sign in sign up
<<
Home , Fluorometholone acetate, Fluoxymesterone, Furazolidone

INTEGRIS Formulary July 2017

Foreword FORMULARY EXCLUDED THERAPEUTIC DRUG This document represents the efforts of the MedImpact Healthcare Systems THERAPEUTIC DRUGS CLASS Pharmacy and Therapeutics (P & T) and Formulary Committees to provide ALTERNATIVES physicians and pharmacists with a method to evaluate the safety, efficacy and cost- /tretinoin, AGENTS, effectiveness of commercially available drug products. A structured approach to the VELTIN drug selection process is essential in ensuring continuing patient access to rational ZIANA TOPICAL drug therapies. The ultimate goal of the MedPerform Formulary is to provide a morphine sulfate ER process and framework to support the dynamic evolution of this document to guide tablets, oxycodone ANALGESICS, KADIAN prescribing decisions that reflect the most current clinical consensus associated ER, NUCYNTA, NARCOTICS with drug therapy decisions. NUCYNTA ER

ANALGESICS, This is accomplished through the auspices of the MedImpact P & T and Formulary BELBUCA BUTRANS PATCH Committees. These committees meet quarterly and more often as warranted to NARCOTICS ensure clinical relevancy of the Formulary. To accommodate changes to this ABSTRAL, document, updates are made accessible as necessary. FENTORA, fentanyl citrate ANALGESICS, LAZANDA, lozenge NARCOTICS As you use this Formulary, you are encouraged to review the information and ONSOLIS, provide your input and comments to the MedImpact P & T and Formulary SUBSYS Committees. immediate-release GRALISE ANTICONVULSANTS The MedImpact P & T and Formulary Committees use the following criteria in the gabapentin evaluation of drug selection for the MedPerform Formulary: • Drug safety profile ACTIVE-PAC immediate-release • Drug efficacy gabapentin & KIT, • Comparison of relevant therapeutic benefits to current formulary agents of lidocaine/menthol SMARTRX similar use, and to minimize therapeutic duplication where possible topical, or ANTICONVULSANTS • GABA-V KIT, Cost-effectiveness relative to comparable therapies capsaicin/methyl SMART RX salicylate/menthol How to Use the Formulary GABA KIT The Formulary is a list of available to MedImpact members under their topical pharmacy benefit. All drugs are listed by their generic names and most common proprietary (branded) name. The Formulary may be accessed by using the index, immediate-release ANTICONVULSANTS either by generic or proprietary name (in capital letters) and by therapeutic drug gabapentin, (RESTLESS LEG HORIZANT category. In situations where an FDA approved generic equivalent is available, ropinirole, SYNDROME/POST brand names are listed for reference purposes only, and do not denote coverage pramipexole HERPETIC NEURALGIA) for the brand, unless specifically noted. Any drug not found in this Formulary listing, or any Formulary updates published by MedImpact shall be considered a FORFIVO XL bupropion ER ANTIDEPRESSANTS Non-Formulary drug. IRENKA duloxetine ANTIDEPRESSANTS desvenlafaxine All drugs are listed in each category in alphabetical order by generic name. Where succinate ER, KHEDEZLA ANTIDEPRESSANTS an FDA approved generic is available for the listed generic name, the generic name desvenlafaxine ER is bolded. (Ranbaxy)

For certain agents within the Formulary, a recommended prescribing guideline may PEXEVA paroxetine ANTIDEPRESSANTS apply. These are denoted throughout the document using the following symbols: ZUPLENZ ondansetron ODT ANTIEMETIC AGENTS

AGE Age Edit Coverage may depend on patient age NYATA topical ANTI-INFECTIVE CU Concurrent Coverage or lack thereof may depend upon Use Edit concurrent use of another drug DAXBIA cephalexin ANTI-INFECTIVE MD Physician Coverage may depend on prescribing physician’s ZIPSOR, ANTI-INFLAMMATORY Specialty Edit specialty or board certification diclofenac ZORVOLEX NON-STEROIDAL PA Prior Requires specific physician request process ANTI-INFLAMMATORY NAPRELAN naproxen Authorization NON-STEROIDAL ANTI-INFLAMMATORY VIVLODEX meloxicam QL Quantity Coverage may be limited to specific quantities NON-STEROIDAL Limit per prescription and/or time period ANTI-INFLAMMATORY ST Step Therapy Coverage may depend on previous use of another TIVORBEX indomethacin drug NON-STEROIDAL naproxen & Please refer to the prescribing guideline appendix within this document for details esomeprazole ANTI-INFLAMMATORY regarding specific agents. , VIMOVO NON-STEROIDAL lansoprazole, COMBINATION AGENTS Benefit Coverage and Limitations omeprazole, or This printed Formulary does not provide information regarding the specific coverage and limitations an individual member may be subject to. Many members pantoprazole ANTI-INFLAMMATORY have specific benefit inclusions, exclusions, copays, or a lack of coverage, which famotidine & are not reflected in the Formulary. DUEXIS NON-STEROIDAL ibuprofen COMBINATION AGENTS The Formulary applies only to outpatient drugs provided to members, and does not APTENSIO dextroamphetamine/ ATTENTION DEFICIT- apply to medications used in inpatient settings. If a member has any specific XR, questions regarding their coverage, they should contact their Plan Sponsor or amphetamine, HYPERACTIVITY ADZENYS XR MedImpact at (800) 788-2949. methylphenidate (ADHD)/NARCOLEPSY ODT Excluded Agents immediate-release ANTI-INFLAMMATORY RAYOS As new drugs become available, they will be considered for coverage under the STEROIDAL MedPerform Formulary. The plan administrator has the right to decide what drugs ZONACORT, ANTI-INFLAMMATORY are covered and to what extent, as well as the right to modify coverage including LOCORT 1.5mg tab STEROIDAL the exclusion of any prescription drugs. Please note that prescribing guidelines diphenoxylate/atropi such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to MOTOFEN ANTI-MOTILITY Formulary Therapeutic Alternatives. ne

INTEGRIS Formulary – July 2017 iii INTEGRIS Formulary

FORMULARY FORMULARY EXCLUDED THERAPEUTIC DRUG EXCLUDED THERAPEUTIC DRUG THERAPEUTIC THERAPEUTIC DRUGS CLASS DRUGS CLASS ALTERNATIVES ALTERNATIVES codeine/pseudoephe LEVITRA, HYCOFENIX ANTITUSSIVES DRUGS TO TREAT drine/guaifenesin sol STENDRA, VIAGRA IMPOTENCY ANTI-INFLAMMATORY STAXYN celecoxib & NON-STEROIDAL EMERGENCY epinephrine 0.3mg CAPXIB capsaicin/menthol CYCLOOXYGENASE-2 TREATMENT OF AUVI-Q or 0.15mg auto- topical patch (COX-2) SELECTIVE ALLERGIC REACTIONS injector INHIBITOR (TYPE 1) HUMIRA, ENBREL, VIEKIRA PAK, HARVONI, HEPATITIS C COSENTYX, DAKLINZA EPCLUSA STELARA, CIMZIA, HORMONAL XELJANZ/XR,OTEZ ESTROGEL DIVIGEL KEVZARA, DEFICIENCY LA, *SIMPONI AUTOIMMUNE DISEASE SIMPONI NATESTO, 100mg (*for 50mg, TALTZ TESTIM, ANDROGEL, HORMONAL diagnosis of VOGELXO, AXIRON DEFICIENCY ulcerative colitis FORTESTA only) GENOTROPI alendronate 70mg, BONE RESORPTION N, BINOSTO ibandronate INHIBITORS HUMATROPE aspirin (OTC), , NUTROPIN, DURLAZA CARDIOLOGY NUTROPIN OMNITROPE, clopidogrel GROWTH HORMONES AQ, NORDITROPIN YOSPRALA aspirin (OTC) CARDIOLOGY NUTROPIN GONITRO nitroglycerin CARDIOLOGY AQ NUSPIN, KELOCOTE, BEAU RX DERMATOLOGY SAIZEN, RECEDO ZOMACTON DERMAPAK amlodipine and tretinoin topical DERMATOLOGY PRESTALIA PLUS benazepril hcl APIDRA, ACCUCAINE lidocaine topical DERMATOLOGY APIDRA SOLOSTAR, PEDIPAK DERMATOLOGY HUMALOG INSULINS NOVOLOG, OTC EMOLLIENTS NOVOLOG (EUCERIN, FLEXPLEN SYNERDERM CETAPHIL, DERMATOLOGY LEVEMIR, VASELINE, BASAGLAR, LANTUS, TOUJEO INSULINS AQUAPHOR) TRESIBA URE-K, NOVOLIN HUMULIN INSULINS KERALAC, atorvastatin, UTOPIC, lovastatin, urea 40%, urea 50% DERMATOLOGY ALTOPREV, UREVAZ, pravastatin, LIPID IRREGULARITY LESCOL XL DERMASORB simvastatin, XM rosuvastatin diclofenac sodium DERMATOLOGY - PENNSAID fenofibrate/ 1% topical ANTIINFLAMMATORY ANTARA micronized/ LIPOTROPICS ADLYXIN, nanocrystallized BYDUREON, TRULICITY, balsalazide DIABETES LOWER BYETTA, VICTOZA DELZICOL, disodium, APRISO, GASTROINTESTINAL TANZEUM DIPENTUM LIALDA, PENTASA, TRULICITY, DISORDERS XULTOPHY, sulfasalazine VICTOZA, LANTUS, DIABETES SOLIQUA ONZETRA, TOUJEO ZEMBRACE sumatriptan MIGRAINE INVOKANA, SYMTOUCH, INVOKAMET, TREXIMET FARXIGA, INVOKAMET XR, DIABETES REBIF, GILENYA, XIGDUO XR JARDIANCE, PLEGRIDY, SYNJARDY, TECFIDERA, EXTAVIA MULTIPLE SCLEROSIS SYNJARDY XR AVONEX, GLUMETZA metformin ER DIABETES GLATOPA, NESINA, JENTADUETO, AUBAGIO KAZANO, JENTADUETO XR, Individual vitamin MULTIVITAMIN METHAVER OSENI, TRADJENTA, components PREPARATIONS DIABETES ONGLYZA, JANUVIA, Nasal , OMNARIS, KOMBIGLYZE JANUMET, , ZETONNA, XR JANUMET XR , NASAL ANTI- BECONASE ALL OTHER , INFLAMMATORY MANUFACTU AQ, ABBOTT , RERS OF DIABETIC SUPPLIES TICANASE (PRECISION AND QNASL DIABETIC (TEST STRIPS, NASAL ANTI- FREESTYLE azelastine & TEST STRIPS METERS) INFLAMMATORY/ANTI- BRAND) TICALAST fluticasone nasal AND sprays METERS COMBINATION phentermine & QSYMIA OBESITY AGENTS topiramate

37012 MedPerform Medium Formulary – July 2017 iv INTEGRIS Formulary

FORMULARY • EXCLUDED THERAPEUTIC DRUG A multi-source drug product manufactured by at least one (1) nationally THERAPEUTIC DRUGS CLASS marketed company. ALTERNATIVES • At least one (1) of the generic manufacturer’s products must have an latanoprost, “A” rating or the generic product has been determined to be travoprost, OPHTHALMIC unassociated with efficacy, safety or bioequivalency concerns by the ZIOPTAN LUMIGAN, GLAUCOMA MedImpact P & T Committee. TRAVATAN Z • Drug product will be approved for generic substitution by the NARCAN NASAL MedImpact P & T Committee. EVZIO OPIOID REVERSAL SPRAY This list is reviewed and updated periodically based on the clinical literature LASTACAFT, and pharmacokinetic characteristics of currently available versions of these BEPREVE, PATADAY, OPHTHALMIC drug products. EMADINE, olopatadine ANTIHISTAMINES PAZEO If a member or physician requests a brand name product in lieu of an approved generic, the member, based upon their coverage, will typically be ORAL/PHARYNGEAL required to pay the difference in cost between the brand and the generic. If a ARESTIN N/A DISORDERS physician determines that there is a documented medical need for the brand equivalent, a request for coverage may be made using the lipase/protease/amyl request process. PANCREAZE, ase, CREON, PANCREATIC ENZYMES Three Tier Benefit PERTZYE ZENPEP The Formulary may be applied to a three tier benefit design, where the member shares the cost of prescription drug therapy at three levels of AIRDUO copayment. In most instances, generically available drugs will be covered RESPICLICK under the first or lowest copay tier, branded drugs listed on the Formulary will AND be covered under the second copay tier, and branded drugs not on the AUTHORIZED Formulary will be covered under the third or highest copay tier. GENERIC ADVAIR, BREO 2. Medication Request Process FLUTICASON ELIPTA, RESPIRATORY Depending upon plan benefit design, a medication request process may E/SALMETER SYMBICORT, ASTHMA apply as follows: OL DULERA A. Formulary Agents (55/14mcg, Drugs that are listed in the Formulary with associated Prior Authorization (PA) require evaluation, per MedImpact P & T Committee 113/14mcg, Prior Authorization guidelines prior to dispensing at a network and pharmacy. Each request will be reviewed on an individual patient need 232/14mcg) basis. If the request does not meet the guidelines established by the ALVESCO, ASMANEX HFA, P & T Committee, the request will not be approved and alternative FLOVENT ASMANEX therapy may be recommended. RESPIRATORY DISKUS, TWISTHALER, B. Non-Formulary Agents ASTHMA FLOVENT PULMICORT Any drug not found in the Formulary listing, or any Formulary updates HFA FLEXHALER, QVAR published by MedImpact, shall be considered a Non-Formulary drug. PROVENTIL Coverage for non-formulary agents may be applied for in advance. When a member gives a prescription order for a non-formulary drug to a HFA, PROAIR HFA, RESPIRATORY pharmacist, the pharmacist will evaluate the patient’s drug history and levalbuterol VENTOLIN HFA ASTHMA AND COPD contact the physician to determine if there is a reasonable medical need HFA for a non-formulary drug. Each request will be reviewed on an TUDORZA SPIRIVA individual patient need basis. Approval will be given if a documented PRESSAIR, HANDIHALER, medical need exists. The following basic guidelines are used: RESPIRATORY COPD SEEBRI SPIRIVIA • The use of Formulary Drugs is contraindicated in the patient. • NEOHALER RESPIMAT The patient has failed an appropriate trial of Formulary or related agents. UTIBRON, STIOLTO RESPIRATORY COPD • The choices available in the Formulary are not suited for the BEVESPI present patient care need, and the drug selected is required for ROSACEA AGENTS, patient safety. NORITATE 0.75% cream, gel or • The use of a Formulary drug may provoke an underlying TOPICAL lotion condition, which would be detrimental to patient care. EDLUAR, INTERMEZZO eszopiclone, SEDATIVE-HYPNOTICS, If the request does not meet the guidelines established by the P & T Committee, the request will not be approved and alternative therapy , ROZEREM, zaleplon, zolpidem NON-BARBITURATE may be recommended. ZOLPIMIST C. Obtaining Coverage AMRIX, cyclobenzaprine SKELETAL MUSCLE Coverage, questions or information regarding the medication request or FEXMID, 5mg or 10mg RELAXANTS formulary process may be obtained by: FLEXEPAX 1. Faxing a completed Medication Request Form to MedImpact at butalbital/acetamino (858) 790-7100. ALLZITAL TENSION HEADACHE phen 2. Contacting MedImpact at (800) 788-2949 and providing all necessary information requested. TIROSINT levothyroxine THYROID HORMONES

MedImpact will provide an authorization number, specific for the Please note that prescribing guidelines such as Prior Authorization, Step medical need, for all approved requests. Non-approved requests may Therapy, Quantity Limit, etc., may still apply to Formulary Therapeutic be appealed. The prescriber must provide information to support the Alternatives appeal on the basis of medical necessity. Prior Authorization is

generally not available for drugs that are specifically excluded by benefit

design. Depending upon a member’s specific benefit parameters, the following topics may apply: 3. General Exclusions 1. Generic Substitution A. Over the Counter (OTC) medications or their equivalents, unless When available, FDA approved generic drugs are to be used in all situations, otherwise specified in the Formulary listing. regardless of the brand name indicated. The generic names are bolded in B. Smoking Cessation products (i.e., nicotine, the formulary listing wherever an FDA approved generic drug product is nicotine gum, nicotine inhaler). available. Greater economy is realized through the use of generic C. Drugs specifically listed as not covered. equivalents. This policy is not meant to preclude or supplant any state D. Any drug products used for cosmetic purposes. statutes that may exist. All drugs that are or become available generically are E. Experimental drug products or any drug product used in an subject to review by MedImpact’s Pharmacy and Therapeutics Committee. experimental manner. MedImpact approves such multi-source drugs for addition to the MAC list F. Replacement of lost or stolen medication. based on the following criteria:

37012 MedPerform Medium Formulary – July 2017 v INTEGRIS Formulary

G. Non self-administered injectable drug products unless otherwise physicians, pharmacists, and ancillary medical providers, in this dynamic specified in the Formulary listing. process. Physicians and pharmacists are highly encouraged to direct any H. Foreign sourced drugs or drugs not approved by the United States suggestions, comments or formulary additions to MedImpact at the following Food & Drug Administration. address:

The P & T and Formulary Committees recognize that not all medical needs Chairperson, Pharmacy & Therapeutics Committee can be met with this document and encourage inquiries about alternative MedImpact Healthcare Systems, Inc. therapies. 10181 Scripps Gateway Court San Diego, CA 92131 4. 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 Foreword ...... iii Antihypertensives, Angiotensin ...... 11 1. Generic Substitution ...... v Antihypertensives, Sympatholytic ...... 11 Three Tier Benefit ...... v Antihypertensives, Vasodilators...... 11 2. Medication Request Process ...... v Beta-Adrenergic Blocking Agents ...... 11 3. General Exclusions ...... v Beta-Adrenergic Blocking Agents/Thiazide & Related ...... 11 4. Pharmacist and Physician Communication ...... vi Channel Blocking Agents ...... 11 ALLERGY ...... 9 Loop Diuretics ...... 11 Allergenic extracts ...... 9 Potassium Sparing Diuretics ...... 11 2nd Generation Antihistamine & Decongestant Combinations ...... 9 Potassium Sparing Diuretics in Combination ...... 11 Antihistamines - 1st Generation ...... 9 Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors ...... 11 Antihistamines - 2nd Generation ...... 9 Pulmonary Anti-HTN, Endothelin Receptor Antagonists ...... 11 Nasal Anti-Inflammatory ...... 9 Pulmonary Anti-HTN, Prostacyclin-Type ...... 11 Nasal Antihistamine ...... 9 Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators ...... 11 ANTIEMESIS/ANTIVERTIGO ...... 9 Thiazide & Related Diuretics ...... 11 Antiemetic/Antivertigo Agents ...... 9 CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ...... 11 ASTHMA ...... 9 Antihyperlipidemic - APO B-100 Synthesis Inhibitor ...... 11 Beta-Adrenergic Agents ...... 9 Antihyperlipidemic - HMG CoA Reductase Inhibitors ...... 11 Beta-Adrenergic & Anticholinergic Combinations ...... 9 Antihyperlipidemic - MTP Inhibitors ...... 11 Beta-Adrenergic & Combinations ...... 9 Antihyperlipidemic – PCSK9 Inhibitors ...... 11 General Bronchodilator Agents ...... 9 Bile Salt Sequestrants...... 12 Leukotriene Receptor Antagonists ...... 9 Lipotropics ...... 12 Mast Cell Stabilizers...... 9 Niacin Preparations ...... 12 Oral Inhaled ...... 9 CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ...... 12 Phosphodiesterase-4 (PDE4) Inhibitors ...... 9 Adrenergic Vasopressor Agents ...... 12 Xanthines ...... 9 Angiotensin Recept-Neprilysin Inhibitor Comb(ARNI) ...... 12 AUTONOMIC NERVOUS SYSTEM DISORDERS ...... 9 Antianginal & Anti-Ischemic Agents, Non-Hemodynamic ...... 12 Alzheimer's Therapy, Nmda Receptor Antagonists ...... 9 Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker Combinations ... 12 Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines Inhibitors ...... 9 Heart Rate Reducing, Selective I(F) Current Inhib...... 12 Cholinesterase Inhibitors ...... 9 CARDIOVASCULAR DISEASE - VASODILATION ...... 12 BEHAVIORAL HEALTH - ANTIDEPRESSANTS ...... 9 Vasodilators, Combination ...... 12 Alpha-2 Receptor Antagonist Antidepressants ...... 9 Vasodilators, Coronary ...... 12 Maois - Non-Selective & Irreversible ...... 9 CONTRACEPTION/OXYTOCICS ...... 12 & Reuptake Inhibitors (NDRIs) ...... 9 Contraceptives, Intravaginal, Systemic ...... 12 Selective Reuptake Inhibitors (SSRIs) ...... 9 Contraceptives, Oral ...... 12 SSRI & Antipsychotics, Atyp, Dopamine & Serotonin Antag Comb ...... 9 Contraceptives, Transdermal ...... 12 SSRI, Serotonin Antidepressants ...... 9 Oxytocics ...... 12 SSRI & 5HT1A Partial Antidepressants...... 9 COUGH AND COLD ...... 12 Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs) ...... 9 1st Generation Antihistamine & Decongestant Combinations ...... 12 Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) ...... 9 Narcotic Antitussive-1st Generation Antihistamine-Decongestants ...... 12 Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib ...... 10 Narcotic Antitussive-1st Generation Antihistamines...... 12 BEHAVIORAL HEALTH - OTHER ...... 10 Narcotic Antitussive-Anticholinergic Comb...... 12 Adrenergics, Aromatic, Non-Catecholamine ...... 10 Non-Narcotic Antitussive-1st Generation Antihistamine Combinations ...... 12 Anti-Alcoholic Preparations ...... 10 DERMATOLOGY - ACNE ...... 12 Anti-Anxiety Drugs ...... 10 Acne Agents, Systemic ...... 12 Anti-Mania Drugs ...... 10 Acne Agents, Topical ...... 12 Antipsychotics, Phenothiazines ...... 10 Keratolytic-Glucocorticoid Combinations ...... 12 Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed ...... 10 Keratolytics...... 12 Antipsychotics, Atypical, D3/D2 Partial Agonist/5HT Mixed ...... 10 Rosacea Agents, Topical ...... 12 Antipsychotics, Dopamine & Serotonin Antagonists ...... 10 Vitamin A Derivatives ...... 12 Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists ...... 10 DERMATOLOGY - ANTIINFECTIVE ...... 12 Antipsychotics, Dopamine Antagonists, Thioxanthenes ...... 10 Topical ...... 12 Antipsychotics, Dopamine Antagonists, Butyrophenones ...... 10 Topical ...... 13 Barbiturates ...... 10 Topical ...... 13 Narcolepsy and Sleep Disorder Therapy Agents ...... 10 Topical Antivirals ...... 13 Narcotic Antagonists ...... 10 Topical Sulfonamides...... 13 Sedative-Hypnotics, Non-Barbiturate ...... 10 DERMATOLOGY - ANTIINFLAMMATORY ...... 13 Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy ...... 10 Topical Anti-Inflammatory Steroidal ...... 13 Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type ...... 10 Topical Anti-Inflammatory, NSAIDs ...... 13 CARDIOVASCULAR DISEASE - ARRHYTHMIA ...... 10 Topical Antibiotics/Antiinflammatory, Steroidal ...... 13 Antiarrhythmics ...... 10 DERMATOLOGY - MISCELLANEOUS ...... 13 CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS ...... 10 Antiperspirants ...... 13 Digitalis Glycosides ...... 10 Antiseborrheic Agents ...... 13 CARDIOVASCULAR DISEASE - HYPERTENSION ...... 10 Topical Antineoplastic & Premalignant Lesion Agents ...... 13 ACE Inhibitor/Calcium Channel Blocker Combinations ...... 10 Topical Local Anesthetics ...... 13 ACE Inhibitor/Thiazide & Thiazide-Like Diuretics ...... 10 DERMATOLOGY - PIGMENTATION DISORDERS ...... 13 Alpha-Adrenergic Blocking Agents ...... 11 Topical Hyperpigmentation Agents ...... 13 Alpha/Beta-Adrenergic Blocking Agents ...... 11 DERMATOLOGY - PSORIASIS/ECZEMA ...... 13 Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Antipsoriatic Agents, Systemic ...... 13 Combinations ...... 11 Antipsoriatics Agents ...... 13 Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations ...... 11 Topical Immunosuppressive Agents ...... 13 Angiotensin II Receptor Blocker-Beta Blocker Comb...... 11 Topical Phosphodiesterase (PDE-4) Inhibitor ...... 13 Angiotensin Receptor Antagonist & Calcium Channel Blockers ...... 11 DIABETES ...... 13 Antihypertensives, ACE Inhibitors ...... 11 Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea) ...... 13

