIL quinine sulfate QUALAQUIN ampicillin trihydrate POLYCILLIN primaquine phosphate PRIMAQUINE dicloxacillin sodium PATHOCIL PA pyrimethamine DARAPRIM penicillin v potassium V-CILLIN K pyrimethamine/sulfadoxine FANSIDAR Quinolones Antiprotozoal Drugs, Miscellaneous ciprofloxacin CIPRO ORAL SUSPENSION pentamidine isethionate NEBUPENT ciprofloxacin hcl CIPRO INFECTIOUS DISEASE - VIRAL levofloxacin LEVAQUIN All oral, non-experimental antiviral agents used for the treatment of AIDS or HIV-related diseases are considered a formulary moxifloxacin hcl AVELOX benefit. AVELOX ABC PACK Antiretroviral Combination, Integrase Inhibitors ofloxacin FLOXIN QL abacavir/dolutegravir/lamivudine TRIUMEQ Tetracyclines QL elvitegravir/cobicistat/emtricitabine/ STRIBILD QL + doxycycline hyclate VIBRA-TABS tenofovir disoproxil fumarate ST VIBRAMYCIN QL elviteg/cobi/emtric/tenofo ala GENVOYA QL doxycycline monohydrate ADOXA Antivirals, General doxycycline monohydrate VIBRAMYCIN ORAL SUSPENSION acyclovir ZOVIRAX CYTOVENE minocycline hcl DYNACIN ganciclovir MINOCIN valacyclovir hcl VALTREX tetracycline hcl ALA-TET QL oseltamivir phosphate TAMIFLU doxycycline calcium VIBRAMYCIN SYRUP ribavirin VIRAZOLE INFECTIOUS DISEASE - FUNGAL Antivirals, HIV-Spec, Non-Peptidic Protease Inhib Antifungal Agents QL darunavir ethanolate PREZISTA clotrimazole MYCELEX QL darunavir/cobicistat PREZCOBIX fluconazole DIFLUCAN PA tipranavir APTIVUS CAPS itraconazole SPORANOX PA tipranavir/vitamin e tpgs APTIVUS SOLN ketoconazole NIZORAL Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog terbinafine hcl LAMISIL QL emtricitabine/tenofovir TRUVADA voriconazole VFEND Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb terbinafine hcl LAMISIL GRANULES PA abacavir/lamivudine/zidovudine TRIZIVIR Antifungal Antibiotics QL abacavir sulfate/lamivudine EPZICOM griseofulvin ultramicrosize GRIS-PEG QL lamivudine/zidovudine COMBIVIR nystatin MYCOSTATIN Antivirals, HIV-Specific, CCR5 Co-Receptor Antag. griseofulvin suspension GRISEOFULVIN V PA maraviroc SELZENTRY INFECTIOUS DISEASE - MISCELLANEOUS Antivirals, HIV-Specific, Fusion Inhibitors Aminoglycosides QL + enfuvirtide FUZEON ST neomycin sulfate MYCIFRADIN PA tobramycin in 0.225% nacl TOBI Antivirals, HIV-Specific, Non-Nucleoside, RTI PA tobramycin TOBI PODHALER QL nevirapine VIRAMUNE VIRAMUNE XR Anti-Mycobacterium Agents nevirapine ER delavirdine mesylate RESCRIPTOR ethambutol hcl MYAMBUTOL efavirenz SUSTIVA isoniazid NYDRAZID PA etravirine INTELENCE pyrazinamide PYRAZINAMIDE PA rilpivirine EDURANT Antileprotics dapsone AVLOSULFON Antivirals, HIV-Specific, Nucleoside Analog, RTI PA thalidomide THALOMID QL abacavir sulfate ZIAGEN QL VIDEX EC Antitubercular Antibiotics didanosine QL EPIVIR rifampin RIFADIN lamivudine QL ZERIT rifampin/isoniazid RIFAMATE stavudine QL RETROVIR Rifamycins and Related Derivative Antibiotics zidovudine PA rifaximin XIFAXAN 550MG QL didanosine VIDEX

Portfolio High Formulary – April 2016 14 Scripps Health Formulary

QL emtricitabine EMTRIVA budesonide ENTOCORT EC Antivirals, HIV-Specific, Nucleotide Analog, RTI Mineralocorticoids QL tenofovir disoproxil fumarate VIREAD acetate FLORINEF ACETATE Antivirals, HIV-Specific, Protease Inhibitor Comb Monoclonal antibody-human interleukin QL lopinavir/ritonavir KALETRA PA ustekinumab STELARA Antivirals, HIV-Specific, Protease Inhibitors NSAIDs, Cyclooxygenase Inhibitor-Type atazanavir sulfate REYATAZ celecoxib CELEBREX QL atazanavir sulfate/cobicistat EVOTAZ diclofenac sodium VOLTAREN PA fosamprenavir calcium LEXIVA VOLTAREN-XR indinavir sulfate CRIXIVAN etodolac LODINE nelfinavir mesylate VIRACEPT fenoprofen calcium NALFON TABLET QL ritonavir NORVIR flurbiprofen ANSAID QL + saquinavir mesylate INVIRASE ibuprofen MOTRIN ST indomethacin INDOCIN Antivirals, HIV-1 Integrase Strand Transfer Inhibtors INDOCIN SR PA dolutegravir TIVICAY ketoprofen ORUVAIL QL + elvitegravir VITEKTA QL ketorolac tromethamine TORADOL ST meclofenamate sodium MECLOMEN raltegravir potassium ISENTRESS meloxicam MOBIC Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside nabumetone RELAFEN RTI naproxen EC-NAPROSYN QL efavirenz/emtricitab/tenofovir ATRIPLA NAPROSYN PA emtricitab/rilpivirine/tenofovir COMPLERA naproxen sodium ANAPROX Cytochrome P450 Inhibitors ANAPROX DS PA cobicistat TYBOST oxaprozin DAYPRO Hepatitis B Treatment Agents piroxicam FELDENE adefovir dipivoxil HEPSERA sulindac CLINORIL entecavir BARACLUDE tolmetin sodium TOLECTIN 600 lamivudine EPIVIR HBV TABLET fenoprofen calcium NALFON CAPSULE lamivudine EPIVIR HBV SOLUTION indomethacin INDOCIN SUPPOS. telbivudine TYZEKA INDOCIN ORAL SUSP. Hepatitis C Combination Agents LOCAL ANESTHESIA PA ledipasvir/sofosbuvir HARVONI Local Anesthetics Hepatitis C Treatment Agents lidocaine hcl XYLOCAINE ribavirin 200mg COPEGUS LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT REBETOL CAPSULE Bowel Antiinflamatory Agents PA peginterferon alfa-2a PEGASYS sulfasalazine AZULFIDINE PA PEGASYS PROCLICK Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx ribavirin REBETOL SOLUTION mesalamine SFROWASA PA sofosbuvir SOVALDI mesalamine w/cleansing wipes ROWASA INFLAMMATORY DISEASE mesalamine CANASA Anti-Arthritic & Chelating Agents Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat penicillamine CUPRIMINE balsalazide disodium COLAZAL DEPEN mesalamine APRISO Anti-Arthritic, Folate Antagonist Agents LIALDA methotrexate sodium RHEUMATREX PENTASA QL methotrexate OTREXUP Hemorrhoidal Preparations ST hc acetate/pramoxine hcl ANALPRAM HC Anti-Inflammatory Tumor Necrosis Factor Inhibitor Irritable Bowel Agents, Guanylate Cylase-C Agonists PA adalimumab HUMIRA QL linaclotide LINZESS PA etanercept ENBREL Rectal Preparations Anti-Inflammatory, Pyrimidine Synthesis Inhibitors hydrocortisone PROCTO-KIT leflunomide ARAVA PROCTOCORT CREAM Bradykinin B2 Receptor Antagonists PROCTOCREAM-HC PA icatibant acetate FIRAZYR hydrocortisone acetate ANUSOL-HC PROCTOCORT Glucocorticoids SUPPOS. budesonide BUDESONIDE hc acetate/pramoxine hcl PROCTOFOAM-HC CORTONE ACETATE acetate Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) DECADRON tablet, elixir hydrocortisone CORTENEMA CORTEF hydrocortisone LOWER GASTROINTESTINAL DISORDERS - OTHER MEDROL Ammonia Inhibitors MILLIPRED prednisolone lactulose CHRONULAC MILLIPRED DP sodium phenylbutyrate BUPHENYL POWDER prednisolone sod phosphate ORAPRED sodium phenylbutyrate BUPHENYL TABLET PEDIAPRED Antidiarrheals DELTASONE PREDNISONE diphenoxylate hcl/atrop sulf LOMOTIL INTENSOL Bile Salts

Portfolio High Formulary – April 2016 15 Scripps Health Formulary

ursodiol ACTIGALL Antineoplastic - Topoisomerase I Inhibitors URSO topotecan hcl HYCAMTIN URSO FORTE Antineoplastic - Immunomodulator Agents Laxatives & Cathartics PA + lenalidomide REVLIMID peg 3350/na sulf,bicarb,cl/kcl COLYTE WITH FLAVOR QL PACKETS PA pomalidomide POMALYST polyethylene glycol 3350 MIRALAX Antineoplastic - Systemic Enzyme Inhibitors sod chloride/nahco3/kcl/peg's NULYTELY WITH PA imatinib mesylate GLEEVEC FLAVOR PACKS PA afatinib GILOTRIF lactulose KRISTALOSE PA+ alectinib hydrochloride ALECENSA QL lubiprostone AMITIZA QL peg 3350/na sulf,bicarb,cl/kcl GOLYTELY PA axitinib INLYTA OCL PA bosutinib BOSULIF Narcotic Antagonists, Peripherally-Acting PA cabozanitinib COMETRIQ QL naloxegol oxalate MOVANTIK PA ceritinib ZYKADIA PA methylnaltrexone bromide RELISTOR PA crizotinib XALKORI Glucagon-Like Peptide (GLP-2) Analogs PA dabrafanib TAFINLAR PA teduglutide [rDNA origin] GATTEX PA dasatinib SPRYCEL MISCELLANEOUS AGENTS PA erlotinib hcl TARCEVA Anaphylaxis Therapy Agents PA gefitinib IRESSA EPIPEN epinephrine PA ibrutinib IMBRUVICA epinephrine EPIPEN JR PA idelalisib ZYDELIG Parasympathetic Agents bethanechol chloride URECHOLINE cevimeline hcl EVOXAC PA ixazomib citrate NINLARO pilocarpine hcl SALAGEN PA lapatinib ditosylate TYKERB Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase PA lenvatinib mesylate LENVIMA PA sapropterin dihydrochloride KUVAN PA nilotinib hydrochloride TASIGNA NEOPLASTIC DISEASE PA olaparib LYNPARZA Alkylating Agents PA + osimertinib mesylate TAGRISSO cyclophosphamide CYTOXAN QL hydroxyurea HYDREA PA pazopanib hydrochloride VOTRIENT lomustine CEENU PA palbociclib IBRANCE PA temozolomide TEMODAR PA ponatinib ICLUSIG altretamine HEXALEN PA regorafenib STIVARGA busulfan MYLERAN PA sorafenib tosylate NEXAVAR chlorambucil LEUKERAN PA sunitinib malate SUTENT melphalan ALKERAN PA trametinib dimethyl sulfoxide MEKINIST Antiandrogenic Agents PA vemurafenib ZELBORAF CASODEX Antineoplastic, Histone Deacetylase Inhibitors, HDIS flutamide EULEXIN PA panobinostat lactate FARYDAK PA abiraterone acetate ZYTIGA vorinostat ZOLINZA PA enzalutamide XTANDI Antineoplastics, Miscellaneous QL nilutamide NILANDRON etoposide VEPESID Antimetabolites LYSODREN PA capecitabine XELODA procarbazine hcl MATULANE mercaptopurine PURINETHOL tretinoin VESANOID methotrexate sodium METHOTREXATE PA everolimus AFINITOR TABLET PA AFINITOR DISPERZ methotrexate sodium METHOTREXATE VIAL Chemotherapy Rescue/Antidote Agents thioguanine THIOGUANINE leucovorin calcium LEUCOVORIN CALCIUM fludarabine phosphate OFORTA Selective Estrogen Receptor Modulators (SERM) ST mercaptopurine PURIXAN tamoxifen citrate NOLVADEX methotrexate sodium TREXALL PA toremifene citrate FARESTON PA trifluridine/tipiracil hcl LONSURF Selective Retinoid X Receptor Agonists (RXR) Antineoplastic - Aromatase Inhibitors PA bexarotene TARGRETIN anastrozole ARIMIDEX Steroid Antineoplastics exemestane AROMASIN acetate MEGACE letrozole FEMARA estramustine phosphate sodium EMCYT Antineoplastic – Hedgehog Pathway Inhibitors NEUROLOGICAL DISEASE - MISCELLANEOUS PA vismodegib ERIVEDGE Agents to Treat Multiple Sclerosis PA sonidegib phosphate ODOMZO PA glatiramer acetate COPAXONE Antineoplastic – Janus Kinase (JAK) Inhibitors PA dimethyl fumarate TECFIDERA PA ruxolitinib JAKAFI PA fingolimod hcl GILENYA

Antineoplastic - MEK1 and MEK2 Kinase Inhibitors PA interferon beta-1a AVONEX PA + cobimetinib fumarate COTELLIC PA interferon beta-1a/albumin AVONEX QL ADMINISTRATION PACK

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PA REBIF (300mg/15ml) oral solution PA REBIF REBIDOSE QL hydrocodone bit/acetaminophen HYCET PA peginterferon beta-1a PLEGRIDY oral elixir (325mg/15ml) PA PLEGRIDY PEN hydromorphone hcl DILAUDID Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor methadone hcl DOLOPHINE HCL milnacipran hcl SAVELLA QL morphine sulfate AVINZA Movement Disorders (Drug Therapy) QL morphine sulfate MS CONTIN PA tetrabenazine XENAZINE morphine sulfate MSIR ORAL/PHARYNGEAL DISORDERS ORAMORPH SR Dental Aids & Preparations ROXANOL chlorhexidine gluconate PERIDEX oxycodone hcl PERCOLONE ROXICODONE triamcinolone acetonide KENALOG IN ORABASE ROXICODONE INTENSOL Nose Preparations, Antibiotics QL PERCOCET mupirocin calcium BACTROBAN NASAL oxycodone hcl/acetaminophen (325mg) Nose Preparations, Miscellaneous (Rx) QL oxycodone hcl/acetaminophen ROXICET ATROVENT ipratropium bromide (325mg/5ml) OTHER DRUGS oxycodone hcl/aspirin PERCODAN Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome tramadol hcl ULTRAM MEGACE tramadol hcl/acetaminophen ULTRACET MEGACE ES QL buprenorphine BUTRANS General Inhalation Agents CU + buprenorphine hcl/naloxone hcl SUBOXONE sodium chloride for inhalation HYPER-SAL 7% PA Metabolic disease enzyme replace, hypophosphatasia QL hydrocodone bit/acetaminophen STAGESIC-10 PA asfotase alfa STRENSIQ (250mg) Needles/Needleless Devices QL hydrocodone bit/acetaminophen XODOL 10-300 needles, insulin disp., safety PEN NEEDLE (300mg) Somatostatic Agents hydromorphone hcl DILAUDID-5 octreotide acetate SANDOSTATIN QL oxycodone hcl OXYCONTIN OTHER RESPIRATORY DISORDERS QL tapentadol hcl NUCYNTA Antifibrotic Therapy – Pyridone Analogs QL tapentadol hcl ER NUCYNTA ER PA pirfenidone ESBRIET Antimigraine Preparations Cystic Fibrosis-Cftr Potentiator & Corrector Comb. QL ergotamine tartrate/caffeine CAFERGOT lumacaftor/ivacaftor ORKAMBI QL MIGERGOT Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) isomethept/acetaminop/dichlphn MIDRIN Potentiators QL naratriptan AMERGE PA ivacaftor KALYDECO QL rizatriptan benzoate MAXALT Mucolytics MAXALT MLT acetylcysteine MUCOMYST-10 QL sumatriptan IMITREX NASAL SPRAY PA dornase alfa PULMOZYME QL sumatriptan succinate IMITREX TABLET Pulmonary Fibrosis – Systemic Enzyme Inhibitors IMITREX INJECTION PA nintedanib esylate OFEV QL + zolmitriptan ZOMIG PAIN MANAGEMENT - ANALGESICS ST ZOMIG ZMT Analgesic, Non-Salicylate & Barbiturate Combinations Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine butalbital/acetaminophen PHRENILIN Combinations butalbital/acetaminophen PHRENILIN FORTE codeine/butalbit/acetamin/caff FIORICET WITH Analgesic, Salicylate, Barbiturate & Xanthine Combinations CODEINE butalbital/aspirin/caffeine FIORINAL Narcotic & Salicylate Analgesics, Barbiturates & Xanthines Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations codeine/butalbital/asa/caffein FIORINAL WITH CODEINE #3 butalb/acetaminophen/caffeine ESGIC FIORICET Narcotic Analgesic & Non-Salicylate Analgesic Combinations Analgesic/Antipyretics, Salicylates acetaminophen with codeine TYLENOL-CODEINE NO.3 DOLOBID diflunisal TYLENOL-CODEINE salsalate DISALCID NO.4 Analgesics, Narcotics acetaminophen and codeine CAPITAL AND CODEINE CU + buprenorphine hcl SUBUTEX PARKINSON’S DISEASE PA Antiparkinsonism Drugs, Anticholinergic codeine phos/carisoprodol/asa SOMA COMPOUND benztropine mesylate COGENTIN WITH CODEINE trihexyphenidyl hcl ARTANE PA fentanyl DURAGESIC Antiparkinsonism Drugs, Other PA fentanyl citrate lozenge ACTIQ amantadine hcl SYMMETREL QL hydrocodone bit/acetaminophen VICODIN (300mg) VICODIN ES bromocriptine mesylate PARLODEL VICODIN HP carbidopa/levodopa PARCOPA QL hydrocodone bit/acetaminophen LORCET SINEMET 25-100 (325mg) LORCET PLUS SINEMET CR LORTAB carbidopa/levodopa/entacapone STALEVO NORCO entacapone COMTAN QL hydrocodone bit/acetaminophen LORTAB ELIXIR pramipexole di-hcl MIRAPEX

Portfolio High Formulary – April 2016 17 Scripps Health Formulary

ropinirole hcl REQUIP sucralfate CARAFATE QL + REQUIP XL Anti-Ulcer-H.pylori Agents ST lansoprazole/amox tr/clarith PREVPAC selegiline hcl ELDEPRYL Anticholinergics, Quaternary Ammonium QL rasagiline mesylate AZILECT chlordiazepoxide/clidinium br LIBRAX QL + rotigotine NEUPRO Histamine H2-Receptor Inhibitors ST cimetidine hcl TAGAMET Decarboxylase Inhibitors famotidine PEPCID carbidopa LODOSYN nizatidine AXID SEIZURE DISORDER ranitidine hcl ZANTAC Anticonvulsants Intestinal Motility Stimulants carbamazepine CARBATROL metoclopramide hcl REGLAN TEGRETOL TEGRETOL XR Proton-Pump Inhibitors QL + NEXIUM clonazepam KLONOPIN esomeprazole magnesium ST QL diazepam DIASTAT lansoprazole PREVACID RX divalproex sodium DEPAKOTE DEPAKOTE ER omeprazole capsules (RX) PRILOSEC CAPSULES DEPAKOTE SPRINKLE (RX) PRILOSEC OTC ethosuximide ZARONTIN omeprazole magnesium tablets (OTC) TABLETS (OTC) gabapentin NEURONTIN pantoprazole sodium PROTONIX lamotrigine LAMICTAL ST lansoprazole PREVACID SOLUTABS levetiracetam KEPPRA ST pantoprazole sodium suspension PROTONIX SUSP oxcarbazepine TRILEPTAL URINARY TRACT - FUNCTIONAL DISORDERS phenytoin DILANTIN-125 DILANTIN CHEW TAB Benign Prostatic Hypertrophy/Micturition Agents UROXATRAL phenytoin sodium extended DILANTIN alfuzosin PHENYTEK G + dutasteride AVODART ST primidone MYSOLINE PROSCAR topiramate TOPAMAX finasteride TOPAMAX SPRINKLE tamsulosin hcl FLOMAX sodium DEPAKENE SYRUP Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag valproic acid DEPAKENE CAPSULES comb agents G + JALYN zonisamide ZONEGRAN dutasteride/tamsulosin hcl ST pregabalin LYRICA Kidney Stone Agents SKELETAL MUSCLE DISORDER PA cysteamine bitartrate PROCYSBI Agents To Treat Periodic Paralysis Overactive Bladder Agents, Beta-3 Adrenergic Recep PA dichlorphenamide KEVEYIS ST mirabegron MYRBETRIQ Skeletal Muscle Relaxants Urinary Tract Analgesic Agents baclofen LIORESAL pentosan polysulfate sodium ELMIRON carisoprodol SOMA Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) carisoprodol/aspirin SOMA COMPOUND phenazopyridine hcl PYRIDIUM chlorzoxazone PARAFON FORTE DSC Urinary Tract Antispasmodic, M(3) Selective Antagonists cyclobenzaprine hcl FLEXERIL ST solifenacin succinate VESICARE dantrolene sodium DANTRIUM Urinary Tract Antispasmodic/Antiincontinence Agents metaxalone SKELAXIN oxybutynin chloride DITROPAN XL methocarbamol ROBAXIN ROBAXIN-750 ST trospium chloride SANCTURA ST DETROL orphenadrine citrate NORFLEX tolterodine tartrate ST DETROL LA orphenadrine/aspirin/caffeine NORGESIC FORTE ST fesoterodine fumarate TOVIAZ tizanidine hcl ZANAFLEX VAGINAL DISORDERS UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE Vaginal Antibiotics Pancreatic Enzymes metronidazole METROGEL-VAGINAL PANCRELIPASE 5,000 amylase/lipase/protease VANDAZOLE amylase/lipase/protease CREON Vaginal Antifungals ULTRASE ULTRASE MT nitrate MONISTAT 3 ZENPEP butoconazole nitrate GYNAZOLE-1 UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE Vaginal Estrogen Preparations Anticholinergics/Antispasmodics estradiol ESTRACE VAGIFEM dicyclomine hcl BENTYL estrogens, conjugated PREMARIN Belladonna Alkaloids belladonna alkaloids/phenobarb DONNATAL Vaginal Sulfonamides sulfanilamide AVC hyoscyamine sulfate ANASPAZ LEVBID VITAMIN AND/OR MINERAL DEFICIENCY LEVSIN-SL Fluoride Preparations UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE sodium fluoride FLUORITAB Anti-Ulcer Preparations FLURA-DROPS FLURA-TABS misoprostol CYTOTEC