37012 MedPerform Medium Formulary – July 2017 vi INTEGRIS Formulary

Antihyperglycemic, Amylin Analog-Type ...... 13 Cephalosporins - 1st Generation ...... 16 Antihyperglycemic, DPP-4 Inhibitors ...... 13 Cephalosporins - 2nd Generation ...... 16 Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations ...... 13 Cephalosporins - 3rd Generation...... 16 Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor ) ...... 13 Chemotherapeutics, Antibacterial, Miscellaneous...... 16 Antihyperglycemic, Insulin-Release Stimulant Type ...... 13 Ketolides ...... 16 Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea) ...... 14 Lincosamides ...... 16 Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) ...... 14 Macrolides ...... 16 Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations ...... 14 Derivatives ...... 17 Antihyperglycemic, Insulin-Response & Release Combinations ...... 14 Oxazolidinones ...... 17 Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations ...... 14 Penicillins ...... 17 Antihyperglycemic- Blockers ...... 14 Quinolones ...... 17 Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors ...... 14 ...... 17 Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and INFECTIOUS DISEASE - FUNGAL ...... 17 Biguanide Combination ...... 14 Agents ...... 17 Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination ...... 14 Antifungal Antibiotics...... 17 Diabetic Supplies ...... 14 INFECTIOUS DISEASE - MISCELLANEOUS...... 17 Diabetic Ulcer Preparations, Topical ...... 14 Aminoglycosides ...... 17 Hyperglycemics ...... 14 Anti-Mycobacterium Agents ...... 17 Insulins ...... 14 Antileprotics...... 17 Syringes & Accessories ...... 14 Antitubercular Antibiotics ...... 17 EAR - GENERAL DISORDERS ...... 14 and Related Derivative Antibiotics ...... 17 Ear Preparations, Misc. Anti-Infectives ...... 14 Vancomycin & Derivatives ...... 17 Ear Preparations, Antibiotics...... 14 INFECTIOUS DISEASE - PARASITIC ...... 17 Otic Preparations, Anti-Inflammatory-Antibiotics ...... 14 Amebacides ...... 17 Otic Preparations, Local anesthetics ...... 14 Anaerobic -Antibacterial Agents ...... 17 ELECTROLYTE REGULATION ...... 14 Anthelmintics ...... 17 Electrolyte Depleters ...... 14 Antimalarial Drugs ...... 17 Potassium Replacement ...... 14 Antiprotozoal Drugs, Miscellaneous ...... 17 ENDOCRINE DISORDER - FERTILITY ...... 14 INFECTIOUS DISEASE - VIRAL ...... 17 Drugs to Treat Impotency ...... 14 Antivirals, HIV-Spec, Non-Peptidic Protease Inhib ...... 17 Fertility Stimulating Preparations, Non-FSH ...... 14 Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog ...... 17 Follicle Stimulating / Luteinizing Hormones ...... 14 Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb ...... 17 Pregnancy Facilitating/Maintaining Agents, Hormonal ...... 14 Antivirals, HIV-Specific, CCR5 Co-Receptor Antag...... 17 ENDOCRINE DISORDER - OTHER ...... 14 Antivirals, HIV-Specific, Fusion Inhibitors ...... 17 Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants ...... 14 Antivirals, HIV-Specific, Non-Nucleoside, RTI ...... 17 Antidiuretic & Vasopressor Hormones ...... 14 Antivirals, HIV-Specific, Nucleoside Analog, RTI ...... 17 Bone Formation Stim. Agents - Parathyroid Hormone ...... 14 Antivirals, HIV-Specific, Nucleotide Analog, RTI ...... 18 Bone Resorption Inhibitor & Vitamin D Combinations ...... 14 Antivirals, HIV-Specific, Protease Inhibitor Comb ...... 18 Bone Resorption Inhibitors ...... 14 Antivirals, HIV-Specific, Protease Inhibitors ...... 18 Growth Hormone Receptor Antagonists ...... 15 Antivirals, HIV-1 Integrase Strand Transfer Inhibtors ...... 18 Growth Hormones ...... 15 Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI ...... 18 Hyperparathyroid Tx Agent, Vitamin D Analog-Type ...... 15 Cytochrome P450 Inhibitors ...... 18 LHRH (GnRH) Antagonist, Pituitary Suppressant Agents ...... 15 Hepatitis B Treatment Agents ...... 18 Luteinizing Hormone Releasing Hormone –LHRH (GnRH) ...... 15 Hepatitis C Combination Agents ...... 18 Pituitary Suppressive Agents ...... 15 Hepatitis C Treatment Agents ...... 18 ENDOCRINE DISORDER - THYROID ...... 15 INFLAMMATORY DISEASE ...... 18 Antithyroid Preparations ...... 15 Anti-Arthritic & Chelating Agents ...... 18 Iodine Containing Agents ...... 15 Anti-Arthritic, Folate Antagonist Agents ...... 18 Thyroid Hormones...... 15 Anti-Inflammatory Tumor Necrosis Factor Inhibitor ...... 18 EYE - GENERAL DISORDERS ...... 15 Anti-Inflammatory, Pyrimidine Synthesis Inhibitors ...... 18 Eye -Corticoid Combinations...... 15 Bradykinin B2 Receptor Antagonists ...... 18 Eye Antihistamines...... 15 ...... 18 Eye Antiinflammatory Agents ...... 15 Mineralocorticoids ...... 18 Eye Antivirals ...... 15 Monoclonal antibody-human interleukin ...... 18 Eye Sulfonamides ...... 15 NSAIDs, Cyclooxygenase Inhibitor-Type ...... 18 EYE - MISCELLANEOUS ...... 15 LOCAL ANESTHESIA ...... 18 Ophthalmic Cystine Delpleting Agents ...... 15 Local Anesthetics ...... 18 Ophthalmic Anti-Inflammatory Immunomodulator-Type ...... 15 LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT ...... 18 Ophthalmic Antibiotics ...... 15 Bowel Antiinflamatory Agents ...... 18 Ophthalmic Mast Cell Stabilizers ...... 15 Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx ...... 18 EYE - GLAUCOMA ...... 15 Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat ...... 18 Carbonic Anhydrase Inhibitors ...... 15 Hemorrhoidal Preparations ...... 18 Miotics/Other Intraoccula Pressure Reducers ...... 15 Rectal Preparations ...... 18 Mydriatics ...... 15 Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) ...... 18 GOUT AND RELATED DISEASES ...... 16 LOWER GASTROINTESTINAL DISORDERS - OTHER ...... 18 Hyperuricemia Treatment - Purine Inhibitors ...... 16 Ammonia Inhibitors ...... 18 Uricosuric Agents ...... 16 Antidiarrheals ...... 18 HEMATOLOGICAL DISORDERS ...... 16 Bile Salts ...... 19 Anticoagulants, Coumarin Type ...... 16 Laxatives & Cathartics ...... 19 Hematinics, Other ...... 16 Narcotic Antagonists, Peripherally-Acting ...... 19 Hemorrheologic Agents ...... 16 Hydroxylase Inhibitor ...... 19 Heparin & Related Preparations ...... 16 MISCELLANEOUS AGENTS ...... 19 Leukocyte (WBC) Stimulants ...... 16 Anaphylaxis Therapy Agents ...... 19 Platelet Aggregation Inhibitors ...... 16 Parasympathetic Agents ...... 19 Platelet Reducing Agents ...... 16 Pku Tx Agent-Cofactor Of Hydroxylase ...... 19 Thrombopoietin Receptor Agonists ...... 16 NEOPLASTIC DISEASE ...... 19 Vitamin K Preparations ...... 16 Alkylating Agents ...... 19 HORMONAL DEFICIENCY ...... 16 Antiandrogenic Agents ...... 19 Androgenic Agents ...... 16 Antimetabolites ...... 19 / Combinations ...... 16 Antineoplastic - Inhibitors ...... 19 Estrogenic Agents ...... 16 Antineoplastic – B Cell Lymphoma 2(BCL-2) Inhibitors ...... 19 Progestational Agents ...... 16 Antineoplastic – Hedgehog Pathway Inhibitors ...... 19 IMMUNOSUPPRESSION/MODULATION ...... 16 Antineoplastic – Janus Kinase (JAK) Inhibitors ...... 19 Immunomodulators ...... 16 Antineoplastic - MEK1 and MEK2 Kinase Inhibitors ...... 19 Immunosuppressives ...... 16 Antineoplastic - Topoisomerase I Inhibitors...... 19 INFECTIOUS DISEASE - BACTERIAL ...... 16 Antineoplastic - Immunomodulator Agents ...... 19 Absorbable Sulfonamides ...... 16 Antineoplastic - Systemic Enzyme Inhibitors ...... 19 Betalactams ...... 16 Antineoplastic, Histone Deacetylase Inhibitors, HDIS ...... 19

37012 MedPerform Medium Formulary – July 2017 vii INTEGRIS Formulary

Antineoplastics, Miscellaneous ...... 19 Chemotherapy Rescue/Antidote Agents ...... 19 Selective Estrogen Receptor Modulators (SERM) ...... 19 Selective Retinoid X Receptor Agonists (RXR) ...... 19 Antineoplastics ...... 19 NEUROLOGICAL DISEASE - MISCELLANEOUS ...... 20 Agents to Treat Multiple Sclerosis ...... 20 Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor ...... 20 Movement Disorders (Drug Therapy) ...... 20 ORAL/PHARYNGEAL DISORDERS ...... 20 Dental Aids & Preparations ...... 20 Nose Preparations, Antibiotics ...... 20 Nose Preparations, Miscellaneous (Rx) ...... 20 OTHER DRUGS ...... 20 Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome ...... 20

General Inhalation Agents ...... 20 Metabolic disease enzyme replace, hypophosphatasia ...... 20 Needles/Needleless Devices ...... 20 Nucleic Acid/Nucleotide Supplements ...... 20 Somatostatic Agents ...... 20 Drugs to treat hereditary tyrosinemia...... 20 OTHER RESPIRATORY DISORDERS ...... 20 Antifibrotic Therapy – Pyridone Analogs ...... 20 Cystic Fibrosis-Cftr Potentiator & Corrector Comb...... 20 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiators ...... 20 Mucolytics...... 20 Pulmonary Fibrosis - Systemic Enzyme Inhibitors ...... 20 PAIN MANAGEMENT - ANALGESICS ...... 20 Analgesic, Non-Salicylate & Barbiturate Combinations ...... 20 Analgesic, Salicylate, Barbiturate & Xanthine Combinations ...... 20 Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations ...... 20 Analgesic/Antipyretics, Salicylates ...... 20 Analgesics, Narcotics ...... 20 Antimigraine Preparations ...... 20 Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations . 20 Narcotic & Salicylate Analgesics, Barbiturates & Xanthines ...... 20 Narcotic Analgesic & Non-Salicylate Analgesic Combinations ...... 20 Narcotic Withdrawal Therapy Agents ...... 21 PARKINSON’S DISEASE ...... 21 Antiparkinsonism Drugs, Anticholinergic ...... 21 Antiparkinsonism Drugs, Other ...... 21 Decarboxylase Inhibitors ...... 21 SEIZURE DISORDER ...... 21 Anticonvulsants ...... 21 SKELETAL MUSCLE DISORDER ...... 21 Agents To Treat Periodic Paralysis ...... 21 Skeletal Muscle Relaxants ...... 21 UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ...... 21 Pancreatic Enzymes ...... 21 UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE ...... 21 Anticholinergics/Antispasmodics ...... 21 Belladonna Alkaloids ...... 21 UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ...... 21 Anti-Ulcer Preparations ...... 21 Anti-Ulcer-H.pylori Agents ...... 21 Anticholinergics, Quaternary Ammonium ...... 21 Histamine H2-Receptor Inhibitors ...... 21 Intestinal Motility Stimulants...... 21 Proton-Pump Inhibitors ...... 21 URINARY TRACT - FUNCTIONAL DISORDERS ...... 21 Benign Prostatic Hypertrophy/Micturition Agents ...... 21 Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag comb agents ...... 21

Kidney Stone Agents ...... 21 Overactive Bladder Agents, Beta-3 Adrenergic Recep ...... 21 Urinary Tract Analgesic Agents ...... 21 Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) ...... 21 Urinary Tract Antispasmodic, M(3) Selective Antagonists ...... 22 Urinary Tract Antispasmodic/Antiincontinence Agents ...... 22 VAGINAL DISORDERS ...... 22 Vaginal Antibiotics ...... 22 Vaginal Antifungals ...... 22 Preparations ...... 22 Vaginal Sulfonamides ...... 22 VITAMIN AND/OR MINERAL DEFICIENCY ...... 22 Fluoride Preparations ...... 22 Folic Acid Preparations ...... 22 Multivitamin Preparations ...... 22 Pediatric Vitamin Preparations ...... 22 Prenatal Vitamin Preparations ...... 22 Vitamin B Preparations ...... 22 Vitamin D Preparations ...... 22 SPECIALTY INJECTABLE CROSS REFERENCE LISTING ...... 22

37012 MedPerform Medium Formulary – July 2017 viii INTEGRIS Formulary

ALLERGY QL tiotropium bromide SPIRIVA Allergenic extracts QL tiotropium bromide SPIRIVA RESPIMAT PA 5-grass pollen extract ORALAIR Leukotriene Receptor Antagonists PA short ragweed pollen extract RAGWITEK montelukast sodium SINGULAIR PA timothy grass pollen extract GRASTEK Mast Cell Stabilizers 2nd Generation Antihistamine & Decongestant Combinations cromolyn sodium INTAL p-ephed hcl/cetirizine hcl (OTC) ZYRTEC-D (OTC) Oral Inhaled Corticosteroids p-ephed sul/loratadine (OTC) CLARITIN-D 12 HOUR QL budesonide PULMICORT RESPULES (OTC) QL beclomethasone dipropionate QVAR CLARITIN-D 24 HOUR QL budesonide PULMICORT FLEXHALER (OTC) QL mometasone furoate ASMANEX Antihistamines - 1st Generation QL ASMANEX HFA hydroxyzine hcl ATARAX Phosphodiesterase-4 (PDE4) Inhibitors hydroxyzine pamoate VISTARIL QL+ roflumilast DALIRESP promethazine hcl PHENERGAN ST Antihistamines - 2nd Generation Xanthines cetirizine hcl (OTC) ZYRTEC (OTC) aminophylline AMINOPHYLLIN levocetirizine dihydrochloride XYZAL TABS theophylline anhydrous UNIPHYL loratadine (OTC) CLARITIN (OTC) theophylline anhydrous THEO-24 Nasal Anti-Inflammatory Steroids AUTONOMIC NERVOUS SYSTEM DISORDERS QL flunisolide NASAREL Alzheimer's Therapy, Nmda Receptor Antagonists QL FLONASE QL memantine hcl NAMENDA QL NASACORT AQ QL memantine hcl NAMENDA XR QL dipropionate QNASL Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines QL QNASL CHILDREN Inhibitors QL mometasone furoate NASONEX QL + memantine hcl/donepezil hcl NAMZARIC Nasal Antihistamine ST QL azelastine hcl ASTELIN QL + NAMZARIC TITIRATION QL + ASTEPRO ST PACK ST Cholinesterase Inhibitors ANTIEMESIS/ANTIVERTIGO donepezil hcl ARICEPT Antiemetic/Antivertigo Agents ARICEPT ODT QL + dronabinol MARINOL QL galantamine hydrobromide RAZADYNE ST QL RAZADYNE ER meclizine hcl ANTIVERT pyridostigmine bromide MESTINON ondansetron ZOFRAN ODT QL rivastigmine EXELON PATCH QL ondansetron hcl (QL on ZOFRAN rivastigmine tartrate EXELON solution) neostigmine bromide PROSTIGMIN prochlorperazine maleate COMPAZINE BEHAVIORAL HEALTH - ANTIDEPRESSANTS promethazine hcl PHENERGAN Alpha-2 Receptor Antagonist Antidepressants QL netupitant/palonosetron hcl AKYNZEO mirtazapine REMERON QL aprepitant EMEND Maois - Non-Selective & Irreversible prochlorperazine edisylate COMPAZINE SYRUP sulfate PARNATE ASTHMA sulfate NARDIL Beta-Adrenergic Agents Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs) albuterol sulfate ALBUTEROL SULFATE bupropion hcl WELLBUTRIN metaproterenol sulfate ALUPENT WELLBUTRIN SR WELLBUTRIN XL terbutaline sulfate BRETHINE albuterol sulfate PROAIR HFA Selective Serotonin Reuptake Inhibitors (SSRIs) PROAIR RESPICLICK citalopram hydrobromide CELEXA VENTOLIN HFA escitalopram oxalate LEXAPRO QL formoterol fumarate PERFOROMIST fluoxetine hcl PROZAC QL olodaterol hcl STRIVERDI RESPIMAT fluoxetine er PROZAC WEEKLY QL salmeterol xinafoate SEREVENT DISKUS paroxetine hcl PAXIL Beta-Adrenergic & Anticholinergic Combinations PAXIL CR ipratropium/albuterol sulfate DUONEB sertraline hcl ZOLOFT ipratropium/albuterol sulfate COMBIVENT SSRI & Antipsychotics, Atyp, Dopamine & Serotonin Antag Comb COMBIVENT RESPIMAT QL olanzapine/fluoxetine SYMBYAX QL tiotropium br/olodaterol hcl STIOLTO RESPIMAT SSRI, Serotonin Receptor Modulator Antidepressants Beta-Adrenergic & Glucocorticoid Combinations QL vortioxetine hydrobromide TRINTELLIX QL fluticasone/salmeterol ADVAIR DISKUS SSRI & 5HT1A Partial Agonist Antidepressants QL ADVAIR HFA QL vilazodone hcl VIIBRYD QL fluticasone/vilanterol BREO ELLIPTA Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs) QL mometasone/formoterol DULERA trazodone hcl DESYREL 300MG QL budesonide/formoterol fumarate SYMBICORT Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) General Bronchodilator Agents QL desvenlafaxine ER (Ranbaxy DESVENLAFAXINE ER ipratropium bromide ATROVENT Brand) (RANBAXY BRAND) QL ipratropium bromide ATROVENT HFA QL desvenlafaxine succinate PRISTIQ

37012 MedPerform Medium Formulary – July 2017 9 INTEGRIS Formulary

QL duloxetine hcl CYMBALTA QL ziprasidone hcl GEODON QL levomilnacipran hcl FETZIMA Antipsychotics, Dopamine Antagonists, Thioxanthenes venlafaxine hcl EFFEXOR, EFFEXOR XR thiothixene NAVANE Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib Antipsychotics, Dopamine Antagonists, Butyrophenones amitriptyline hcl ELAVIL HALDOL amoxapine ASENDIN haloperidol lactate HALDOL ORAL CONC. clomipramine hcl ANAFRANIL Barbiturates desipramine hcl NORPRAMIN phenobarbital PHENOBARBITAL doxepin hcl SINEQUAN Narcolepsy and Sleep Disorder Therapy Agents imipramine hcl TOFRANIL QL modafinil PROVIGIL maprotiline hcl LUDIOMIL Narcotic Antagonists nortriptyline hcl PAMELOR naltrexone hcl NARCAN BEHAVIORAL HEALTH - OTHER naltrexone hcl REVIA Adrenergics, Aromatic, Non-Catecholamine Sedative-Hypnotics, Non-Barbiturate QL amphet asp/amphet/d-amphet ADDERALL chloral hydrate NOCTEC QL ADDERALL XR QL doxepin hcl SILENOR QL dextroamphetamine sulfate DEXEDRINE estazolam PROSOM QL dextroamphetamine capsule DEXEDRINE SPANSULE flurazepam hcl DALMANE QL dextroamphetamine (5mg, ZENZEDI QL eszopiclone LUNESTA 10mg) QL suvorexant BELSOMRA QL + dextroamphetamine tablet (2.5mg, ZENZEDI temazepam RESTORIL ST 7.5mg) triazolam HALCION QL dextroamphetamine tablet (15mg, ZENZEDI QL zaleplon SONATA 20mg, 30mg) QL zolpidem tartrate AMBIEN QL lisdexamfetamine dimesylate VYVANSE QL + zolpidem tartrate ER AMBIEN CR Anti-Alcoholic Preparations ST ANTABUSE Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy Anti-Anxiety Drugs QL dexmethylphenidate hcl FOCALIN alprazolam XANAX QL FOCALIN XR ALPRAZOLAM INTENSOL QL methylphenidate hcl CONCERTA buspirone hcl BUSPAR QL METADATE CD VANSPAR QL+ METADATE ER chlordiazepoxide hcl LIBRIUM AGE METHYLIN CHEW TAB clorazepate dipotassium TRANXENE T-TAB QL+ METHYLIN SOLN AGE RITALIN diazepam VALIUM QL+ RITALIN LA lorazepam ATIVAN AGE RITALIN SR LORAZEPAM INTENSOL QL methylphenidate hcl QUILLICHEW ER meprobamate MILTOWN QL methylphenidate ER susp QUILLIVANT XR oxazepam SERAX Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type Anti-Mania Drugs QL atomoxetine hcl STRATTERA lithium carbonate ESKALITH CARDIOVASCULAR DISEASE - ARRHYTHMIA LITHOBID Antiarrhythmics lithium citrate CIBALITH-S amiodarone hcl CORDARONE Antipsychotics, Phenothiazines disopyramide phosphate NORPACE hcl THORAZINE flecainide acetate TAMBOCOR fluphenazine hcl PROLIXIN mexiletine hcl MEXITIL perphenazine TRILAFON procainamide hcl PRONESTYL thioridazine hcl MELLARIL propafenone hcl RYTHMOL trifluoperazine hcl STELAZINE quinidine gluconate QUINAGLUTE Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed quinidine sulfate QUINIDEX QL aripiprazole ABILIFY SOLUTION disopyramide phosphate NORPACE CR QL aripiprazole ABILIFY TABLET dofetilide TIKOSYN QL aripiprazole ABILIFY DISCMELT QL brexpiprazole REXULTI dronedarone hcl MULTAQ Antipsychotics, Atypical, D3/D2 Partial Agonist/5HT Mixed propafenone hcl RYTHMOL SR QL cariprazine hcl VRAYLAR CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS Antipsychotics, Dopamine & Serotonin Antagonists Digitalis Glycosides loxapine succinate LOXITANE digoxin LANOXIN Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists DIGOXIN ORAL SOLN. QL asenapine maleate SAPHRIS CARDIOVASCULAR DISEASE - HYPERTENSION QL clozapine CLOZARIL ACE Inhibitor/Calcium Channel Blocker Combinations QL lurasidone LATUDA amlodipine besylate/benazepril LOTREL QL olanzapine ZYPREXA ACE Inhibitor/Thiazide & Thiazide-Like Diuretics QL olanzapine ODT ZYPREXA ZYDIS benazepril/hydrochlorothiazide LOTENSIN HCT QL quetiapine fumarate SEROQUEL captopril/hydrochlorothiazide CAPOZIDE QL quetiapine fumarate ER SEROQUEL XR enalapril/hydrochlorothiazide VASERETIC QL RISPERDAL fosinopril/hydrochlorothiazide MONOPRIL HCT QL risperidone ODT RISPERDAL M-TAB lisinopril/hydrochlorothiazide PRINZIDE

37012 MedPerform Medium Formulary – July 2017 10 INTEGRIS Formulary

ZESTORETIC metoprolol/hctz LOPRESSOR HCT moexipril/hydrochlorothiazide UNIRETIC propranolol/hydrochlorothiazid INDERIDE-40/25 quinapril/hydrochlorothiazide ACCURETIC Calcium Channel Blocking Agents Alpha-Adrenergic Blocking Agents amlodipine besylate NORVASC doxazosin mesylate CARDURA diltiazem hcl CARDIZEM phenoxybenzamine hcl DIBENZYLINE CARDIZEM CD prazosin hcl MINIPRESS DILACOR XR TIAZAC terazosin hcl HYTRIN felodipine PLENDIL Alpha/Beta-Adrenergic Blocking Agents isradipine IR capsules DYNACIRC CR carvedilol COREG nicardipine hcl CARDENE labetalol hcl TRANDATE ADALAT CC carvedilol phosphate COREG CR nifedipine PROCARDIA Angiotensin Receptor Antagonist/Calcium Channel PROCARDIA XL Blocker/Thiazide Combinations nimodipine NIMOTOP amlodipine/valsartan/hctz EXFORGE HCT verapamil hcl CALAN olmesartan/amlodipin/hctz TRIBENZOR VERELAN Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations VERELAN PM azilsartan med/chlorthalidone EDARBYCLOR verapamil hcl ER CALAN SR irbesartan/hydrochlorithiazide AVALIDE VERELAN PM losartan/hydrochlorothiazide HYZAAR Loop Diuretics valsartan/hydrochlorothiazide DIOVAN HCT bumetanide BUMEX olmesartan/hydrochlorothiazide BENICAR HCT furosemide LASIX Angiotensin II Receptor Blocker-Beta Blocker Comb. torsemide DEMADEX nebivolol hcl/valsartan BYVALSON Potassium Sparing Diuretics Angiotensin Receptor Antagonist & Calcium Channel Blockers eplerenone INSPRA amlodipine/valsartan EXFORGE ALDACTONE 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 azilsartan EDARBI PA selexipag t UPTRAVI irbesartan AVAPRO Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators losartan potassium COZAAR PA riociguat ADEMPAS valsartan DIOVAN Thiazide & Related Diuretics olmesartan medoxomil BENICAR chlorthalidone HYGROTON Antihypertensives, Sympatholytic hydrochlorothiazide MICROZIDE clonidine hcl CATAPRES indapamide LOZOL guanfacine hcl TENEX metolazone ZAROXOLYN ALDOMET chlorthalidone THALITONE reserpine SERPASIL CARDIOVASCULAR DISEASE - LIPID IRREGULARITY Antihypertensives, Vasodilators Antihyperlipidemic - APO B-100 Synthesis Inhibitor hcl APRESOLINE Antihyperlipidemic - HMG CoA Reductase Inhibitors Beta-Adrenergic Blocking Agents atorvastatin calcium LIPITOR acebutolol hcl SECTRAL lovastatin MEVACOR atenolol TENORMIN QL pitavastatin LIVALO bisoprolol fumarate ZEBETA pravastatin sodium PRAVACHOL metoprolol succinate TOPROL XL simvastatin ZOCOR metoprolol tartrate LOPRESSOR ST simvastatin (80mg only) nadolol CORGARD QL rosuvastatin calcium CRESTOR pindolol VISKEN QL ezetimibe/simvastatin VYTORIN 10/10mg, propranolol hcl INDERAL LA 10/20mg, 10/40mg sotalol hcl BETAPACE QL + ezetimibe/simvastatin BETAPACE AF ST VYTORIN 10/80mg timolol maleate BLOCADREN Antihyperlipidemic - MTP Inhibitors PA + lomitapide JUXTAPID nebivolol hcl BYSTOLIC Beta-Adrenergic Blocking Agents/Thiazide & Related QL atenolol/chlorthalidone TENORETIC 100 Antihyperlipidemic – PCSK9 Inhibitors TENORETIC 50 PA alirocumab PRALUENT bisoprolol fumarate/hctz ZIAC PA evolocumab REPATHA

37012 MedPerform Medium Formulary – July 2017 11 INTEGRIS Formulary

Bile Salt Sequestrants AVIANE-28 cholestyramine/aspartame QUESTRAN LIGHT LESSINA cholestyramine/sucrose QUESTRAN LUTERA ORSYTHIA colesevelam hcl WELCHOL SRONYX WELCHOL POWDER PACKETS ST noreth a-et estra/fe fumarate LOESTRIN FE LOESTRIN FE24 colestipol COLESTID COLESTID GRANULES norethindrone NOR-Q-D ORTHO MICRONOR Lipotropics norethindrone a-e LOESTRIN fenofibrate FENOGLIDE LOFIBRA TABS norethindrone-ethinyl estrad NORINYL 1+35 ORTHO-NOVUM fenofibrate, micronized LOFIBRA CAPS TRI-NORINYL fenofibrate nanocrystallized TRICOR norethindrone- 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 fenofibrate TRIGLIDE ST noreth a-et estra/fe fumarate LO LOESTRIN FE QL icosapent ethyl VASCEPA Contraceptives, Transdermal Niacin Preparations QL /ethin.estradiol ORTHO EVRA 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 Angiotensin Recept-Neprilysin Inhibitor Comb(ARNI) phenylephrine hcl/prometh hcl PHENERGAN VC QL sacubitril/valsartan ENTRESTO Narcotic Antitussive-1st Generation Antihistamine- Antianginal & Anti-Ischemic Agents, Non-Hemodynamic Decongestants QL ranolazine RANEXA phenylephrine hcl/cod/prometh PHENERGAN VC Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker W/CODEINE Combinations Narcotic Antitussive-1st Generation Antihistamines QL amlodipine/atorvastatin CADUET codeine/promethazine hcl PHENERGAN Heart Rate Reducing, Selective I(F) Current Inhib. W/CODEINE PA + ivabradine hcl CORLANOR hydrocodone/chlorphen p-stirex TUSSIONEX QL Narcotic Antitussive-Anticholinergic Comb. CARDIOVASCULAR DISEASE - VASODILATION HYCODAN hydrocodone/homatrop me-br Vasodilators, Combination Non-Narcotic Antitussive-1st Generation Antihistamine isosorb dinit/hydralazine hcl BIDIL Combinations Vasodilators, Coronary d-methorphan hb/prometh hcl PHENERGAN W/ isosorbide dinitrate ISOCHRON DEXTROMETHORPHAN ISORDIL DERMATOLOGY - ACNE ISORDIL TITRADOSE Acne Agents, Systemic isosorbide mononitrate IMDUR AMNESTEEM ISMO isotretinoin CLARAVIS MONOKET MYORISAN nitroglycerin transdermal patch NITRO-DUR SOTRET nitroglycerin sublingual soln NITROLINGUAL ZENATANE nitroglycerin transdermal ointment NITRO-BID Acne Agents, Topical nitroglycerin sublingual tablet NITROSTAT AGE adapalene/benzoyl peroxide EPIDUO, EPIDUO FORTE CONTRACEPTION/OXYTOCICS clindamycin phos/benzoyl ONEXTON Contraceptives, Intravaginal, Systemic peroxide QL /ethinyl estradiol NUVARING clindamycin/Tretinoin ZIANA Contraceptives, Oral sodium KLARON desog-et estra/ethin estra MIRCETTE Keratolytic-Glucocorticoid Combinations -ethinyl estradiol CYCLESSA benzoyl peroxide/hydrocortison VANOXIDE-HC DESOGEN Keratolytics ORTHO-CEPT benzoyl peroxide BREVOXYL-4 ST ethinyl estradiol/ GIANVI BREVOXYL-8 ST LORYNA TRIAZ ST OCELLA podofilox CONDYLOX ST SYEDA 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 erythromycin base/benz per BENZAMYCIN

37012 MedPerform Medium Formulary – July 2017 12 INTEGRIS Formulary

erythromycin base/ EMGEL hydrocort/sal acid/sulf/shmp#1 SCALACORT DK ERYGEL TEXACORT gentamicin sulfate GARAMYCIN /emoll LOCOID LIPOCREAM mupirocin ointment BACTROBAN hydrocortisone probutate PANDEL CENTANY Topical Anti-Inflammatory, NSAIDs mupirocin calcium cream BACTROBAN diclofenac sodium VOLTAREN GEL clindamycin phosphate EVOCLIN Topical Antibiotics/Antiinflammatory, Steroidal erythromycin base/benz per BENZAMYCIN PAK neomy sulf/polymyx b sulf/hc CORTISPORIN CREAM

/bacitra/polymyxin/hc CORTISPORIN OINT Topical Antifungals DERMATOLOGY - MISCELLANEOUS ciclopirox olamine LOPROX Antiperspirants ciclopirox 8% solution CICLODAN aluminum chloride DRYSOL /betamet diprop LOTRISONE Antiseborrheic Agents KURIC selenium sulfide SELSUN RX NIZORAL sulfacetamide sodium OVACE PLUS NAFTIN naftifine hcl 1% cream SUSPENSION naftifine hcl 1% gel, 2% NAFTIN Topical Antineoplastic & Premalignant Lesion Agents cream/gel fluorouracil EFUDEX nystatin MYCOSTATIN PA bexarotene TARGRETIN nystatin/triamcin MYCOLOG II QL ingenol PICATO sulconazole nitrate EXELDERM PA mechlorethamine gel VALCHLOR terbinafine hcl LAMISIL Topical Local Anesthetics Topical Antiparasitics hc acetate/pramoxine hcl PRAMOSONE lindane KWELL DERMATOLOGY - PIGMENTATION DISORDERS malathion OVIDE Topical Hyperpigmentation Agents permethrin ELIMITE methoxsalen OXSORALEN crotamiton EURAX DERMATOLOGY - PSORIASIS/ECZEMA Topical Antivirals Antipsoriatic Agents, Systemic acyclovir ZOVIRAX OINTMENT acitretin SORIATANE acyclovir ZOVIRAX CREAM PA apremilast OTEZLA Topical Sulfonamides methoxsalen, rapid OXSORALEN-ULTRA SILVADENE silver methoxsalen 8-MOP THERMAZENE PA secukinumab COSENTYX DERMATOLOGY - ANTIINFLAMMATORY Antipsoriatics Agents Topical Anti-Inflammatory Steroidal calcipotriene DOVONEX dipropionate ACLOVATE anthralin DRITHO-SCALP CYCLOCORT ST anthralin DRITHOCREME HP betamet diprop/prop gly DIPROLENE DIPROLENE AF tazarotene TAZORAC betamethasone dipropionate DEL-BETA Topical Immunosuppressive Agents DIPROSONE tacrolimus PROTOPIC VALISONE pimecolimus ELIDEL propionate CLOBEX Topical Phosphodiesterase (PDE-4) Inhibitor OLUX TEMOVATE crisaborole EUCRISA clobetasol propionate/emoll TEMOVATE EMOLLIENT DESOWEN TRIDESILON DIABETES TOPICORT Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non- TOPICORT LP Sulfonylurea) diacetate APEXICON acarbose PRECOSE acetonide SYNALAR Antihyperglycemic, Amylin Analog-Type LIDEX pramlintide acetate SYMLIN VANOS SYMLINPEN 120 SYMLINPEN 60 fluocinonide/emollient LIDEX-E Antihyperglycemic, DPP-4 Inhibitors fluticasone propionate CUTIVATE QL linagliptin TRADJENTA halobetasol propionate ULTRAVATE QL sitagliptin phosphate JANUVIA hydrocortisone LACTICARE-HC REDERM Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations SCALACORT QL linagliptin/metformin hcl JENTADUETO /urea CARMOL HC QL sitagliptin phos/metformin hcl JANUMET QL sitagliptin phos/metformin hcl JANUMET XR hydrocortisone butyrate LOCOID WESTCORT Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists) mometasone furoate ELOCON QL + dulaglutide TRULICITY triamcinolone acetonide KENALOG ST TRIDERM QL + liraglutide VICTOZA /emoll APEXICON E ST flurandrenolide CORDRAN Antihyperglycemic, Insulin-Release Stimulant Type CORDRAN SP chlorpropamide DIABINESE

37012 MedPerform Medium Formulary – July 2017 13 INTEGRIS Formulary

glimepiride AMARYL Insulins glipizide GLUCOTROL QL insulin glargine,hum.rec.anlog LANTUS GLUCOTROL XL QL TOUJEO glipizide/metformin hcl METAGLIP QL insulin lispro HUMALOG glyburide MICRONASE QL insulin nph hum/reg insulin hm HUMULIN 70-30 nateglinide STARLIX QL insulin nph human isophane HUMULIN N repaglinide PRANDIN QL insulin npl/insulin lispro HUMALOG MIX 50-50 tolazamide TOLINASE QL HUMALOG MIX 75-25 tolbutamide ORINASE QL insulin regular, human HUMULIN R glyburide DIABETA QL insulin regular, human HUMULIN R U-500 KWIK Antihyperglycemic, Insulin-Response Enhancer (Non- PEN Sulfonylurea) Syringes & Accessories pioglitazone hcl ACTOS syringes & needles ALL COMMERCIALLY AVAILABLE SYRINGES AND NEEDLES Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) EAR - GENERAL DISORDERS metformin hcl GLUCOPHAGE GLUCOPHAGE XR Ear Preparations, Misc. Anti-Infectives metformin hcl RIOMET VOSOL Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations acetic acid/aluminum acetate DOMEBORO glyburide, micro/metformin hcl GLUCOVANCE acetic acid/hydrocortisone VOSOL HC repaglinide/metformin hcl PRANDIMET Ear Preparations, Antibiotics neomy sulf/polymyx b sulf/hc CORTISPORIN OTIC Antihyperglycemic, Insulin-Response & Release Combinations OTICIN HC ST pioglitazone/glimepiride DUETACT FLOXIN Antihyperglycemic Insul-Resp. Enhancer & Biguanide Otic Preparations, Anti-Inflammatory-Antibiotics Combinations hcl/dexameth CIPRODEX ST pioglitazone hcl/metformin hcl ACTOPLUS MET Otic Preparations, Local anesthetics ST pioglitazone hcl/metformin hcl ACTOPLUS MET XR antipyrine/benzocaine otic BENZOTIC Antihyperglycemic-Glucocorticoid Receptor Blockers ELECTROLYTE REGULATION PA KORLYM Electrolyte Depleters Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors calcium acetate PHOSLO QL + canagliflozin INVOKANA sodium polystyrene sulfonate KAYEXALATE ST sevelamer carbonate RENVELA QL + empagliflozin JARDIANCE sevelamer hcl RENAGEL ST Potassium Replacement Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) potassium chloride K-DUR Inhibitor and Biguanide Combination K-TAB QL + canagliflozin/metformin hcl INVOKAMET MICRO-K ST ENDOCRINE DISORDER - FERTILITY QL + canagliflozin/metformin hcl XR INVOKAMET XR Drugs to Treat Impotency ST QL sildenafil citrate VIAGRA QL + empagliflozin/metformin hcl SYNJARDY Fertility Stimulating Preparations, Non-FSH ST QL + empagliflozin/metformin hcl XR SYNJARDY XR clomiphene citrate CLOMID ST SEROPHENE Follicle Stimulating / Luteinizing Hormones Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination follitropin alpha, recomb GONAL-F QL + empagliflozin/linagliptin GLYXAMBI GONAL-F RFF ST ,chorionic, human NOVAREL Diabetic Supplies PREGNYL PROFASI blood-glucose calib. control ABBOTT CONTROL PRODUCTS (e.g., hcg alpha, recombinant OVIDREL FREESTYLE, menotropins MENOPUR PRECISION) REPRONEX Pregnancy Facilitating/Maintaining Agents, Hormonal blood-glucose meter ABBOTT METERS(e.g., , micronized CRINONE FREESTYLE, ENDOMETRIN PRECISION) PROCHIEVE ENDOCRINE DISORDER - OTHER blood sugar diagnostics ABBOTT TEST STRIPS Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants (e.g., FREESTYLE, PA leuprolide ELIGARD PRECISION) Antidiuretic & Vasopressor Hormones

desmopressin (nonrefrigerated) DDAVP lancing device/lancets ABBOTT PRODUCTS Bone Formation Stim. Agents - Parathyroid Hormone

QL teriparatide FORTEO Diabetic Ulcer Preparations, Topical Bone Resorption Inhibitor & Vitamin D Combinations becaplermin REGRANEX alendronate sodium/vitamin d3 FOSAMAX PLUS D Hyperglycemics Bone Resorption Inhibitors glucagon,human recombinant GLUCAGON EMERGENCY KIT alendronate sodium tablet FOSAMAX QL alendronate sodium solution FOSAMAX SOLUTION

37012 MedPerform Medium Formulary – July 2017 14 INTEGRIS Formulary

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

37012 MedPerform Medium Formulary – July 2017 15 INTEGRIS Formulary

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

37012 MedPerform Medium Formulary – July 2017 16 INTEGRIS Formulary

erythromycin base ERY-TAB PA THALOMID PCE Antitubercular Antibiotics erythromycin ethylsuccinate ERYPED 200 rifampin RIFADIN ERYPED 400 rifampin/ RIFAMATE QL + DIFICID Rifamycins and Related Derivative Antibiotics ST PA XIFAXAN 550MG

Vancomycin & Derivatives Nitrofuran Derivatives QL vancomycin hcl VANCOCIN HCL macrocrystal MACRODANTIN INFECTIOUS DISEASE - PARASITIC nitrofurantoin/nitrofuran mac MACROBID Amebacides furazolidone FUROXONE sulfate HUMATIN nitrofurantoin FURADANTIN iodoquinol YODOXIN Oxazolidinones Anaerobic Antiprotozoal-Antibacterial Agents PA ZYVOX metronidazole FLAGYL PA tedizolid phosphate tablet SIVEXTRO TABLET metronidazole FLAGYL ER Penicillins Anthelmintics amox tr/potassium clavulanate AUGMENTIN AUGMENTIN ES-600 praziquantel BILTRICIDE AUGMENTIN XR PA mebendazole EMVERM amoxicillin trihydrate AMOXIL Antimalarial Drugs ampicillin trihydrate POLYCILLIN chloroquine phosphate ARALEN PHOSPHATE dicloxacillin sodium PATHOCIL hydroxychloroquine sulfate PLAQUENIL penicillin v potassium V-CILLIN K mefloquine hcl LARIAM Quinolones quinine sulfate QUALAQUIN ciprofloxacin CIPRO ORAL SUSP primaquine phosphate PRIMAQUINE ciprofloxacin hcl CIPRO PA pyrimethamine DARAPRIM LEVAQUIN Antiprotozoal Drugs, Miscellaneous moxifloxacin hcl AVELOX PA miltefoside IMPAVIDO AVELOX ABC PACK isethionate NEBUPENT Ofloxacin FLOXIN INFECTIOUS DISEASE - VIRAL Tetracyclines All oral, non-experimental antiviral agents used for the treatment QL hyclate VIBRAMYCIN 100MG of AIDS or HIV-related diseases are considered a formulary CAPSULE benefit. QL MORGIDOX 50MG Antiretroviral Combination, Integrase Inhibitors CAPSULE QL abacavir/dolutegravir/lamivudine TRIUMEQ QL MORGIDOX 100MG QL elvitegravir/cobicistat/emtricitabine STRIBILD CAPSULE / tenofovir disoproxil fumarate QL elviteg/cobi/emtric/tenofo ala GENVOYA QL doxycycline monohydrate DOXYCYCLINE Antivirals, General MONOHYDRATE 150MG acyclovir ZOVIRAX TABLET ganciclovir CYTOVENE minocycline hcl DYNACIN MINOCIN valacyclovir hcl VALTREX 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 QL tipranavir APTIVUS CAPS itraconazole SPORANOX QL tipranavir/vitamin e tpgs APTIVUS SOLN ketoconazole NIZORAL Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog terbinafine hcl LAMISIL QL emtricitabine/tenofov alafenam DESCOVY voriconazole VFEND QL emtricitabine/tenofovir TRUVADA terbinafine hcl LAMISIL GRANULES Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb Antifungal Antibiotics QL abacavir/lamivudine/zidovudine TRIZIVIR griseofulvin ultramicrosize GRIS-PEG QL abacavir sulfate/lamivudine EPZICOM nystatin MYCOSTATIN QL lamivudine/zidovudine COMBIVIR griseofulvin suspension GRISEOFULVIN V Antivirals, HIV-Specific, CCR5 Co-Receptor Antag. INFECTIOUS DISEASE - MISCELLANEOUS QL maraviroc SELZENTRY Aminoglycosides Antivirals, HIV-Specific, Fusion Inhibitors neomycin sulfate MYCIFRADIN QL enfuvirtide FUZEON PA tobramycin in 0.225% nacl TOBI Antivirals, HIV-Specific, Non-Nucleoside, RTI PA tobramycin TOBI PODHALER QL nevirapine VIRAMUNE Anti-Mycobacterium Agents QL nevirapine ER VIRAMUNE XR ethambutol hcl MYAMBUTOL delavirdine mesylate RESCRIPTOR isoniazid NYDRAZID efavirenz SUSTIVA pyrazinamide PYRAZINAMIDE QL etravirine INTELENCE Antileprotics QL rilpivirine EDURANT AVLOSULFON Antivirals, HIV-Specific, Nucleoside Analog, RTI

37012 MedPerform Medium Formulary – July 2017 17 INTEGRIS Formulary

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

Glucocorticoids hc acetate/pramoxine hcl PROCTOFOAM-HC budesonide BUDESONIDE Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) acetate CORTONE ACETATE hydrocortisone CORTENEMA dexamethasone tablet, elixir DECADRON LOWER GASTROINTESTINAL DISORDERS - OTHER hydrocortisone CORTEF Ammonia Inhibitors MEDROL lactulose CHRONULAC prednisolone MILLIPRED sodium phenylbutyrate BUPHENYL POWDER MILLIPRED DP sodium phenylbutyrate BUPHENYL TABLET prednisolone sod phosphate ORAPRED Antidiarrheals PEDIAPRED diphenoxylate hcl/atrop sulf LOMOTIL prednisone DELTASONE

37012 MedPerform Medium Formulary – July 2017 18 INTEGRIS Formulary

Bile Salts PA tofacitinib XELJANZ ursodiol ACTIGALL PA tofacitinib XR XELJANZ XR URSO Antineoplastic - MEK1 and MEK2 Kinase Inhibitors URSO FORTE PA + cobimetinib fumarate COTELLIC Laxatives & Cathartics QL peg 3350/na sulf,bicarb,cl/kcl COLYTE WITH FLAVOR Antineoplastic - Topoisomerase I Inhibitors PACKETS topotecan hcl HYCAMTIN polyethylene glycol 3350 MIRALAX Antineoplastic - Immunomodulator Agents sod chloride/nahco3/kcl/peg's NULYTELY WITH PA + lenalidomide REVLIMID FLAVOR PACKS QL lactulose KRISTALOSE PA pomalidomide POMALYST peg 3350/na sulf,bicarb,cl/kcl GOLYTELY Antineoplastic - Systemic Enzyme Inhibitors OCL PA afatinib GILOTRIF Narcotic Antagonists, Peripherally-Acting PA + alectinib hydrochloride ALECENSA QL naloxegol oxalate MOVANTIK QL Inhibitor PA+ axitinib INLYTA PA telotristat XERMELO QL Glucagon-Like Peptide (GLP-2) Analogs PA bosutinib BOSULIF PA teduglutide [rDNA origin] GATTEX PA cabozanitinib COMETRIQ MISCELLANEOUS AGENTS PA cabozantinib s-malate CABOMETYX Anaphylaxis Therapy Agents PA ceritinib ZYKADIA epinephrine EPIPEN PA crizotinib XALKORI QL epinephrine EPIPEN JR PA dabrafanib TAFINLAR Parasympathetic Agents PA dasatinib SPRYCEL bethanechol chloride URECHOLINE PA + erlotinib hcl TARCEVA cevimeline hcl EVOXAC QL pilocarpine hcl SALAGEN PA gefitinib IRESSA Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase PA ibrutinib IMBRUVICA PA sapropterin dihydrochloride KUVA PA idelalisib ZYDELIG NEOPLASTIC DISEASE PA imatinib mesylate GLEEVEC Alkylating Agents PA lapatinib ditosylate TYKERB cyclophosphamide CYTOXAN PA ixazomib citrate NINLARO hydroxyurea HYDREA PA lenvatinib mesylate LENVIMA lomustine CEENU PA nilotinib hydrochloride TASIGNA PA temozolomide TEMODAR PA olaparib LYNPARZA altretamine HEXALEN PA + osimertinib mesylate TAGRISSO busulfan MYLERAN QL chlorambucil LEUKERAN PA pazopanib hydrochloride VOTRIENT melphalan ALKERAN PA palbociclib IBRANCE Antiandrogenic Agents PA ponatinib ICLUSIG CASODEX PA regorafenib STIVARGA EULEXIN PA ribociclib succinat KISQALI PA ZYTIGA PA sorafenib tosylate NEXAVAR PA XTANDI PA sunitinib malate SUTENT QL NILANDRON PA trametinib dimethyl sulfoxide MEKINIST Antimetabolites PA vemurafenib ZELBORAF PA capecitabine XELODA mercaptopurine PURINETHOL Antineoplastic, Histone Deacetylase Inhibitors, HDIS methotrexate sodium METHOTREXATE PA panobinostat lactate FARYDAK TABLET vorinostat ZOLINZA methotrexate sodium METHOTREXATE VIAL Antineoplastics, Miscellaneous thioguanine THIOGUANINE etoposide VEPESID fludarabine phosphate OFORTA LYSODREN ST mercaptopurine PURIXAN hcl MATULANE methotrexate sodium TREXALL tretinoin VESANOID PA trifluridine/tipiracil hcl LONSURF PA everolimus AFINITOR Antineoplastic - Aromatase Inhibitors QL ARIMIDEX PA everolimus AFINITOR DISPERZ AROMASIN Chemotherapy Rescue/Antidote Agents FEMARA leucovorin calcium LEUCOVORIN CALCIUM Antineoplastic – B Cell Lymphoma 2(BCL-2) Inhibitors QL vridine triacetate VISTOGARD PA venetoclax VENCLEXTA Selective Estrogen Receptor Modulators (SERM) Antineoplastic – Hedgehog Pathway Inhibitors citrate NOLVADEX PA vismodegib ERIVEDGE PA citrate FARESTON PA sonidegib phosphate ODOMZO Selective Retinoid X Receptor Agonists (RXR) Antineoplastic – Janus Kinase (JAK) Inhibitors PA bexarotene TARGRETIN PA ruxolitinib JAKAFI Steroid Antineoplastics