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LURIDE • Epaned < 12 years old Folic Acid Preparations • Epaned (Step Therapy applies) ≥ 12 years old folic acid FOLIC ACID • Epiduo ≤ 25 years old • Multivitamin Preparations Epiduo Forte ≤ 25 years old • Oracea ≥ 18 years old folic acid/mu-vits-min th VICON FORTE • Refissa ≤ 25 years old Pediatric Vitamin Preparations • Renova ≤ 25 years old TRI-VI-FLOR W/IRON fluoride ion/iron/vit a,c&d • Retin-A ≤ 25 years old fluoride ion/multivitamins POLY-VI-FLOR • Retin-A Micro ≤ 25 years old fluoride ion/multivits w-fe POLY-VI-FLOR W/IRON • Retin-A Micro Pump ≤ 25 years old fluoride ion/vit a,c&d FLUORABON BASIC • Solodyn ≥ 12 years old Prenatal Vitamin Preparations • Tretin-X ≤ 25 years old prenatal vit 15/iron cb/fa/dss TRIADVANCE 3. QUANTITY RESTRICTIONS (FORMULARY) prenatal vit 16/iron cb/fa/dss VINATE GT • Abilify prenatal vit 18/iron cb/fa/dss VINATE ULTRA tablets 30 tablets per 30 days solution 900mL per 30 days prenatal vit 95/fe fum/fa PRENAVITE • Abilify Discmelt Vitamin B Preparations 10mg 90 tablets per 30 days cyanocobalamin/fa/pyridoxine FOLGARD RX 15mg 60 tablets per 30 days Vitamin D Preparations • Adderall 60 tablets per 30 days calcitriol ROCALTROL • Adderall XR ST VECTICAL 5mg, 10mg, 15mg 30 capsules per 30 days ergocalciferol DRISDOL 20mg, 25mg, 30mg 60 capsules per 30 days dihydrotachysterol DHT • Advair Diskus 60 units per 30 days • Advair HFA 12g (1 inhaler) per 30 days • Akynzeo 1 capsule per 28 days SPECIALTY INJECTABLE CROSS REFERENCE LISTING • Aldara 24 packets per 30 days

• Alecensa 240 capsules per 30 days The following cross reference is being provided as a guide to • Alendronate solution 300mL per 28 days formulary choices within prominent “specialty” injectable drug • 30 tablets per 30 days categories. General specialty categories are cross referenced to Ambien / Ambien CR their corresponding formulary classification status and page • Amerge 18 tablets per 30 days number. This cross reference is not meant to be all-inclusive. • Amitiza 60 capsules per 30 days Please refer to the Table of Contents or Index to determine • Androxy 120 tablets per 30 days formulary status of injectable medications not listed in this cross • Anoro Ellipta 60 blister packs per 30 days reference (e.g., Antineoplastics, Leukocyte Stimulants, etc.). • Arixtra 2.5mg/0.5mL 5mL (10 syringes) per 30 days EPO 5mg/0.4mL 4mL (10 syringes) per 30 days Hematinics, Other Page 7 7.5mg/0.6mL 6mL (10 syringes) per 30 days 10mg/0.8mL 8mL (10 syringes) per 30 days HEPATITIS C • Asmanex 1 inhaler per 30 days Hepatitis C Treatment Agents Page 9 • Asmanex HFA 13 grams per 30 days • Astelin 60mL (2 bottles) per 30 days HUMAN GROWTH FACTORS • Astepro 60mL (2 bottles) per 30 days Growth Hormones Page 6 • Atripla 30 tablets per 30 days • Atrovent HFA 2 inhalers per 28 days LOW MOLECULAR WEIGHT HEPARINS • Avinza Heparin and Related Preparations Page 7 30mg, 45mg, 60mg, 75mg, 90mg 1 capsule per day MULTIPLE SCLEROSIS 120mg 2 capsules per day Agents to Treat Multiple Sclerosis Page 10 • Azilect 30 tablets per 30 days

• Breo Ellipta 60 units per 30 days RHEUMATOID ARTHRITIS • Brilinta 60 tablets per 30 days Anti-Inflammatory, Pyrimidine Synthesis Inhibitors Page 9 • Butrans 4 patches per 28 days

• 30 tablets per 30 days MEDICATION PRESCRIBING LIMITATIONS Caduet • Cafergot 40 tablets 28 days 1. AGE RESTRICTIONS (FORMULARY)- Covered for ages: • Cialis • Concerta ≤ 18 years old 2.5mg, 5mg 30 tablets per 30 days • Differin ≤ 25 years old 10mg, 20mg 6 tablets per 30 days • • Fabior ≥ 12 years old Climara 4 patches per 28 days • • Metadate ER ≤ 18 years old Clozaril 90 tablets per 30 day • • Protopic Colcrys 120 tablets per 30 days 0.03% ≥ 2 years old • Combipatch 8 patches per 30 days 0.1% ≥ 15 years old • Combivir 60 tablets per 30 days • Ritalin LA 60mg ≤ 18 years old • Concerta • Ritalin SR ≤ 18 years old 18mg, 27mg, 54mg 30 tablets per 30 days 2. AGE RESTRICTIONS (NON FORMULARY)- Covered for ages: 36mg 60 tablets per 30 days • All carbinoxamine containing ≥ 2 years old • Corlanor 60 tablets per 30 days products (i.e., Palgic, Tussafed, • Crestor 30 tablets per 30 days etc.) • Cymbalta 60 capsules per 30 days • Aptensio XR ≤ 18 years old • Daliresp 30 tablets per 30 days • Atralin ≤ 25 years old • Depo-Testosterone 10mL per 30 days • Avita ≤ 25 years old • Desvenlavaxine ER 30 tablets per 30 days • Elidel ≥ 2 years old (Ranbaxy Brand)

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injection (kits and • Dexedrine Spansule vials): 4 vials per 30 days 5mg, 10mg 60 capsules per 30 days 6mg/0.5ml vial 2 kits per 30 days 15mg 120 capsules per 30 days 6mg/0.5ml kit/refill kit 2 kits per 30 days • Diastat 1 kit per copay 4mg/0.5ml kit/refill kit • Dificid 20 tablets per 30 days • Invirase • Dulera 13g (1 inhaler) per 30 days 200mg capsules 300 capsules per 30 days • Duragesic 10 patches per 30 days 500mg tablets 120 tablets per 30 days • Effient 30 tablets per 30 days • Invokamet 60 tablets per 30 days • Eliquis 60 tablets per 30 days • Invokana 30 tablets per 30 days • Emend • Janumet 60 tablets per 30 days 40mg 1 capsules per 21 days • Janumet XR 80mg 2 capsules per 21 days 100-1000mg 30 tablets per 30 days 125mg 1 capsule per 21 days 50-1000mg 60 tablets per 30 days • Emend Trifold Pack 1 packet per 21 days 50-500mg 60 tablets per 30 days • Emtriva • Januvia 30 tablets per 30 days 10mg/mL oral solution 720mL per 30 days • Jentadueto 60 tablets per 30 days 200mg capsules 30 capsules per 30 days • Jardiance 30 tablets per 30 days • Epivir • Juxtapid 30 capsules per 30 days 10mg/mL oral solution 900mL per 30 days • Kaletra 150mg tablets 60 tablets per 30 days oral solution 390mL per 30 days 300mg tablets 30 tablets per 30 days 100/25mg tablets 300 tablets per 30 days • Epzicom 30 tablets per 30 days 200/50mg tablets 120 tablets per 30 days • Evista 30 tablets per 30 days • Lantus • Evotaz 30 tablets per 30 days vial 40mL (4 vials) per 28 days • Exelon patch 30 patches per 30 days Solostar 30mL (10 pens) per 28 days • Flonase 16gm (1 bottle) per 30 days • Linzess 30 capsules per 30 days • Flunisolide 25mL (1 bottle) per 30 days • Lovaza 120 capsules per 30 days • Focalin 60 tablets per 30 days • Lovenox • Focalin XR 30 capsules per 30 days 30mg/0.3mL 6mL (20 syringes) per 30 days • Forteo 2.4mL (1 pen) per 28 days with 40mg/0.4mL 8mL (20 syringes) per 30 days a max duration of 2 years per 60mg/0.6mL 12mL (20 syringes) per 30 lifetime 80mg/0.8mL days • Fragmin 100mg/1mL 16mL (20 syringes) per 30 2500 units/0.2mL 2mL (10 syringes) per 30 days 120mg/0.8mL days 5000 units/0.2mL 2mL (10 syringes) per 30 days 150mg/1mL 20mL (20 syringes) per 30 7500 units/0.3mL 3mL (10 syringes) per 30 days 300mg/3mL days 10,000 units/1mL 10mL (10 syringes) per 30 16mL (20 syringes) per 30 12,500 units/0.5mL days days 15,000 units/0.6mL 5mL (10 syringes) per 30 days 20mL (20 syringes) per 30 18,000 units/0.72mL 6mL (10 syringes) per 30 days days 25,000 units/ml 7.2mL (10 syringes) per 30 30mL (10 vials) per 30 days days • Lumigan 2.5ml per 30 days 7.6mL (2 vials) per 30 days • Lunesta 30 tablets per 30 days • Fuzeon 1 kit per 30 days • Lynparza 16 capsules per day • Genvoya 30 tablets per 30 days • Marinol 60 capsules per 30 days • Geodon (oral) 60 capsules per 30 days • Maxalt/ 18 tablets per 30 days • Glyxambi 30 tablets per 30 days Maxalt MLT • Humulin N • Metadate CD vial 40mL (4 vials) per 28 days 30mg 60 tablets per 30 days Kwikpen 30mL (10 pens) per 28 days 10mg, 20mg, 40mg, • Humulin R 60mg 30 tablets per 30 days 100u/mL 40mL (4 vials) per 28 days • Metadate ER 90 tablets per 30 days 500u/mL 40mL (2 vials) per 28 days • Methylin chewable tablet 90 tablets per 30 days • Humulin 70/30 • Migergot 20 units per 28 days vial 40mL (4 vials) per 28 days • Movantik 30 tablets per 30 days Kwikpen 30mL (10 pens) per 28 days • MS Contin 90 tablets per 30 days • Humalog • Namenda vial 40mL (4 vials) per 28 days tablets 60 tablets per 30 days pen/cartridge 30mL (10 pens/cartridges) per titration pack 49 tablets per 28 days 28 days solution 300mLper 30 days • Humalog Mix 50/50 / • Namenda XR 75/25 40mL (4 vials) per 28 days capsules 30 capsules per 30 days vial 30mL (10 pens) per 28 days titration pack 28 capsules per 28 days Kwikpen • Namzaric 30 capsules per 30 days • Hydrocodone bit/acetaminophen (maximum of 4gm of • Narcan Nasal 2 boxes (4 nasal sprays per 30 acetaminophen per day): days 250mg 16 tablets per 1 day supply • Nasacort AQ 16.5g (1 canister) per 30 days 300mg 13 tablets per 1 day supply • Nasarel 25ml (1 bottle) per 30 days 325mg 12 tablets per 1 day supply • Nasonex 17g (1 canister) per 30 days 300mg/15ml soln 200ml per 1 day supply • Neupro 30 patches per 30 days 325mg/15ml elixir 184ml per 1 day supply • Nexium • Imitrex capsules 30 capsules per 30 days tablets (all strengths) 18 tablets per 30 days packets 30 packets per 30 days nasal spray 12 units per 30 days • Nilandron 150mg tablet 60 tablets for first 30 days,

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then 30 tablets per 30 days • Spiriva 30 capsules per 30 days thereafter • Spiriva Respimat 1 inhaler per 30 days • Sonata 30 capsules per 30 days • Norvir • Stiolto Respimat 4g (60 inhalations) per 30 days oral solution 450mL per 30 days • Strattera capsules/tablets 360 capsules/tablets per 30 10mg, 18mg, 25mg, days 40mg 60 capsules per 30 days • Nucynta 180 tablets per 30 days 60mg, 80mg, 100mg 30 capsules per 30 days • Nucynta ER 60 tablets per 30 days • Stribild 30 tablets per 30 days • Nuvaring 1 ring per 28 days • Striverdi Respimat 4g (60 inhalations) per 30 days • Ortho Evra 3 patches per 28 days • Symbyax 30 capsules per 30 days • Otrexup 1.6mL per 28 days • Synjardy 60 capsules per 30 days • Oxycodone hcl/acetaminophen (maximum of 4gm • Tagrisso 1 tablet per day acetaminophen per day): • Tamiflu 325mg 12 tablets per 1 day supply 30mg tablets 40 tablets per 183 days 325mg/5ml soln 61mL per 1 day supply 45mg, 75mg tablets 20 tablets per 183 days • Oxycontin suspension 360mL per 183 days 10mg, 15mg, 20mg, NOTE: The FDA recommends a maximum of 5 days of 30mg, 40mg, 60mg 60 tablets per 30 days therapy with this drug 80mg 120 tablets per 30 days • Toradol 20 tablets per fill • Perforomist 120mL per 30 days • Tradjenta 30 tablets per 30 days • Picato • Travatan/Travatan Z 2.5ml per 30 days 0.015% gel 3 tubes per 56 days • Triumeq 30 tablets per 30 days 2 tubes per 56 days 0.05% gel • Trulicity 2mL (4 pens) per 28 days • 4 tablets per 30 days Plavix 300mg tablet • Truvada 30 tablets per 30 days • 30 tablets per 30 days Prezcobix • Toujeo 7.5mL (5 pens) per 28 days • Prezista • Uloric 30 tablets per 30 days oral suspension 240mL per 30 days • Vascepa 120 capsules per 30 days capsules 180 capsules per 30 days • Vancocin Oral 75mg tablets 480 tablets per 30 days 125mg and 250mg 40 capsules per 30 days 150mg tablets 240 tablets per 30 days • 6 tablets per 30 days 400mg, 600mg 60 tablets per 30 days Viagra • tablets 30 tablets per 30 days Vibramycin 60 capsules per 30 days 800mg tablets • Vibra-Tabs 60 tablets per 30 days • Pristiq 30 tablets per 30 days • Victoza 9mL (3 pens) per 30 days • Promacta 30 tablets per 30 days • Videx • Pulmicort Flexhaler 1 inhaler per 30 days solution 1200mL per 30 days 60 capsules per 30 days • Pulmicort Respules 60mL (30 respules) per 30 capsules days • Viramune • Qnasl 8.7g (1 canister) per 30 days solution 1200mL per 30 days 60 tablets per 30 days • Qnasl Children 4.9g (1 canister) per 30 days tablets • • Quillivant XR Viread 225g powder per 30 days 60mL 60mL (1 bottle) per 30 days powder 30 tablets per 30 days 120mL 240mL (2 bottles) per 30 days tablets • 150mL 300mL (2 bottles) per 30 days Vivelle Dot 8 patches per 30 days 180mL 360mL (2 bottles) per 30 days • Vitekta 30 tablets per 30 days • QVAR 17.4g (2 inhalers) per 30 days • Vyvanse 30 capsules per 30 days • Ranexa • Xarelto 500mg 120 tablets per 30 days 10mg, 20mg 30 tablets per 30 days 1000mg 60 tablets per 30 days 15mg loading dose 42 tablets per 21 days, • Requip XL 30 tablets per 30 days followed by 30 tablets per 30 days • Restasis 64 vials per 30 days • Zenzedi • Retrovir 2.5mg, 5mg, 7.5mg, syrup 1800mL per 30 days 15mg 90 tablets per 30 days capsules 180 capsules per 30 days 10mg 180 tablets per 30 days tablets 60 tablets per 30 days 20mg, 30mg 60 tablets per 30 days • Risperdal • Zerit tablets/ODT 60 tablets per 30 days oral solution 2400mL per 30 days solution 240ml per 30 days capsules 60 tablets per 30 days • Ritalin 90 tablets per 30 days • Zetia 30 tablets per 30 days • Ritalin LA • Ziagen 10mg, 20mg, 40mg, 30 capsules per 30 days solution 900mL per 30 days 60mg tablets 60 tablets per 30 days 30mg 60 capsules per 30 days • Zofran oral solution • Ritalin SR 90 tablets per 30 days 4mg/5ml oral solution 50ml per 15 days • Seasonale 91 tablets per 84 days • Zomig/Zomig ZMT • Serevent 60 doses (1 diskus) per 30 Tablets 12 tablets per 30 days days Nasal Spray 12 units per 30 days • Seroquel 90 tablets per 30 days • Zyprexa/Zyprexa Zydis 30 tablets per 30 days • Seroquel XR 30 tablets per 30 days 4. QUANTITY RESTRICTIONS (NON FORMULARY) • Simcor • Abstral 120 tablets per 30 days 500/20mg, 500/40mg 30 tablets per 30 days • Aciphex 30 tablets per 30 days 1000/40mg 30 tablets per 30 days • 30 capsules per 30 days 750/20mg, 60 tablets per 30 days Aciphex Sprinkle • 1000/20mg Acticlate 60 tablets per 30 days