37012 MedPerform Medium Formulary – July 2017 19 INTEGRIS Formulary

acetate MEGACE Analgesics, Narcotics phosphate sodium EMCYT codeine phos/carisoprodol/asa SOMA COMPOUND WITH NEUROLOGICAL DISEASE - MISCELLANEOUS CODEINE Agents to Treat Multiple Sclerosis PA fentanyl DURAGESIC PA glatiramer acetate COPAXONE PA fentanyl citrate lozenge ACTIQ PA dimethyl fumarate TECFIDERA QL hydrocodone VICODIN PA fingolimod hcl GILENYA bit/acetaminophen (300mg) VICODIN ES VICODIN HP PA interferon beta-1a AVONEX QL LORCET PA interferon beta-1a/albumin AVONEX hydrocodone LORCET PLUS ADMINISTRATION PACK bit/acetaminophen (325mg) LORTAB PA REBIF NORCO PA REBIF REBIDOSE QL LORTAB ELIXIR PA peginterferon beta-1a PLEGRIDY hydrocodone PA PLEGRIDY PEN bit/acetaminophen PA teriflunomide AUBAGIO (300mg/15ml) oral solution QL hydrocodone HYCET Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor bit/acetaminophen oral elixir milnacipran hcl SAVELLA (325mg/15ml) Movement Disorders (Drug Therapy) QL hydrocodone bitartrate HYSINGLA ER PA tetrabenazine XENAZINE hydromorphone hcl DILAUDID ORAL/PHARYNGEAL DISORDERS methadone hcl DOLOPHINE HCL Dental Aids & Preparations QL + methadone solution METHADONE chlorhexidine gluconate PERIDEX ST triamcinolone acetonide KENALOG IN ORABASE QL morphine sulfate AVINZA Nose Preparations, Antibiotics QL morphine sulfate MS CONTIN mupirocin calcium BACTROBAN NASAL morphine sulfate MSIR Nose Preparations, Miscellaneous (Rx) ORAMORPH SR ipratropium bromide ATROVENT ROXANOL OTHER DRUGS oxycodone hcl PERCOLONE Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome ROXICODONE ROXICODONE MEGACE INTENSOL MEGACE ES QL oxycodone hcl/acetaminophen PERCOCET General Inhalation Agents (325mg) sodium chloride for inhalation HYPER-SAL 7% QL oxycodone hcl/acetaminophen ROXICET Metabolic disease enzyme replace, hypophosphatasia (325mg/5ml) PA asfotase alfa STRENSIQ oxycodone hcl/aspirin PERCODAN Needles/Needleless Devices tramadol hcl ULTRAM needles, insulin disp., safety PEN NEEDLE tramadol hcl/acetaminophen ULTRACET Nucleic Acid/Nucleotide Supplements QL buprenorphine BUTRANS PA uridine triacetate XURIDEN QL hydrocodone bit/acetaminophen STAGESIC-10 Somatostatic Agents (250mg) octreotide acetate SANDOSTATIN QL hydrocodone bit/acetaminophen XODOL 10-300 Drugs to treat hereditary tyrosinemia (300mg) PA nitisinone ORFADIN hydromorphone hcl DILAUDID-5 OTHER RESPIRATORY DISORDERS QL oxycodone hcl OXYCONTIN Antifibrotic Therapy – Pyridone Analogs QL tapentadol hcl NUCYNTA PA pirfenidone ESBRIET QL tapentadol hcl ER NUCYNTA ER Cystic Fibrosis-Cftr Potentiator & Corrector Comb. Antimigraine Preparations PA lumacaftor/ivacaftor ORKAMBI QL ergotamine tartrate/caffeine CAFERGOT Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) QL MIGERGOT Potentiators isomethept/acetaminop/ MIDRIN PA ivacaftor KALYDECO dichlphn Mucolytics QL naratriptan AMERGE acetylcysteine MUCOMYST-10 QL rizatriptan benzoate MAXALT PA dornase alfa PULMOZYME MAXALT MLT Pulmonary Fibrosis - Systemic Enzyme Inhibitors QL sumatriptan IMITREX NASAL SPRAY PA nintedanib esylate OFEV QL sumatriptan succinate IMITREX TABLET PAIN MANAGEMENT - ANALGESICS IMITREX INJECTION Analgesic, Non-Salicylate & Barbiturate Combinations QL + zolmitriptan ZOMIG butalbital/acetaminophen PHRENILIN ST ZOMIG ZMT butalbital/acetaminophen PHRENILIN FORTE Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine Analgesic, Salicylate, Barbiturate & Xanthine Combinations Combinations butalbital/aspirin/caffeine FIORINAL codeine/butalbit/acetamin/caff FIORICET WITH Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations CODEINE butalb/acetaminophen/caffeine ESGIC Narcotic & Salicylate Analgesics, Barbiturates & Xanthines FIORICET codeine/butalbital/asa/caffein FIORINAL WITH Analgesic/Antipyretics, Salicylates CODEINE #3 diflunisal DOLOBID Narcotic Analgesic & Non-Salicylate Analgesic Combinations salsalate DISALCID acetaminophen with codeine TYLENOL-CODEINE NO.3

37012 MedPerform Medium Formulary – July 2017 20 INTEGRIS Formulary

TYLENOL-CODEINE NO.4 carisoprodol SOMA acetaminophen and codeine CAPITAL AND CODEINE carisoprodol/aspirin SOMA COMPOUND chlorzoxazone PARAFON FORTE DSC cyclobenzaprine hcl FLEXERIL

dantrolene sodium DANTRIUM Narcotic Withdrawal Therapy Agents metaxalone SKELAXIN QL + buprenorphine hcl/naloxone hcl SUBOXONE methocarbamol ROBAXIN CU ROBAXIN-750 PA + buprenorphine hcl SUBUTEX CU orphenadrine citrate NORFLEX QL + buprenorphine hcl/naloxone hcl ZUBSOLV orphenadrine/aspirin/caffeine NORGESIC FORTE CU tizanidine hcl ZANAFLEX PARKINSON’S DISEASE UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE Antiparkinsonism Drugs, Anticholinergic Pancreatic Enzymes benztropine mesylate COGENTIN amylase/lipase/protease PANCRELIPASE 5,000 trihexyphenidyl hcl ARTANE amylase/lipase/protease CREON Antiparkinsonism Drugs, Other ULTRASE amantadine hcl SYMMETREL ULTRASE MT ZENPEP bromocriptine mesylate PARLODEL UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE /levodopa PARCOPA SINEMET 25-100 Anticholinergics/Antispasmodics SINEMET CR dicyclomine hcl BENTYL carbidopa/levodopa/ STALEVO Belladonna Alkaloids entacapone COMTAN belladonna alkaloids/phenobarb DONNATAL pramipexole di-hcl MIRAPEX hyoscyamine sulfate ANASPAZ ropinirole hcl REQUIP LEVBID QL + REQUIP XL LEVSIN-SL ST UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE hcl ELDEPRYL Anti-Ulcer Preparations QL mesylate AZILECT misoprostol CYTOTEC QL + rotigotine NEUPRO sucralfate CARAFATE ST Anti-Ulcer-H.pylori Agents Decarboxylase Inhibitors lansoprazole/amox tr/clarith PREVPAC carbidopa LODOSYN Anticholinergics, Quaternary Ammonium SEIZURE DISORDER chlordiazepoxide/clidinium br LIBRAX Anticonvulsants Histamine H2-Receptor Inhibitors carbamazepine CARBATROL hcl TAGAMET TEGRETOL famotidine PEPCID TEGRETOL XR nizatidine AXID clonazepam KLONOPIN ranitidine hcl ZANTAC QL diazepam DIASTAT Intestinal Motility Stimulants divalproex sodium DEPAKOTE hcl REGLAN DEPAKOTE ER Proton-Pump Inhibitors DEPAKOTE SPRINKLE QL esomeprazole magnesium NEXIUM Ethosuximide ZARONTIN lansoprazole PREVACID RX QL ezogabine POTIGA omeprazole capsules (RX) PRILOSEC (RX) gabapentin NEURONTIN CAPSULES QL lacosamide VIMPAT ORAL SOLUTION omeprazole magnesium (OTC) PRILOSEC OTC QL lacosamide VIMPAT TABLETS tablets TABLETS (OTC) lamotrigine LAMICTAL pantoprazole sodium PROTONIX levetiracetam KEPPRA ST lansoprazole PREVACID SOLUTABS oxcarbazepine TRILEPTAL ST pantoprazole sodium suspension PROTONIX SUSP phenytoin DILANTIN-125 URINARY TRACT - FUNCTIONAL DISORDERS DILANTIN CHEW TAB Benign Prostatic Hypertrophy/Micturition Agents phenytoin sodium extended DILANTIN alfuzosin UROXATRAL PHENYTEK AVODART primidone MYSOLINE PROSCAR topiramate TOPAMAX tamsulosin hcl FLOMAX topiramate TOPAMAX SPRINKLE Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag QL topiramate TROKENDI XR comb agents sodium DEPAKENE SYRUP ST dutasteride/tamsulosin hcl JALYN valproic acid DEPAKENE CAPSULES Kidney Stone Agents zonisamide ZONEGRAN PA cysteamine bitartrate PROCYSBI pregabalin LYRICA Overactive Bladder Agents, Beta-3 Adrenergic Recep SKELETAL MUSCLE DISORDER mirabegron MYRBETRIQ Agents To Treat Periodic Paralysis Urinary Tract Analgesic Agents PA dichlorphenamide KEVEYIS pentosan polysulfate sodium ELMIRON Skeletal Muscle Relaxants Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) baclofen LIORESAL phenazopyridine hcl PYRIDIUM

37012 MedPerform Medium Formulary – July 2017 21 INTEGRIS Formulary

Urinary Tract Antispasmodic, M(3) Selective Antagonists Agents to Treat Multiple Sclerosis Page 10 solifenacin succinate VESICARE Urinary Tract Antispasmodic/Antiincontinence Agents RHEUMATOID ARTHRITIS Anti-Inflammatory, Pyrimidine Synthesis Inhibitors Page 9 tolterodine tartrate DETROL

DETROL LA MEDICATION PRESCRIBING LIMITATIONS oxybutynin chloride DITROPAN XL fesoterodine fumarate TOVIAZ 1. AGE RESTRICTIONS (FORMULARY)- Covered for ages: VAGINAL DISORDERS • Differin ≤ 25 years old Vaginal Antibiotics • Epiduo ≤ 25 years old metronidazole METROGEL-VAGINAL • EpiduoForte ≤ 25 years old VANDAZOLE • Fabior ≥ 12 years old • Ritalin LA 60mg ≤ 18 years old Vaginal Antifungals • Ritalin SR ≤ 18 years old nitrate MONISTAT 3 nitrate GYNAZOLE-1 Vaginal Estrogen Preparations 2. AGE RESTRICTIONS (NON FORMULARY)- Covered for ages: • ≥ 2 years old estradiol cream ESTRACE All carbinoxamine containing products (i.e., Palgic, Tussafed, etc.) estradiol tablet VAGIFEM • Atralin ≤ 25 years old estrogens, conjugated PREMARIN • Avita ≤ 25 years old Vaginal Sulfonamides • Epaned (Step Therapy applies) ≥ 12 years old AVC • Oracea ≥ 18 years old VITAMIN AND/OR MINERAL DEFICIENCY • Refissa ≤ 25 years old Fluoride Preparations • Renova ≤ 25 years old sodium fluoride FLUORITAB • Retin-A ≤ 25 years old FLURA-DROPS • Retin-A Micro ≤ 25 years old FLURA-TABS • Retin-A Micro Pump ≤ 25 years old LURIDE • Solodyn ≥ 12 years old Folic Acid Preparations • Tretin-X ≤ 25 years old folic acid FOLIC ACID Multivitamin Preparations 3. QUANTITY RESTRICTIONS (FORMULARY) folic acid/mu-vits-min th VICON FORTE • Abilify 30 tablets per 30 days Pediatric Vitamin Preparations tablets solution 900mL per 30 days fluoride /iron/vit a,c&d TRI-VI-FLOR W/IRON • Abilify Discmelt fluoride ion/multivitamins POLY-VI-FLOR 10mg 90 tablets per 30 days fluoride ion/multivits w-fe POLY-VI-FLOR W/IRON 15mg 60 tablets per 30 days fluoride ion/vit a,c&d FLUORABON BASIC • Adderall 60 tablets per 30 days Prenatal Vitamin Preparations • Adderall XR prenatal vit 15/iron cb/fa/dss TRIADVANCE 5mg, 10mg, 15mg 30 capsules per 30 days prenatal vit 16/iron cb/fa/dss VINATE GT 20mg, 25mg, 30mg 60 capsules per 30 days • 60 units per 30 days prenatal vit 18/iron cb/fa/dss VINATE ULTRA Advair Diskus • Advair HFA 12g (1 inhaler) per 30 days prenatal vit 95/fe fum/fa PRENAVITE • Afinitor 30 tablets per 30 days Vitamin B Preparations • Akynzeo 1 capsule per 28 days cyanocobalamin/fa/pyridoxine FOLGARD RX • Aldara 24 packets per 30 days Vitamin D Preparations • Ambien / Ambien CR 30 tablets per 30 days calcitriol ROCALTROL • Amerge 18 tablets per 30 days calcitriol VECTICAL • Androxy 120 tablets per 30 days ergocalciferol DRISDOL • Anoro Ellipta 60 blister packs per 30 days • Aptivus SPECIALTY INJECTABLE CROSS REFERENCE LISTING capsule 120 capsules per 30 days solution 380mL (4 bottles) per 30 days The following cross reference is being provided as a guide to • Arixtra 10 syringes per 30 days formulary choices within prominent “specialty” injectable drug • Asmanex 1 inhaler per 30 days categories. General specialty categories are cross referenced to • Asmanex HFA 13g (1 inhaler) per 30 days their corresponding formulary classification status and page • Astelin 60mL (2 bottles) per 30 days number. This cross reference is not meant to be all-inclusive. • Astepro 60mL (2 bottles) per 30 days Please refer to the Table of Contents or Index to determine • Atripla 30 tablets per 30 days formulary status of injectable medications not listed in this cross • Atrovent HFA 2 inhalers per 28 days reference (e.g., Antineoplastics, Leukocyte Stimulants, etc.). • Avinza

EPO 30mg, 45mg, 60mg, 30 capsule per 60 days Hematinics, Other Page 7 75mg, 90mg 120mg 60 capsules per 30 days HEPATITIS C • Azilect 30 tablets per 30 days Hepatitis C Treatment Agents Page 9 • Baraclude 0.5mg, 1mg 30 tablets per 30 days HUMAN GROWTH FACTORS oral solution 630ml per 30 days Growth Hormones Page 6 • Belsomra 30 tablets per 30 days • Breo Ellipta 60 units per 30 days LOW MOLECULAR WEIGHT HEPARINS • Brilinta 60 tablets per 30 days Heparin and Related Preparations Page 7 • Butrans 4 patches per 28 days • Caduet 30 tablets per 30 days MULTIPLE SCLEROSIS

37012 MedPerform Medium Formulary – July 2017 22 INTEGRIS Formulary

• Cafergot 40 tablets 28 days Kwikpen 30mL (10 pens) per 28 days • Climara 4 patches per 28 days • Humulin R • Clozaril 90 tablets per 30 day 100u/mL 40mL (4 vials) per 28 days • Colcrys 120 tablets per 30 days 500u/mL 40mL (2 vials) per 28 days • Combipatch 8 patches per 30 days • Humulin R U-500 • Combivir 60 tablets per 30 days Kwikpen 8 pens (4 boxes of 2 pens) per 28 • Complera 30 tablets per 30 days days • • Concerta Humulin 70/30 18mg, 27mg, 54mg 30 tablets per 30 days vial 40mL (4 vials) per 28 days 36mg 60 tablets per 30 days Kwikpen 30mL (10 pens) per 28 days • • Corlanor 60 tablets per 30 days Humalog 40mL (4 vials) per 28 days • Cotellic 63 tablets per 28 days vial pen/cartridge 30mL (10 pens/cartridges) per 28 • Crestor 30 tablets per 30 days days • Cymbalta 60 capsules per 30 days • Humalog Mix 50/50 / • 30 tablets per 30 days Daliresp 75/25 40mL (4 vials) per 28 days • Depo-Testosterone 10mL per 30 days vial 30mL (10 pens) per 28 days • Descovy 30 tablets per 30 days Kwikpen • Desvenlafaxine ER 30 tablets per 30 days • Hydrocodone bit/acetaminophen (maximum of 4gm of (Ranbaxy Brand) acetaminophen per day): • Dexedrine Spansule 250mg 16 tablets per 1 day supply 5mg, 10mg 60 capsules per 30 days 300mg 13 tablets per 1 day supply 15mg 120 capsules per 30 days 325mg 12 tablets per 1 day supply • Diastat 1 kit per copay 300mg/15ml soln 200ml per 1 day supply • Dificid 20 tablets per 30 days 325mg/15ml soln 184ml per 1 day supply • Doxycycline Hyclate 60 tablets per 30 days • Hysingla ER 30 tablets per 30 days 100mg • Imitrex • Dulera 13g (1 inhaler) per 30 days tablets (all strengths) 18 tablets per 30 days • Duragesic 10 patches per 30 days nasal spray 12 units per 30 days • Edurant 30 tablets per 30 days injection (kits and • Effient 30 tablets per 30 days vials): • Eliquis 60 tablets per 30 days 6mg/0.5ml vial 4 vials per 30 days • Emend 6mg/0.5ml kit/refill kit 2 kits per 30 days 40mg 1 capsules per -28 days 4mg/0.5ml kit/refill kit 2 kits per 30 days 80mg 2 capsules per 21 days • Inlyta 125mg 1 capsule per 21 days 1mg 180 tablets per 30 days • Emend Trifold Pack 1 packet per 21 days 5mg 120 tablets per 30 days • Emtriva • Intelence 10mg/mL oral solution 850mL per 30 days 25mg, 100mg 120 tablets per 30 days 200mg capsules 30 capsules per 30 days 200mg 60 tablets per 30 days • Entresto 60 tablets per 30 days • Invirase • Epivir 200mg capsules 300 capsules per 30 days 150mg tablets 60 tablets per 30 days 500mg tablets 120 tablets per 30 days 300mg tablets 30 tablets per 30 days • Invokamet 60 tablets per 30 days 10mg/mL oral solution 960mL (4 bottles) per 30 days • Invokamet XR 60 tablets per 30 days • Epivir HBV • Invokana 30 tablets per 30 days 100mg 30 tablets per 30 days • Isentress oral solution 720ml per 30 days 400mg tablets 60 tablets per 30 days • Epzicom 30 tablets per 30 days 25mg, 100mg tablets 180 chew tablets per 30 days • Evista 30 tablets per 30 days 100mg powder 60 packets per 30 days • Evotaz 30 tablets per 30 days • Janumet 60 tablets per 30 days • Exelon patch 30 patches per 30 days • Janumet XR • Fetzima 30 capsules per 30 days 100-1000mg 30 tablets per 30 days • Flonase 16gm (1 bottle) per 30 days 50-1000mg 60 tablets per 30 days • Flunisolide 25mL (1 bottle) per 30 days 50-500mg 60 tablets per 30 days • Focalin 60 tablets per 30 days • Januvia 30 tablets per 30 days • Focalin XR 30 capsules per 30 days • Jentadueto 60 tablets per 30 days • • Forteo 2.4mL (1 pen) per 28 days with a Jardiance 30 tablets per 30 days max duration of 2 years per lifetime • Juxtapid 30 capsules per 30 days • Fragmin • Kaletra 2500 units/0.2mL 2mL (10 syringes) per 30 days 100-25mg tablets 60 tablets per 30 days 5000 units/0.2mL 2mL (10 syringes) per 30 days 200-50mg tablets 120 tablets per 30 days 7500 units/0.3mL 3mL (10 syringes) per 30 days oral solution 480mL (3 bottles) per 30 days 10,000 units/1mL 10mL (10 syringes) per 30 days • Latuda 12,500 units/0.5mL 5mL (10 syringes) per 30 days 20mg, 40mg, 60mg 30 tablets per 30 days 15,000 units/0.6mL 6mL (10 syringes) per 30 days 80mg, 120mg 60 tablets per 30 days 18,000 units/0.72mL 7.2mL (10 syringes) per 30 days • Lantus 25,000 units/ml 7.6mL (2 vials) per 30 days vial 40mL (4 vials) per 28 days • Fuzeon 60 vials per 30 days Solostar 30mL (10 pens) per 28 days • Genvoya 30 tablets per 30 days • Lexiva • Geodon (oral) 60 capsules per 30 days suspension 1800mL (8 bottles) per 30 days • Glyxambi 30 tablets per 30 days tablet 120 tablets per 30 days • Hepsera 30 tablets per 30 days • Linzess 30 capsules per 30 days • Humulin N • Livalo 30 tablets per 30 days vial 40mL (4 vials) per 28 days • Lovaza 120 capsules per 30 days

37012 MedPerform Medium Formulary – July 2017 23 INTEGRIS Formulary

• Lovenox • Prezista 30mg/0.3mL 6mL (20 syringes) per 30 days oral suspension 400mL (2 bottles) per 30 days 40mg/0.4mL 8mL (20 syringes) per 30 days 75mg 480 tablets per 30 days 60mg/0.6mL 12mL (20 syringes) per 30 days 150mg 240 tablets per 30 days 80mg/0.8mL 16mL (20 syringes) per 30 days 400mg, 600mg 60 tablets per 30 days 100mg/1mL 20mL (20 syringes) per 30 days 800mg 30 tablets per 30 days 120mg/0.8mL 16mL (20 syringes) per 30 days • Pristiq 30 tablets per 30 days 150mg/1mL 20mL (20 syringes) per 30 days • Promacta 30 tablets per 30 days 300mg/3mL 30mL (10 vials) per 30 days • Provigil 60 tablets per 30 days • Lumigan 2.5ml per 30 days • Pulmicort Flexhaler 1 inhaler per 30 days • Lunesta 30 tablets per 30 days • Pulmicort Respules 60mL (30 respules) per 30 days • Lynparza 16 capsules per day • Qnasl 8.7g (1 canister) per 30 days • Marinol 60 capsules per 30 days • Qnasl Children 4.9g (1 canister) per 30 days • Maxalt/Maxalt MLT 18 tablets per 30 days • Quillichew ER • Metadate CD 20mg, 40mg 30 tablets per 30 days 30mg 60 tablets per 30 days 30mg 60 tablets per 30 days 10mg, 20mg, 40mg, • Quillivant XR 60mg 30 tablets per 30 days 60mL 60mL (1 bottle) per 30 days • Metadate ER 90 tablets per 30 days 120mL 240mL (2 bottles) per 30 days • Methadone Injection 120mL (6 vials) per 30 days 150mL 300mL (2 bottles) per 30 days Solution 180mL 360mL (2 bottles) per 30 days • Methylin chewable tablet 90 tablets per 30 days • QVAR 17.4g (2 inhalers) per 30 days • Migergot 20 units per 28 days • Ranexa • Morgidox 60 capsules per 30 days 500mg 120 tablets per 30 days 50mg, 100mg 1000mg 60 tablets per 30 days • Movantik 30 tablets per 30 days • Rayaldee 60 capsules per 30 days • MS Contin 90 tablets per 30 days • Requip XL 30 tablets per 30 days • Namenda • Restasis SDV 60 single use vials per 30 days tablets 60 tablets per 30 days • Restasis MDV 1 multidose vial per 30 days titration pack 49 tablets per 28 days • Retrovir solution 300mLper 30 days syrup 1920mL (8 bottles) per 30 days • Namenda XR capsules 180 capsules per 30 days capsules 30 capsules per 30 days tablets 60 tablets per 30 days titration pack 28 capsules per 28 days • Revlimid 30 capsules per 30 days • Namzaric • Rexulti 30 tablets per 30 days capsules 30 capsules per 30 days • Risperdal titration pack 28 capsules per 28 days tablets 60 tablets per 30 days • Narcan 2 boxes (4 nasal sprays) per 30 solution 240ml per 30 days days • Reyataz • Nasacort AQ 16.5g (1 canister) per 30 days 150mg, 200mg 60 capsules per 30 days • Nasarel 25ml (1 bottle) per 30 days 300mg 30 capsules per 30 days • Nasonex 17g (1 canister) per 30 days 50mg 150 packets per 30 days • Neupro 30 patches per 30 days • Ritalin 90 tablets per 30 days • Nexium • Ritalin LA capsules 30 capsules per 30 days 10mg, 20mg, 40mg, 30 capsules per 30 days packets 30 packets per 30 days 60mg • Nilandron 150mg tablet 60 tablets for first 30 days, then 30 30mg 60 capsules per 30 days tablets per 30 days thereafter • Ritalin SR 90 tablets per 30 days • Norvir • Saphris 60 tablets per 30 days oral solution 480mL (2 bottles) per 30 days • Seasonale 91 tablets per 84 days capsules/tablets 360 capsules/tablets per 30 days • Selzentry • Nucynta 180 tablets per 30 days 75mg, 150mg 60 tablets per 30 days • Nucynta ER 60 tablets per 30 days 25mg, 300mg 120 tablets per 30 days • Nuvaring 1 ring per 28 days • Serevent 60 doses (1 diskus) per 30 days • Odefsey 30 tablets per 30 days • Seroquel 90 tablets per 30 days • Ortho Evra 3 patches per 28 days • Silenor 30 tablets per 30 days • Otrexup 1.6mL per 28 days • Spiriva 30 capsules per 30 days • Oxycodone hcl/acetaminophen (maximum of 4gm • Spiriva Respimat 1 inhaler per 30 days acetaminophen per day): • Sonata 30 capsules per 30 days 300mg 13 tablets per 1 day supply • Stiolto Respimat 4g (60 inhalations) per 30 days 325mg 12 tablets per 1 day supply • Strattera 325mg/5ml soln 61mL per 1 day supply 10mg, 18mg, 25mg, • Oxycontin 40mg 60 capsules per 30 days 10mg, 15mg, 20mg, 60mg, 80mg, 100mg 30 capsules per 30 days 30mg, 40mg, 60mg 60 tablets per 30 days • Stribild 30 tablets per 30 days 80mg 120 tablets per 30 days • Striverdi Respimat 4g (60 inhalations) per 30 days • Perforomist 120mL per 30 days • Suboxone • Picato 2/0.5mg, 4/1mg 30 films per 30 days 0.015% gel 3 tubes per 56 days 8/2mg, 12/3mg 60 films per 30 days 0.05% gel 2 tubes per 56 days Tablets 90 tablets per 30 days • Plavix 300mg tablet 4 tablets per 30 days • Symbicort 1 inhaler per 30 days (10.2 grams) • Potiga • Symbyax 30 capsules per 30 days 50mg 270 tablets per 30 days • Synjardy 60 capsules per 30 days 90 tablets per 30 days 200mg, 300mg, 400mg • Synjardy XR • Prezcobix 30 tablets per 30 days