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5mg 30 tablets per 30 days • Actonel 5mg/10ml syrup 300ml per 30 days 5mg, 30mg 30 tablets per 30 days • Clarinex-D 12 hour 60 tablets per 30 days 35mg 4 tablets per 28 days • Clarinex-D 24 hour 30 tablets per 30 days 150mg 1 tablet per 28 days • Climara Pro 4 patches per 30 days • Adoxa • Conzip 30 capsules per 30 days 50mg, 75mg, 100mg 60 tablets per 30 days • Cosopt PF 60 droperettes per 30 days 150mg 60 capsules per 30 days • Daytrana 30 patches per 30 days • Adoxa Pak 100mg, 60 tablets per 30 days • Demerol 150mg solution 900mL per 30 days • Advicor tablets 180 tablets per 30 days 500/20mg, 1000/40mg 30 tablets per 30days • Depo-Provera 1mL per 84 days 750/20mg, 100/20mg 60 tablets per 30 days • Depo-subQ Provera 104 0.65mL per 84 days • Aerospan 17.8g (2 inhalers) per 30 days • DermacinRx Silapak 1 kit per 30 days • Afrezza • DermasilkRx SDS 1 kit per 30 days 4 unit 180 cartridges (2 kits) per 28 • Desoxyn 150 tablets per 30 days days 30-4 unit + 60-8 unit • Desvenlafaxine ER 30 tablets per 30 days 360 cartridges (4 kits) per 28 60-4 unit + 30-8 unit (fumarate) 60-8 unit + 30-12 unit days • Dexilant 30 capsules per 30 days 360 cartridges (4 kits) per 28 • 30 ampules per 28 days days D.H.E.45 • 360 cartridges (4 kits) per 28 Diclegis 120 tablets per 30 days days • Doryx • Allegra 50mg, 75mg 60 tablets per 30 days 30mg/5ml oral susp 300ml per 30 days 100mg 60 tablets/capsules per 30 days • Alsuma 4 units per 28 days 150mg, 200mg 30 tablets per 30 days • Altoprev 30 tablets per 30 days • Duexis 90 tablets per 30 days • Alvesco 12.2gms (2 inhalers) per 25 • 240mL per 30 days days Dyanavel XR • 23g (1 bottle) per 30 days • Anoro Ellipta 60 blister packs per 30 days Dymista • 1 dose per 5 days • Anzemet Edex • 50mg 8 tablets per fill Edluar 30 tablets per 30 days 100mg 4 tablets per fill • Emadine 10mL (2 bottles) per 30 days • Apidra • Embeda vial 40mL (4 vials) per 28 days 20-0.8mg, 30-1.2mg, Solostar/cartridge 30mL (10 pens/cartridges) per 50-2mg, 60-2.4mg, 28 days 80-3.2mg 2 capsules per day • Aplenzin 30 tablets per 30 days 100-4mg 4 capsules per day • Aptensio XR 30 capsules per 30 days • Emsam 30 patches per 30 days • Aptiom • Entresto 60 tablets per 30 days 200, 400 30 tablets per 30 days • Epaned 1200mL per 30 days 600mg, 800mg 60 tablets per 30 days • Epiduo 45g (1 tube) per 30 days • Arcapta 30 capsules per 30 days • Epduo Forte 45g (1 tube) per 30 days • Arnuity Ellipta 30 blister packs per 30 days • Ergomar SL 40 tablets per 28 days • Atelvia 4 tablets per 28 days • Esomeprazole Strontium • Auryxia 12 tablets per day 24.65mg 30 capsules per 30 days • Avidoxy 60 tablets per 30 days 49.3mg 120 capsules per 30 days • Avidoxy DK 1 kit per 30 days • Estring 1 ring per 90 days • Axert 12 tablets per 30 days • Evzio 0.8mL (2 syringes) per 365 • Banzel days • 200mg 480 tablets per 30 days Fanapt 400mg 240 tablets per 30 days Tablets 60 tablets per 30 days 40mg/ml suspension 2400ml per 30 days Titration Pack 1 pack per 28 days • • Basaglar 30mL (10 pens) per 28 days Farxiga 30 tablets per 30 days • • Beau Rx 30g (1 tube) per 30 days Fazaclo 90 tablets per 30 days • • Beconase AQ 25g (1 bottle) per 30 days Felbatol 270 tablets per 30 days • Belbuca 2 buccal films per day 400mg 600mg 180 tablets per 30 days • Belsomra 30 tablets per 30 days 600mg/5ml solution 900mL per 30 days • Benoxyldoxy 1 kit per 30 days • Fentora 120 tablets per 30 days • Bepreve 10mL (1 bottle) per 30 days • Fetzima 30 capsules per 30 days • Binosto 4 tablets per 28 days • Firmagon 80mg/vial 1 vial per 30 days • Brintellix 30 tablets per 30 days • Firmagon 120mg/vial 2 vials per 365 days • Brisdelle 30 capsules per 30 days • Flovent Diskus • Brovana 120mL per 30 days 50mcg, 100mcg 60 units (1 diskus) per 30 days • 4 vials/pens per 28 days Bydureon/Bydureon Pen 250mcg 120 units (2 diskus) per 30 • Byetta days 5mcg 1.2mL (1 pen) per 30 days • Flovent HFA 10mcg 2.4mL (1 pen) per 30 days 44mcg 21.2g (2 inhalers) per 30 days • Cambia 9 packets per 30 days 110mcg 12g (1 inhaler) per 30 days • Caverject 1 dose per 5 days 220mcg 24g (2 inhalers) per 30 days • Cesamet 180 capsules per 30 days • Foradil 60 capsules per 30 days • Chantix 56 tablets per 28 days • Forfivo XL 30 capsules per 30 days • Clarinex • Frova 18 tablets per 30 days 2.5mg, 5mg reditab 30 tablets per 30 days • Fulyzaq 60 tablets per 30 days

Portfolio High Formulary – April 2016 22 Scripps Health Formulary

• Moban • Fycompa 2 9 tablets per 1 day 25 mg 2mg 120 tablets per 30 days 5 supply 10 mg 4mg, 6mg 60 tablets per 30 days 8 tablets per 1 day 5 mg 8mg, 10mg, 12mg 30 tablets per 30 days supply • Gabitril 4 tablets per 1 day 2mg, 4mg, 12mg 120 tablets per 30 days supply 16mg 90 tablets per 30 days • Morgidox 1 kit per 30 days • Gralise • Muse 1 dose per 5 days 300mg, 600mg 90 tablets per 30 days • Myalept 11.3mg vial 30 vials per 30 days Starter Pack 78 tablets per 30 days • Nesina 30 tablets per 30 days • Granisol solution 60mL per 30 days • Nicotrol cartridge 1008 cartridges (6 inhalers) per • Hemangeol 360mL (3 bottles) per 30 days 90 days • Horizant • Nicotrol NS 160mL (4 packs) per 90 days 300mg 30 tablets per 30 days • Novolin N/Novolin R/ 40mL (4 vials) per 28 days 600mg 60 tablets per 30 days Novolin 70/30 • Hydrocodone bit/ (max 4gm per day) • Novolog acetaminophen vial 40mL (4 vials) per 28 days Xodol 5-300mg 13 tablets per 1 day supply Flexpen/cartridge 30mL (10 pens/cartridges) per Zamicet Soln 184mL per 1 day supply 28 days 325mg/15ml • Novolog Mix 70/30 • Hycofenix 473mL (1 bottle) per 30 days vial 40mL (4 vials) per 28 days • Hysingla ER 30 tablets per 30 days Kwikpen 30mL (10 pens) per 28 days • Incruse Ellipta 30 blisters per 30 days • Obredon 600mL per 10 days • Intermezzo 30 tablets per 30 days • Oleptro ER • Intuniv 30 tablets per 30 days 150mg 45 tablets per 30 days • Invega 300mg 30 tablets per 30 days 1.5mg, 3mg, 9mg 30 tablets per 30 days • Omnaris 12.5g (1 bottle) per 30 days 6mg 60 tablets per 30 days • Onfi • Iprivask 6 syringes per 30 days Tablets 60 tablets per 30 days • Irenka 30 capsules per 30 days Suspension 480mL per 30 days • Kadian • Onglyza 30 tablets per 30 days 10mg, 20mg, 30mg, • Onsolis 120 films per 30 days 40mg, 50mg, 60mg, • Opana ER 70mg, 80mg, 100mg, 5mg, 7.5mg, 10mg, 130mg, 150mg 60 capsules per 30 days 15mg, 20mg 60 tablets per 30 days 200mg 120 capsules per 30 days 30mg, 40mg 120 tablets per 30 day • Kapvay 120 tablets per 30 days • Oracea 30 capsules per 30 days • Karbinal ER 960mL (2 bottles) per 30 days • Oseni 30 tablets per 30 days • Kazano 60 tablets per 30 days • Osphena 30 tablets per 30 days • Khedezla 30 tablets per 30 days • Oxycodone hcl/acetaminophen (maximum of 4gm • Kombiglyze XR acetaminophen per day): 2.5-1000mg 60 tablets per 30 days 300mg 13 tablets per 1 day supply 5-500mg, 5-1000mg 30 tablets per 30 days 325mg 12 tablets per 1 day supply • Kytril 8 tablets per 30 days • Oxtellar XR • Lamictal ODT 150mg, 300mg 30 tablets per 30 days 25mg, 50mg 180 tablets per 30 days 600mg 120 tablets per 30 days 100mg 90 tablets per 30 days • Patanase 30.5g (1 bottle) per 30 days 200mg 60 tablets per 30 days • Pazeo 2.5mL (1 bottle) per 30 days • Lamictal XR • Pataday 2.5mL (1 bottle per 30 days) 25mg, 50mg 180 tablets per 30 days • Patanol 2.5mL (1 bottle per 30 days) 100mg 90 tablets per 30 days • Pexeva 30 tablets per 30 days 200mg, 250mg, 300mg 60 tablets per 30 days • Potiga • Lastacft 3mL (1 bottle) per 30 days 50mg 270 tablets per 30 days • Latuda 200mg, 300mg, 90 tablets per 30 days 20mg, 40mg, 60mg 30 tablets per 30 days 400mg 80mg 60 tablets per 30 days • Pradaxa 60 capsules per 30 days • Lazanda 15 bottles per 30 days • Prestalia 30 tablets per 30 days • Lescol 60 tablets per 30 days • Procentra 1800mL per 30 days • Lescol XL 30 tablets per 30 days • Qudexy XR • Levemir 25mg, 50mg, 100mg 30 capsules per 30 days vial 40mL (4 vials) per 28 days 150mg, 200mg 60 capsules per 30 days Flextouch 30mL (10 pens) per 28 days • Quillichew • Levitra 6 tablets per 30 days 20mg, 40mg 1 tablet per day • Liptruzet 30 tablets per 30 days 30mg 2 tablets per day • Livalo 30 tablets per 30 days • Rasuvo • LoSeasonique 91 tablets per 84 days 7.5mg/0.15mL 1.6mL (4 syringes) per 28 days • Luvox CR 60 capsules per 30 days 10mg/0.2mL 0.8mL (4 syringes) per 28 days • Luzu 60g (1 tube) per 28 days 12.5mg/0.25mL 1mL (4 syringes) per 28 days • Menostar 4 patches per 30 days 15mg/0.3mL 1.2mL (4 syringes) per 28 days • Migranal 8 vials per 28 days 17.5mg/0.35mL 1.4mL (4 syringes) per 28 days 1.8mL (4 syringes) per 28 days • Mirapex ER 30 tablets per 30 days 22.5mg/0.46mL 25mg/0.5mL 2mL (4 syringes) per 28 days • Mirvaso 30g (1 tube) per 30 days 27.5mg/0.55mL 2.2mL (4 syringes) per 28 days • Mitigare 60 capsules per 30 days 30mg/0.6mL 2.4mL (4 syringes) per 28 days

Portfolio High Formulary – April 2016 23 Scripps Health Formulary

• Razadyne Capsules 30 capsules per 30 days Tablets 60 tablets per 30 days • Zelapar 60 tablets per 30 days Solution 200mL (2 bottles) per 30 days • Zetonna 6.1g (1 bottle) per 30 days • Razadyne ER 30 capsules per 30 days • Zioptan 30 droperettes per 30 days • Relenza 2 boxes (#20 diskhalers/box) • Zipsor 120 capsules per 30 days per 183 days • Zohydro ER 60 capsules per 30 days • Relpax 12 tablets per 30 days • Zolpimist 7.7mL (1 pump) per 30 days • Rescula 10mL (2 bottles) per 30 days • Zontivity 30 tablets per 30 days • Rexulti 30 tablets per 30 days • Zorvolex 90 capsules per 30 days • Revlimid 3 capsules per 28 days • Zuplenz • Rhinocort Aqua 17.2g (2 canisters) per 30 days 4mg 20 films per 30 days • Risperdal/Risperdal M- 60 tablets per 30 days 8mg 10 films per 30 days Tab • Zyclara 2.5%: 7.5 grams (1 bottle) per • Rozerem 30 tablets per 30 days 28 days. • Rytary 300 capsules per 30 days 3.75% pump:7.5 grams (1 • Ryzodeg 70/30 30mL (10 pens) per 28 days bottle) per 28 days • Sabril 180 tablets per 30 days 3.75% packet: 28 packets per • Samsca 28 days 15mg tablets 30 tablets per 365 days 30mg tablets 60 tablets per 365 days • SanadermRX 1 kit per 30 days 5. STEP THERAPY EDITS (FORMULARY) • Sancuso 4 patches per 28 days • Abilify tablets Trial of two preferred atypical • Saphris 60 tablets per 30 days Abilify Discmelt antipsychotics (olanzapine, quetiapine IR, risperidone, ziprasidone) or SSRIs • Savaysa 30 tablets per 30 days Abilify solution (sertraline, fluoxetine, paroxetine, • Seasonique 91 tablets per 84 days citalopram, or escitalopram) or SNRIs • 60 blister packs (1 Seebri Seebri Neohaler (venlafaxine) within the past 365 days. inhaler) per 30 days • Actoplus Met Trial of metformin, metformin ER, • Seroquel XR 30 tablets per 30 days Actoplus Met XR sulfonylurea (e.g., glyburide, glipizide) • 30 tablets per 30 days Silenor or pioglitazone within the past 120 days • 4 tablets per 365 days Sitavig • Ambien CR Trial of Ambien IR within the past 180 • Solodyn 30 tablets per 30 days days • Sotylize • Astepro Trial of Astelin (azelastine) within the 250mL 2000mL (8 bottles) per 30 days past 120 days 480mL 3840mL (8 bottles) per 30 days • Avodart Trial of Proscar, alfuzosin, doxazosin, • Sprix 5 bottles per 30 days prazosin, silodosin, tamsulosin or • Staxyn ODT 6 tablets per 30 days terazosin within the past 120 days • Stendra 6 tablets per 30 days • Azor Trial of ACE inhibitor, ACE inhibitor • Sumavel DosePro 4 units per 28 days combination, formulary generic ARB, or • Subsys 120 sprays per 30 days formulary generic ARB combination • Symbicort 10.2g (1 inhaler) per 30 days within the past 120 days • Tanzeum 4 pens per 28 days • Benicar Trial of ACE inhibitor, ACE inhibitor • Tasmar 90 tablets per 30 days Benicar HCT combination, formulary generic ARB, or • Testim 300g (60 x 5g tubes) per 30 formulary generic ARB combination days within the past 120 days • Timoptic Ocudose 60 droperettes per 30 days • Crestor 5mg Trial of two of the following: • Tivorbex 90 capsules per 30 days atorvastatin, lovastatin, pravastatin or • Tresiba (100 U) 30 mL (10 pens) per 28 days simvastatin within the past 365 days • Trial of atorvastatin 40mg or • Tresiba (200 U) 18 mL (6 pens) per 28 days Crestor 10mg, 20mg, 40mg atorvastatin 80mg within the past 120 • Trezix 10 capsules per day days • Treximet 9 tablets per 30 days • Daliresp Trial of Spiriva, Serevent,Breo Ellipta, • Trokendi XR Advair Diskus, or Dulera within the past 25mg, 50mg, 100mg 30 capsules per 30 days 120 days 60 capsules per 30 days 200mg • Desvenlafaxine ER Trial of two of the following: paroxetine, • Tudorza Pressair 1 inhaler per 30 days (Ranbaxy Brand) fluoxetine, citalopram, sertraline, • Tuzistra XR 600mL per 30 days escitalopram, mirtazapine, • Utibron Neohaler 60 blister packs (Utibron bupropion, venlafaxine IR/ER within the Inhaler) per 30 days past 365 days • Varubi 2 tablets per 14 days • Detrol Trial of oxybutynin or oxybutynin ER • Veramyst 10g (1 bottle) per 30 days Detrol LA within the past 120 days • Versacloz 540mL per 30 day • Dificid Trial of vancomycin capsules within the • Viibryd 30 tablets per 30 days past 120 days • Vimpat • Dovonex Trial of a topical within Tablets 60 tablets per 30 days the past 120 days Solution 1200mL per 30 days • Drithocreme HP Trial of a topical corticosteroid within • Vivlodex 1 capsule per day the past 120 days • Vytorin 30 tablets per 30 days • Duetact Trial of metformin, metformin ER, • Xartemis XR 360 tablets per 30 days sulfonylurea (e.g., glyburide, glipizide) • Xerese 10gm (2 tubes) per 365 days or pioglitazone within the past 120 days • Xifaxan 200mg 9 tablets per fill • Exforge Trial of ACE inhibitor, ACE inhibitor • Xigduo XR 60 tablets per 30 days Exforge HCT combination, formulary generic ARB, or • Xyzal solution 300mL per 30 days formulary generic ARB combination within the past 120 days • Zecuity 1 carton per 28 days • Fenoglide Trial of gemifibrozil or generic • Zegerid fenofibrate within the past 120 days Packets 30 packets per 30 days

Portfolio High Formulary – April 2016 24 Scripps Health Formulary

• Fuzeon Trial of any antiretroviral medication sertraline, escitalopram, mirtazapine, within the past 30 days bupropion, or venlafaxine IR/ER within • Gianvi Trial of two different non-drospirenone the past 365 days oral contraceptives (containing • Protonix Suspension Trial of Prilosec OTC or omeprazole levonorgestrel, norethindrone, within the past 120 days norgestimate, norgestrel, desogestrel, • Protopic Trial of a topical corticosteroid within or ethinynodiol ace.) within the past the past 120 days 365 days. • Purixan Trial of mercaptopurine tablet within the • Glyxambi Trial of metformin (IR/ER), a past 120 days sulfonylurea, pioglitazone or a • Qnasl Trial of fluticasone or flunisolide within combination product containing any two the past 120 days of the three agents above within the • Qnasl Children Trial of fluticasone or flunisolide within past 120 days. the past 120 days • Invirase Trial of Isentress, Reyataz, Prezista, • Quillivant XR Trial of Metadate CD or Ritalin LA Sustiva or Atripla within the past 120 within the past 120 days days • Retin-A Micro Pump Trial of generic tretinoin microspheres • Invokamet Trial of metformin (IR/ER), a 0.04% AND tretinoin gel 0.10% within sulfonylurea, pioglitazone or a the past 365 days combination product containing any two • Requip XL Trial of pramipexole IR or ropinirole IR of the three agents above within the within the past 120 days past 120 days. • Sanctura Trial of oxybutynin or oxybutynin ER • Invokana Trial of metformin (IR/ER), a within the past 120 days sulfonylurea, pioglitazone or a • Simcor Trial of two of the following; combination product containing any two atorvastatin, lovastatin, pravastatin or of the three agents above within the simvastatin within the past 365 days past 120 days. • Syeda Trial of two different non-drospirenone • Jalyn Trial of finasteride 5mg, alfuzosin, oral contraceptives (containing doxazosin, prazosin,tamsulosin or levonorgestrel, norethindrone, terazosin within the past 120 days norgestimate, norgestrel, desogestrel, • Jardiance Trial of metformin (IR/ER), a or ethinynodiol ace.) within the past sulfonylurea, pioglitazone, or a 365 days. combination product containing any • Synjardy Trial of metformin (IR/ER), a two of the three agents above within sulfonylurea, pioglitazone, or a the past 120 days. combination product containing any two • Loestrin FE Trial of one generic contraceptive of the three agents above within the within the past 120 days past 120 days. • Loestrin FE24 Trial of two generic oral contraceptives • Tribenzor Trial of ACE inhibitor, ACE inhibitor within the past 365 days combination, formulary generic ARB or • Lo Loestrin FE Trial of two generic oral contraceptives ARB combination within the past 120 within the past 365 days days • Loryna Trial of two different non-drospirenone • Toviaz Trial of oxybutynin or oxybutynin ER oral contraceptives (containing within the past 120 days levonorgestrel, norethindrone, • Triglide Trial of gemifibrozil or generic norgestimate, norgestrel, desogestrel, fenofibrate within the past 120 days or ethinynodiol ace.) within the past • Trulicity Trial of metformin (IR/ER), a 365 days. sulfonylurea, pioglitazone or a • Marinol Trial of ondansetron, corticosteroids combination product containing any two and Emend within the past 365 days of the three agents above within the • Myrbetriq Trial of oxybutynin IR/ER within the past 120 days. past 120 days • Uloric Trial of allopurinol within the past 120 • Neupro Trial of pramipexole IR or ropinirole IR days within the past 120 days • Vectical Trial of a topical corticosteroid within • Nexium Trial of omeprazole, lansoprazole or the past 120 days Nexium Suspension pantoprazole within the past 120 days • Vesicare Trial of oxybutynin or oxybutynin ER • Namzaric Trial of donepezil and memantine within the past 120 days within the past 365 days • Vestura Trial of two different non-drospirenone • Niaspan Trial of generic/multisource statin oral contraceptives (containing (atorvastatin, lovastatin, pravastatin, or levonorgestrel, norethindrone, simvastatin), or generic/multisource norgestimate, norgestrel, desogestrel, gemfibrozil or fenofibrate within the or ethinynodiol ace.) within the past past 365 days 365 days. • Nuvaring Trial of a generic oral contraceptive • Vibramycin/Vibra-Tabs Trial of generic doxycycline within the past 120 days monohydrate capsules within the past • Ocella Trial of two different non-drospirenone 120 days oral contraceptives (containing • Victoza Trial of metformin (IR/ER), a levonorgestrel, norethindrone, sulfonylurea, pioglitazone or a norgestimate, norgestrel, desogestrel, combination product containing any two or ethinynodiol ace.) within the past of the three agents above within the 365 days. past 120 days. • Ortho Evra Trial of a generic oral contraceptive • Vitekta Trial of previous HIV anti-retroviral within the past 120 days therapy within the past 120 days • Otrexup Trial of methotrexate tablet or solution • Vyvanse Trial of one of the following: SSRI for injection within the past 120 days (sertraline, escitalopram, citalopram, • Prevacid Solutabs Trial of lansoprazole, omeprazole or fluoxetine, fluvoxamine, paroxetine), pantoprazole within the past 120 days topiramate, generic/multisource mixed • Pristiq Trial of two of the following: generic amphetamine salts (Adderall IR/XR), or paroxetine, fluoxetine, citalopram, methylphenidate (IR, ER, LA, CD)