37012 MedPerform Medium Formulary – July 2017 24 INTEGRIS Formulary

5/1000mg,12.5/1000mg 2 tablets per day 20mg, 30mg 60 tablets per 30 days 10/1000mg, 25/1000mg 1 tablet per day • Zerit oral solution 2400mL (12 bottles) per 30 days • Tagrisso 1 tablet per day capsules 60 tablets per 30 days • Tamiflu • Zetia 30 tablets per 30 days 30mg tablets 40 tablets per 183 days • Ziagen 45mg, 75mg tablets 20 tablets per 183 days solution 960mL (4 bottles) per 30 days suspension 360mL per 183 days tablets 60 tablets per 30 days • Trintellix 30 tablets per 30 days • Zofran oral solution • Vimpat 4mg/5ml oral solution 50ml per 15 days 50mg, 100mg, 60 tablets per 30 days • Zomig/Zomig ZMT 150mg, 200mg Tablets 12 tablets per 30 days 10mg/ml oral solution 1200mL per 30 days Nasal Spray 12 units per 30 days • Zubsolv • Zurampic 30 tablets per 30 days 0.7mg/0.18mg 30 sublingual tablets per 30 days • Zyprexa/Zyprexa Zydis 30 tablets per 30 days 1.4/0.36mg 2.9/0.71mg 4. QUANTITY RESTRICTIONS (NON FORMULARY) 5.7/1.4mg • Aciphex 30 tablets per 30 days 60 sublingual tablets per 30 days 11.4/2.9mg • Aciphex Sprinkle 30 capsules per 30 days

8.6/2.1mg • Acticlate 75mg, 150mg 60 tablets per 30 days • Actonel NOTE: The FDA recommends a maximum of 5 days of therapy with 5mg, 30mg 30 tablets per 30 days this drug 35mg 4 tablets per 28 days 150mg 1 tablet per 28 days • Tarceva 30 tablets per 30 days • Aerospan 17.8g (2 inhalers) per 30 days • Tivicay 30 tablets per 30 days • Afrezza • Toradol 20 tablets per fill 4 unit 180 cartridges (2 kits) per 28 days • Toujeo 13.5mL (9 pens) per 28 days 30-4 unit + 60-8 unit 360 cartridges (4 kits) per 28 days • Tradjenta 30 tablets per 30 days 60-4 unit + 30-8 unit 360 cartridges (4 kits) per 28 days • Travatan/Travatan Z 2.5ml per 30 days 60-8 unit + 30-12 unit 360 cartridges (4 kits) per 28 days • Triumeq 30 tablets per 30 days Titration pack 180 cartridges (1 kit) per 28 days • Trizivir 60 tablets per 30 days • Alecensa 240 capsules per 30 days • Trulicity 2mL (4 pens) per 28 days • Alendronate solution 300mL per 28 days • Truvada 30 tablets per 30 days • Allegra • Tybost 30 tablets per 30 days 30mg/5ml oral susp 300ml per 30 days • Uloric 30 tablets per 30 days • Alsuma 4 units per 28 days • Vascepa • Amitiza 60 capsules per 30 days 0.5g 240 capsules per 30 days • Anoro Ellipta 60 blister packs per 30 days 1g 120 capsules per 30 days • Anzemet • Vancocin Oral 50mg 8 tablets per fill 125mg and 250mg 40 capsules per 30 days 100mg 4 tablets per fill • Viagra 6 tablets per 30 days • Aplenzin 30 tablets per 30 days • Vibramycin 100mg 60 capsules per 30 days • Aptiom • Vibra-Tabs 60 tablets per 30 days 200, 400 30 tablets per 30 days • Victoza 9mL (3 pens) per 30 days 600mg, 800mg 60 tablets per 30 days • Videx solution 600mL per 30 days • Arcapta 30 capsules per 30 days • Videx EC • Arnuity Ellipta 30 blister packs per 30 days 125mg, 200mg 60 capsules per 30 days • Atelvia 4 tablets per 28 days 250mg, 400mg 30 capsules per 30 days • Auryxia 12 tablets per day • Viibryd tablets 30 tablets per 30 days • Avidoxy 60 tablets per 30 days • Viramune • Axert 12 tablets per 30 days solution 1200mL (5 bottles) per 30 days • Banzel tablets 60 tablets per 30 days 200mg 480 tablets per 30 days • Viramune XR 400mg 240 tablets per 30 days 100mg 90 tablets per 30 days 40mg/ml suspension 2400ml per 30 days 400mg 30 tablets per 30 days • Viread • Benoxyldoxy 1 kit per 30 days powder 240g powder per 30 days • Brisdelle 30 capsules per 30 days tablets 30 tablets per 30 days • Briviact • Vistogard tablet 60 tablets per 30 days granules 24 packets per 14 days oral solution 600ml per 30 days • Vivelle Dot 8 patches per 30 days • Brovana 120mL per 30 days • Vraylar • Bunavail All Strengths 30 capsules per 30 days 2.1/0.3mg 30 films per 30 days Titration Pack 7 blisters (1 dose-pack) per 28 days 4.2/0.7mg, 6.3/1mg 60 films per 30 days • Vyvanse 30 capsules/tablets per 30 days • Bupap 180 tablets per 30 days • Xalkori 60 capsules per 30 days • Cambia 9 packets per 30 days • Xarelto • Caverject 1 dose per 5 days 10mg, 20mg 30 tablets per 30 days • Cesamet 180 capsules per 30 days 15mg 60 tablets per 30 days • Chantix 56 tablets per 28 days • Xiidra 60 vials per 30 days • Cialis • Zenzedi 2.5mg, 5mg 30 tablets per 30 days 2.5mg, 5mg, 7.5mg, 10mg, 20mg 6 tablets per 30 days 15mg 90 tablets per 30 days • Clarinex 10mg 180 tablets per 30 days

37012 MedPerform Medium Formulary – July 2017 25 INTEGRIS Formulary

2.5mg, 5mg reditab 30 tablets per 30 days • Kapvay 120 tablets per 30 days 5mg 30 tablets per 30 days • Karbinal ER 960mL (2 bottles) per 30 days 5mg/10ml syrup 300ml per 30 days • Kytril 8 tablets per 30 days • Clarinex-D 12 hour 60 tablets per 30 days • Lamictal ODT • Clarinex-D 24 hour 30 tablets per 30 days 25mg, 50mg 180 tablets per 30 days • Climara Pro 4 patches per 30 days 100mg 90 tablets per 30 days • Clozapine ODT 90 tablets per 30 days 200mg 60 tablets per 30 days • Conzip 30 capsules per 30 days • Lamictal XR • Cosopt PF 60 droperettes per 30 days 25mg, 50mg 180 tablets per 30 days • Daytrana 30 patches per 30 days 100mg 90 tablets per 30 days • Demerol 200mg, 250mg, 300mg 60 tablets per 30 days solution 900mL per 30 days • Lescol 60 tablets per 30 days tablets 180 tablets per 30 days • Liptruzet 30 tablets per 30 days • Depo-Provera 1mL per 84 days • LoSeasonique 91 tablets per 84 days • Depo-subQ Provera 104 0.65mL per 84 days • Luvox CR 60 capsules per 30 days • Desoxyn 150 tablets per 30 days • Luzu 60g (1 tube) per 28 days • Desvenlafaxine ER 30 tablets per 30 days • Menostar 4 patches per 30 days (fumarate) • Migranal 8 vials per 28 days • Dexilant 30 capsules per 30 days • Mirapex ER 30 tablets per 30 days • Doryx • Mitigare 60 capsules per 30 days 50mg 60 tablets per 30 days • Moban 200mg 30 tablets per 30 days 25 mg 9 tablets per 1 day supply • Doryx MPC 120mg 60 tablets per 30 days 10 mg 8 tablets per 1 day supply • Doxycycline Hyclate DR 60 tablets per 30 days 5 mg 4 tablets per 1 day supply 100mg • Mondoxyne NL 60 capsules per 30 days • Dutoprol 50mg, 75mg, 100mg 25-12.5mg. 50-12.5mg 30 tablets per 30 days • Monodox 60 capsules per 30 days 100-12.5mg 60 tablets per 30 days 50mg, 75mg, 100mg • Dyanavel XR 240mL per 30 days • Muse 1 dose per 5 days • Dymista 23g (1 bottle) per 30 days • Myalept 1 vial (11.3mg) per day • Edex 1 dose per 5 days • Nicotrol cartridge 1008 cartridges (6 inhalers) per 90 • Embeda days 20-0.8mg, 30-1.2mg, • Nicotrol NS 160mL (4 packs) per 90 days 50-2mg, 60-2.4mg, • Nuvigil 80-3.2mg 2 capsules per day 50mg 90 tablets per 30 days 100-4mg 4 capsules per day 150mg, 200mg, 250mg 30 tablets per 30 days • Emsam 30 patches per 30 days • Obredon 600mL per 10 days • Epaned 1200mL (8 bottles) per 30 days • Oleptro ER • Ergomar SL 40 tablets per 28 days 150mg 45 tablets per 30 days • Esomeprazole 300mg 30 tablets per 30 days 24.65mg 30 capsules per 30 days • Onfi 49.3mg 120 capsules per 30 days Tablets 60 tablets per 30 days • Estring 1 ring per 90 days Suspension 480mL per 30 days • Fanapt • Opana ER Tablets 60 tablets per 30 days 5mg, 7.5mg, 10mg, Titration Pack 1 pack per 28 days 15mg, 20mg 60 tablets per 30 days • Fazaclo 90 tablets per 30 days 30mg, 40mg 120 tablets per 30 days • Felbatol • Oracea 30 capsules per 30 days 400mg 270 tablets per 30 days • Osphena 30 tablets per 30 days 600mg 180 tablets per 30 days • Oxycodone hcl/acetaminophen (maximum of 4gm 600mg/5ml solution 900mL per 30 days acetaminophen per day): • Firmagon 80mg/vial 1 vial per 30 days 300mg 13 tablets per 1 day supply • Firmagon 120mg/vial 2 vials per 365 days • Oxtellar XR • Foradil 60 capsules per 30 days 150mg, 300mg 30 tablets per 30 days • Frova 18 tablets per 30 days 600mg 120 tablets per 30 days • Fulyzaq 60 tablets per 30 days • Patanase 30.5g (1 bottle) per 30 days • Fycompa • Pradaxa 60 capsules per 30 days 2mg 120 tablets per 30 days • Procentra 1800mL per 30 days 4mg, 6mg 60 tablets per 30 days • Qbrelis 1200ml per 30 days 8mg, 10mg, 12mg 30 tablets per 30 days • Qudexy XR 0.5mg/mL suspension 680mL (2 bottles) per 28 days 25mg, 50mg, 100mg 30 capsules per 30 days • Gabitril 150mg, 200mg 60 capsules per 30 days 2mg, 4mg, 12mg 120 tablets per 30 days • Rasuvo 16mg 90 tablets per 30 days 7.5mg/0.15mL 1.6mL (4 syringes) per 28 days • Granisol solution 60mL per 30 days 10mg/0.2mL 0.8mL (4 syringes) per 28 days • Hemangeol 360mL (3 bottles) per 30 days 12.5mg/0.25mL 1mL (4 syringes) per 28 days • Hydrocodone 15mg/0.3mL 1.2mL (4 syringes) per 28 days bit/acetaminophen (max 4gm per day) 17.5mg/0.35mL 1.4mL (4 syringes) per 28 days • Incruse Ellipta 30 blisters per 30 days 22.5mg/0.46mL 1.8mL (4 syringes) per 28 days • Intuniv 30 tablets per 30 days 25mg/0.5mL 2mL (4 syringes) per 28 days 2.2mL (4 syringes) per 28 days • Invega 27.5mg/0.55mL 2.4mL (4 syringes) per 28 days 1.5mg, 3mg, 9mg 30 tablets per 30 days 30mg/0.6mL 6mg 60 tablets per 30 days • Razadyne 60 tablets per 30 days • Iprivask 6 syringes per 30 days Tablets Solution 200mL (2 bottles) per 30 days

37012 MedPerform Medium Formulary – July 2017 26 INTEGRIS Formulary

Razadyne ER 30 capsules per 30 days sulfonylurea (e.g., glyburide, glipizide) • Relenza 2 boxes (#20 diskhalers/box) per or pioglitazone within the past 120 183 days days. • Relpax 12 tablets per 30 days • Gianvi Trial of two different non-drospirenone • Rhinocort Aqua 17.2g (2 canisters) per 30 days oral contraceptives (containing • Risperdal M-Tab 60 tablets per 30 days levonorgestrel, norethindrone, • Rubraca 120 tablets per 30 days norgestimate, norgestrel, desogestrel, • Rytary 300 capsules per 30 days or ethinynodiol ace.) within the past • Ryzodeg 70/30 30mL (10 pens) per 28 days 365 days. • • Sabril 180 tablets per 30 days Glyxambi Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a • Samsca combination product containing any two 15mg tablets 30 tablets per 365 days of the three agents above within the • 30mg tablets 60 tablets per 365 days past 120 days. Sancuso 4 patches per 28 days • Invokamet Trial of metformin (IR/ER), a • 30 tablets per 30 days Savaysa sulfonylurea, pioglitazone or a • Seasonique 91 tablets per 84 days combination product containing any two • Seroquel XR 30 tablets per 30 days of the three agents above within the • Sitavig 4 tablets per 365 days past 120 days. • Solodyn 30 tablets per 30 days • Invokamet XR Trial of metformin (IR/ER), a • Sotylize sulfonylurea, pioglitazone or a 250mL 2000mL (8 bottles) per 30 days combination product containing any two • 480mL 3840mL (8 bottles) per 30 days of the three agents above within the • Spritam past 120 days. 250/500/750mg 120 tablets per 30 days • Invokana Trial of metformin (IR/ER), a 1000mg 60 tablets per 30 days sulfonylurea, pioglitazone or a • Sprix 5 bottles per 30 days combination product containing any two • Sumavel DosePro 4 units per 28 days of the three agents above within the • Targadox 120 tablets per 30 days past 120 days. • Tasmar 90 tablets per 30 days • Jalyn Trial of finasteride 5mg, alfuzosin, • Timoptic Ocudose 60 droperettes per 30 days doxazosin, prazosin,tamsulosin or • Trezix 10 capsules per day terazosin within the past 120 days. • • Trokendi XR Jardiance Trial of metformin (IR/ER), a 25mg, 50mg, 100mg 30 capsules per 30 days sulfonylurea, pioglitazone, or a combination product containing any two • 200mg 60 capsules per 30 days of the three agents above within the • Trulance 30 tablets per 30 days past 120 days. Tuzistra XR 600mL per 30 days • Loestrin FE Trial of one generic contraceptive • 2 tablets per 14 days Varubi within the past 120 days. • 1 packet per day Veltassa • Loestrin FE24 Trial of two generic oral contraceptives • Vemlidy 30 tablets per 30 days within the past 365 days. 540mL per 30 day • Versacloz • Lo Loestrin FE Trial of two generic oral contraceptives • Vytorin 30 tablets per 30 days within the past 365 days • Xartemis XR 360 tablets per 30 days • Loryna Trial of two different non-drospirenone • Xerese 10gm (2 tubes) per 365 days oral contraceptives (containing • Xifaxan 200mg 9 tablets per fill levonorgestrel, norethindrone, • Xodol 5-300mg 13 tablets per 1 day supply norgestimate, norgestrel, desogestrel, • Xyzal solution 300mL per 30 days or ethinynodiol ace.) within the past • Zamicet Soln 325mg/15ml 184mL per 1 day supply 365 days. • Zegerid • Marinol Trial of ondansetron, corticosteroids Packets 30 packets per 30 days and Emend within the past 365 days. • Capsules 30 capsules per 30 days • Methadone Injection Trial of lower strength oral methadone Zelapar 60 tablets per 30 days Solution solution or tablets required within the • Zohydro ER 60 capsules per 30 days past 120 days. • Zontivity 30 tablets per 30 days • Namzaric Trial of donepezil and memantine within the past 365 days. • Zyclara • Trial of pramipexole IR or ropinirole IR 2.5% 7.5 grams (1 bottle) per 28 days Neupro within the past 120 days. 3.75% pump 7.5 grams (1 bottle) per 28 days • Niaspan Trial of generic/multisource statin • 3.75% packet 28 packets per 28 days (atorvastatin, lovastatin, pravastatin, or simvastatin), or generic/multisource • Zyclara gemfibrozil or fenofibrate within the 2.5% 7.5 grams (1 bottle) per 28 days past 365 days. 3.75% pump 7.5 grams (1 bottle) per 28 days • Trial of two different non-drospirenone 3.75% packet 28 packets per 28 days Ocella oral contraceptives (containing levonorgestrel, norethindrone, 5. STEP THERAPY EDITS (FORMULARY) • Actoplus Met Trial of metformin, metformin ER, norgestimate, norgestrel, desogestrel, Actoplus Met XR sulfonylurea (e.g., glyburide, glipizide) oror ethinynodiol pioglitazone ace.) within within the ptheast past 120 365days days.. • Trial of methotrexate tablet or solution • Astepro Trial of Astelin (azelastine) within the Otrexup past 120 days for injection within the past 120 days • Trial of lansoprazole, omeprazole or • Dificid Trial of vancomycin capsules within the Prevacid Solutabs past 120 days pantoprazole within the past 120 days. • Trial of Prilosec OTC or omeprazole • Drithocreme HP Trial of a topical within Protonix Susp the past 120 days within the past 120 days. • Trial of mercaptopurine tablet within the • Duetact Trial of metformin, metformin ER, Purixan past 120 days.

37012 MedPerform Medium Formulary – July 2017 27 INTEGRIS Formulary

• Zomig ZMTZocor (80mg the past 180 daysTrial of simvastatin • Synjardy Trial of metformin (IR/ER), a only) 80mg or Vytorin 10/80mg within the Synjardy XR sulfonylurea, pioglitazone, or a past 365 days combination product containing any two • Zolpidem Tartrate ER Trial of ZolpidemIR within the past 180 of the three agents above within the days. past 120 days. • ZurampicZomig Trial of allopurinol or Uloric (febuxostat) • Trulicity Trial of metformin (IR/ER), a • Zomig ZMT within the past 120 daysTrial of sulfonylurea, pioglitazone or a sumatriptan or rizatriptan within the combination product containing any two past 180 days of the three agents above within the Zurampic Trial of allopurinol or Uloric (febuxostat) past 120 days. within the past 120 days • Uloric Trial of allopurinol within the past 120 days. 6. STEP THERAPY EDITS (NON FORMULARY) • Trial of two different non-drospirenone Vestura • Trial of generic isotretinoin within the oral contraceptives (containing Absorica past 120 days levonorgestrel, norethindrone,

norgestimate, norgestrel, desogestrel, • Trial of two of the following; or ethinynodiol ace.) within the past Aciphex Sprinkle omeprazole, lansoprazole, 365 days.Trial of a topical pantoprazole or rabeprazole within the corticosteroid within the past 120 days. past 365 days • Victoza Trial of metformin (IR/ER), a • Acticlate 75mg Trial of generic doxycycline sulfonylurea, pioglitazone or a monohydrate 75mg tablets within the combination product containing any two past 120 days of the three agents above within the • Acticlate 150mg Trial of generic doxycycline past 120 days. monohydrate 150mg tablet within the • Trial of two different non-drospirenone Vestura past 120 days oral contraceptives (containing • Trial of alendronate and ibandronate levonorgestrel, norethindrone, Actonel within the past 365 days norgestimate, norgestrel, desogestrel, • Trial of at least two of the following: or ethinynodiol ace.) within the past Aerospan QVAR, Asmanex or Pulmicort within 365 days. the past 365 days • Victoza Trial of metformin (IR/ER), a • Trial of Linzess or Movantik within the sulfonylurea, pioglitazone or a Amitiza past 120 days. combination product containing any two of the three agents above within the • Anoro Ellipta Trial of Stiolto Respimat and one of the following: Spiriva, Striverdi or Serevent past 120 days. within the past 365 days • Vytorin 10/80 Trial of simvastatin 80mg or Vytorin • Trial of ondansetron tablets or ODT 10/80mg within the past 365 days Anzemet within the past 120 days • Trial of two different non-drospirenone YazYasmin 28 • Trial of Serevent Diskus or Striverdi oral contraceptives (containing Arcapta levonorgestrel, norethindrone, Respimat within the past 120 days • Trial of at least two of the following: norgestimate, norgestrel, desogestrel, Arnuity Ellipta Asmanex, Pulmicort, or QVAR within or ethinynodiol ace.) within the past 365 days.Trial of two different non- the past 365 days • Trial of alendronate and ibandronate drospirenone oral contraceptives Atelvia within the past 365 days (containing levonorgestrel, • norethindrone, norgestimate, Avandia/ Trial of metformin (IR/ER), a sulfonylurea, pioglitazone, or a norgestrel, desogestrel, or ethinynodiol Avandaryl/ combination product containing any ace.) within the past 365 days. Avandamet two of the three agents above within • ZarahYaz Trial of two different non-drospirenone the past 120 days. oral contraceptives (containing • Trial of sumatriptan or rizatriptan within levonorgestrel, norethindrone, Axert the past 180 days norgestimate, norgestrel, desogestrel, • Trial of generic doxycycline or ethinynodiol ace.) within the past Benoxyldoxy monohydrate 100mg capsules within 365 days.Trial of two different non- the past 120 days drospirenone oral contraceptives • Trial of two different non-drospirenone (containing levonorgestrel, Beyaz oral contraceptives (containing norethindrone, norgestimate, levonorgestrel, norethindrone, norgestrel, desogestrel, or ethinynodiol norgestimate, norgestrel, desogestrel, ace.) within the past 365 days. or ethinynodiol ace.) within the past • Zenzedi (2.5mg, Trial of a multisource 365 days 7.5mg)Zarah dextroamphetamine sulfate tablet or Trial of Gonal-F or Gonal-F-RFF dextroamphetamine solution within the • Bravelle required. past 120 daysTrial of two different non- • Trial of paroxetine or venlafaxine within drospirenone oral contraceptives Brisdelle the past 120 days (containing levonorgestrel, • Trial of generic norethindrone, norgestimate, Bupap butalbital/acetaminophen combination norgestrel, desogestrel, or ethinynodiol product required within the last 120 ace.) within the past 365 days. days • Zocor (80mg only) Trial of simvastatin 80mg or Vytorin • Cesamet Trial of ondansetron tablet or ODT 10/80mg within the past 365 days within the past 120 days • Zolpidem Tartrate Trial of ZolpidemIR within the past 180 • Clarinex Reditabs/ Trial of desloratadine or levocetirizine ERZenzedi (2.5mg, days.Trial of a multisource Clarinex syrup/ tablet within the past 120 days 7.5mg) dextroamphetamine sulfate tablet or dextroamphetamine solution within the Clarinex D past 120 days • Clindagel Trial of generic clindamycin gel required within the past 120 days • Zomig Trial of sumatriptan or rizatriptan within

37012 MedPerform Medium Formulary – July 2017 28 INTEGRIS Formulary

• Conzip Trial of tramadol ER (Ultram ER) within • Liptruzet the past 120 days 10/10mg Trial of 2 of the following: atorvastatin, • Cosopt PF Trial of dorzolamide/timolol within the simvastatin, pravastatin or lovastatin past 120 days within the past 365 days. • Cycloset Trial of metformin (Glucophage), 10/20mg, 10/40mg, Trial of 40mg atorvastatin or 80mg metformin ER, glyburide/metformin 10/80mg atorvastatin within the past 120 days. (Glucovance), or glipizide/metformin • Loestrin 24 Fe Trial of two generic oral contraceptives (Metaglip) within the past 180 days within the past 365 days • Daytrana Trial of methylphenidate CD, ER, or LA • Luzu Trial of ketoconazole and clotrimazole formulation or methylphenidate cream within the past 365 days suspension/solution within the past 120 • Mirapex ER Trial of pramipexole IR or ropinirole IR days within the past 120 days • Dexilant Trial of omeprazole, lansoprazole, or • Moderiba Dosepak Trial of ribavirin 200mg capsule or pantoprazole within the past 120 days tablet within the past 120 days • Doryx 50mg tabs Trial of generic doxycycline • Monodox 75mg caps Trial of generic doxycycline monohydrate 50mg tablets or capsules monohydrate 75mg tabs within the or doxycycline hyclate 50mg capsule past 120 days within the past 120 days • Natazia Trial of two generic oral contraceptives • Doryx 75mg tabs Trial of generic doxycycline within the past 365 days monohydrate 75mg tablets within the • Neo-Synalar Trial of fluocinolone and bacitracin past 120 days within the past 365 days • Doryx 100mg tabs/caps Trial of generic doxycycline • Obredon Trial of hydrocodone/homatropine monohydrate 100mg capsules within methylbromide within the past 120 the past 120 days days • Doryx 150mg tabs Trial of generic doxycycline • Oracea Trial of generic doxycycline monohydrate 150mg tablets within the monohydrate 50mg capsule within the past 120 days past 120 days • Doryx 200mg tabs Trial of generic doxycycline hyclate • Ovace Plus Lotion Trial of ketoconazole shampoo/cream 100mg tablets or capsules or or ciclopirox shampoo/gel within the doxycycline monohydrate tablets or past 120 days capsules within the past 120 days • Patanase Trial of Astelin (azelastine) within the • Doryx MPC 120mg Trial of generic doxycycline 100mg past 120 days tablets tablets or capsules within the past 120 • Pradaxa Trial of Eliquis and Xarelto within the days past 365 days • Doxycycline Hyclate DR Trial of generic doxycycline 100mg • Qbrelis If age ≥ 12 years, trial of lisinopril tablet tablets or capsules within the past 120 tablets within the past 120 days days. • Dyanavel XR Trial of extended-release • Rapaflo Trial of finasteride 5mg, alfuzosin, amphetamine/dextroamphetamine oral doxazosin, prazosin,tamsulosin or capsules within the past 120 days terazosin within the past 120 days • Dymista Trial of fluticasone or flunisolide within • Rasuvo Trial of Otrexup and methotrexate the past 365 days tablet or solution for injection within the past 365 days. • Epaned If age ≥ 12 years, trial of enalapril • Relpax Trial of sumatriptan or rizatriptan within tablets within the past 120 days the past 180 days • Esomeprazole Strontium Trial of omeprazole, lansoprazole or • Rhinocort Aqua Trial of fluticasone or flunisolide within pantoprazole within the past 120 days the past 365 days • Follistim AQ Trial of Gonal-F or Gonal-F-RFF • Ribasphere 400mg, Trial of ribavirin 200mg capsule or required within the past 120 days 600mg, RibaPak tablet within the past 120 days • Fortamet Trial of generic metformin ER • Rytary Trial of Sinemet IR or CR within the (Glucophage XR) within the past 120 past 120 days days • Foradil Trial of Serevent Diskus or Striverdi • Ryzodeg 70/30 Trial of preferred long acting insulin Respimat within the past 120 days and preferred pre-mixed insulin) within • Frova Trial of sumatriptan or rizatriptan within the past 365 days the past 180 days • Safyral Trial of two different non-drospirenone • Fulyzaq Trial of antiretroviral therapy within the oral contraceptives (containing past 120 days levonorgestrel, norethindrone, • Giazo Trial of balsalazide or Apriso within the norgestimate, norgestrel, desogestrel, past 120 days or ethinynodiol ace.) within the past • Hemangeol For age over 1 year, trial of generic 365 days. propranolol oral solution within the past • Savaysa Trial of Eliquis and Xarelto within the 120 days past 365 days • Incruse Ellipta Trial of preferred LAMA (Spiriva) within • Sancuso Trial of ondansetron tablet or ODT the past 120 days within the past 120 days • Inderal XL Trial of Inderal LA within the past 120 • Sernivo Trial of Kenalog (triamcinolone days acetonide) 0.147mg/g spray within the • Innopran XL Trial of Inderal LA within the past 120 past 120 days days • Seroquel XR Trial of two generic atypical anti- • Karbinal ER Trial of generic immediate-release psychotics, SSRIs, or SNRIs within the carbinoxamine maleate within the past past 365 days 120 days • Kytril Trial of ondansetron tablets or ODT • Sitavig Trial of oral acyclovir, valacyclovir or within the past 120 days famciclovir within the past 120 days • Lescol/XL Trial of two of the following: • Solodyn Trial of generic minocycline immediate atorvastatin, lovastatin, pravastatin or release within the past 120 days simvastatin within the past 365 days • Sorilux Trial of a topical corticosteroid within

37012 MedPerform Medium Formulary – July 2017 29 INTEGRIS Formulary

the past 120 days • Juxtapid • Sotylize Trial of sotolol tablets within the past • Kalydeco 120 days • Keveyis • Sumavel Dose-Pro Trial of generic/multisource injectable • Kisqali sumatriptan or nasal sumatriptan • Korlym (Imitrex or equivalent) within the past • Kynamro 180 days • Lenvima

• Letairis • Targadox Trial of generic doxycycline • Leukine monohydrate 50mg capsule or generic • doxycycline hyclate 50mg capsule Lonsurf within the past 120 days • Lynparza • • Tasmar Trial of Comtan within the past 120 Mekinist days • Neulasta • Timoptic Ocudose Trial of timolol drops within the past • Neupogen 120 days • Nexavar • Topicort Spray Trial of mometasone 0.1% ointment, • Ninlaro fluocinonide 0.05% • Norditropin cream/ointment/gel, desoximetasone • Odomzo 0.25% cream, or betamethasone • Ofev dipropionate 0.05% cream within the • Omnitrope past 120 days • Opsumit • Trulance Trial of Linzess within the past 120 • Oralair days. • Orfadin • Tuzistra XR Trial of promethazine with codeine • Orkambi syrup within the past 120 days • Otezla • Uceris rectal foam Trial of mesalamine enema within the • Pegasys ast 120 days • Pegasys Proclick • Uceris tablet Trial of balsalazide within the past 120 • days Plegridy • • Xerese Trial of oral acyclovir, valacyclovir or Plegridy Pen famciclovir within the past 120 days • Pomalyst • Xyzal Solution Trial of desloratadine or levocetirizine • Praluent tablet within the past 120 days • Procrit • Zegerid Trial of omeprazole, lansoprazole or • Procysbi pantoprazole within the past 120 days • Promacta • Zithranol / Zithranol RR Trial of a topical corticosteroid within • Pulmozyme the past 120 days • Ragwitek • Rebif • Rebif Rebidose 7. PRIOR AUTHORIZATION RESTRICTIONS (FORMULARY) • Repatha • Actiq • Revatio tablets • Adcirca • Revlimid • Adempas • Sprycel • Afinitor /Afinitor Disperz • Stelara SC • Aldara • Stivarga • Alecensa • Strensiq • Androgel • Subutex • Aubagio • Sutent • Avonex • Tafinlar • Avonex Admin Pack • Tagrisso • Axiron • Tarceva • Bosulif • Targretin • Cabometyx • Tasigna • Depen • Tecfidera • Emverm • Temodar capsules • Enbrel • Thalomid • Epclusa • Tobi • Farydak • Tobi PodhalerTobi • Firazyr • TracleerTobi Podhaler • Gattex • Tracleer • Gilenya • Tykerb • Gilotrif • Uptravi • Gleevec • Valchlor • Grastek • Venclexta • Harvoni • Votrient • Humira • Xalkori • Ibrance • Xeljanz • Iclusig • Xeljanz XR • Imbruvica • Xeloda • Impavido • Xenazine • Inlyta • Xermelo • Intron A • Xifaxan 550mg • Iressa • Xtandi • Jakafi

37012 MedPerform Medium Formulary – July 2017 30 INTEGRIS Formulary

• Xuriden • Gazyva* • Zelboraf • Gel-One* • Zydelig • Gleostine • Zykadia • Granix* • Zytiga • H.P. Acthar* • Zyvox • Halaven* • Herceptin* • Hetlioz • Hizentra • Hyalgan* • Hymovis* 8. PRIOR AUTHORIZATION RESTRICTIONS (NON FORMULARY) • Hyqvia IG component • Abraxane* • Ilaris* • Actemra IV* • Imlygic* • Actemra SC • Incivek • Adcetris* • Increlex • Addyi • Inflectra* • Afrezza • Ingrezza • Alimta* • Iprivask • Ampyra • Istodax* • Amturnide • Ixempra* • Anadrol-50 • Jublia • Androderm • Kadcyla* • Apokyn • Kalbitor* • Aranesp • Kanuma* • Arzerra* • Kineret • Austedo • Kitabis Pak • Avastin* • Kyprolis* • Bavencio* • Lartruvo* • Beleodaq* • Lemtrada* • Belviq • Lucentis* • Belviq XR • Lumizyme* • Bivigam* • Macugen* • Blincyto* • Makena • Botox* • Marqibo* • Caprelsa • Mircera • Carimune NF Nanofiltered* • Monovisc* • Cerezyme* • Mozobil* • Cholbam • Myobloc* • Cialis • Natpara • Cinryze • Neulasta Delivery Kit* • Cinqair • Northera • Contrave • Novantrone* • Cuprimine • Nucala* • Cuvitru • Nuplazid • Cyramza* • Nymalize • Darzalex* • Ocaliva • Duopa • Octagam* • Dysport* • Ocrevus* • Egrifta • Olysio • Elelyso* • Opdivo* • Elspar* • Orencia IV* • Emflaza • Orencia SC • Empliciti* • Orenitram ER • Entyvio* • Orthovisc* • Epogen • Oxandrin • Erbitux* • Pegintron • Erwinase* • Pegintron Redipen • Euflexxa* • Perjeta* • Evekeo • Photofrin* • Exalgo • Portrazza* • Exondys 51* • Privigen* • Eylea* • Prolia* • Faslodex* • Qutenza • Flebogamma DIF* • Ravicti • Flolan* • Relistor • Gamastan S-D* • Remicade* • Gammagard Liquid • Remodulin • Gammagard S-D* • Revatio Vial* • Gammaked • Revatio suspension • Gammaplex* • Rituxan* • Gamunex-C • Rubraca

37012 MedPerform Medium Formulary – July 2017 31 INTEGRIS Formulary

• Saxenda • Serostim • Signifor • Siliq • Simponi SC • Simponi Aria IV* • Solaraze • Soliris* • Spinraza* • Stelara IV* • Stivarga • Striant • Sucraid • Supartz* • Suprenza ODT • Sylvant* • Synagis* • Synribo* • Synvisc* • Synvisc-One* • Tecentriq* • Technivie • Testred • Tymlos • Veltassa • Xyrem • Yervoy* • Yondelis* • Zaltrap* • Zarxio • Zavesca • Zepatier • Zinbryta • Zoladex* • Zorbtive • Zyclara

* = Dependent on plan benefit. If covered under pharmacy benefit, then non-formulary with prior authorization

9. CONCURRENT USE EDITS (FORMULARY) • Suboxone • Subutex • Zubsolv

10. CONCURRENT USE EDITS (NON FORMULARY) • Bunavail

37012 MedPerform Medium Formulary – July 2017 32 MedPerform Medium Formulary INDEX

5-grass pollen extract ...... 9 AMERGE ...... 20 AVLOSULFON ...... 17 8-MOP ...... 13 AMINOPHYLLIN ...... 9 AVODART ...... 21 abacavir sulfate ...... 18 aminophylline ...... 9 AVONEX ...... 20 abacavir sulfate/lamivudine ...... 17 amiodarone hcl ...... 10 AVONEX ADMINISTRATION PACK ...... 20 abacavir/dolutegravir/lamivudine ...... 17 amitriptyline hcl ...... 10 AXID ...... 21 abacavir/lamivudine/zidovudine ...... 17 amlodipine bes/olmesartan med ...... 11 AXIRON ...... 16 ABBOTT DIABETIC SUPPLIES...... 14 amlodipine besylate ...... 11 axitinib ...... 19 Abilify ...... 22 amlodipine besylate/benazepril ...... 10 AYGESTIN ...... 16 ABILIFY DISCMELT ...... 10 amlodipine/atorvast cal ...... 12 azathioprine ...... 16 ABILIFY SOLUTION...... 10 amlodipine/valsartan ...... 11 azelastine hcl ...... 9, 15 ABILIFY TABLET ...... 10 amlodipine/valsartan/hctz ...... 11 AZILECT ...... 21 acarbose ...... 13 AMNESTEEM ...... 12 azilsartan ...... 11 ACCUPRIL ...... 11 amox tr/potassium clavulanate ...... 17 azilsartan med/chlorthalidone ...... 11 ACCURETIC...... 11 amoxapine ...... 10 azithromycin ...... 16 acebutolol hcl ...... 11 amoxicillin trihydrate ...... 17 AZOPT ...... 15 acetaminophen with codeine ...... 20, 21 AMOXIL ...... 17 AZOR ...... 11 acetazolamide ...... 15 amphet asp/amphet/d-amphet ...... 10 aztreonam lysine ...... 16 acetic acid ...... 14 ampicillin trihydrate ...... 17 AZULFIDINE...... 18 acetic acid/aluminum acetate ...... 14 amylase/lipase/protease ...... 21 bacitracin...... 15 acetic acid/hydrocortisone ...... 14 ANAFRANIL ...... 10 bacitracin/polymyxin b sulfate...... 15 acetylcysteine ...... 20 anagrelide hcl ...... 16 baclofen ...... 21 acitretin ...... 13 ANALPRAM HC ...... 18 BACTRIM DS ...... 16 ACLOVATE ...... 13 ANAPROX ...... 18 BACTROBAN ...... 13 ACTIGALL ...... 19 ANAPROX DS ...... 18 BACTROBAN NASAL ...... 20 ACTIQ ...... 20 ANASPAZ ...... 21 balsalazide disodium ...... 18 ACTOPLUS MET ...... 14 anastrozole...... 19 BARACLUDE ...... 18 ACTOPLUS MET XR ...... 14 ANDROGEL ...... 16 becaplermin ...... 14 ACTOS ...... 14 ANDROID ...... 16 beclomethasone dipropionate ...... 9 ACULAR ...... 15 ANDROXY ...... 16 belladonna alkaloids/phenobarb ...... 21 ACULAR LS...... 15 ANSAID ...... 18 BELSOMRA...... 10 acyclovir ...... 13, 17 ANTABUSE ...... 10 benazepril hcl ...... 11 ADALAT CC ...... 11 anthralin ...... 13 benazepril/hydrochlorothiazide ...... 10 adalimumab ...... 18 Antipsychotics, Atypical, D3/D2 Partial BENEMID ...... 16 adapalene ...... 12 Agonist/5HT Mixed ...... 10 BENICAR ...... 11 ADCIRCA ...... 11 antipyrine/benzocaine otic ...... 14 BENICAR HCT ...... 11 ADDERALL...... 10 ANTIVERT ...... 9 BENTYL ...... 21 ADDERALL XR ...... 10 ANUSOL-HC ...... 18 BENZAMYCIN ...... 12 adefovir dipivoxil ...... 18 APEXICON ...... 13 BENZAMYCIN PAK ...... 13 ADEMPAS ...... 11 APEXICON E ...... 13 BENZOTIC ...... 14 ADRENACLICK ...... 19 apixaban ...... 16 benzoyl peroxide ...... 12 ADVAIR DISKUS ...... 9 aprepitant ...... 9 benzoyl peroxide/hydrocortison ...... 12 ADVAIR HFA ...... 9 APRESOLINE ...... 11 benztropine mesylate ...... 21 afatinib ...... 19 APRISO ...... 18 besifloxacin hcl drops susp 0.6% ...... 15 AFINITOR ...... 19 APTIVUS ...... 17 BESIVANCE ...... 15 AFINITOR DISPERZ ...... 19 ARALEN PHOSPHATE ...... 17 BETAGAN ...... 15 AFTERA ...... 12 ARAVA ...... 18 betamet diprop/prop gly ...... 13 AGRYLIN ...... 16 ARICEPT ...... 9 betamethasone dipropionate...... 9, 13 AK-TRACIN ...... 15 ARICEPT ODT ...... 9 betamethasone valerate ...... 13 AKYNZEO ...... 9 ARIMIDEX ...... 19 BETAPACE ...... 11 ALAMAST ...... 15 aripiprazole ...... 10 BETAPACE AF ...... 11 ALA-TET ...... 17 ARIXTRA ...... 16 betaxolol hcl ...... 15 ALAWAY OTC ...... 15 ARMOUR THYROID ...... 15 bethanechol chloride ...... 19 albuterol sulfate ...... 9 AROMASIN ...... 19 BETIMOL ...... 15 ALBUTEROL SULFATE ...... 9 ARTANE ...... 21 BETOPTIC...... 15 alclometasone dipropionate ...... 13 ASACOL ...... 18 BETOPTIC S ...... 15 ALDACTONE ...... 11 ASENDIN ...... 10 bexarotene...... 13, 19 ALDARA ...... 16 asfotase alfa ...... 20 BIAXIN ...... 16 ALDOMET ...... 11 ASMANEX ...... 9 BIAXIN XL ...... 16 ALECENSA ...... 19 ASMANEX HFA ...... 9 bicalutamide ...... 19 alectinib hydrochloride...... 19 ASTELIN ...... 9 BIDIL ...... 12 alendronate sodium ...... 14 ASTEPRO ...... 9 BILTRICIDE ...... 17 alendronate sodium solution ...... 14 ATARAX ...... 9 bimatoprost ...... 15 alendronate sodium/vitamin d3 ...... 14 atazanavir sulfate ...... 18 bimonidine/timolol ...... 15 alfuzosin ...... 21 atazanavir sulfate.cobicistat ...... 18 bisoprolol fumarate ...... 11 alirocumab ...... 11 atenolol ...... 11 bisoprolol fumarate/hctz ...... 11 ALKERAN ...... 19 atenolol/chlorthalidone ...... 11 BLEPHAMIDE ...... 15 allopurinol ...... 16 ATIVAN ...... 10 BLEPHAMIDE S.O.P...... 15 ALOCRIL ...... 15 atomoxetine hcl ...... 10 BLOCADREN ...... 11 ALOMIDE ...... 15 atorvastatin calcium...... 11 blood sugar diagnostic ...... 14 ALORA ...... 16 ATRIPLA ...... 18 blood-glucose calib. control ...... 14 ALPHAGAN P ...... 15 atropine sulfate ...... 15 blood-glucose meter ...... 14 alprazolam ...... 10 ATROVENT ...... 9, 20 BONIVA ...... 15 ALPRAZOLAM INTENSOL ...... 10 ATROVENT HFA ...... 9 bosentan ...... 11 ALREX ...... 15 AUBAGIO ...... 20 BOSULIF ...... 19 ALTACE ...... 11 AUGMENTIN ...... 17 bosutinib ...... 19 altretamine ...... 19 AUGMENTIN ES-600 ...... 17 BREO ELLIPTA ...... 9 aluminum chloride ...... 13 AUGMENTIN XR ...... 17 BRETHINE ...... 9 ALUPENT ...... 9 AVALIDE ...... 11 BREVOXYL-4 ...... 12 amantadine hcl ...... 21 AVAPRO ...... 11 BREVOXYL-8 ...... 12 AMARYL ...... 14 AVC ...... 22 BRILINTA ...... 16 AMBIEN ...... 10 AVELOX ...... 17 brimonidine tartrate ...... 15 AMBIEN CR...... 10 AVELOX ABC PACK ...... 17 brinzolamide ...... 15 ambrisentan ...... 11 AVIANE-28 ...... 12 brinzolamide/brimonidine ...... 15 amcinonide...... 13 AVINZA ...... 20 bromocriptine mesylate ...... 21