Portfolio High Formulary – April 2016 25 Scripps Health Formulary

within the past 120 days. divalproex, topiramate, or zonisamide • Yasmin 28 Trial of two different non-drospirenone within the past 365 days oral contraceptives (containing • Arcapta Trial of Serevent Diskus or Striverdi levonorgestrel, norethindrone, Respimat within the past 120 days norgestimate, norgestrel, desogestrel, • Arnuity Ellipta Trial of at least two of the following: or ethinynodiol ace.) within the past Asmanex, Pulmicort, or QVAR within 365 days. the past 365 days • Yaz Trial of two different non-drospirenone • Asacol HD Trial of balsalazide, Lialda, Pentasa or oral contraceptives (containing Apriso within the past 120 days levonorgestrel, norethindrone, • Atelvia Trial of alendronate and ibandronate norgestimate, norgestrel, desogestrel, within the past 365 days or ethinynodiol ace.) within the past • Auvi-Q Trial of Epipen within the past 120 365 days. days • Zarah Trial of two different non-drospirenone • Avandia/ Trial of metformin (IR/ER), a oral contraceptives (containing Avandaryl/ sulfonylurea, pioglitazone, or a levonorgestrel, norethindrone, Avandamet combination product containing any norgestimate, norgestrel, desogestrel, two of the three agents above within or ethinynodiol ace.) within the past the past 120 days. 365 days. • Avidoxy/Avidoxy DK Trial of generic doxycycline • Zenzedi (2.5mg, 7.5mg) Trial of a multisource monohydrate 100mg capsules within dextroamphetamine sulfate tablet or the past 120 days dextroamphetamine solution within the • Axert Trial of sumatriptan or rizatriptan within past 120 days the past 180 days • Zocor (80mg only) Trial of simvastatin 80mg or Vytorin • Banzel Trial of lamotrigine, valproic acid or 10/80mg within the past 365 days topiramate within the past 120 days • Zomig Trial of sumatriptan or rizatriptan within • Basaglar Trial of preferred long acting insulin Zomig ZMT the past 180 days within the past 120 days 6. STEP THERAPY EDITS (NON FORMULARY) • Beconase AQ Trial of fluticasone or flunisolide within • Absorica Trial of generic isotretinoin within the the past 365 days past 120 days • Belbuca Trial of Butrans (buprenorphine • Aciphex Trial of two of the following; transdermal) patch within the past 120 omeprazole, lansoprazole or days pantoprazole or rabeprazole within the • Belsomra Trial of zolpidem IR (Ambien), zaleplon past 365 days (Sonata) or eszopiclone (Lunesta) • Aciphex Sprinkle Trial of two of the following; within the past 120 days omeprazole, lansoprazole, • Benoxyldoxy Trial of generic doxycycline pantoprazole or rabeprazole within the monohydrate 100mg capsules within past 365 days the past 120 days • Acticlate Trial of generic doxycycline • Beau Rx Trial of Kelo-cote or Recedo within the monohydrate tablets within the past past 120 days 120 days • Benzaclin pump Trial of two preferred topical • Actonel Trial of alendronate and ibandronate combination acne agents (Ziana and within the past 365 days Acanya) within the past 365 days • Adrenaclick Trial of Epipen within the past 120 • Bepreve Trial of generic ophthalmic days. antihistamine (epinastine, azelastine, • Advicor Trial of two of the following; or olapatadine) AND Pataday atorvastatin, lovastatin, pravastatin or (olapatadine 0.2%) within the past 365 simvastatin within the past 365 days days • Aerospan Trial of at least two of the following: • Beyaz Trial of two different non-drospirenone QVAR, Asmanex or Pulmicort within oral contraceptives (containing the past 365 days levonorgestrel, norethindrone, • Altoprev Trial of two of the following: norgestimate, norgestrel, desogestrel, atorvastatin, lovastatin, pravastatin or or ethinynodiol ace.) within the past simvastatin within the past 365 days 365 days • Alvesco Trial of at least two of the following: • Binosto Trial of generic alendronate and QVAR, Asmanex or Pulmicort within ibandronate within the past 365 days the past 365 days • Brintellix Trial of two of the following • Anoro Ellipta Trial of Stiolto Respimat and one of the generic/multisource products: following: Spiriva, Striverdi or Serevent paroxetine, venlafaxine ER or IR, within the past 365 days fluoxetine, citalopram, sertraline, • Antara Trial of gemifibrozil or generic escitalopram, mirtazapine or bupropion fenofibrate within the past 120 days within the past 365 days • Anzemet Trial of ondansetron tablets or ODT • Brisdelle Trial of paroxetine or venlafaxine within within the past 120 days the past 120 days • Apidra Trial of Humalog within the past 120 • Bydureon Trial of metformin (IR/ER), a days sulfonylurea, pioglitazone, or a • Aplenzin Trial of bupropion hcl SR or XL within combination product containing any the past 120 days two of the three agents above and • Aptensio XR Trial of methylphenidate IR, Trulicity or Victoza within the past 365 generic/multisource mixed days. amphetamine salts (Adderall) or long- • Byetta Trial of metformin (IR/ER), a acting formulation of methylphenidate sulfonylurea, pioglitazone, or a (ER, LA, CD) within the past 120 days combination product containing any • Aptiom Trial of two of the following; two of the three agents above and carbamazepine, gabapentin, Trulicity or Victoza within the past 365 lamotrigine, levetiracetam IR or ER, days. oxcarbazepine, valproic acid or • Cesamet Trial of ondansetron tablet or ODT

Portfolio High Formulary – April 2016 26 Scripps Health Formulary

within the past 120 days • Emadine Trial of generic ophthalmic • Clarinex Reditabs/ Trial of desloratadine or levocetirizine antihistamine (epinastine, azelastine, Clarinex syrup/ tablet within the past 120 days or olapatadine) AND Pataday Clarinex D (olapatadine 0.2%) within the past 365 • Conzip Trial of tramadol ER (Ultram ER) within days the past 120 days • Enstilar Trial of topical corticosteroid within the • Cosopt PF Trial of dorzolamide/timolol within the past 120 days past 120 days • Epaned If age ≥ 12 years, trial of enalapril • Cycloset Trial of metformin (Glucophage), tablets within the past 120 days metformin ER, glyburide/metformin • Epiduo Trial of adapalene 0.1% gel within the (Glucovance), or glipizide/metformin past 120 days (Metaglip) within the past 180 days • Epiduo Forte Trial of adapalene 0.1% gel within the • Daytrana Trial of methylphenidate CD, ER, or LA past 120 days formulation or methylphenidate • Esomeprazole Strontium Trial of omeprazole, lansoprazole or suspension/solution within the past 120 pantoprazole within the past 120 days days • Evzio Trial of Narcan nasal spray within the • Delzicol Trial of balsalazide, Lialda, Pentasa or past 120 days Apriso within the past 120 days • Fanapt Trial of two preferred atypical • DermacinRx Silapak Trial of all three individual ingredients: antipsychotics (olanzapine, quetiapine triamcinolone 0.1% (RX), dimethicone IR, risperidone, ziprasidone) within the 5% (OTC) and silicone tape (OTC) past 365 days within the past 365 days • Farxiga Trial of metformin (IR/ER), a • DermasilkRx SDS Trial of all three individual ingredients: sulfonylurea, pioglitazone, or a triamcinolone 0.1% (RX), dimethicone combination product containing any 5% (OTC) and silicone tape (OTC) two of the three agents above and within the past 365 days Invokana, Invokamet, Jardiance or • Desvenlafaxine ER Trial of two of the following; generic Synjardy within the past 365 days fumarate paroxetine, fluoxetine, citalopram, • Fazaclo Trial of two preferred atypical sertraline, escitalopram, venlafaxine antipsychotics (olanzapine, quetiapine ER or IR, mirtazapine or bupropion IR, risperidone, ziprasidone) within the within the past 365 days past 365 days • Dexilant Trial of omeprazole, pantoprazole, or • Felbatol Trial of lamotrigine or topiramate within lansoprazole within the past 120 days the past 120 days • Diabetes blood glucose Trial of 1) one FreeStyle or Precision • Fetzima Trial of two of the following; paroxetine, test strips, Bayer brands brand test strip and 2) one OneTouch fluoxetine, citalopram, sertraline, (Contour, Breeze) test strip within the past 365 days escitalopram, mirtazapine, bupropion • Diabetes blood glucose Trial of 1) one FreeStyle or Precision or venlafaxine IR/ER within the past test strips, Roche brand test strip and 2) one OneTouch 365 days brands (Accu-chek, test strip within the past 365 days • Flovent Diskus/HFA Trial of two of the following: QVAR, ChemStrip) Pulmicort or Asmanex within the past • Dipentum Trial of balsalazide, Lialda, Pentasa or 365 days Apriso within the past 120 days • Foradil Trial of Serevent Diskus or Striverdi • Doryx 50mg tabs Trial of generic doxycycline Respimat within the past 120 days monohydrate 50mg capsules within the • Forfivo XL Trial of generic bupropion within the past 120 days past 120 days • Doryx 75mg tabs Trial of generic doxycycline • Fortamet Trial of generic metformin ER monohydrate 75mg tablets within the (Glucophage XR) within the past 120 past 120 days days • Doryx 100mg tabs/caps Trial of generic doxycycline • Frova Trial of sumatriptan or rizatriptan within monohydrate 100mg capsules within the past 180 days the past 120 day • Fulyzaq Trial of antiretroviral therapy within the • Doryx 150mg tabs Trial of generic doxycycline past 120 days monohydrate 150mg tablets within the • Fycompa Trial of two of the following: past 120 days carbamazepine, gabapentin, • Doryx 200mg tabs Trial of generic doxycycline lamotrigine, levetiracetam IR or ER, monohydrate 100mg capsules within oxcarbazepine, valproic acid, the past 120 days divalproex, topiramate or zonisamide • Duexis Trial of generic oral NSAID within the within the past 365 days past 120 days • Gabitril Trial of two of the following: • Dyanavel XR Trial of extended-release carbamazepine, gabapentin, amphetamine/dextroamphetamine oral lamotrigine, levetiracetam IR or ER, capsules within the past 120 days oxcarbazepine, valproic acid, • Dymista Trial of fluticasone or flunisolide within divalproex, topiramate or zonisamide the past 365 days within the past 365 days • Edarbi Trial of ACE inhibitor, ACE inhibitor • Giazo Trial of balsalazide or Apriso within the combination, formulary generic ARB, past 120 days or formulary generic ARB combination • Glumetza Trial of generic metformin ER within the past 120 days (Glucophage XR) within the past 120 • Edarbyclor Trial of ACE inhibitor, ACE inhibitor days combination, formulary generic ARB, • Gralise Trial of gabapentin (Neurontin) within or formulary generic ARB combination the past 120 days within the past 120 days • Hemangeol For age over 1 year, trial of generic • Edluar Trial of zolpidem immediate-release propranolol oral solution within the past tablets within the past 120 days 120 days • Elidel Trial of a topical corticosteroid within • Horizant Trial of pramiprexole (Mirapex), the past 120 days ropinirole IR (Requip) or generic gabapentin (Neurontin) within the past

Portfolio High Formulary – April 2016 27 Scripps Health Formulary

120 days • Monodox 75mg caps Trial of generic doxycycline • Hycofenix Trial of monohydrate 75mg tabs within the codine/pseudoephedrine/guaifenesin past 120 days within the past 120 days • Morgidox Trial of generic doxycycline • Incruse Ellipta Trial of preferred LAMA (Spiriva) within monohydrate 100mg cap within the the past 120 days past 120 days • Inderal XL Trial of Inderal LA within the past 120 • Natazia Trial of two generic oral contraceptives days within the past 365 days • Innopran XL Trial of Inderal LA within the past 120 • Neo-Synalar Trial of fluocinolone and bacitracin days within the past 365 days • Intermezzo Trial of zolpidem immediate-release • Nesina Trial of a formulary DPP4 tablets within the past 120 days inhibitor(s)/combination (Januvia, • Invega Trial of two preferred atypical Janumet, Janumet XR, Tradjenta, or antipsychotics (olanzapine, quetiapine Jentadueto within the past 120 days IR, risperidone, ziprasidone) within the • Novolin N Trial of Humulin N within the past 120 past 365 days. days • Irenka Trial of generic duloxetine 20mg • Novolin R Trial of Humulin R within the past 120 capsules within the past 120 days days • Kazano Trial of a formulary DPP4 • Novolin 70/30 Trial of Humulin 70/30 within the past inhibitor(s)/combination (Januvia, 120 days Janumet, Janumet XR, Tradjenta, or • Novolog Trial of Humalog within the past 120 Jentadueto within the past 120 days days • Karbinal ER Trial of generic immediate-release • Novolog Mix 70/30 Trial of Humalog Mix 75/25 within the carbinoxamine maleate within the past past 120 days 120 days • Obredon Trial of hydrocodone/homatropine • Khedezla Trial of two of the following generic methylbromide within the past 120 products: paroxetine, venlafaxine ER/ days IR, fluoxetine, citalopram, sertraline, • Oleptro ER Trial of immediate release trazodone escitalopram, mirtazapine or bupropion within the past 120 days within the past 365 days • Omnaris Trial of fluticasone or flunisolide within • Kombiglyze XR Trial of a formulary DPP4 the past 365 days inhibitor(s)/combination (Januvia, • Onfi Trial of lamotrigine or topiramate within Janumet, Janumet XR, Tradjenta, or the past 120 days Jentadueto within the past 120 days • Onglyza Trial of a formulary DPP4 • Lastacaft Trial of generic ophthalmic inhibitor(s)/combination (Januvia, antihistamine (epinastine, azelastine, Janumet, Janumet XR, Tradjenta, or or olapatadine) AND Pataday Jentadueto within the past 120 days (olapatadine 0.2%) within the past 365 • Oracea Trial of generic doxycycline days monohydrate 50mg capsule within the • Kytril Trial of ondansetron tablets or ODT past 120 days within the past 120 days • Oseni Trial of a formulary DPP4 • Lamictal ODT/XR Trial of lamotrigine IR within the past inhibitor(s)/combination (Januvia, 120 days Janumet, Janumet XR, Tradjenta, or • Latuda Trial of two preferred atypical Jentadueto within the past 120 days antipsychotics (olanzapine, quetiapine • Ovace Plus Lotion Trial of ketoconazole shampoo/cream IR, risperidone, ziprasidone) or SSRIs or ciclopirox shampoo/gel within the (sertraline, fluoxetine, paroxetine, past 120 days citalopram, or escitalopram) or SNRIs • Oxtellar XR Trial of two of the following: (venlafaxine) within the past 365 days carbamazepine, gabapentin, • Lescol/XL Trial of two of the following: lamotrigine, levetiracetam IR or ER, atorvastatin, lovastatin, pravastatin or oxcarbazepine, valproic acid, simvastatin within the past 365 days divalproex, topiramate, or zonisamide • Levemir Trial of Lantus or Toujeo within the within the past 365 days past 120 days • Patanase Trial of Astelin (azelastine) within the • Levitra Trial of Cialis and Viagra within the past 120 days past 365 days • Pazeo Trial of generic antihistamine and • Liptruzet Pataday within the past 365 days 10/10mg Trial of 2 of the following: atorvastatin, • Pennsaid Trial of Voltaren gel within the past 120 simvastatin, pravastatin or lovastatin days within the past 365 days • Pexeva Trial of paroxetine IR within the past 10/20mg, 10/40mg, Trial of 40mg atorvastatin or 80mg 120 days 10/80mg atorvastatin within the past 120 days • Potiga Trial of two of the following: • Livalo Trial of two of the following: carbamazepine, gabapentin, atorvastatin, lovastatin, pravastatin or lamotrigine, levetiracetam IR or ER, simvastatin within the past 365 days oxcarbazepine, valproic acid, • Loestrin 24 Fe Trial of two generic oral contraceptives divalproex, topiramate, or zonisamide within the past 365 days within the past 365 days • Luvox CR Trial of generic paroxetine, fluoxetine, • Pradaxa Trial of Eliquis and Xarelto within the citalopram, sertraline, escitalopram, past 365 days mirtazapine, or fluvoxamine IR within • Prestalia Trial of amlodipine and ACE inhibitor the past 120 days (quinapril hcl, perindopril erbumine, • Luzu Trial of ketoconazole and clotrimazole ramipril, benazepril hcl, captopril, cream within the past 365 days enalapril maleate, fosinopril sodium, • Mirapex ER Trial of pramipexole IR or ropinirole IR lisinopril, trandolapril or moexipril hcl) within the past 120 days within the past 365 days • Moderiba Dosepak Trial of ribavirin 200mg capsule or • Qudexy XR Trial of topiramate immediate release tablet within the past 120 days within the past 120 days

Portfolio High Formulary – April 2016 28 Scripps Health Formulary

• Quillichew Trial of Ritalin LA or Metadate CD (Imitrex or equivalent) within the past within the past 120 days 180 days • Rapaflo Trial of finasteride 5mg, alfuzosin, • Symbicort Trial of Dulera, Advair or Breo Ellipta doxazosin, prazosin,tamsulosin or within the past 120 days terazosin within the past 120 days • Taclonex Trial of a topical corticosteroid within • Rasuvo Trial of Otrexup and methotrexate Taclonex Scalp the past 120 days tablet or solution for injection within the • Tanzeum Trial of metformin (IR/ER), a past 365 days. sulfonylurea, pioglitazone, or a • Rayos Trial of generic prednisone within the combination product containing any past 120 days two of the three agents above and • Relpax Trial of sumatriptan or rizatriptan within Trulicity or Victoza within the past 365 the past 180 days days. • Rescula Trial of latanoprost and Lumigan or • Tasmar Trial of Comtan within the past 120 Travatan Z within the past 365 days days • Rexulti Trial of two preferred atypical • Teveten Trial of ACE inhibitor, ACE inhibitor antipsychotics (olanzapine, quetiapine Teveten HCT combination, formulary generic ARB, IR, risperidone, ziprasidone) or SSRIs or formulary generic ARB combination (sertraline, fluoxetine, paroxetine, within the past 120 days citalopram, or escitalopram) or SNRIs • Timoptic Ocudose Trial of timolol drops within the past (venlafaxine) within the past 365 days 120 days • Rhinocort Aqua Trial of fluticasone or flunisolide within • Tivorbex Trial of generic indomethacin within the the past 365 days past 120 days • Ribasphere 400mg, Trial of ribavirin 200mg capsule or • Topicort Spray Trial of mometasone 0.1% ointment, 600mg, RibaPak tablet within the past 120 days fluocinonide 0.05% cream/ointment/ • Rozerem Trial of zolpidem IR (Ambien), zaleplon gel, desoximetasone 0.25% cream, or (Sonata) or eszopiclone (Lunesta) betamethasone dipropionate 0.05% within the past 120 days cream within the past 120 days • Rytary Trial of Sinemet IR or CR within the • Tresiba Trial of preferred long-acting insulin past 120 days within the past 120 days • Ryzodeg 70/30 Trial of preferred long acting insulin • Treximet Trial of sumatriptan within the past 180 and preferred pre-mixed insulin) within days the past 365 days • Trokendi XR Trial of topiramate IR within the past • Safyral Trial of two different non-drospirenone 120 days oral contraceptives (containing • Tudorza Pressair Trial of Spiriva within the past 120 days levonorgestrel, norethindrone, • Utibron Neohaler Trial of preferred LAMA or LABA and norgestimate, norgestrel, desogestrel, LAMA/LABA(s) within the past 365 or ethinynodiol ace.) within the past days 365 days. • Tuzistra XR Trial of promethazine with codeine • Savaysa Trial of Eliquis and Xarelto within the syrup within the past 120 days past 365 days • Uceris rectal foam Trial of mesalamine enema within the • SanadermRX Trial of all three individual ingredients: past 120 days triamcinolone 0.1% (RX), dimethicone • Uceris tablet Trial of balsalazide within the past 120 5% (OTC) and silicone tape (OTC) days within the past 365 days • Veltin Trial of two preferred topical • Seebri Neohaler Trial of preferred LAMA within the past combination acne agents (Ziana and 120 days Acanya) within the past 365 days • Sancuso Trial of ondansetron tablet or ODT • Veramyst Trial of fluticasone or flunisolide within within the past 120 days the past 365 days • Saphris Trial of two preferred atypical • Versacloz Trial of two preferred atypical antipsychotics (olanzapine, quetiapine antipsychotics (olanzapine, quetiapine IR, risperidone, ziprasidone) within the IR, risperidone, ziprasidone) within the past 365 days. past 365 days. • Seroquel XR Trial of two preferred atypical • Viibryd Trial of two of the following: paroxetine, antipsychotics (olanzapine, quetiapine fluoxetine, citalopram, sertraline, IR, risperidone, ziprasidone) or SSRIs escitalopram, mirtazapine, bupropion, (sertraline, fluoxetine, paroxetine, venlafaxine IR/ER within the past 365 citalopram, or escitalopram) or SNRIs days (venlafaxine) within the past 365 days • Vimovo Trial of generic naproxen within the • Silenor Trial of zolpidem IR (Ambien), zaleplon past 120 days (Sonata) or eszopiclone (Lunesta) • Vimpat Trial of two of the following: within the past 120 days carbamazepine, gabapentin, • Sitavig Trial of oral acyclovir, valacyclovir or lamotrigine, levetiracetam IR or ER, famciclovir within the past 120 days oxcarbazepine, valproic acid, • Staxyn ODT Trial of Cialis and Viagra within the divalproex, topiramate or zonisamide past 365 days within the past 365 days • Stendra Trial of Cialis and Viagra within the • Vivlodex Trial of generic meloxicam within the past 365 days past 120 days • Solodyn Trial of generic minocycline immediate • Vytorin: Trial of two of the following: release within the past 120 days 10/10mg atorvastatin, lovastatin, pravastatin or • Sorilux Trial of a topical corticosteroid within simvastatin within the past 365 days the past 120 days 10/20mg, 10/40mg Trial of atorvastatin 40mg or • Sotylize Trial of sotolol tablets within the past atorvastatin 80mg within the past 120 120 days days • Stavzor Trial of generic valproic acid or 10/80mg Trial of simvastatin 80mg or Vytorin divalproex within the past 120 days 10/80mg within the past 365 days • Sumavel Dose-Pro Trial of generic/multisource injectable • Xerese Trial of oral acyclovir, valacyclovir or sumatriptan or nasal sumatriptan famciclovir within the past 120 days