37012 MedPerform Medium Formulary – July 2017 33 MedPerform Medium Formulary INDEX

budesonide ...... 9, 18 chlorpromazine hcl ...... 10 CORTISPORIN OTIC ...... 14 BUDESONIDE ...... 18 chlorpropamide ...... 13 CORTONE ACETATE ...... 18 bumetanide ...... 11 chlorthalidone ...... 11 COSENTYX ...... 13 BUMEX ...... 11 chlorzoxazone ...... 21 COSOPT ...... 15 BUPHENYL POWDER ...... 18 cholestyramine/aspartame ...... 12 COTELLIC ...... 19 BUPHENYL TABLET ...... 18 cholestyramine/sucrose ...... 12 COUMADIN ...... 16 buprenorphine ...... 20 CHRONULAC ...... 18 COZAAR ...... 11 bupropion hcl ...... 9 CIBALITH-S ...... 10 CREON ...... 21 BUSPAR ...... 10 CICLODAN ...... 13 CREON 36K ...... 21 buspirone hcl ...... 10 ciclopirox 8% solution ...... 13 CRESTOR ...... 11 busulfan ...... 19 ciclopirox olamine ...... 13 CRINONE ...... 14 butalb/acetaminophen/caffeine ...... 20 cilostazol ...... 16 CRIXIVAN...... 18 butalbital/acetaminophen ...... 20 CILOXAN ...... 15 crizotinib ...... 19 butalbital/aspirin/caffeine ...... 20 cimetidine hcl ...... 21 cromolyn sodium ...... 9, 15 butoconazole nitrate ...... 22 CIPRO ...... 17 crotamiton ...... 13 BUTRANS ...... 20 CIPRO ORAL SUSPENSION ...... 17 CUPRIMINE ...... 18 BYSTOLIC ...... 11 CIPRODEX ...... 14 CUTIVATE ...... 13 BYVALSON ...... 11 ciprofloxacin ...... 17 cyanocobalamin/fa/pyridoxine ...... 22 cabergoline ...... 15 ciprofloxacin hcl ...... 15, 17 CYCLESSA ...... 12 CABOMETYX ...... 19 ciprofloxacin hcl/dexameth ...... 14 cyclobenzaprine hcl ...... 21 cabozanitinib ...... 19 citalopram hydrobromide ...... 9 CYCLOCORT ...... 13 cabozantinib s-malate ...... 19 CLARAVIS ...... 12 CYCLOGYL ...... 15 CADUET ...... 12 clarithromycin ...... 16 cyclopentolate hcl ...... 15 CAFERGOT...... 20 CLARITIN (OTC) ...... 9 cyclophosphamide ...... 19 CALAN ...... 11 CLARITIN-D 12 HOUR...... 9 cyclosporine...... 15, 16 CALAN SR...... 11 CLARITIN-D 24 HOUR...... 9 cyclosporine, modified ...... 16 calcipotriene ...... 13 CLEOCIN HCL ...... 16 CYMBALTA ...... 10 calcitriol ...... 22 CLEOCIN T ...... 12 CYSTARAN ...... 15 calcium acetate ...... 14 CLIMARA ...... 16 cysteamine ...... 15 canagliflozin ...... 14 clindamycin ...... 16 cysteamine bitartrate ...... 21 canagliflozin/metformin hcl ...... 14 clindamycin phosphate ...... 12, 13 CYTOMEL ...... 15 CANASA ...... 18 clindamycin/tretinoin ...... 12 CYTOTEC ...... 21 capecitabine ...... 19 CLINORIL ...... 18 CYTOVENE ...... 17 CAPITAL W-CODEINE ...... 21 clobetasol propionate ...... 13 CYTOXAN ...... 19 CAPOTEN ...... 11 clobetasol propionate/emoll ...... 13 dabrafanib...... 19 CAPOZIDE ...... 10 CLOBEX ...... 13 DALIRESP ...... 9 captopril ...... 11 CLOMID ...... 14 DALMANE ...... 10 captopril/hydrochlorothiazide...... 10 clomiphene citrate ...... 14 dalteparin sodium,porcine ...... 16 CARAFATE ...... 21 clomipramine hcl ...... 10 danazol ...... 15 carbachol ...... 15 clonazepam ...... 21 DANOCRINE ...... 15 carbamazepine ...... 21 clonidine hcl ...... 11 DANTRIUM...... 21 CARBATROL ...... 21 clopidogrel bisulfate ...... 16 dantrolene sodium ...... 21 carbidopa ...... 21 clorazepate dipotassium ...... 10 dapsone ...... 17 carbidopa/levodopa ...... 21 clotrimazole...... 17 DARAPRIM...... 17 carbidopa/levodopa/entacapone ...... 21 clotrimazole/betamet diprop ...... 13 darunavir ethanolate...... 17 CARDENE ...... 11 clozapine ...... 10 darunavir/cobicistat ...... 17 CARDIZEM ...... 11 CLOZARIL ...... 10 dasatinib ...... 19 CARDIZEM CD ...... 11 cobicistat ...... 18 DAYPRO ...... 18 CARDURA ...... 11 cobimetinib fumarate ...... 19 DDAVP ...... 14 carisoprodol ...... 21 codeine phos/carisoprodol/asa ...... 20 DECADRON ...... 18 carisoprodol/aspirin ...... 21 codeine/butalbit/acetamin/caff...... 20 DELATESTRYL ...... 16 CARMOL HC ...... 13 codeine/butalbital/asa/caffein ...... 20 delavirdine mesylate...... 17 carteolol hcl ...... 15 codeine/promethazine hcl ...... 12 DEL-BETA ...... 13 carvedilol ...... 11 COGENTIN...... 21 DELTASONE ...... 18 carvedilol phosphate ...... 11 COLAZAL ...... 18 DEMADEX ...... 11 CASODEX ...... 19 colesevelam hcl ...... 12 DEMULEN 1-50-21 ...... 12 CATAPRES ...... 11 COLESTID...... 12 DEPAKENE CAPSULES ...... 21 CAYSTON ...... 16 COLESTID GRANULES ...... 12 DEPAKENE SYRUP ...... 21 CECLOR ...... 16 colestipol ...... 12 DEPAKOTE ...... 21 CEENU ...... 19 COLYTE WITH FLAVOR PACKETS ...... 19 DEPAKOTE ER ...... 21 cefaclor ...... 16 COMBIGAN ...... 15 DEPAKOTE SPRINKLE ...... 21 cefadroxil hydrate ...... 16 COMBIPATCH ...... 16 DEPEN ...... 18 cefdinir ...... 16 COMBIVENT ...... 9 DEPO-TESTOSTERONE ...... 16 cefixime ...... 16 COMBIVENT RESPIMAT ...... 9 DESCOVY ...... 17 cefpodoxime proxetil ...... 16 COMBIVIR ...... 17 desipramine hcl ...... 10 cefprozil ...... 16 COMETRIQ ...... 19 desmopressin (nonrefrigerated) ...... 14 CEFTIN ...... 16 COMPAZINE ...... 9 DESOGEN...... 12 cefuroxime axetil ...... 16 COMPAZINE SYRUP...... 9 desogestrel-ethinyl estradiol ...... 12 CEFZIL ...... 16 COMPLERA ...... 18 desog-et estra/ethin estra ...... 12 CELEBREX ...... 18 COMTAN ...... 21 desonide ...... 13 celecoxib ...... 18 CONCERTA ...... 10 DESOWEN ...... 13 CELEXA ...... 9 CONDYLOX ...... 12 desoximetasone ...... 13 CELLCEPT ...... 16 COPAXONE ...... 20 DESVENLAFAXINE ER (RANBAXY BRAND) .... 9 CENTANY ...... 13 CORDARONE ...... 10 desvenlafaxine ER (Ranbaxy)...... 9 cephalexin monohydrate ...... 16 CORDRAN ...... 13 desvenlafaxine succinate ...... 9 ceritinib ...... 19 CORDRAN SP ...... 13 DESYREL 300MG ...... 9 cetirizine hcl (OTC)...... 9 COREG ...... 11 DETROL ...... 22 cetrorelix acetate ...... 15 COREG CR ...... 11 DETROL LA...... 22 CETROTIDE ...... 15 CORGARD ...... 11 dexamethasone ...... 18 cevimeline hcl ...... 19 CORLANOR ...... 12 DEXEDRINE...... 10 chloral hydrate ...... 10 CORTEF ...... 18 DEXEDRINE SPANSULE ...... 10 chlorambucil ...... 19 CORTENEMA ...... 18 dexmethylphenidate hcl ...... 10 chlordiazepoxide hcl ...... 10 ...... 18 dextroamphetamine capsule...... 10 chlordiazepoxide/clidinium br ...... 21 CORTISPORIN CREAM ...... 13 dextroamphetamine sulfate ...... 10 chlorhexidine gluconate ...... 20 CORTISPORIN OINTMENT ...... 13 dextroamphetamine tablet ...... 10 chloroquine phosphate ...... 17 CORTISPORIN OPHTH SUSPENSION ...... 15 DIABETA ...... 14

37012 MedPerform Medium Formulary – July 2017 34 MedPerform Medium Formulary INDEX

DIABINESE ...... 13 EFFEXOR...... 10 eszopiclone ...... 10 DIAMOX SEQUELS ...... 15 EFFEXOR XR ...... 10 etanercept...... 18 DIASTAT ...... 21 EFFIENT ...... 16 ethambutol hcl ...... 17 diazepam ...... 10, 21 EFUDEX ...... 13 ethinyl estradiol/drospirenone...... 12 DIBENZYLINE ...... 11 ELAVIL ...... 10 ethosuximide ...... 21 dichlorphenamide ...... 21 ELDEPRYL ...... 21 ethynodiol d-ethinyl estradiol ...... 12 diclofenac sodium ...... 13, 15, 18 ELIDEL ...... 13 etidronate disodium ...... 15 dicloxacillin sodium ...... 17 ELIGARD ...... 14 etodolac ...... 18 dicyclomine hcl ...... 21 ELIMITE ...... 13 etonogestrel/ethinyl estradiol ...... 12 didanosine...... 18 ELIQUIS ...... 16 etoposide...... 19 DIDRONEL ...... 15 ELMIRON ...... 21 etravirine ...... 17 DIFFERIN ...... 12 ELOCON ...... 13 EUCRISA ...... 13 DIFICID ...... 17 eltrombopag olamine ...... 16 EULEXIN ...... 19 diflorasone diacetate ...... 13 elviteg/cobi/emtric/tenofo ala ...... 17 EURAX ...... 13 diflorasone diacetate/emoll ...... 13 elvitegravir/cobicistat/emtricitabine/ tenofovir everolimus ...... 16, 19 DIFLUCAN...... 17 disoproxil fumarate ...... 17 EVISTA ...... 15 diflunisal ...... 20 EMCYT ...... 20 EVOCLIN ...... 13 difluprednate ...... 15 EMEND ...... 9 evolocumab ...... 11 digoxin ...... 10 EMGEL ...... 13 EVOTAZ ...... 18 DIGOXIN ORAL SOLN...... 10 empagliflozin...... 14 EVOXAC ...... 19 DILACOR XR ...... 11 empagliflozin/linagliptin ...... 14 EXELDERM ...... 13 DILANTIN ...... 21 empagliflozin/metformin hcl XR...... 14 EXELON CAPSULE ...... 9 DILANTIN CHEW TAB ...... 21 empagliflozin/metformin hcll ...... 14 EXELON PATCH ...... 9 DILANTIN-125 ...... 21 emtricitab/rilpiviri/tenof ala ...... 18 exemestane ...... 19 DILAUDID ...... 20 emtricitab/rilpivirine/tenofovir ...... 18 EXFORGE ...... 11 DILAUDID-5...... 20 emtricitabine ...... 18 EXFORGE HCT ...... 11 diltiazem hcl ...... 11 emtricitabine/tenofov alafenam ...... 17 ezetimibe ...... 12 dimethyl fumarate ...... 20 emtricitabine/tenofovir ...... 17 FABIOR ...... 12 DIOVAN ...... 11 EMTRIVA ...... 18 famotidine ...... 21 DIOVAN HCT ...... 11 EMVERM ...... 17 FARESTON ...... 19 diphenoxylate hcl/atrop sulf ...... 18 enalapril maleate ...... 11 FARYDAK...... 19 dipivefrin hcl...... 16 enalapril/hydrochlorothiazide ...... 10 febuxostat ...... 16 DIPROLENE ...... 13 ENBREL ...... 18 FELDENE ...... 18 DIPROLENE AF ...... 13 ENDOMETRIN ...... 14 felodipine ...... 11 DIPROSONE ...... 13 enfuvirtide ...... 17 FEMARA ...... 19 dipyridamole ...... 16 enoxaparin sodium ...... 16 FEMHRT ...... 16 DISALCID ...... 20 entacapone...... 21 fenofibrate ...... 12 disopyramide phosphate ...... 10 entecavir ...... 18 fenofibrate nanocrystallized ...... 12 disulfiram ...... 10 ENTOCORT EC ...... 18 fenofibrate, micronized ...... 12 DITROPAN XL ...... 22 ENTRESTO ...... 12 FENOGLIDE ...... 12 divalproex sodium ...... 21 enzalutamide ...... 19 fenoprofen calcium ...... 18 d-methorphan hb/prometh hcl ...... 12 EPCLUSA ...... 18 fentanyl ...... 20 dofetilide ...... 10 EPIDUO ...... 12 fentanyl citrate lozenge ...... 20 DOLOBID ...... 20 epinephrine ...... 19 fesoterodine fumarate ...... 22 DOLOPHINE HCL ...... 20 EPIPEN ...... 19 FETZIMA ...... 10 dolutegravir ...... 18 EPIPEN JR ...... 19 fidaxomicin...... 17 DOMEBORO ...... 14 EPIVIR ...... 18 filgrastim ...... 16 donepezil hcl ...... 9 EPIVIR HBV SOLUTION ...... 18 finasteride ...... 21 DONNATAL ...... 21 EPIVIR HBV TABLET...... 18 fingolimod hcl ...... 20 dornase alfa ...... 20 eplerenone ...... 11 FIORICET ...... 20 dorzolamide hcl ...... 15 epoetin alfa ...... 16 FIORICET WITH CODEINE ...... 20 dorzolamide hcl/timolol maleat ...... 15 EPZICOM ...... 17 FIORINAL ...... 20 DOSTINEX ...... 15 ergocalciferol ...... 22 FIORINAL WITH CODEINE ...... 20 DOVONEX...... 13 ergotamine tartrate/caffeine ...... 20 FIRAZYR ...... 18 doxazosin mesylate ...... 11 ERIVEDGE ...... 19 FIRST-HYDROCORTISONE ...... 13 doxepin hcl...... 10 erlotinib hcl ...... 19 FLAGYL ...... 17 doxycycline calcium ...... 17 ery e-succ/sulfisoxazole ...... 16 FLAGYL ER ...... 17 doxycycline hyclate ...... 17 ERYC ...... 16 FLAREX ...... 15 DOXYCYCLINE HYCLATE 100MG TABLET .... 17 ERYGEL ...... 13 flecainide acetate ...... 10 DOXYCYCLINE MONOHYDRATE 150MG ERYPED 200 ...... 16, 17 FLEXERIL...... 21 TABLET ...... 17 ERYPED 400 ...... 17 FLOMAX ...... 21 DRISDOL ...... 22 ERY-TAB ...... 17 FLONASE ...... 9 DRITHOCREME HP...... 13 ERYTHROCIN STEARATE ...... 16 FLORINEF ACETATE ...... 18 DRITHO-SCALP ...... 13 erythromycin base ...... 15, 16, 17 FLOXIN ...... 14, 17 dronabinol ...... 9 erythromycin base/benz per ...... 12, 13 fluconazole ...... 17 dronedarone hcl ...... 10 erythromycin base/ethanol ...... 13 fludarabine phosphate ...... 19 DRYSOL ...... 13 erythromycin ethylsuccinate ...... 16, 17 fludrocortisone acetate ...... 18 DUAVEE ...... 16 erythromycin stearate ...... 16 flunisolide...... 9 DUETACT ...... 14 ESBRIET ...... 20 ...... 13 DULERA ...... 9 escitalopram oxalate ...... 9 fluocinonide ...... 13 duloxetine hcl ...... 10 ESGIC ...... 20 fluocinonide/emollient ...... 13 DUONEB ...... 9 ESKALITH ...... 10 FLUORABON BASIC ...... 22 DURAGESIC ...... 20 esomeprazole magnesium ...... 21 fluoride ion/iron/vit a,c&d ...... 22 DUREZOL ...... 15 estazolam ...... 10 fluoride ion/multivitamins ...... 22 DURICEF ...... 16 ESTRACE...... 16, 22 fluoride ion/multivits w-fe ...... 22 dutasteride ...... 21 ESTRADERM ...... 16 fluoride ion/vit a,c&d ...... 22 dutasteride/tamsulosin ...... 21 estradiol ...... 16, 22 FLUORITAB ...... 22 DYAZIDE ...... 11 estradiol/noreth ac ...... 16 fluorometholone ...... 15 DYNACIN ...... 17 sodium ...... 20 fluorometholone acetate ...... 15 DYNACIRC CR ...... 11 ESTRATEST H.S...... 16 fluorouracil ...... 13 EC-NAPROSYN ...... 18 estrogen, con/m-progest acet ...... 16 fluoxetine er ...... 9 EDARBI ...... 11 estrogen, ester/me-testosterone ...... 16 fluoxetine hcl ...... 9 EDARBYCLOR ...... 11 estrogens, conj/bazedoxifene ...... 16 fluoxymesterone ...... 16 EDURANT ...... 17 estrogens, conjugated ...... 16, 22 fluphenazine hcl ...... 10 efavirenz ...... 17 estrogens, esterified ...... 16 FLURA-DROPS ...... 22 efavirenz/emtricitab/tenofovir ...... 18 estropipate ...... 16 flurandrenolide ...... 13

37012 MedPerform Medium Formulary – July 2017 35 MedPerform Medium Formulary INDEX

FLURA-TABS ...... 22 HEXALEN ...... 19 INVOKAMET ...... 14 flurazepam hcl ...... 10 homatropine hbr ...... 15 INVOKANA ...... 14 flurbiprofen ...... 18 HUMALOG ...... 14 iodoquinol ...... 17 flurbiprofen sodium ...... 15 HUMALOG MIX 50-50...... 14 ipratropium bromide ...... 9, 20 flutamide ...... 19 HUMALOG MIX 75-25...... 14 ipratropium/albuterol sulfate ...... 9 fluticasone propionate ...... 9, 13 HUMATIN ...... 17 irbesartan ...... 11 fluticasone/salmeterol...... 9 HUMIRA ...... 18 irbesartan/hydrochlorithiazide...... 11 fluticasone/vilanterol ...... 9 HUMULIN 70-30 ...... 14 IRESSA ...... 19 FML ...... 15 HUMULIN N...... 14 ISENTRESS ...... 18 FML FORTE ...... 15 HUMULIN R...... 14 ISMO ...... 12 FML S.O.P...... 15 HUMULIN R U-500 KWIK PEN ...... 14 ISOCHRON ...... 12 FOCALIN ...... 10 HYCAMTIN ...... 19 isomethept/acetaminop/dichlphn ...... 20 FOCALIN XR ...... 10 HYCET ...... 20 isoniazid ...... 17 FOLGARD RX ...... 22 HYCODAN...... 12 ISOPTO ATROPINE ...... 15 folic acid ...... 22 hydralazine hcl ...... 11 ISOPTO CARBACHOL ...... 15 FOLIC ACID ...... 22 HYDREA ...... 19 ISOPTO CARPINE ...... 15 folic acid/mu-vits-min th ...... 22 hydrochlorothiazide ...... 11 ISOPTO HOMATROPINE ...... 15 follitropin alpha,recomb ...... 14 hydrocodone bit/acetaminophen ...... 20 ISORDIL ...... 12 fondaparinux sodium ...... 16 hydrocodone bit/acetaminophen oral elixir .. 20 ISORDIL TITRADOSE ...... 12 formoterol fumarate ...... 9 hydrocodone bit/acetaminophen oral solution isosorb dinit/hydralazine hcl ...... 12 FORTEO ...... 14 ...... 20 isosorbide dinitrate ...... 12 FOSAMAX ...... 14 hydrocodone bit/homatrop me-br ...... 12 isosorbide mononitrate ...... 12 FOSAMAX PLUS D ...... 14 hydrocodone bitartrate ...... 20 isotretinoin ...... 12 fosamprenavir calcium ...... 18 hydrocodone/chlorphen p-stirex ...... 12 isradipine IR capsules ...... 11 fosinopril sodium ...... 11 hydrocort/sal acid/sulf/shmp#1...... 13 itraconazole...... 17 fosinopril/hydrochlorothiazide ...... 10 hydrocortisone ...... 13, 18 ivabradine hcl ...... 12 FRAGMIN ...... 16 hydrocortisone acetate ...... 18 ivacaftor ...... 20 FURADANTIN ...... 17 hydrocortisone acetate/urea ...... 13 ixazomib ixazomib citrate ...... 19 furazolidone ...... 17 hydrocortisone butyrate ...... 13 JAKAFI ...... 19 furosemide ...... 11 hydrocortisone butyrate/emoll ...... 13 JALYN ...... 21 FUROXONE ...... 17 hydrocortisone probutate ...... 13 JANUMET ...... 13 FUZEON ...... 17 hydrocortisone valerate ...... 13 JANUMET XR ...... 13 gabapentin ...... 21 hydromorphone hcl...... 20 JANUVIA ...... 13 galantamine hbr ...... 9 hydroxychloroquine sulfate ...... 17 JARDIANCE ...... 14 ganciclovir...... 15, 17 hydroxyurea ...... 19 JENTADUETO ...... 13 ganirelix acetate ...... 15 hydroxyzine hcl ...... 9 JUXTAPID ...... 11 GANIRELIX ACETATE...... 15 hydroxyzine pamoate ...... 9 KALETRA ...... 18 GANTRISIN ...... 16 HYGROTON ...... 11 KALYDECO ...... 20 GARAMYCIN ...... 13, 15 hyoscyamine sulfate ...... 21 KAYEXALATE ...... 14 gatifloxacin...... 15 HYPER-SAL 7% ...... 20 K-DUR ...... 14 GATTEX ...... 19 HYSINGLA ER ...... 20 KEFLEX ...... 16 gefitinib ...... 19 HYTRIN ...... 11 KENALOG ...... 13 gemfibrozil ...... 12 HYZAAR ...... 11 KENALOG IN ORABASE ...... 20 gentamicin sulfate ...... 13, 15 ibandronate ...... 15 KEPPRA ...... 21 GENVOYA ...... 17 IBRANCE ...... 19 KETEK ...... 16 GEODON ...... 10 ibrutinib ...... 19 ketoconazole ...... 13, 17 GIANVI ...... 12 ibuprofen ...... 18 ketoprofen ...... 18 GILENYA ...... 20 icatibant ...... 18 ketorolac tromethamine ...... 15, 18 GILOTRIF ...... 19 ICLUSIG ...... 19 ketotifen fumarate (OTC) ...... 15 glatiramer acetate ...... 20 icosapent ethyl ...... 12 KEVEYIS ...... 21 glimepiride ...... 14 idelalisib ...... 19 KISQALI ...... 19 glipizide ...... 14 ILEVRO ...... 15 KLARON ...... 12 glipizide/metformin hcl ...... 14 IMBRUVICA...... 19 KLONOPIN ...... 21 glucagon ...... 14 IMDUR ...... 12 KORLYM ...... 14 GLUCAGON KIT ...... 14 imipramine hcl ...... 10 KRISTALOSE ...... 19 GLUCOPHAGE ...... 14 imiquimod ...... 16 K-TAB ...... 14 GLUCOPHAGE XR ...... 14 IMITREX INJECTION ...... 20 KURIC ...... 13 GLUCOTROL ...... 14 IMITREX NASAL SPRAY ...... 20 KUVAN ...... 19 GLUCOTROL XL ...... 14 IMITREX TABLET ...... 20 KWELL ...... 13 GLUCOVANCE ...... 14 IMPAVIDO ...... 17 labetalol hcl ...... 11 glyburide ...... 14 IMURAN ...... 16 LACTICARE-HC ...... 13 glyburide, micro/metformin hcl ...... 14 indapamide...... 11 lactulose ...... 18, 19 GLYXAMBI ...... 14 INDERAL LA...... 11 LAMICTAL ...... 21 GOLYTELY...... 19 INDERIDE-40/25 ...... 11 LAMISIL ...... 13, 17 gonadotropin,chorionic, human ...... 14 indinavir sulfate ...... 18 LAMISIL GRANULES ...... 17 GONAL-F ...... 14 INDOCIN ...... 18 lamivudine ...... 18 GONAL-F RFF ...... 14 INDOCIN ORAL SUSP...... 18 lamivudine/zidovudine ...... 17 GRASTEK ...... 9 INDOCIN SR ...... 18 lamotrigine ...... 21 griseofulvin ultramicrosize ...... 17 INDOCIN SUPPOS ...... 18 lancing device/lancets ...... 14 GRIS-PEG ...... 17 indomethacin ...... 18 LANOXIN ...... 10 guanfacine hcl ...... 11 ingenol ...... 13 lansoprazole ...... 21 GYNAZOLE-1 ...... 22 INLYTA ...... 19 lansoprazole/amox tr/clarith ...... 21 HALCION ...... 10 INSPRA ...... 11 LANTUS ...... 14 HALDOL ...... 10 insulin glargine,hum.rec.anlog ...... 14 lapatinib ditosylate ...... 19 HALDOL ORAL CONC...... 10 insulin lispro ...... 14 LARIAM ...... 17 halobetasol propionate ...... 13 insulin nph hum/reg insulin hm...... 14 LASIX ...... 11 haloperidol ...... 10 insulin nph human isophane ...... 14 latanoprost ...... 15 haloperidol lactate ...... 10 insulin npl/insulin lispro ...... 14 LATUDA ...... 10 HARVONI ...... 18 insulin regular, human ...... 14 ledipasvir/sofosbuvir ...... 18 hc acetate/pramoxine hcl ...... 13, 18 INTAL ...... 9 leflunomide ...... 18 hcg alpha, recombinant ...... 14 INTELENCE ...... 17 lenalidomide ...... 19 HEPARIN LOCK ...... 16 interferon alfa-2b, recomb...... 16 lenvatinib mesylate ...... 19 heparin sodium, porcine ...... 16 interferon beta-1a ...... 20 LENVIMA ...... 19 heparin sodium, porcine/pf ...... 16 interferon beta-1a/albumin ...... 20 LESSINA ...... 12 HEP-LOCK ...... 16 INTRON A ...... 16 LETAIRIS ...... 11 HEPSERA ...... 18 INVIRASE ...... 18 letrozole ...... 19