Portfolio High Formulary – April 2016 29 Scripps Health Formulary

• Xigduo XR Trial of metformin (IR/ER), a • Grastek sulfonylurea, pioglitazone, or a • Harvoni combination product containing any • Humira two of the three agents above and • Ibrance Invokana, Invokamet, Jardiance or • Iclusig Synjardy within the past 365 days. • Imbruvica • Xyzal Solution Trial of desloratadine or levocetirizine • Inlyta tablet within the past 120 days • Intelence • Zecuity Trial of generic/multisource • Intron A sumatriptan and nasal sumatriptan • within the past 365 days Iressa • • Zegerid Trial of omeprazole, lansoprazole or Jakafi pantoprazole within the past 120 days • Juxtapid • Zetonna Trial of fluticasone or flunisolide within • Kalydeco the past 365 days • Keveyis • Zioptan Trial of latanoprost and Lumigan or • Korlym Travatan Z within the past 365 days • Kynamro • Zipsor Trial of diclofenac sodium within the • Lenvima past 120 days • Letairis • Zithranol Trial of a topical corticosteroid within • Leukine Zithranol RR the past 120 days • Lexiva • Zolpimist Trial of zolpidem immediate-release • Lonsurf tablets within the past 120 days • Lynparza • Zorvolex Trial of diclofenac sodium within the • Mekinist past 120 days • Neulasta • Zuplenz Trial of ondansetron tablet or ODT • Neupogen within the past 120 days • Nexavar 7. GENDER EDITS (FORMULARY) • Ninlaro • Avodart Male only • Norditropin • Cialis Male only • Odomzo • Jalyn Male only • Ofev • Viagra Male only • Omnitrope 8. GENDER EDITS (NON-FORMULARY) • Opsumit • Levitra Male only • Oralair • Rapaflo Male only • Orkambi • Staxyn ODT Male only • Pegasys • Stendra Male only • Plegridy 9. PRIOR AUTHORIZATION RESTRICTIONS (FORMULARY) • • Actiq Plegridy Pen • • Adcirca Pomalyst • • Adempas Procrit • • Afinitor /Afinitor Disperz Procysbi • • Aldara Promacta • • Alecensa Provigil • • Androgel Pulmozyme • • Aptivus Ragwitek • • Avonex Rebif • • Avonex Admin Pack Rebif Rebidose • • Axiron Relistor • • Bosulif Revatio tablets • • Cayston Revlimid • • Cometriq Selzentry • • Complera Sivextro • • Copaxone Sovaldi • • Corlanor Sprycel • • Cosentyx Stivarga • • Cotellic Stelara • • Cystaran Strensiq • • Daraprim Suboxone • • Delatestryl Subutex • • Depo-Testosterone Sutent • • Duragesic Tafinlar • • Edurant Tagrisso • Eligard • Tarceva • Enbrel • Targretin • Erivedge • Tasigna • Esbriet • Tecfidera • Fareston • Temodar capsules • Farydak • Thalomid • Firazyr • Tivicay • Gattex • Tobi • Gilenya • Tobi Podhaler • Gilotrif • Tracleer • Gleevec • Trizivir

Portfolio High Formulary – April 2016 30 Scripps Health Formulary

• Tybost • Fentora • Tykerb • Flebogamma DIF* • Uptravi • Flolan* • Valchlor • Fortesta • Votrient • Gamastan S-D* • Xalkori • Gammagard Liquid • Xeloda • Gammagard S-D* • Xenazine • Gammaked • Xifaxan 550mg • Gammaplex* • Xtandi • Gamunex-C • Zelboraf • Gazyva* • Zydelig • Gleostine • Zykadia • Gel-One* • Zytiga • Genotropin • Zyvox • Granix* • H.P. Acthar* • 10. PRIOR AUTHORIZATION RESTRICTIONS (NON FORMULARY) Halaven* • • Abraxane* Herceptin* • • Abstral Hetlioz • • Actemra IV* Hizentra • • Actemra SC Humatrope • • Adcetris* Hyalgan* • • Addyi Ilaris* • • Afrezza Imlygic* • • Alimta* Increlex • • Ampyra Iprivask • • Amturnide Istodax* • • Anadrol-50 Ixempra* • • Androderm Jublia • • Apokyn Kadcyla* • • Aranesp Kalbitor* • • Arzerra* Kanuma* • • Aubagio Keytruda* • • Avastin* Kineret • • Beleodaq* Kitabis Pak • • Belviq Kyprolis* • • Berinert Lazanda • • Betaseron Lemtrada* • • Bethkis Lucentis* • • Bivigam* Lumizyme* • • Blincyto* Macugen* • • Botox* Makena • • Bunavail Marqibo* • • Caprelsa Mircera • • Carimune NF Nanofiltered* Monovisc* • • Cerezyme* Mozobil* • • Cholbam Myobloc* • • Cimzia Natesto • • Cinryze Natpara • • Contrave Neulasta Delivery Kit* • • Cyramza* Northera • • Daklinza Novantrone* • • Darzalex* Nucala* • • Durlaza Nuedexta • • Duopa Nutropin • • Dysport* Nutropin AQ • • Egrifta Nutropin AQ NuSpin • • Elelyso* Nuvigil • • Elspar* Nymalize • • Empliciti* Octagam* • • Entresto Olysio • • Entyvio* Omontys • • Epogen Oncaspar* • • Erbitux* Onivyde* • • Erwinase* Onsolis • • Euflexxa* Opdivo* • • Evekeo Orencia IV* • • Exalgo Orencia SC • • Exondys 51* Orenitram ER • • Extavia Orthovisc* • • Eylea* Otezla • • Faslodex* Oxandrin

Portfolio High Formulary – April 2016 31 Scripps Health Formulary

• Pegintron • Technivie • Pegintron Redipen • Yervoy* • Perjeta* • Yondelis* • Photofrin* • Zaltrap* • Portrazza* • Zarxio • Praluent • Zavesca • Privigen* • Zepatier • Prolia* • Zoladex* • Provigil • Zomacton • Qsymia • Zorbtive • Qutenza • Zubsolv • Ravicti • Zyclara • Remicade* • Remodulin * = Dependent on plan benefit. If covered under pharmacy benefit, then • Repatha non-formulary with prior authorization • Revatio Vial* • Revatio suspension 11. CONCURRENT USE EDITS (FORMULARY) • Rituxan* • Suboxone • Saizen • Subutex • Saxenda 12. CONCURRENT USE EDITS (NON FORMULARY) • Serostim • Bunavail • Signifor • Zubsolv • Simponi SC • Simponi Aria IV* • Sirturo • Solaraze • Soliris* • Stivarga • Striant • Subsys • Sucraid • Supartz* • Suprenza ODT • Sylatron • Sylvant* • Synagis* • Synribo* • Synvisc* • Synvisc-One* • Technivie • Tekamlo • Tekturna • Tekturna HCT • Temodar Vial* • Testim • Testred • Tev-Tropin • Thyrogen* • Torisel* • Translarna • Tysabri* • Tyvaso • Unituxin* • Valturna • Vecamyl • Vectibix* • Velcade* • Veletri* • Veltassa • Ventavis • Viberzi • Viekira Pak • Vimizim* • Vogelxo • Vpriv* • Xeljanz • Xeljanz XR • Xeomin* • Xgeva* • Xolair* • Xuriden • Xyrem

Portfolio High Formulary – April 2016 32 Scripps Health Formulary INDEX

5-grass pollen extract...... 6 aminophylline ...... 6 AXID ...... 18 8-MOP ...... 10 amiodarone hcl ...... 7 AXIRON ...... 13 abacavir sulfate ...... 14 AMITIZA ...... 16 axitinib ...... 16 abacavir sulfate/lamivudine ...... 14 amitriptyline hcl ...... 7 AYGESTIN...... 13 abacavir/dolutegravir/lamivudine ...... 14 amlodipine bes/olmesartan med ...... 8 azathioprine ...... 13 abacavir/lamivudine/zidovudine ...... 14 amlodipine besylate ...... 8 azelastine hcl ...... 6, 12 ABBOTT DIABETIC SUPPLIES ...... 11 amlodipine besylate/benazepril ...... 7 AZILECT ...... 18 ABILIFY DISCMELT ...... 7 amlodipine/atorvast cal ...... 9 azithromycin ...... 13 ABILIFY SOLUTION ...... 7 amlodipine/valsartan ...... 8 AZOPT ...... 12 ABILIFY TABLET ...... 7 amlodipine/valsartan/hctz ...... 8 AZOR ...... 8 abiraterone acetate ...... 16 AMNESTEEM ...... 9 aztreonam lysine ...... 13 ACANYA ...... 9 amox tr/potassium clavulanate ...... 14 AZULFIDINE ...... 15 acarbose ...... 10 amoxapine ...... 7 bacitracin ...... 12 ACCUPRIL ...... 8 amoxicillin trihydrate ...... 14 bacitracin/polymyxin b sulfate ...... 12 ACCURETIC ...... 8 AMOXIL ...... 14 baclofen ...... 18 acebutolol hcl ...... 8 amphet asp/amphet/d-amphet ...... 7 BACTRIM DS ...... 13 acetaminophen with codeine ...... 17 ampicillin trihydrate ...... 14 BACTROBAN ...... 9, 10 acetazolamide ...... 12 amylase/lipase/protease ...... 18 BACTROBAN NASAL ...... 17 acetic acid ...... 11 ANAFRANIL...... 7 balsalazide disodium ...... 15 acetic acid/aluminum acetate ...... 11 anagrelide hcl ...... 13 BARACLUDE ...... 15 acetic acid/hydrocortisone ...... 11 ANALPRAM HC ...... 15 becaplermin ...... 11 acetylcysteine ...... 17 ANAPROX ...... 15 beclomethasone dipropionate ...... 6 acitretin ...... 10 ANAPROX DS ...... 15 belladonna alkaloids/phenobarb ...... 18 ACLOVATE ...... 10 ANASPAZ ...... 18 benazepril hcl ...... 8 ACTIGALL ...... 16 anastrozole ...... 16 benazepril/hydrochlorothiazide ...... 7 ACTIQ ...... 17 ANDROGEL...... 13 BENEMID ...... 13 ACTOPLUS MET ...... 11 ANDROID ...... 13 BENICAR ...... 8 ACTOPLUS MET XR ...... 11 ANDROXY ...... 13 BENICAR HCT ...... 8 ACTOS ...... 11 ANSAID ...... 15 BENTYL ...... 18 ACULAR ...... 12 ANTABUSE ...... 7 BENZACLIN ...... 9 ACULAR LS ...... 12 anthralin ...... 10 BENZAMYCIN ...... 9 acyclovir ...... 10, 14 antipyrine/benzocaine otic ...... 11 BENZAMYCIN PAK ...... 10 ADALAT CC ...... 8 ANTIVERT ...... 6 BENZOTIC...... 11 adalimumab ...... 15 ANUSOL-HC ...... 15 benzoyl peroxide...... 9 adapalene ...... 9 APEXICON ...... 10 benzoyl peroxide/hydrocortison ...... 9 ADCIRCA ...... 8 APEXICON E ...... 10 benztropine mesylate ...... 17 ADDERALL ...... 7 apixaban ...... 13 besifloxacin hcl drops susp 0.6% ...... 12 ADDERALL XR ...... 7 aprepitant ...... 6 BESIVANCE ...... 12 ADEMPAS ...... 8 APRESOLINE ...... 8 BETAGAN ...... 12 ADVAIR DISKUS ...... 6 APRISO ...... 15 betamet diprop/prop gly ...... 10 ADVAIR HFA ...... 6 APTIVUS ...... 14 betamethasone dipropionate ...... 6, 10 afatinib ...... 16 ARALEN PHOSPHATE ...... 14 betamethasone valerate ...... 10 AFINITOR ...... 16 ARAVA ...... 15 BETAPACE ...... 8 AFINITOR DISPERZ ...... 16 ARICEPT ...... 6 BETAPACE AF ...... 8 AFTERA ...... 9 ARICEPT ODT ...... 6 betaxolol hcl ...... 12 AGRYLIN ...... 13 ARIMIDEX ...... 16 bethanechol chloride ...... 16 AK-TRACIN ...... 12 aripiprazole...... 7 BETIMOL ...... 12 AKYNZEO ...... 6 ARIXTRA ...... 13 BETOPTIC ...... 12 ALAMAST ...... 12 ARMOUR THYROID ...... 12 BETOPTIC S ...... 12 ALA-TET ...... 14 AROMASIN...... 16 bexarotene ...... 10, 16 ALAWAY OTC ...... 12 ARTANE ...... 17 BIAXIN ...... 13 albuterol sulfate ...... 6 ASACOL ...... 15 BIAXIN XL ...... 13 ALBUTEROL SULFATE ...... 6 ASENDIN ...... 7 bicalutamide ...... 16 alclometasone dipropionate ...... 10 asfotase alfa., STRENSIQ ...... 17 BIDIL ...... 9 ALDACTONE ...... 8 ASMANEX ...... 6 BILTRICIDE ...... 14 ALDARA ...... 13 ASMANEX HFA ...... 6 bimatoprost 0.01% ...... 12 ALDOMET ...... 8 ASTELIN ...... 6 bimatoprost 0.03% ...... 12 ALECENSA ...... 16 ASTEPRO ...... 6 bimonidine/timolol ...... 12 alectinib hydrochloride ...... 16 ATARAX ...... 6 bisoprolol fumarate ...... 8 alendronate sodium ...... 11 atazanavir sulfate ...... 15 bisoprolol fumarate/hctz ...... 8 alendronate sodium solution ...... 11 atazanavir sulfate/cobicistat ...... 15 BLEPHAMIDE ...... 12 alendronate sodium/vitamin d3 ...... 11 atenolol ...... 8 BLEPHAMIDE S.O.P...... 12 alfuzosin ...... 18 atenolol/chlorthalidone ...... 8 BLOCADREN ...... 8 ALKERAN ...... 16 ATIVAN ...... 7 blood sugar diagnostic ...... 11 allopurinol ...... 13 atomoxetine hcl ...... 7 blood-glucose calib. control ...... 11 ALOCRIL ...... 12 atorvastatin calcium ...... 8 blood-glucose meter ...... 11 ALOMIDE ...... 12 ATRIPLA ...... 15 BONIVA ...... 11 ALORA ...... 13 atropine sulfate ...... 12 bosentan ...... 8 ALPHAGAN P ...... 12 ATROVENT ...... 6, 17 BOSULIF ...... 16 alprazolam ...... 7 ATROVENT HFA ...... 6 bosutinib ...... 16 ALPRAZOLAM INTENSOL ...... 7 AUGMENTIN ...... 14 BRAVELLE ...... 11 ALREX ...... 12 AUGMENTIN ES-600 ...... 14 BREO ELLIPTA ...... 6 ALTACE ...... 8 AUGMENTIN XR ...... 14 BRETHINE...... 6 altretamine ...... 16 AVALIDE ...... 8 BREVOXYL-4 ...... 9 aluminum chloride ...... 10 AVAPRO ...... 8 BREVOXYL-8 ...... 9 ALUPENT ...... 6 AVC ...... 18 BRILINTA ...... 13 amantadine hcl ...... 17 AVELOX ...... 14 brimonidine tartrate ...... 12 AMARYL ...... 10 AVELOX ABC PACK ...... 14 brinzolamide ...... 12 AMBIEN ...... 7 AVIANE-28 ...... 9 brinzolamide/brimonidine ...... 12 AMBIEN CR ...... 7 AVINZA ...... 17 bromocriptine mesylate...... 17 ambrisentan ...... 8 AVLOSULFON ...... 14 budesonide ...... 6, 15 amcinonide ...... 10 AVODART ...... 18 BUDESONIDE ...... 15 AMERGE ...... 17 AVONEX ...... 16 bumetanide ...... 8 AMINOPHYLLIN ...... 6 AVONEX ADMINISTRATION PACK ...... 16 BUMEX ...... 8

Portfolio High Formulary – April 2016 33 Scripps Health Formulary INDEX

BUPHENYL POWDER ...... 15 cholestyramine/sucrose ...... 8 ...... 15 BUPHENYL TABLET ...... 15 CHRONULAC ...... 15 CORTISPORIN CREAM ...... 10 buprenorphine ...... 17 CIALIS ...... 11 CORTISPORIN OINTMENT ...... 10 buprenorphine hcl ...... 17 CIBALITH-S ...... 7 CORTISPORIN OPHTH OINTMENT ...... 12 buprenorphine hcl/naloxone hcl ...... 17 CICLODAN ...... 10 CORTISPORIN OPHTH SUSPENSION ...... 12 bupropion hcl ...... 6 ciclopirox 8% solution ...... 10 CORTISPORIN OTIC ...... 11 BUSPAR ...... 7 ciclopirox olamine ...... 10 CORTONE ACETATE ...... 15 buspirone hcl ...... 7 cilostazol ...... 13 COSENTYX ...... 10 busulfan ...... 16 CILOXAN ...... 12 COSOPT ...... 12 butalb/acetaminophen/caffeine ...... 17 cimetidine hcl ...... 18 COTELLIC ...... 16 butalbital/acetaminophen ...... 17 CIPRO ...... 14 COUMADIN ...... 13 butalbital/aspirin/caffeine ...... 17 CIPRO ORAL SUSPENSION ...... 14 COZAAR ...... 8 butoconazole nitrate ...... 18 CIPRODEX ...... 11 CREON ...... 18 BUTRANS ...... 17 ciprofloxacin ...... 14 CRESTOR ...... 8 BYSTOLIC ...... 8 ciprofloxacin hcl ...... 12, 14 CRINONE ...... 11 cabergoline ...... 12 ciprofloxacin hcl/dexameth ...... 11 CRIXIVAN ...... 15 cabozanitinib ...... 16 citalopram hydrobromide ...... 6 crizotinib ...... 16 CADUET ...... 9 CLARAVIS ...... 9 cromolyn sodium ...... 6, 12 CAFERGOT ...... 17 clarithromycin ...... 13 crotamiton ...... 10 CALAN ...... 8 CLARITIN (OTC) ...... 6 CUPRIMINE ...... 15 CALAN SR ...... 8 CLARITIN-D 12 HOUR ...... 6 CUTIVATE ...... 10 calcipotriene...... 10 CLARITIN-D 24 HOUR ...... 6 cyanocobalamin/fa/pyridoxine ...... 19 calcitriol ...... 19 CLEOCIN HCL ...... 13 CYCLESSA ...... 9 calcium acetate ...... 11 CLEOCIN PALMITATE ...... 13 cyclobenzaprine hcl ...... 18 canagliflozin ...... 11 CLEOCIN T...... 9 CYCLOCORT ...... 10 canagliflozin/metformin hcl ...... 11 CLIMARA ...... 13 CYCLOGYL ...... 12 CANASA ...... 15 clindamycin ...... 13 cyclopentolate hcl ...... 12 capecitabine ...... 16 clindamycin palmitate ...... 13 cyclophosphamide ...... 16 CAPITAL W-CODEINE ...... 17 clindamycin phos/benzoyl perox ...... 9 cyclosporine ...... 12, 13 CAPOTEN ...... 8 clindamycin phosphate ...... 9, 10 cyclosporine, modified ...... 13 CAPOZIDE ...... 7 clindamycin/tretinoin ...... 9 CYMBALTA ...... 6 captopril ...... 8 CLINORIL ...... 15 CYSTARAN ...... 12 captopril/hydrochlorothiazide ...... 7 clobetasol propionate ...... 10 cysteamine...... 12 CARAFATE ...... 18 clobetasol propionate/emoll ...... 10 cysteamine bitartrate ...... 18 carbachol ...... 12 CLOBEX ...... 10 CYTOMEL ...... 12 carbamazepine ...... 18 CLOMID ...... 11 CYTOTEC...... 18 CARBATROL ...... 18 clomiphene citrate ...... 11 CYTOVENE ...... 14 carbidopa ...... 18 clomipramine hcl ...... 7 CYTOXAN ...... 16 carbidopa/levodopa ...... 17 clonazepam ...... 18 dabrafanib ...... 16 carbidopa/levodopa/entacapone ...... 17 clonidine hcl ...... 8 DALIRESP ...... 6 CARDENE ...... 8 clopidogrel bisulfate ...... 13 DALMANE ...... 7 CARDIZEM ...... 8 clorazepate dipotassium ...... 7 dalteparin sodium,porcine ...... 13 CARDIZEM CD ...... 8 clotrimazole ...... 14 danazol ...... 12 CARDURA ...... 8 clotrimazole/betamet diprop ...... 10 DANOCRINE ...... 12 carisoprodol ...... 18 clozapine ...... 7 DANTRIUM ...... 18 carisoprodol/aspirin ...... 18 CLOZARIL ...... 7 dantrolene sodium ...... 18 CARMOL HC ...... 10 cobicistat ...... 15 dapsone ...... 14 carteolol hcl...... 12 cobimetinib fumarate ...... 16 DARAPRIM ...... 14 carvedilol ...... 8 codeine phos/carisoprodol/asa ...... 17 darunavir ethanolate ...... 14 carvedilol phosphate ...... 8 codeine/butalbit/acetamin/caff ...... 17 darunavir/cobicistat ...... 14 CASODEX ...... 16 codeine/butalbital/asa/caffein ...... 17 dasatinib ...... 16 CATAPRES ...... 8 codeine/promethazine hcl ...... 9 DAYPRO ...... 15 CAYSTON ...... 13 COGENTIN ...... 17 DDAVP ...... 11 CECLOR ...... 13 COLAZAL ...... 15 DECADRON ...... 15 CEENU ...... 16 COL-BENEMID ...... 13 DELATESTRYL ...... 13 cefaclor ...... 13 colchicine ...... 13 delavirdine mesylate ...... 14 cefadroxil hydrate ...... 13 colchicine/probenecid ...... 13 DEL-BETA ...... 10 cefdinir ...... 13 COLCRYS ...... 13 DELTASONE ...... 15 cefixime ...... 13 colesevelam hcl ...... 8 DEMADEX ...... 8 cefpodoxime proxetil ...... 13 COLESTID ...... 8 DEMULEN 1-50-21 ...... 9 cefprozil ...... 13 COLESTID GRANULES ...... 8 DEPAKENE CAPSULES ...... 18 CEFTIN ...... 13 colestipol ...... 8 DEPAKENE SYRUP ...... 18 cefuroxime axetil ...... 13 COLYTE WITH FLAVOR PACKETS ...... 16 DEPAKOTE ...... 18 CEFZIL ...... 13 COMBIGAN ...... 12 DEPAKOTE ER ...... 18 CELEBREX ...... 15 COMBIPATCH ...... 13 DEPAKOTE SPRINKLE ...... 18 celecoxib ...... 15 COMBIVENT ...... 6 DEPEN ...... 15 CELEXA ...... 6 COMBIVENT RESPIMAT ...... 6 DEPO-TESTOSTERONE ...... 13 CELLCEPT ...... 13 COMBIVIR ...... 14 desipramine hcl ...... 7 CENTANY ...... 9 COMETRIQ ...... 16 desmopressin (nonrefrigerated) ...... 11 cephalexin monohydrate ...... 13 COMPAZINE ...... 6 DESOGEN ...... 9 ceritinib ...... 16 COMPAZINE SYRUP ...... 6 desogestrel-ethinyl estradiol ...... 9 cetirizine hcl (OTC) ...... 6 COMPLERA...... 15 desog-et estra/ethin estra ...... 9 cetrorelix acetate ...... 12 COMTAN ...... 17 desonide ...... 10 CETROTIDE ...... 12 CONCERTA...... 7 DESOWEN ...... 10 cevimeline hcl ...... 16 CONDYLOX...... 9 desoximetasone ...... 10 chloral hydrate ...... 7 COPAXONE ...... 16 DESVENLAFAXINE ER (RANBAXY BRAND) .... 6 chlorambucil ...... 16 COPEGUS ...... 15 desvenlafaxine ER (Ranbaxy) ...... 6 chlordiazepoxide hcl ...... 7 CORDARONE ...... 7 desvenlafaxine succinate ...... 6 chlordiazepoxide/clidinium br ...... 18 CORDRAN ...... 10 DESYREL 300MG ...... 6 chlorhexidine gluconate ...... 17 CORDRAN SP ...... 10 DETROL ...... 18 chloroquine phosphate ...... 14 COREG ...... 8 DETROL LA ...... 18 chlorpromazine hcl ...... 7 COREG CR ...... 8 dexamethasone ...... 15 chlorpropamide ...... 10 CORGARD ...... 8 DEXEDRINE ...... 7 chlorthalidone ...... 8 CORLANOR ...... 9 DEXEDRINE SPANSULE ...... 7 chlorzoxazone ...... 18 CORTEF ...... 15 dexmethylphenidate hcl ...... 7 cholestyramine/aspartame ...... 8 CORTENEMA ...... 15 dextroamphetamine capsule ...... 7

Portfolio High Formulary – April 2016 34 Scripps Health Formulary INDEX dextroamphetamine sulfate ...... 7 efavirenz/emtricitab/tenofovir ...... 15 etidronate disodium ...... 11 dextroamphetamine tablet ...... 7 EFFEXOR ...... 6 etodolac ...... 15 DHT ...... 19 EFFEXOR XR ...... 6 etonogestrel/ethinyl estradiol ...... 9 DIABETA ...... 10 EFFIENT ...... 13 etoposide ...... 16 DIABINESE ...... 10 EFUDEX ...... 10 etravirine ...... 14 DIAMOX SEQUELS ...... 12 ELAVIL ...... 7 EULEXIN ...... 16 DIASTAT ...... 18 ELDEPRYL ...... 18 EURAX ...... 10 diazepam ...... 7, 18 ELIGARD ...... 11 everolimus ...... 13, 16 DIBENZYLINE ...... 8 ELIMITE ...... 10 EVISTA ...... 11 dichlorphenamide ...... 18 ELIQUIS ...... 13 EVOCLIN ...... 10 diclofenac sodium ...... 10, 12, 15 ELMIRON ...... 18 EVOTAZ ...... 15 dicloxacillin sodium ...... 14 ELOCON ...... 10 EVOXAC ...... 16 dicyclomine hcl ...... 18 eltrombopag olamine ...... 13 EXELDERM ...... 10 didanosine ...... 14 elviteg/cobi/emtric/tenofo ala ...... 14 EXELON ...... 6 DIDRONEL ...... 11 elvitegravir ...... 15 EXELON PATCH ...... 6 DIFFERIN ...... 9 elvitegravir/cobicistat/emtricitabine/ tenofovir exemestane ...... 16 DIFICID ...... 14 disoproxil fumarate ...... 14 EXFORGE ...... 8 diflorasone diacetate ...... 10 EMCYT ...... 16 EXFORGE HCT ...... 8 diflorasone diacetate/emoll ...... 10 EMEND ...... 6 ezetimibe ...... 9 DIFLUCAN ...... 14 EMGEL ...... 9 FABIOR ...... 9 diflunisal ...... 17 empagliflozin ...... 11 famotidine...... 18 difluprednate ...... 12 empagliflozin/linagliptin ...... 11 FANSIDAR...... 14 digoxin ...... 7 empagliflozin/metformin hcl ...... 11 FARESTON ...... 16 DIGOXIN ORAL SOLN ...... 7 emtricitab/rilpivirine/tenofovir ...... 15 FARYDAK ...... 16 dihydrotachysterol ...... 19 emtricitabine ...... 15 febuxostat ...... 13 DILACOR XR ...... 8 emtricitabine/tenofovir ...... 14 FELDENE ...... 15 DILANTIN ...... 18 EMTRIVA ...... 15 felodipine ...... 8 DILANTIN CHEW TAB ...... 18 enalapril maleate ...... 8 FEMARA ...... 16 DILANTIN-125 ...... 18 enalapril/hydrochlorothiazide ...... 7 FEMHRT ...... 13 DILAUDID ...... 17 ENBREL ...... 15 fenofibrate ...... 9 DILAUDID-5 ...... 17 ENDOMETRIN ...... 11 fenofibrate nanocrystallized ...... 9 diltiazem hcl ...... 8 enfuvirtide ...... 14 fenofibrate, micronized...... 9 dimethyl fumarate ...... 16 enoxaparin sodium ...... 13 fenoprofen calcium ...... 15 DIOVAN ...... 8 entacapone ...... 17 fentanyl ...... 17 DIOVAN HCT ...... 8 entecavir ...... 15 fentanyl citrate lozenge ...... 17 diphenoxylate hcl/atrop sulf ...... 15 ENTOCORT EC ...... 15 FERTINEX ...... 11 dipivefrin hcl ...... 12 enzalutamide ...... 16 fesoterodine fumarate ...... 18 DIPROLENE ...... 10 epinephrine ...... 16 fidaxomicin ...... 14 DIPROLENE AF ...... 10 EPIPEN ...... 16 filgrastim ...... 13 DIPROSONE ...... 10 EPIPEN JR ...... 16 finasteride...... 18 dipyridamole ...... 13 EPIVIR ...... 14 fingolimod hcl ...... 16 DISALCID ...... 17 EPIVIR HBV SOLUTION ...... 15 FIORICET ...... 17 disopyramide phosphate ...... 7 EPIVIR HBV TABLET ...... 15 FIORICET WITH CODEINE ...... 17 disulfiram ...... 7 eplerenone...... 8 FIORINAL ...... 17 DITROPAN XL ...... 18 epoetin alfa ...... 13 FIORINAL WITH CODEINE ...... 17 divalproex sodium ...... 18 EPZICOM ...... 14 FIRAZYR ...... 15 d-methorphan hb/prometh hcl ...... 9 ergocalciferol ...... 19 FIRST-HYDROCORTISONE ...... 10 dofetilide ...... 7 ergotamine tartrate/caffeine ...... 17 FLAGYL ...... 14 DOLOBID ...... 17 ERIVEDGE ...... 16 FLAGYL ER ...... 14 DOLOPHINE HCL ...... 17 erlotinib hcl ...... 16 FLAREX ...... 12 dolutegravir ...... 15 ery e-succ/sulfisoxazole ...... 13 flecainide acetate ...... 7 DOMEBORO ...... 11 ERYC ...... 13 FLEXERIL ...... 18 donepezil hcl ...... 6 ERYGEL ...... 9 FLOMAX ...... 18 DONNATAL ...... 18 ERYPED 200 ...... 13, 14 FLONASE ...... 6 dornase alfa ...... 17 ERYPED 400 ...... 14 FLORINEF ACETATE ...... 15 dorzolamide hcl ...... 12 ERY-TAB ...... 13 FLOXIN ...... 11, 14 dorzolamide hcl/timolol maleat ...... 12 ERYTHROCIN STEARATE ...... 13 fluconazole ...... 14 DOSTINEX ...... 12 erythromycin base ...... 12, 13 fludarabine phosphate ...... 16 DOVONEX ...... 10 erythromycin base/benz per ...... 9, 10 fludrocortisone acetate ...... 15 doxazosin mesylate ...... 8 erythromycin base/ethanol ...... 9 flunisolide ...... 6 doxepin hcl ...... 7 erythromycin ethylsuccinate ...... 13, 14 ...... 10 doxycycline calcium ...... 14 erythromycin stearate ...... 13 fluocinonide ...... 10 doxycycline hyclate ...... 14 ESBRIET ...... 17 fluocinonide/emollient ...... 10 doxycycline monohydrate ...... 14 escitalopram oxalate ...... 6 FLUORABON BASIC ...... 19 DRISDOL ...... 19 ESGIC ...... 17 fluoride ion/iron/vit a,c&d ...... 19 DRITHOCREME HP ...... 10 ESKALITH ...... 7 fluoride ion/multivitamins ...... 19 DRITHO-SCALP ...... 10 esomeprazole magnesium ...... 18 fluoride ion/multivits w-fe ...... 19 dronabinol ...... 6 estazolam ...... 7 fluoride ion/vit a,c&d ...... 19 dronedarone hcl ...... 7 ESTRACE ...... 13, 18 FLUORITAB ...... 18 DRYSOL ...... 10 ESTRADERM ...... 13 fluorometholone...... 12 DUAVEE ...... 13 estradiol ...... 13, 18 fluorometholone acetate ...... 12 DUETACT ...... 11 estradiol/noreth ac ...... 13 fluorouracil ...... 10 DULERA ...... 6 estramustine phosphate sodium ...... 16 fluoxetine er ...... 6 duloxetine hcl ...... 6 ESTRATEST H.S...... 13 fluoxetine hcl ...... 6 DUONEB ...... 6 estrogen, con/m-progest acet ...... 13 fluoxymesterone ...... 13 DURAGESIC ...... 17 estrogen, ester/me-testosterone...... 13 fluphenazine hcl ...... 7 DUREZOL ...... 12 estrogens, conj/bazedoxifene ...... 13 FLURA-DROPS ...... 18 DURICEF ...... 13 estrogens, conjugated ...... 13, 18 flurandrenolide ...... 10 dutasteride ...... 18 estrogens, esterified...... 13 FLURA-TABS ...... 18 dutasteride/tamsulosin ...... 18 estropipate ...... 13 flurazepam hcl ...... 7 DYAZIDE ...... 8 eszopiclone ...... 7 flurbiprofen ...... 15 DYNACIN ...... 14 etanercept ...... 15 flurbiprofen sodium ...... 12 DYNACIRC ...... 8 ethambutol hcl ...... 14 flutamide ...... 16 EC-NAPROSYN ...... 15 ethinyl estradiol/drospirenone ...... 9 fluticasone propionate ...... 6, 10 EDURANT ...... 14 ethosuximide ...... 18 fluticasone/salmeterol ...... 6 efavirenz ...... 14 ethynodiol d-ethinyl estradiol ...... 9 fluticasone/vilanterol ...... 6

Portfolio High Formulary – April 2016 35 Scripps Health Formulary INDEX

FML ...... 12 HUMALOG ...... 11 irbesartan ...... 8 FML FORTE ...... 12 HUMALOG MIX 50-50 ...... 11 irbesartan/hydrochlorithiazide ...... 8 FML S.O.P...... 12 HUMALOG MIX 75-25 ...... 11 IRESSA ...... 16 FOCALIN ...... 7 HUMATIN ...... 14 ISENTRESS ...... 15 FOCALIN XR ...... 7 HUMIRA ...... 15 ISMO ...... 9 FOLGARD RX ...... 19 HUMULIN 70-30 ...... 11 ISOCHRON ...... 9 folic acid ...... 19 HUMULIN N ...... 11 isomethept/acetaminop/dichlphn ...... 17 FOLIC ACID ...... 19 HUMULIN R ...... 11 isoniazid ...... 14 folic acid/mu-vits-min th ...... 19 HYCAMTIN ...... 16 ISOPTO ATROPINE ...... 12 FOLLISTIM AQ ...... 11 HYCET ...... 17 ISOPTO CARBACHOL ...... 12 follitropin alpha,recomb ...... 11 HYCODAN ...... 9 ISOPTO CARPINE ...... 12 follitropin beta,recomb ...... 11 hydralazine hcl ...... 8 ISOPTO HOMATROPINE ...... 12 fondaparinux sodium...... 13 HYDREA ...... 16 ISORDIL ...... 9 formoterol fumarate ...... 6 hydrochlorothiazide ...... 8 ISORDIL TITRADOSE ...... 9 FORTEO ...... 11 hydrocodone bit/acetaminophen ...... 17 isosorb dinit/hydralazine hcl ...... 9 FOSAMAX ...... 11 hydrocodone bit/acetaminophen oral elixir .. 17 isosorbide dinitrate ...... 9 FOSAMAX PLUS D ...... 11 hydrocodone bit/acetaminophen oral solution isosorbide mononitrate ...... 9 fosamprenavir calcium ...... 15 ...... 17 isotretinoin ...... 9 fosinopril sodium ...... 8 hydrocodone bit/homatrop me-br ...... 9 isradipine IR capsules ...... 8 fosinopril/hydrochlorothiazide ...... 7 hydrocodone/chlorphen p-stirex ...... 9 itraconazole ...... 14 FRAGMIN ...... 13 hydrocort/sal acid/sulf/shmp#1 ...... 10 ivabradine hcl ...... 9 FURADANTIN ...... 14 hydrocortisone ...... 10, 15 ivacaftor ...... 17 furazolidone ...... 14 hydrocortisone acetate ...... 15 ixazomib citrate ...... 16 furosemide ...... 8 hydrocortisone acetate/urea ...... 10 JAKAFI ...... 16 FUROXONE ...... 14 hydrocortisone butyrate ...... 10 JALYN ...... 18 FUZEON ...... 14 hydrocortisone butyrate/emoll ...... 10 JANUMET ...... 10 gabapentin ...... 18 hydrocortisone probutate ...... 10 JANUMET XR ...... 10 galantamine hbr ...... 6 hydrocortisone valerate ...... 10 JANUVIA ...... 10 ganciclovir ...... 12, 14 hydromorphone hcl ...... 17 JARDIANCE ...... 11 ganirelix acetate ...... 12 hydroxychloroquine sulfate ...... 14 JENTADUETO ...... 10 GANIRELIX ACETATE ...... 12 hydroxyurea ...... 16 JUXTAPID ...... 8 GANTRISIN ...... 13 hydroxyzine hcl ...... 6 KALETRA ...... 15 GARAMYCIN ...... 9, 12 hydroxyzine pamoate ...... 6 KALYDECO ...... 17 gatifloxacin ...... 12 HYGROTON ...... 8 KAYEXALATE ...... 11 GATTEX ...... 16 hyoscyamine sulfate ...... 18 K-DUR ...... 11 gefitinib ...... 16 HYPER-SAL 7% ...... 17 KEFLEX ...... 13 gemfibrozil ...... 9 HYTRIN ...... 8 KENALOG ...... 10 gentamicin sulfate ...... 9, 12 HYZAAR ...... 8 KENALOG IN ORABASE ...... 17 GENVOYA ...... 14 ibandronate ...... 11 KEPPRA ...... 18 GEODON ...... 7 IBRANCE ...... 16 KETEK ...... 13 GIANVI ...... 9 ibrutinib ...... 16 ketoconazole ...... 10, 14 GILENYA ...... 16 ibuprofen ...... 15 ketoprofen ...... 15 GILOTRIF ...... 16 icatibant ...... 15 ketorolac tromethamine ...... 12, 15 glatiramer acetate ...... 16 ICLUSIG ...... 16 ketotifen fumarate (OTC) ...... 12 GLEEVEC ...... 16 icosapent ethyl ...... 9 KEVEYIS ...... 18 glimepiride ...... 10 idelalisib ...... 16 KLARON ...... 9 glipizide ...... 10 ILEVRO ...... 12 KLONOPIN ...... 18 glipizide/metformin hcl ...... 10 imatinib mesylate ...... 16 KORLYM ...... 11 glucagon ...... 11 IMBRUVICA ...... 16 KRISTALOSE ...... 16 GLUCAGON KIT ...... 11 IMDUR ...... 9 K-TAB ...... 11 GLUCOPHAGE ...... 11 imipramine hcl ...... 7 KURIC ...... 10 GLUCOPHAGE XR ...... 11 imiquimod ...... 13 KUVAN ...... 16 GLUCOTROL ...... 10 IMITREX INJECTION ...... 17 KWELL ...... 10 GLUCOTROL XL ...... 10 IMITREX NASAL SPRAY ...... 17 KYNAMRO...... 8 GLUCOVANCE ...... 11 IMITREX TABLET ...... 17 labetalol hcl ...... 8 glyburide ...... 10 IMURAN ...... 13 LACTICARE-HC ...... 10 glyburide, micro/metformin hcl ...... 11 indapamide ...... 8 lactulose ...... 15, 16 GLYXAMBI ...... 11 INDERAL LA ...... 8 LAMICTAL ...... 18 GOLYTELY ...... 16 INDERIDE-40/25 ...... 8 LAMISIL ...... 10, 14 gonadorelin acetate ...... 12 indinavir sulfate ...... 15 LAMISIL GRANULES ...... 14 gonadotropin,chorionic, human ...... 11 INDOCIN ...... 15 lamivudine ...... 14 GONAL-F ...... 11 INDOCIN ORAL SUSP...... 15 lamivudine/zidovudine ...... 14 GONAL-F RFF ...... 11 INDOCIN SR ...... 15 lamotrigine ...... 18 GRASTEK ...... 6 INDOCIN SUPPOS ...... 15 lancing device/lancets ...... 11 griseofulvin suspension ...... 14 indomethacin ...... 15 LANOXIN ...... 7 griseofulvin ultramicrosize ...... 14 ingenol ...... 10 lansoprazole ...... 18 GRISEOFULVIN V ...... 14 INLYTA ...... 16 lansoprazole/amox tr/clarith ...... 18 GRIS-PEG ...... 14 INSPRA ...... 8 LANTUS ...... 11 guanfacine hcl ...... 8 insulin glargine,hum.rec.anlog ...... 11 lapatinib ditosylate ...... 16 GYNAZOLE-1 ...... 18 insulin lispro ...... 11 LARIAM ...... 14 HALCION ...... 7 insulin nph hum/reg insulin hm ...... 11 LASIX ...... 8 HALDOL ...... 7 insulin nph human isophane ...... 11 latanoprost ...... 12 HALDOL ORAL CONC ...... 7 insulin npl/insulin lispro ...... 11 ledipasvir/sofosbuvir ...... 15 halobetasol propionate ...... 10 insulin regular, human ...... 11 leflunomide ...... 15 haloperidol ...... 7 INTAL ...... 6 lenalidomide ...... 16 haloperidol lactate ...... 7 INTELENCE...... 14 lenvatinib mesylate ...... 16 HARVONI ...... 15 interferon alfa-2b, recomb...... 13 LENVIMA ...... 16 hc acetate/pramoxine hcl ...... 10, 15 interferon beta-1a ...... 16 LESSINA ...... 9 hcg alpha, recombinant ...... 11 interferon beta-1a/albumin ...... 16 LETAIRIS ...... 8 HEPARIN LOCK ...... 13 INTRON A ...... 13 letrozole ...... 16 heparin sodium, porcine ...... 13 INVIRASE ...... 15 leucovorin calcium ...... 16 heparin sodium, porcine/pf ...... 13 INVOKAMET ...... 11 LEUCOVORIN CALCIUM ...... 16 HEP-LOCK ...... 13 INVOKANA ...... 11 LEUKERAN ...... 16 HEPSERA ...... 15 iodoquinol ...... 14 LEUKINE ...... 13 HEXALEN ...... 16 ipratropium bromide ...... 6, 17 leuprolide ...... 11 homatropine hbr ...... 12 ipratropium/albuterol sulfate ...... 6 LEVAQUIN...... 14

Portfolio High Formulary – April 2016 36 Scripps Health Formulary INDEX

LEVBID ...... 18 LYRICA ...... 18 MICROZIDE ...... 8 levetiracetam ...... 18 LYSODREN ...... 16 midodrine hcl ...... 9 levobunolol hcl ...... 12 macitentan ...... 8 MIDRIN ...... 17 levocetirizine ...... 6 MACROBID ...... 14 mifepristone ...... 11 levofloxacin ...... 14 MACRODANTIN ...... 14 MIGERGOT ...... 17 levonorgestrel ...... 9 malathion ...... 10 MILLIPRED ...... 15 levonorgestrel-eth estra ...... 9 maprotiline hcl ...... 7 MILLIPRED DP ...... 15 LEVOTHROID ...... 12 maraviroc ...... 14 milnacipran hcl ...... 17 levothyroxine sodium ...... 12 MARINOL ...... 6 MILTOWN ...... 7 LEVOXYL ...... 12 MATULANE ...... 16 MINIPRESS ...... 8 LEVSIN-SL ...... 18 MAVIK ...... 8 MINOCIN ...... 14 LEXAPRO ...... 6 MAXALT ...... 17 minocycline hcl ...... 14 LEXIVA ...... 15 MAXALT MLT ...... 17 mipomersen sodium ...... 8 LIBRAX ...... 18 MAXITROL ...... 12 mirabegron...... 18 LIBRIUM ...... 7 MAXZIDE ...... 8 MIRALAX ...... 16 LIDEX ...... 10 MAXZIDE-25MG ...... 8 MIRAPEX ...... 17 LIDEX-E ...... 10 mebendazole ...... 14 MIRCETTE ...... 9 lidocaine hcl ...... 15 mechlorethamine ...... 10 mirtazapine ...... 6 LIFESCAN DIABETIC SUPPLIES ...... 11 meclizine hcl ...... 6 misoprostol ...... 18 linaclotide ...... 15 meclofenamate sodium ...... 15 mitotane ...... 16 linagliptin ...... 10 MECLOMEN ...... 15 MOBIC ...... 15 linagliptin/metformin hcl ...... 10 MEDROL ...... 15 modafinil ...... 7 lindane ...... 10 medroxyprogesterone acet ...... 13 moexipril hcl ...... 8 linezolid ...... 14 mefloquine hcl ...... 14 moexipril/hydrochlorothiazide ...... 8 LINZESS ...... 15 MEGACE ...... 16, 17 mometasone furoate ...... 6, 10 LIORESAL ...... 18 megestrol acetate ...... 16, 17 mometasone/formoterol ...... 6 liothyronine sodium ...... 12 MEKINIST ...... 16 MONISTAT 3 ...... 18 LIPITOR ...... 8 MELLARIL ...... 7 MONOKET...... 9 liraglutide ...... 10 meloxicam ...... 15 MONOPRIL ...... 8 lisdexamfetamine dimesylate ...... 7 melphalan ...... 16 MONOPRIL HCT ...... 7 lisinopril ...... 8 memantine hcl ...... 6 montelukast sodium ...... 6 lisinopril/hydrochlorothiazide ...... 7 memantine hcl/donepezil hcl ...... 6 morphine sulfate ...... 17 lithium carbonate ...... 7 MENEST ...... 13 MOTRIN ...... 15 lithium citrate ...... 7 MENOPUR ...... 11 MOVANTIK ...... 16 LITHOBID ...... 7 menotropins ...... 11 moxifloxacin hcl ...... 12, 14 LO LOESTRIN FE ...... 9 MEPHYTON ...... 13 MSIR ...... 17 LO MINASTRIN FE ...... 9 meprobamate ...... 7 mth/me blue/salicy/na phos/hyo ...... 13 LOCOID ...... 10 mercaptopurine ...... 16 MUCOMYST-10 ...... 17 LOCOID LIPOCREAM ...... 10 mesalamine ...... 15 MULTAQ ...... 7 LODINE ...... 15 mesalamine w/cleansing wipes ...... 15 mupirocin ...... 9 LODOSYN ...... 18 MESTINON ...... 6 mupirocin calcium ...... 10, 17 lodoxamide tromethamine ...... 12 METADATE CD ...... 7 MYAMBUTOL ...... 14 LOESTRIN ...... 9 METADATE ER ...... 7 MYCELEX ...... 14 LOESTRIN FE ...... 9 METAGLIP ...... 10 MYCIFRADIN ...... 14 LOESTRIN FE24 ...... 9 metaproterenol sulfate ...... 6 MYCOLOG II ...... 10 LOFIBRA ...... 9 metaxalone ...... 18 mycophenolate mofetil ...... 13 lomitapide ...... 8 metformin hcl ...... 11 MYCOSTATIN ...... 10, 14 LOMOTIL ...... 15 meth/meth blue/ba/salicy/hyos ...... 13 MYLERAN ...... 16 lomustine ...... 16 methadone hcl ...... 17 MYORISAN ...... 9 LONSURF ...... 16 methazolamide ...... 12 MYRBETRIQ ...... 18 LO-OVRAL-28 ...... 9 METHERGINE ...... 9 MYSOLINE ...... 18 LOPID ...... 9 methimazole ...... 12 na sulfacetm/prednis sp ...... 12 lopinavir/ritonavir ...... 15 METHITEST ...... 13 na sulfacetm/prednisol ac ...... 12 LOPRESSOR ...... 8 METHLYIN SOLN ...... 7 nabumetone ...... 15 LOPRESSOR HCT ...... 8 methocarbamol ...... 18 nadolol ...... 8 LOPROX ...... 10 methotrexate ...... 15 naftifine hcl ...... 10 loratadine (OTC) ...... 6 methotrexate sodium ...... 15, 16 NAFTIN ...... 10 lorazepam ...... 7 METHOTREXATE TABLET ...... 16 NALFON CAPSULE ...... 15 LORAZEPAM INTENSOL ...... 7 METHOTREXATE VIAL ...... 16 NALFON TABLET ...... 15 LORCET ...... 17 methoxsalen ...... 10 naloxegol oxalate ...... 16 LORCET PLUS ...... 17 methoxsalen, rapid ...... 10 naltrexone hcl ...... 7 LORTAB ...... 17 methyldopa...... 8 NAMENDA ...... 6 LORTAB ELIXIR ...... 17 methylergonovine maleate ...... 9 NAMENDA XR ...... 6 LORYNA ...... 9 METHYLIN CHEW TAB ...... 7 NAMZARIC ...... 6 losartan potassium ...... 8 methylnaltrexone bromide ...... 16 NAPROSYN ...... 15 losartan/hydrochlorothiazide ...... 8 methylphenidate ER Susp ...... 7 naproxen ...... 15 LOTEMAX ...... 12 methylphenidate hcl ...... 7 naproxen sodium ...... 15 LOTENSIN ...... 8 methylprednisolone ...... 15 naratriptan ...... 17 LOTENSIN HCT ...... 7 methyltestosterone ...... 13 NARCAN NASAL ...... 7 loteprednol etabonate ...... 12 metipranolol ...... 12 NARDIL ...... 6 LOTREL ...... 7 metoclopramide hcl ...... 18 NASACORT AQ ...... 6 LOTRISONE ...... 10 METOCLOPRAMIDE HCL INTENSOL ...... 18 NASAREL ...... 6 lovastatin ...... 8 metolazone ...... 8 NASONEX ...... 6 LOVAZA ...... 9 metoprolol succinate ...... 8 nateglinide ...... 10 LOVENOX ...... 13 metoprolol tartrate ...... 8 NATURE-THROID ...... 12 loxapine succinate ...... 7 metoprolol/hctz ...... 8 NAVANE ...... 7 LOXITANE ...... 7 METROCREAM ...... 9 nebivolol hcl ...... 8 LOZOL ...... 8 METROGEL-VAGINAL ...... 18 NEBUPENT ...... 14 lubiprostone ...... 16 METROLOTION ...... 9 nedocromil sodium ...... 12 LUDIOMIL ...... 7 metronidazole ...... 9, 14, 18 needles, insulin disp., safety ...... 17 lumacaftor/ivacaftor ...... 17 MEVACOR ...... 8 nelfinavir mesylate ...... 15 LUMIGAN ...... 12 mexiletine hcl ...... 7 neo/polymyx b sulf/dexameth ...... 12 LUNESTA ...... 7 MEXITIL ...... 7 NEODECADRON...... 12 LURIDE ...... 18 miconazole nitrate ...... 18 neomy sulf/bacitrac zn/poly/hc ...... 12 LUTERA ...... 9 MICRO-K ...... 11 neomy sulf/polymyx b sulf/hc ...... 10, 11, 12 LYNPARZA ...... 16 MICRONASE ...... 10 neomy sulf/polymyx b sulf/pred ...... 12

Portfolio High Formulary – April 2016 37 Scripps Health Formulary INDEX neomycin sulfate ...... 14 ofloxacin ...... 11, 12, 14 pegvisomant ...... 12 neomycin sulfate/dex na ph ...... 12 OFORTA ...... 16 pemirolast potassium ...... 12 neomycin/bacitra/polymyxin/hc ...... 10 OGEN ...... 13 penicillamine ...... 15 neomycin/bacitracin/polymyxin ...... 12 olanzapine ...... 7 penicillin v potassium ...... 14 neomycin/polymyxn b/gramicidin ...... 12 olanzapine ODT ...... 7 pentamidine isethionate ...... 14 NEORAL ...... 13 olanzapine/fluoxetine ...... 6 pentosan polysulfate sodium ...... 18 NEOSPORIN OPHTH DROPS ...... 12 olaparib ...... 16 pentoxifylline ...... 13 NEOSPORIN OPHTH OINTMENT ...... 12 olmesartan medoxomil ...... 8 PEPCID ...... 18 neostigmine bromide...... 6 olmesartan/amlodipin/hcthiazid ...... 8 p-ephed hcl/cetirizine hcl (OTC) ...... 6 nepafenac ...... 12 olmesartan/hydrochlorothiazide ...... 8 p-ephed sul/loratadine ...... 6 NEPTAZANE ...... 12 olodaterol hcl ...... 6 PERCOCET ...... 17 netupitant/palonosetron hcl ...... 6 olopatadine hcl ...... 12 PERCODAN ...... 17 NEULASTA ...... 13 OLUX ...... 10 PERCOLONE ...... 17 NEUPOGEN ...... 13 omega-3 acid ethyl esters ...... 9 PERFOROMIST ...... 6 NEUPRO ...... 18 omeprazole ...... 18 PERIDEX ...... 17 NEURONTIN ...... 18 omeprazole magnesium ...... 18 PERISOL ...... 17 NEVANAC ...... 12 OMNICEF ...... 13 permethrin ...... 10 nevirapine ...... 14 OMNIPRED ...... 12 perphenazine ...... 7 nevirapine ER ...... 14 OMNITROPE ...... 12 PERSANTINE ...... 13 NEXAVAR ...... 16 ondansetron ...... 6 phenazopyridine hcl ...... 18 NEXIUM ...... 18 ondansetron hcl ...... 6 phenelzine sulfate ...... 6 niacin ...... 9 OPSUMIT ...... 8 PHENERGAN ...... 6 niacin/simvastatin ...... 8 OPTICROM ...... 12 PHENERGAN VC ...... 9 NIASPAN ...... 9 OPTIPRANOLOL ...... 12 PHENERGAN VC W/CODEINE ...... 9 nicardipine ...... 8 OPTIVAR ...... 12 PHENERGAN W/CODEINE ...... 9 nifedipine ...... 8 ORALAIR ...... 6 PHENERGAN W/DEXTROMETHORPHAN ...... 9 NILANDRON...... 16 ORAMORPH SR ...... 17 phenobarbital ...... 7 nilotinib hydrochloride ...... 16 ORAPRED ...... 15 PHENOBARBITAL ...... 7 nilutamide ...... 16 ORINASE ...... 10 phenoxybenzamine hcl ...... 8 nimodipine ...... 8 ORKAMBI ...... 17 phenylephrine hcl/cod/prometh ...... 9 NIMOTOP ...... 8 orphenadrine citrate ...... 18 phenylephrine hcl/prometh hcl ...... 9 NINLARO ...... 16 orphenadrine/aspirin/caffeine ...... 18 PHENYTEK ...... 18 nintedanib esylate ...... 17 ORSYTHIA ...... 9 phenytoin...... 18 NITRO-BID ...... 9 ORTHO EVRA ...... 9 phenytoin sodium extended ...... 18 NITRO-DUR ...... 9 ORTHO MICRONOR ...... 9 PHOSLO ...... 11 nitrofurantoin ...... 14 ORTHO TRI-CYCLEN ...... 9 PHRENILIN ...... 17 nitrofurantoin macrocrystal ...... 14 ORTHO TRI-CYCLEN LO ...... 9 PHRENILIN FORTE ...... 17 nitrofurantoin/nitrofuran mac ...... 14 ORTHO-CEPT ...... 9 phytonadione ...... 13 nitroglycerin ...... 9 ORTHO-CYCLEN ...... 9 PICATO ...... 10 NITROLINGUAL ...... 9 ORTHO-NOVUM ...... 9 pilocarpine hcl ...... 12, 16 NITROSTAT ...... 9 ORUVAIL ...... 15 pindolol ...... 8 nizatidine ...... 18 OSCELLA ...... 9 pioglitazone hcl ...... 11 NIZORAL ...... 10, 14 oseltamivir phosphate ...... 14 pioglitazone hcl/metformin hcl ...... 11 NOCTEC ...... 7 osimertinib mesylate ...... 16 pioglitazone/glimepiride ...... 11 NOLVADEX ...... 16 OTICIN HC ...... 11 pirfenidone ...... 17 NORCO ...... 17 OTREXUP ...... 15 piroxicam ...... 15 NORDETTE-28 ...... 9 OVACE PLUS SUSPENSION ...... 10 PLAN B ONE-STEP ...... 9 NORDITROPIN ...... 12 OVIDE ...... 10 PLAQUENIL ...... 14 NORDITROPIN FLEXPRO ...... 12 OVIDREL ...... 11 PLAVIX ...... 13 NORDITROPIN NORDIFLEX ...... 12 oxaprozin ...... 15 PLAVIX 300MG ...... 13 norelgestromin/ethin.estradiol ...... 9 oxazepam ...... 7 PLEGRIDY...... 17 noreth a-et estra/fe fumarate ...... 9 oxcarbazepine ...... 18 PLEGRIDY PEN ...... 17 norethindrone ...... 9 OXSORALEN ...... 10 PLENDIL ...... 8 norethindrone acetate ...... 13 OXSORALEN-ULTRA ...... 10 PLETAL ...... 13 norethindrone ac-eth estradiol ...... 13 oxybutynin chloride ...... 18 PODHALER ...... 14 norethindrone a-e estradiol ...... 9 oxycodone hcl ...... 17 podofilox ...... 9 norethindrone-ethinyl estrad ...... 9 oxycodone hcl/acetaminophen ...... 17 POLYCILLIN ...... 14 norethindrone-mestranol ...... 9 oxycodone hcl/aspirin ...... 17 POLYCIN-B ...... 12 NORFLEX ...... 18 OXYCONTIN ...... 17 polyethylene glycol 3350 ...... 16 NORGESIC FORTE...... 18 palbociclib ...... 16 polymyxin b sulfate/tmp ...... 12 norgestimate-ethinyl estradiol ...... 9 PAMELOR ...... 7 POLY-PRED ...... 12 norgestrel-ethinyl estradiol ...... 9 PANCRELIPASE 5,000 ...... 18 POLYTRIM ...... 12 NORINYL 1+35 ...... 9 PANDEL ...... 10 POLY-VI-FLOR ...... 19 NORINYL 1+50 ...... 9 panobinostat lactate ...... 16 POLY-VI-FLOR W/IRON ...... 19 NORPACE ...... 7 pantoprazole sodium ...... 18 pomalidomide ...... 16 NORPACE CR ...... 7 PARAFON FORTE DSC ...... 18 POMALYST ...... 16 NORPRAMIN ...... 7 PARCOPA ...... 17 ponatinib ...... 16 NOR-Q-D ...... 9 paricalcitol ...... 12 potassium chloride ...... 11 nortriptyline hcl ...... 7 PARLODEL...... 17 potassium iodide ...... 12 NORVASC ...... 8 PARNATE ...... 6 POTASSIUM IODIDE ...... 12 NORVIR ...... 15 paromomycin sulfate ...... 14 pramipexole di-hcl ...... 17 NOVAREL ...... 11 paroxetine hcl ...... 6 pramlintide acetate...... 10 NUCYNTA ...... 17 PATADAY ...... 12 PRAMOSONE ...... 10 NUCYNTA ER ...... 17 PATANOL ...... 12 PRANDIMET ...... 11 NULYTELY WITH FLAVOR PACKS ...... 16 PATHOCIL ...... 14 PRANDIN ...... 10 NUVARING ...... 9 PAXIL ...... 6 prasugrel hcl ...... 13 NYDRAZID ...... 14 pazopanib hydrochloride ...... 16 PRAVACHOL ...... 8 nystatin ...... 10, 14 PCE ...... 13 pravastatin sodium ...... 8 nystatin/triamcin ...... 10 PEDIAPRED ...... 15 praziquantel ...... 14 OCL ...... 16 PEDIAZOLE...... 13 prazosin hcl ...... 8 octreotide acetate ...... 17 peg 3350/na sulf,bicarb,cl/kcl ...... 16 PRECOSE ...... 10 OCUFEN ...... 12 PEGASYS ...... 15 PRED FORTE ...... 12 OCUFLOX ...... 12 PEGASYS PROCLICK ...... 15 PRED MILD ...... 12 OCUPRESS ...... 12 pegfilgrastim ...... 13 PREDNISOL ...... 12 ODOMZO ...... 16 peginterferon alfa-2a ...... 15 prednisolone ...... 15 OFEV ...... 17 peginterferon beta-1a ...... 17 prednisolone acetate ...... 12

Portfolio High Formulary – April 2016 38 Scripps Health Formulary INDEX prednisolone sod phosphate ...... 12, 15 quetiapine fumarate ...... 7 salmeterol xinafoate ...... 6 prednisone ...... 15 QUILLIVANT XR ...... 7 salsalate ...... 17 PREDNISONE INTENSOL ...... 15 QUINAGLUTE ...... 7 SANDIMMUNE ...... 13 pregabalin ...... 18 quinapril hcl ...... 8 SANDOSTATIN ...... 17 PREGNYL ...... 11 quinapril/hydrochlorothiazide ...... 8 sapropterin dihydrochloride ...... 16 PREMARIN ...... 13, 18 QUINIDEX ...... 7 saquinavir mesylate ...... 15 PREMPHASE ...... 13 quinidine gluconate ...... 7 sargramostim ...... 13 PREMPRO ...... 13 quinidine sulfate ...... 7 SAVELLA ...... 17 prenatal vit 15/iron cb/fa/dss ...... 19 quinine sulfate ...... 14 SCALACORT ...... 10 prenatal vit 16/iron cb/fa/dss ...... 19 QVAR ...... 6 SCALACORT DK ...... 10 prenatal vit 18/iron cb/fa/dss ...... 19 RAGWITEK...... 6 SEASONALE ...... 9 prenatal vit 95/fe fum/fa ...... 19 raloxifene hcl ...... 11 SECTRAL ...... 8 PRENATE GT ...... 19 raltegravir potassium ...... 15 secukinumab ...... 10 PRENAVITE ...... 19 ramipril ...... 8 selegiline hcl ...... 18 PREVACID ...... 18 RANEXA ...... 9 selenium sulfide ...... 10 PREVACID SOLUTABS ...... 18 ranitidine hcl ...... 18 selexipag ...... 8 PREVPAC ...... 18 ranolazine ...... 9 SELSUN RX ...... 10 PREZCOBIX ...... 14 RAPAMUNE ...... 13 SELZENTRY ...... 14 PREZISTA ...... 14 rasagiline mesylate ...... 18 SEPTRA ...... 13 PRILOSEC ...... 18 RAZADYNE ...... 6 SEPTRA DS ...... 13 PRILOSEC OTC ...... 18 RAZADYNE ER ...... 6 SERAX ...... 7 PRIMAQUINE ...... 14 REBETOL ...... 15 SEREVENT DISKUS ...... 6 primaquine phosphate ...... 14 REBIF ...... 16 SEROPHENE ...... 11 primidone ...... 18 REBIF REBIDOSE ...... 16 SEROQUEL ...... 7 PRIMSOL ...... 13 REDERM ...... 10 SERPASIL ...... 8 PRINIVIL ...... 8 REGLAN ...... 18 sertraline hcl ...... 6 PRINZIDE ...... 7 regorafenib ...... 16 sevelamer carbonate ...... 11 PRISTIQ ...... 6 REGRANEX...... 11 sevelamer hcl ...... 11 PROAIR HFA ...... 6 RELAFEN ...... 15 SFROWASA ...... 15 PROAIR RESPICLICK ...... 6 RELISTOR ...... 16 short ragweed pollen extract ...... 6 PROAMATINE ...... 9 REMERON ...... 6 sildenafil citrate ...... 8, 11 probenecid ...... 13 RENAGEL ...... 11 SILVADENE ...... 10 procainamide hcl ...... 7 RENVELA ...... 11 silver sulfadiazine ...... 10 procarbazine hcl ...... 16 repaglinide...... 10 SIMBRINZA ...... 12 PROCARDIA ...... 8 repaglinide/metformin hcl ...... 11 SIMCOR ...... 8 PROCARDIA XL ...... 8 REPRONEX...... 11 simvastatin ...... 8 PROCHIEVE...... 11 REQUIP ...... 18 simvastatin (80mg only) ...... 8 prochlorperazine edisylate ...... 6 REQUIP XL...... 18 SINEMET 25-100 ...... 17 prochlorperazine maleate ...... 6 RESCRIPTOR ...... 14 SINEMET CR ...... 17 PROCRIT ...... 13 reserpine ...... 8 SINEQUAN ...... 7 PROCTOCORT ...... 15 RESTASIS ...... 12 SINGULAIR ...... 6 PROCTOCREAM-HC ...... 15 RESTORIL ...... 7 sirolimus ...... 13 PROCTOFOAM-HC ...... 15 RETROVIR ...... 14 sitagliptin phos/metformin hcl ...... 10 PROCTO-KIT ...... 15 REVATIO TABLET...... 8 sitagliptin phosphate ...... 10 PROCYSBI ...... 18 REVIA ...... 7 SIVEXTRO...... 14 PROFASI ...... 11 REVLIMID ...... 16 SKELAXIN ...... 18 progesterone, micronized ...... 11, 13 REYATAZ ...... 15 SLO-NIACIN ...... 9 PROGRAF ...... 13 RHEUMATREX ...... 15 sod chloride/nahco3/kcl/peg's ...... 16 PROLIXIN ...... 7 ribavirin ...... 14, 15 sodium chloride for inhalation ...... 17 PROLOPRIM ...... 13 RIFADIN ...... 14 sodium fluoride ...... 18 PROMACTA ...... 13 RIFAMATE ...... 14 sodium phenylbutyrate ...... 15 promethazine hcl ...... 6 rifampin ...... 14 sodium polystyrene sulfonate ...... 11 PROMETRIUM ...... 13 rifampin/isoniazid ...... 14 sofosbuvir ...... 15 PRONESTYL ...... 7 rifaximin ...... 14 SOFTCLIX ...... 11 propafenone hcl ...... 7 rilpivirine ...... 14 SOMA ...... 18 PROPINE ...... 12 riociguat ...... 8 SOMA COMPOUND ...... 18 propranolol hcl ...... 8 RIOMET ...... 11 SOMA COMPOUND WITH CODEINE ...... 17 propranolol/hydrochlorothiazid ...... 8 RISPERDAL ...... 7 somatropin ...... 12 propylthiouracil ...... 12 RISPERDAL M-TAB ...... 7 SOMAVERT ...... 12 PROPYLTHIOURACIL ...... 12 risperidone ...... 7 SONATA ...... 7 PROSCAR ...... 18 risperidone ODT ...... 7 sonidegib phosphate ...... 16 PROSED-DS ...... 13 RITALIN ...... 7 sorafenib tosylate ...... 16 PROSOM ...... 7 RITALIN LA...... 7 SORIATANE ...... 10 PROSTIGMIN ...... 6 RITALIN-SR ...... 7 sotalol hcl ...... 8 PROTONIX ...... 18 ritonavir ...... 15 SOTRET ...... 9 PROTOPIC ...... 10 rivaroxaban ...... 13 SOVALDI ...... 15 PROVERA ...... 13 rivastigmine ...... 6 SPIRIVA ...... 6 PROVIGIL ...... 7 rivastigmine tartrate ...... 6 SPIRIVA RESPIMAT ...... 6 PROZAC ...... 6 rizatriptan benzoate ...... 17 spironolactone ...... 8 PROZAC WEEKLY ...... 6 ROBAXIN ...... 18 SPORANOX ...... 14 PULMICORT FLEXHALER ...... 6 ROBAXIN-750 ...... 18 SPRYCEL ...... 16 PULMICORT RESPULES ...... 6 ROCALTROL ...... 19 STAGESIC-10 ...... 17 PULMOZYME ...... 17 roflumilast ...... 6 STALEVO ...... 17 PURINETHOL ...... 16 ROMYCIN ...... 12 STARLIX ...... 10 PURIXAN ...... 16 ropinirole hcl ...... 18 stavudine ...... 14 pyrazinamide ...... 14 rosuvastatin calcium ...... 8 STELARA ...... 15 PYRAZINAMIDE ...... 14 rotigotine ...... 18 STELAZINE ...... 7 PYRIDIUM ...... 18 ROWASA ...... 15 STIOLTO RESPIMAT ...... 6 pyridostigmine bromide ...... 6 ROXANOL ...... 17 STIVARGA...... 16 pyrimethamine ...... 14 ROXICET ...... 17 STRATTERA ...... 7 pyrimethamine/sulfadoxine ...... 14 ROXICODONE ...... 17 STRIBILD ...... 14 QNASL ...... 6 ROXICODONE INTENSOL...... 17 STRIVERDI RESPIMAT ...... 6 QNASL CHILDREN ...... 6 ruxolitinib ...... 16 SUBOXONE ...... 17 QUALAQUIN...... 14 RYTHMOL ...... 7 SUBUTEX ...... 17 QUESTRAN ...... 8 RYTHMOL SR ...... 7 sucralfate ...... 18 QUESTRAN LIGHT ...... 8 SALAGEN ...... 16 sulconazole nitrate ...... 10

Portfolio High Formulary – April 2016 39 Scripps Health Formulary INDEX

SULFAC ...... 12 THORAZINE ...... 7 ULORIC ...... 13 sulfacetamide sodium ...... 9, 10, 12 thyroid, pork ...... 12 ULTRACET ...... 17 sulfadiazine ...... 13 TIAZAC ...... 8 ULTRAM ...... 17 SULFADIAZINE ...... 13 ticagrelor ...... 13 ULTRASE ...... 18 sulfamethoxazole/trimethoprim ...... 13 TIKOSYN ...... 7 ULTRASE MT ...... 18 sulfanilamide ...... 18 timolol ...... 12 ULTRAVATE ...... 10 sulfasalazine ...... 15 timolol maleate ...... 8, 12 UNIPHYL ...... 6 sulfisoxazole acetyl ...... 13 TIMOPTIC ...... 12 UNIRETIC ...... 8 sulindac ...... 15 TIMOPTIC-XE ...... 12 UNIVASC ...... 8 sumatriptan ...... 17 timothy grass pollen extract ...... 6 UPTRAVI ...... 8 sumatriptan succinate ...... 17 tiotropium br/olodaterol hcl ...... 6 URECHOLINE ...... 16 sunitinib malate ...... 16 tiotropium bromide ...... 6 URETRON D-S ...... 13 SUPRAX ...... 13 tipranavir ...... 14 URIN D.S...... 13 SUSTIVA ...... 14 tipranavir/vitamin e tpgs ...... 14 urofollitropin (fsh) ...... 11 SUTENT ...... 16 TIVICAY ...... 15 UROXATRAL ...... 18 SYEDA ...... 9 tizanidine hcl ...... 18 URSO ...... 16 SYMBYAX ...... 6 TOBI ...... 14 URSO FORTE ...... 16 SYMLIN ...... 10 TOBRADEX ...... 12 ursodiol ...... 16 SYMLINPEN 120 ...... 10 tobramycin for inhalation ...... 14 ustekinumab ...... 15 SYMLINPEN 60 ...... 10 tobramycin sulfate ...... 12 VAGIFEM ...... 18 SYMMETREL ...... 17 tobramycin sulfate/dexameth ...... 12 valacyclovir hcl ...... 14 SYNALAR ...... 10 tobramycin/lotepred etab ...... 12 VALCHLOR ...... 10 SYNJARDY ...... 11 TOBREX ...... 12 VALISONE ...... 10 SYNTHROID...... 12 TOFRANIL ...... 7 VALIUM ...... 7 syringes & needles ...... 11 tolazamide ...... 10 valproate sodium ...... 18 tacrolimus ...... 10 tolbutamide ...... 10 valproic acid ...... 18 tacrolimus anhydrous ...... 13 TOLECTIN 600 ...... 15 valsartan ...... 8 tadalafil ...... 8, 11 TOLINASE ...... 10 valsartan/hydrochlorothiazide ...... 8 TAFINLAR ...... 16 tolmetin sodium ...... 15 VALTREX ...... 14 TAGAMET ...... 18 tolterodine tartrate ...... 18 VANCOCIN HCL ...... 14 TAGRISSO ...... 16 TOPAMAX ...... 18 vancomycin hcl ...... 14 TAKE ACTION ...... 9 TOPAMAX SPRINKLE ...... 18 VANDAZOLE ...... 18 TALADINE ...... 18 TOPICORT ...... 10 VANOS ...... 10 TAMBOCOR ...... 7 TOPICORT LP ...... 10 VANOXIDE-HC ...... 9 TAMIFLU ...... 14 topiramate ...... 18 VANSPAR ...... 7 tamoxifen citrate ...... 16 topotecan hcl ...... 16 VANTIN ...... 13 tamsulosin hcl ...... 18 TOPROL XL...... 8 VASCEPA ...... 9 TAPAZOLE ...... 12 TORADOL ...... 15 VASERETIC ...... 7 tapentadol ...... 17 toremifene citrate ...... 16 VASOCIDIN ...... 12 tapentadol hcl ER ...... 17 torsemide ...... 8 VASOTEC ...... 8 TARCEVA ...... 16 TOUJEO ...... 11 V-CILLIN K...... 14 TARGRETIN ...... 10, 16 TOVIAZ ...... 18 VECTICAL ...... 19 TASIGNA ...... 16 TRACLEER...... 8 vemurafenib ...... 16 tazarotene ...... 10 TRADJENTA ...... 10 venlafaxine hcl ...... 6 TAZORAC ...... 10 tramadol hcl ...... 17 VENTOLIN HFA ...... 6 tazorotene foam ...... 9 tramadol hcl/acetaminophen ...... 17 VEPESID ...... 16 TECFIDERA ...... 16 trametinib dimethyl sulfoxide ...... 16 verapamil hcl ...... 8 tedizolid phosphate ...... 14 TRANDATE ...... 8 verapamil hcl ER ...... 8 teduglutide [rDNA origin] ...... 16 trandolapril ...... 8 VERELAN ...... 8 TEGRETOL ...... 18 TRANXENE T-TAB ...... 7 VERELAN PM ...... 8 TEGRETOL XR ...... 18 tranylcypromine sulfate ...... 6 VERMOX ...... 14 telbivudine ...... 15 TRAVATAN...... 12 VESANOID ...... 16 telithromycin ...... 13 TRAVATAN Z ...... 12 VESTURA ...... 9 temazepam ...... 7 travoprost ...... 12 VFEND ...... 14 TEMODAR ...... 16 travoprost (benzalkonium) ...... 12 VIAGRA ...... 11 TEMOVATE ...... 10 trazodone hcl ...... 6 VIBRAMYCIN ...... 14 TEMOVATE EMOLLIENT ...... 10 TRENTAL ...... 13 VIBRAMYCIN ORAL SUSPENSION ...... 14 temozolomide ...... 16 tretinoin ...... 16 VIBRAMYCIN SYRUP ...... 14 TENEX ...... 8 TREXALL ...... 16 VIBRA-TABS ...... 14 tenofovir disoproxil fumarate ...... 15 triamcinolone acetonide ...... 6, 10, 17 VICODIN ...... 17 TENORETIC 100 ...... 8 triamterene/hydrochlorothiazid ...... 8 VICODIN ES ...... 17 TENORETIC 50 ...... 8 TRIAZ ...... 9 VICODIN HP ...... 17 TENORMIN ...... 8 triazolam ...... 7 VICON FORTE ...... 19 terazosin hcl ...... 8 TRIBENZOR ...... 8 VICTOZA ...... 10 terbinafine hcl ...... 10, 14 TRICOR ...... 9 VIDEX ...... 14 terbutaline sulfate ...... 6 TRIDERM ...... 10 VIDEX EC ...... 14 teriparatide ...... 11 TRIDESILON ...... 10 VIGAMOX ...... 12 testosterone ...... 13 trifluoperazine hcl ...... 7 VIRACEPT ...... 15 testosterone 1% ...... 13 trifluridine ...... 12 VIRAMUNE ...... 14 testosterone cypionate ...... 13 trifluridine/tipiracil hcl ...... 16 VIRAMUNE XR ...... 14 testosterone gel 1.62% ...... 13 TRIGLIDE 160MG ...... 9 VIRAZOLE ...... 14 testosterone solution ...... 13 trihexyphenidyl hcl ...... 17 VIREAD ...... 15 TESTRED ...... 13 TRILAFON ...... 7 VIROPTIC ...... 12 tetrabenazine ...... 17 TRILEPTAL...... 18 VISKEN ...... 8 tetracycline hcl ...... 14 trimethoprim ...... 13 vismodegib...... 16 TEXACORT ...... 10 TRI-NORINYL ...... 9 VISTARIL ...... 6 thalidomide ...... 14 TRIUMEQ ...... 14 VITEKTA ...... 15 THALITONE ...... 8 TRI-VI-FLOR W/IRON ...... 19 VIVELLE-DOT ...... 13 THALOMID ...... 14 TRIZIVIR ...... 14 VOLTAREN ...... 12, 15 THEO-24 ...... 6 TRUSOPT ...... 12 VOLTAREN GEL ...... 10 theophylline anhydrous ...... 6 TRUVADA ...... 14 VOLTAREN-XR ...... 15 THERMAZENE ...... 10 TUSSIONEX ...... 9 voriconazole ...... 14 thioguanine ...... 16 TYBOST ...... 15 vorinostat ...... 16 THIOGUANINE ...... 16 TYKERB ...... 16 VOSOL ...... 11 thioridazine hcl ...... 7 TYLENOL-CODEINE ...... 17 VOSOL HC ...... 11 thiothixene ...... 7 TYZEKA ...... 15 VOTRIENT...... 16

Portfolio High Formulary – April 2016 40 Scripps Health Formulary INDEX

VYVANSE ...... 7 ZANTAC ...... 18 ZOFRAN ...... 6 warfarin sodium ...... 13 ZARAH ...... 9 ZOFRAN ODT ...... 6 WELCHOL ...... 8 ZARONTIN ...... 18 ZOLINZA ...... 16 WELCHOL POWDER PACKETS ...... 8 ZAROXOLYN ...... 8 zolmitriptan ...... 17 WELLBUTRIN ...... 6 ZEBETA ...... 8 ZOLOFT ...... 6 WELLBUTRIN SR ...... 6 ZELBORAF ...... 16 zolpidem tartrate ...... 7 WELLBUTRIN XL ...... 6 ZEMPLAR ...... 12 ZOMIG ...... 17 WESTCORT ...... 10 ZENATANE...... 9 ZOMIG ZMT ...... 17 WESTHROID ...... 12 ZENPEP ...... 18 ZONEGRAN ...... 18 XALATAN ...... 12 ZENZEDI ...... 7 zonisamide ...... 18 XALKORI ...... 16 ZERIT ...... 14 ZORTRESS ...... 13 XANAX ...... 7 ZESTORETIC ...... 7 ZOVIRAX ...... 14 XARELTO ...... 13 ZESTRIL ...... 8 ZOVIRAX CREAM ...... 10 XELODA ...... 16 ZETIA ...... 9 ZOVIRAX OINTMENT ...... 10 XENAZINE ...... 17 ZIAC ...... 8 ZYDELIG ...... 16 XIFAXAN 550MG ...... 14 ZIAGEN ...... 14 ZYKADIA ...... 16 XODOL 10-300 ...... 17 ZIANA ...... 9 ZYLET ...... 12 XTANDI ...... 16 zidovudine ...... 14 ZYLOPRIM ...... 13 XYLOCAINE ...... 15 ziprasidone hcl ...... 7 ZYMAXID ...... 12 XYZAL TABS ...... 6 ZIRGAN ...... 12 ZYPREXA ...... 7 YASMIN 28 ...... 9 ZITHROMAX ...... 13 ZYPREXA ZYDIS ...... 7 YAZ ...... 9 ZITHROMAX TRI-PAK ...... 13 ZYRTEC (OTC) ...... 6 YODOXIN ...... 14 ZMAX ...... 13 ZYRTEC-D (OTC) ...... 6 zaleplon ...... 7 ZMAX PEDIATRIC ...... 13 ZYTIGA ...... 16 ZANAFLEX ...... 18 ZOCOR ...... 8 ZYVOX ...... 14

Portfolio High Formulary – April 2016 41