37012 MedPerform Medium Formulary – July 2017 36 MedPerform Medium Formulary INDEX

leucovorin calcium ...... 19 LUMIGAN ...... 15 mexiletine hcl ...... 10 LEUCOVORIN CALCIUM ...... 19 LUNESTA ...... 10 MEXITIL ...... 10 LEUKERAN ...... 19 LURIDE ...... 22 miconazole nitrate ...... 22 LEUKINE ...... 16 LUTERA ...... 12 MICRO-K ...... 14 leuprolide ...... 14 LYNPARZA...... 19 MICRONASE ...... 14 LEVAQUIN ...... 17 LYRICA ...... 21 MICROZIDE ...... 11 LEVBID ...... 21 LYSODREN ...... 19 midodrine hcl ...... 12 levetiracetam ...... 21 macitentan ...... 11 MIDRIN ...... 20 levobunolol hcl ...... 15 MACROBID ...... 17 mifepristone ...... 14 levocetirizine ...... 9 MACRODANTIN ...... 17 MIGERGOT ...... 20 levofloxacin ...... 17 malathion...... 13 MILLIPRED...... 18 levonorgestrel ...... 12 maprotiline hcl ...... 10 MILLIPRED DP ...... 18 levonorgestrel-eth estra ...... 12 maraviroc ...... 17 milnacipran hcl ...... 20 LEVOTHROID ...... 15 MARINOL ...... 9 miltefoside ...... 17 levothyroxine sodium ...... 15 MATULANE ...... 19 MILTOWN ...... 10 LEVOXYL ...... 15 MAVIK ...... 11 MINIPRESS ...... 11 LEVSIN-SL ...... 21 MAXALT ...... 20 MINOCIN ...... 17 LEXAPRO...... 9 MAXALT MLT ...... 20 minocycline hcl ...... 17 LEXIVA ...... 18 MAXITROL ...... 15 mirabegron ...... 21 LIBRAX ...... 21 MAXZIDE ...... 11 MIRALAX ...... 19 LIBRIUM ...... 10 MAXZIDE-25MG ...... 11 MIRAPEX ...... 21 LIDEX ...... 13 mebendazole ...... 17 MIRCETTE ...... 12 LIDEX-E ...... 13 mechlorethamine ...... 13 mirtazapine...... 9 lidocaine hcl ...... 18 meclizine hcl ...... 9 misoprostol ...... 21 linaclotide ...... 18 meclofenamate sodium ...... 18 mitotane ...... 19 linagliptin ...... 13 MECLOMEN ...... 18 MOBIC ...... 18 linagliptin/metformin hcl ...... 13 MEDROL ...... 18 modafinil ...... 10 lindane ...... 13 medroxyprogesterone acet ...... 16 moexipril hcl ...... 11 linezolid ...... 17 mefloquine hcl ...... 17 moexipril/hydrochlorothiazide ...... 11 LINZESS ...... 18 MEGACE ...... 20 mometasone furoate ...... 9 LIORESAL ...... 21 megestrol acetate ...... 20 mometasone furoate ...... 9, 13 liothyronine sodium ...... 15 MEKINIST...... 19 mometasone/formoterol ...... 9 LIPITOR ...... 11 MELLARIL ...... 10 MONISTAT 3 ...... 22 liraglutide ...... 13 meloxicam ...... 18 MONOKET ...... 12 lisdexamfetamine dimesylate ...... 10 melphalan ...... 19 MONOPRIL ...... 11 lisinopril ...... 11 memantine hcl ...... 9 MONOPRIL HCT ...... 10 lisinopril/hydrochlorothiazide ...... 10 memantine hcl/donepezil hcl ...... 9 montelukast sodium ...... 9 lithium carbonate ...... 10 MENEST ...... 16 MORGIDOX 100MG CAPSULE...... 17 lithium citrate ...... 10 MENOPUR ...... 14 MORGIDOX 50MG CAPSULE...... 17 LITHOBID ...... 10 menotropins ...... 14 morphine sulfate ...... 20 LIVALO ...... 11 MEPHYTON ...... 16 MOTRIN ...... 18 LO LOESTRIN FE ...... 12 meprobamate ...... 10 MOVANTIK ...... 19 LO MINASTRIN FE ...... 12 mercaptopurine ...... 19 moxifloxacin hcl ...... 15, 17 LOCOID ...... 13 mesalamine ...... 18 MSIR ...... 20 LOCOID LIPOCREAM ...... 13 mesalamine w/cleansing wipes ...... 18 mth/me blue/salicy/na phos/hyo ...... 16 LODINE ...... 18 MESTINON...... 9 MUCOMYST-10 ...... 20 LODOSYN ...... 21 METADATE CD ...... 10 MULTAQ ...... 10 lodoxamide tromethamine ...... 15 METADATE ER ...... 10 mupirocin ...... 13 LOESTRIN...... 12 METAGLIP ...... 14 mupirocin calcium ...... 13, 20 LOESTRIN FE ...... 12 metaproterenol sulfate ...... 9 MYAMBUTOL ...... 17 LOESTRIN FE24 ...... 12 metaxalone ...... 21 MYCELEX ...... 17 LOFIBRA ...... 12 metformin hcl ...... 14 MYCIFRADIN ...... 17 lomitapide ...... 11 meth/meth blue/ba/salicy/hyos ...... 16 MYCOLOG II ...... 13 LOMOTIL ...... 18 methadone hcl ...... 20 mycophenolate mofetil ...... 16 lomustine...... 19 methadone injection solution ...... 20 MYCOSTATIN ...... 13, 17 LONSURF ...... 19 methazolamide ...... 15 MYLERAN ...... 19 LO-OVRAL-28 ...... 12 METHERGINE ...... 12 MYORISAN ...... 12 LOPID ...... 12 methimazole ...... 15 MYRBETRIQ ...... 21 lopinavir/ritonavir ...... 18 METHITEST ...... 16 MYSOLINE ...... 21 LOPRESSOR ...... 11 METHLYIN SOLN ...... 10 na sulfacetm/prednis sp ...... 15 LOPRESSOR HCT ...... 11 methocarbamol ...... 21 na sulfacetm/prednisol ac ...... 15 LOPROX ...... 13 methotrexate ...... 18 nabumetone ...... 18 loratadine (OTC) ...... 9 METHOTREXATE 2.5MG TABLET ...... 19 nadolol ...... 11 lorazepam ...... 10 methotrexate sodium ...... 18, 19 naftifine hcl ...... 13 LORAZEPAM INTENSOL ...... 10 METHOTREXATE VIAL ...... 19 NAFTIN ...... 13 LORCET ...... 20 methoxsalen ...... 13 NALFON CAPSULE ...... 18 LORCET PLUS ...... 20 methoxsalen, rapid...... 13 NALFON TABLET ...... 18 LORTAB ...... 20 methyldopa ...... 11 naloxegol oxalate ...... 19 LORTAB ELIXIR ...... 20 methylergonovine maleate ...... 12 naltrexone hcl ...... 10 LORYNA ...... 12 METHYLIN CHEW TAB ...... 10 NAMENDA...... 9 losartan potassium ...... 11 methylphenidate ER Susp ...... 10 NAMENDA XR ...... 9 losartan/hydrochlorothiazide ...... 11 methylphenidate hcl...... 10 NAMZARIC ...... 9 LOTEMAX ...... 15 methylprednisolone ...... 18 NAPROSYN ...... 18 LOTENSIN...... 11 methyltestosterone ...... 16 naproxen ...... 18 LOTENSIN HCT ...... 10 metipranolol ...... 15 naproxen sodium ...... 18 loteprednol etabonate...... 15 metoclopramide hcl ...... 21 naratriptan ...... 20 LOTREL ...... 10 METOCLOPRAMIDE HCL INTENSOL ...... 21 NARCAN ...... 10 LOTRISONE ...... 13 metolazone ...... 11 Narcotic Withdrawal Therapy Agents ...... 21 lovastatin ...... 11 metoprolol succinate ...... 11 NARDIL ...... 9 LOVAZA ...... 12 metoprolol tartrate ...... 11 NASACORT AQ ...... 9 LOVENOX ...... 16 metoprolol/hctz ...... 11 NASAREL ...... 9 loxapine succinate ...... 10 METROCREAM ...... 12 NASONEX ...... 9 LOXITANE ...... 10 METROGEL-VAGINAL ...... 22 nateglinide...... 14 LOZOL ...... 11 METROLOTION ...... 12 NATURE-THROID ...... 15 LUDIOMIL...... 10 metronidazole ...... 12, 17, 22 NAVANE ...... 10 lumacaftor/ivacaftor ...... 20 MEVACOR ...... 11 nebivolol hcl ...... 11

37012 MedPerform Medium Formulary – July 2017 37 MedPerform Medium Formulary INDEX

NEBUPENT ...... 17 octreotide acetate ...... 20 PAXIL CR ...... 9 nedocromil sodium ...... 15 OCUFEN ...... 15 pazopanib hydrochloride ...... 19 needles, insulin disp., safety ...... 20 OCUFLOX ...... 15 PCE ...... 17 nelfinavir mesylate ...... 18 OCUPRESS ...... 15 PEDIAPRED ...... 18 neo/polymyx b sulf/dexameth ...... 15 ODEFSEY ...... 18 PEDIAZOLE ...... 16 neomy sulf/bacitrac zn/poly/hc ...... 15 ODOMZO ...... 19 peg 3350/na sulf,bicarb,cl/kcl ...... 19 neomy sulf/polymyx b sulf/hc ...... 13, 14, 15 OFEV ...... 20 PEGASYS ...... 18 neomycin sulfate ...... 17 ofloxacin ...... 14, 15, 17 PEGASYS PROCLICK ...... 18 neomycin/bacitra/polymyxin/hc ...... 13 OFORTA ...... 19 pegfilgrastim ...... 16 neomycin/bacitracin/polymyxin ...... 15 OGEN ...... 16 peginterferon alfa-2a ...... 18 neomycin/polymyxn b/gramicidin ...... 15 olanzapine ...... 10 peginterferon beta-1a ...... 20 NEO-POLYCIN HCOPHTH OINTMENT...... 15 olanzapine ODT ...... 10 pegvisomant ...... 15 NEORAL ...... 16 olanzapine/fluoxetine ...... 9 pemirolast potassium ...... 15 NEOSPORIN OPHTH DROPS ...... 15 olaparib ...... 19 penicillamine ...... 18 NEOSPORIN OPHTH OINTMENT ...... 15 olmesartan medoxomil ...... 11 penicillin v potassium ...... 17 neostigmine bromide ...... 9 olmesartan/amlodipin/hcthiazid ...... 11 pentamidine isethionate ...... 17 nepafenac ...... 15 olmesartan/hydrochlorothiazide ...... 11 pentosan polysulfate sodium ...... 21 NEPTAZANE ...... 15 olodaterol hcl ...... 9 pentoxifylline ...... 16 netupitant/palonosetron hcl ...... 9 olopatadine hcl ...... 15 PEPCID ...... 21 NEULASTA...... 16 OLUX ...... 13 p-ephed hcl/cetirizine hcl (OTC) ...... 9 NEUPOGEN ...... 16 omega-3 acid ethyl esters ...... 12 p-ephed sul/loratadine ...... 9 NEUPRO ...... 21 omeprazole...... 21 PERCOCET...... 20 NEURONTIN ...... 21 omeprazole magnesium ...... 21 PERCODAN ...... 20 NEVANAC ...... 15 OMNICEF ...... 16 PERCOLONE ...... 20 nevirapine...... 17 OMNIPRED ...... 15 PERFOROMIST ...... 9 nevirapine ER ...... 17 OMNITROPE ...... 15 PERIDEX ...... 20 NEXAVAR ...... 19 ondansetron ...... 9 permethrin ...... 13 NEXIUM ...... 21 ondansetron hcl ...... 9 perphenazine ...... 10 niacin ...... 12 ONEXTON ...... 12 PERSANTINE ...... 16 NIASPAN ...... 12 OPSUMIT ...... 11 phenazopyridine hcl...... 21 nicardipine ...... 11 OPTICROM ...... 15 phenelzine sulfate ...... 9 nifedipine ...... 11 OPTIPRANOLOL ...... 15 PHENERGAN ...... 9 NILANDRON ...... 19 OPTIVAR ...... 15 PHENERGAN VC ...... 12 nilotinib hydrochloride...... 19 ORALAIR ...... 9 PHENERGAN VC W/CODEINE...... 12 nilutamide...... 19 ORAMORPH SR ...... 20 PHENERGAN W/CODEINE ...... 12 nimodipine ...... 11 ORAPRED ...... 18 PHENERGAN W/DEXTROMETHORPHAN ...... 12 NIMOTOP ...... 11 ORFADIN ...... 20 phenobarbital ...... 10 NINLARO ...... 19 ORINASE ...... 14 PHENOBARBITAL ...... 10 nintedanib esylate ...... 20 ORKAMBI ...... 20 phenoxybenzamine hcl ...... 11 NITRO-BID ...... 12 orphenadrine citrate...... 21 phenylephrine hcl/cod/prometh ...... 12 NITRO-DUR ...... 12 orphenadrine/aspirin/caffeine ...... 21 phenylephrine hcl/prometh hcl ...... 12 nitrofurantoin ...... 17 ORSYTHIA ...... 12 PHENYTEK ...... 21 nitrofurantoin macrocrystal ...... 17 ORTHO EVRA ...... 12 phenytoin ...... 21 nitrofurantoin/nitrofuran mac ...... 17 ORTHO MICRONOR ...... 12 phenytoin sodium extended ...... 21 nitroglycerin ...... 12 ORTHO TRI-CYCLEN ...... 12 PHOSLO ...... 14 NITROLINGUAL ...... 12 ORTHO TRI-CYCLEN LO ...... 12 PHRENILIN ...... 20 NITROSTAT ...... 12 ORTHO-CEPT ...... 12 PHRENILIN FORTE ...... 20 nizatidine ...... 21 ORTHO-CYCLEN ...... 12 phytonadione ...... 16 NIZORAL ...... 13, 17 ORTHO-NOVUM ...... 12 PICATO ...... 13 NOCTEC ...... 10 ORUVAIL ...... 18 pilocarpine hcl ...... 15, 19 NOLVADEX ...... 19 OSCELLA ...... 12 pindolol ...... 11 NORCO ...... 20 oseltamivir phosphate ...... 17 pioglitazone hcl ...... 14 NORDETTE-28 ...... 12 osimertinib mesylate...... 19 pioglitazone hcl/metformin hcl ...... 14 NORDITROPIN ...... 15 OTEZLA ...... 13 pioglitazone/glimepiride ...... 14 NORDITROPIN FLEXPRO ...... 15 OTICIN HC ...... 14 pirfenidone ...... 20 NORDITROPIN NORDIFLEX ...... 15 OTREXUP ...... 18 piroxicam...... 18 norelgestromin/ethin.estradiol ...... 12 OVACE PLUS SUSPENSION...... 13 PLAN B ONE-STEP ...... 12 noreth a-et estra/fe fumarate...... 12 OVIDE ...... 13 PLAQUENIL ...... 17 norethindrone ...... 12 OVIDREL ...... 14 PLAVIX ...... 16 norethindrone acetate ...... 16 oxaprozin...... 18 PLAVIX 300MG ...... 16 norethindrone ac-eth estradiol ...... 16 oxazepam ...... 10 PLEGRIDY ...... 20 norethindrone a-e estradiol ...... 12 oxcarbazepine ...... 21 PLEGRIDY PEN ...... 20 norethindrone-ethinyl estrad ...... 12 OXSORALEN ...... 13 PLENDIL ...... 11 norethindrone-mestranol ...... 12 OXSORALEN-ULTRA ...... 13 PLETAL ...... 16 NORFLEX...... 21 oxybutynin chloride ...... 22 PODHALER ...... 17 NORGESIC FORTE ...... 21 oxycodone hcl ...... 20 podofilox ...... 12 norgestimate-ethinyl estradiol ...... 12 oxycodone hcl/acetaminophen ...... 20 POLYCILLIN ...... 17 norgestrel-ethinyl estradiol ...... 12 oxycodone hcl/aspirin ...... 20 POLYCIN-B ...... 15 NORINYL 1+35 ...... 12 OXYCONTIN ...... 20 polyethylene glycol 3350 ...... 19 NORINYL 1+50 ...... 12 palbociclib ...... 19 polymyxin b sulfate/tmp ...... 15 NORPACE ...... 10 PAMELOR ...... 10 POLYTRIM ...... 15 NORPACE CR ...... 10 PANCRELIPASE 5,000 ...... 21 POLY-VI-FLOR ...... 22 NORPRAMIN ...... 10 PANDEL ...... 13 POLY-VI-FLOR W/IRON ...... 22 NOR-Q-D ...... 12 panobinostat lactate ...... 19 pomalidomide ...... 19 nortriptyline hcl ...... 10 pantoprazole sodium ...... 21 POMALYST ...... 19 NORVASC ...... 11 PARAFON FORTE DSC ...... 21 ponatinib ...... 19 NORVIR ...... 18 PARCOPA ...... 21 potassium chloride ...... 14 NOVAREL ...... 14 paricalcitol...... 15 potassium iodide ...... 15 NUCYNTA ...... 20 PARLODEL ...... 21 POTASSIUM IODIDE ...... 15 NUCYNTA ER ...... 20 PARNATE...... 9 POTIGA ...... 21 NULYTELY WITH FLAVOR PACKS ...... 19 paromomycin sulfate ...... 17 PRALUENT ...... 11 NUVARING...... 12 paroxetine hcl ...... 9 pramipexole di-hcl ...... 21 NYDRAZID ...... 17 PATADAY ...... 15 pramlintide acetate ...... 13 nystatin ...... 13, 17 PATANOL ...... 15 PRAMOSONE ...... 13 nystatin/triamcin ...... 13 PATHOCIL...... 17 PRANDIMET ...... 14 OCL ...... 19 PAXIL ...... 9 PRANDIN ...... 14

37012 MedPerform Medium Formulary – July 2017 38 MedPerform Medium Formulary INDEX

prasugrel hcl ...... 16 PYRAZINAMIDE ...... 17 ROMYCIN ...... 15 PRAVACHOL ...... 11 PYRIDIUM ...... 21 ropinirole hcl ...... 21 pravastatin sodium ...... 11 pyridostigmine bromide ...... 9 rosuvastatin calcium...... 11 praziquantel ...... 17 pyrimethamine ...... 17 rotigotine ...... 21 prazosin hcl...... 11 QNASL ...... 9 ROWASA ...... 18 PRECOSE ...... 13 QNASL CHILDREN ...... 9 ROXANOL ...... 20 PRED FORTE ...... 15 QUALAQUIN ...... 17 ROXICET ...... 20 PRED MILD ...... 15 QUESTRAN...... 12 ROXICODONE ...... 20 PREDNISOL ...... 15 QUESTRAN LIGHT ...... 12 ROXICODONE INTENSOL ...... 20 prednisolone ...... 18 quetiapine fumarate ...... 10 ruxolitinib ...... 19 prednisolone acetate ...... 15 QUILLICHEW ER ...... 10 RYTHMOL ...... 10 prednisolone sod phosphate ...... 15, 18 QUILLIVANT XR ...... 10 RYTHMOL SR ...... 10 prednisone ...... 18 QUINAGLUTE ...... 10 sacubitril/valsartan ...... 12 PREDNISONE INTENSOL ...... 18 quinapril hcl ...... 11 SALAGEN...... 19 pregabalin ...... 21 quinapril/hydrochlorothiazide...... 11 salmeterol xinafoate ...... 9 PREGNYL ...... 14 QUINIDEX ...... 10 salsalate ...... 20 PREMARIN...... 16, 22 quinidine gluconate ...... 10 SANDIMMUNE ...... 16 PREMPHASE ...... 16 quinidine sulfate ...... 10 SANDOSTATIN ...... 20 PREMPRO ...... 16 quinine sulfate ...... 17 SAPHRIS ...... 10 prenatal vit 15/iron cb/fa/dss...... 22 QVAR ...... 9 sapropterin dihydrochloride ...... 19 prenatal vit 16/iron cb/fa/dss...... 22 RAGWITEK ...... 9 saquinavir mesylate...... 18 prenatal vit 18/iron cb/fa/dss...... 22 raloxifene hcl ...... 15 sargramostim ...... 16 prenatal vit 95/fe fum/fa ...... 22 raltegravir potassium ...... 18 SAVELLA ...... 20 PRENAVITE ...... 22 ramipril ...... 11 SCALACORT ...... 13 PREVACID ...... 21 RANEXA ...... 12 SCALACORT DK ...... 13 PREVACID SOLUTABS ...... 21 ranitidine hcl ...... 21 SEASONALE ...... 12 PREVPAC ...... 21 ranolazine ...... 12 SECTRAL ...... 11 PREZCOBIX ...... 17 RAPAMUNE ...... 16 secukinumab ...... 13 PREZISTA ...... 17 rasagiline mesylate ...... 21 selegiline hcl ...... 21 PRILOSEC ...... 21 RAYALDEE ...... 15 selenium sulfide ...... 13 PRILOSEC OTC ...... 21 RAZADYNE ...... 9 selexipag ...... 11 PRIMAQUINE ...... 17 RAZADYNE ER ...... 9 SELSUN RX ...... 13 primaquine phosphate ...... 17 REBETOL ...... 18 SELZENTRY ...... 17 primidone ...... 21 REBIF ...... 20 SEPTRA ...... 16 PRIMSOL ...... 16 REBIF REBIDOSE ...... 20 SEPTRA DS ...... 16 PRINIVIL ...... 11 REDERM ...... 13 SERAX ...... 10 PRINZIDE ...... 10 REGLAN ...... 21 SEREVENT DISKUS...... 9 PRISTIQ ...... 9 regorafenib ...... 19 SEROPHENE ...... 14 PROAIR HFA ...... 9 REGRANEX ...... 14 SEROQUEL...... 10 PROAIR RESPICLICK ...... 9 RELAFEN ...... 18 SERPASIL ...... 11 PROAMATINE ...... 12 REMERON ...... 9 sertraline hcl ...... 9 probenecid ...... 16 RENAGEL ...... 14 sevelamer carbonate ...... 14 procainamide hcl ...... 10 RENVELA ...... 14 sevelamer hcl ...... 14 procarbazine hcl ...... 19 repaglinide ...... 14 SFROWASA ...... 18 PROCARDIA ...... 11 repaglinide/metformin hcl ...... 14 short ragweed pollen extract ...... 9 PROCARDIA XL ...... 11 REPATHA...... 11 sildenafil citrate ...... 11, 14 PROCHIEVE ...... 14 REPRONEX ...... 14 SILENOR ...... 10 prochlorperazine edisylate ...... 9 REQUIP ...... 21 SILVADENE ...... 13 prochlorperazine maleate ...... 9 REQUIP XL ...... 21 silver sulfadiazine ...... 13 PROCRIT ...... 16 RESCRIPTOR ...... 17 SIMBRINZA ...... 15 PROCTOCORT ...... 18 reserpine ...... 11 simvastatin ...... 11 PROCTOCREAM-HC...... 18 RESTASIS ...... 15 simvastatin (80mg only) ...... 11 PROCTOFOAM-HC ...... 18 RESTASIS MULTIDOSE ...... 15 SINEMET 25-100 ...... 21 PROCTO-KIT ...... 18 RESTORIL...... 10 SINEMET CR ...... 21 PROCYSBI ...... 21 RETROVIR ...... 18 SINEQUAN ...... 10 PROFASI ...... 14 REVATIO TABLET ...... 11 SINGULAIR ...... 9 progesterone, micronized ...... 14, 16 REVIA ...... 10 sirolimus ...... 16 PROGRAF ...... 16 REVLIMID...... 19 sitagliptin phos/metformin hcl ...... 13 PROLIXIN ...... 10 REXULTI ...... 10 sitagliptin phosphate...... 13 PROLOPRIM ...... 16 REYATAZ ...... 18 SIVEXTRO ...... 17 PROMACTA ...... 16 RHEUMATREX ...... 18 SKELAXIN ...... 21 promethazine hcl ...... 9 ribavirin ...... 17, 18 SLO-NIACIN ...... 12 PROMETRIUM ...... 16 RIFADIN ...... 17 sod chloride/nahco3/kcl/peg's ...... 19 PRONESTYL ...... 10 RIFAMATE ...... 17 sodium chloride for inhalation ...... 20 propafenone hcl ...... 10 rifampin ...... 17 sodium fluoride ...... 22 PROPINE ...... 16 rifampin/isoniazid ...... 17 sodium phenylbutyrate ...... 18 propranolol hcl ...... 11 rifaximin ...... 17 sodium polystyrene sulfonate ...... 14 propranolol/hydrochlorothiazid ...... 11 rilpivirine ...... 17 sofosbuvir/velpatasvir ...... 18 propylthiouracil ...... 15 riociguat ...... 11 SOFTCLIX ...... 14 PROPYLTHIOURACIL ...... 15 RIOMET ...... 14 solifenacin succinate ...... 22 PROSCAR ...... 21 RISPERDAL ...... 10 SOMA ...... 21 PROSED-DS ...... 16 RISPERDAL M-TAB ...... 10 SOMA COMPOUND ...... 21 PROSOM ...... 10 risperidone ...... 10 SOMA COMPOUND WITH CODEINE ...... 20 PROSTIGMIN ...... 9 risperidone ODT ...... 10 somatropin ...... 15 PROTONIX ...... 21 RITALIN ...... 10 SOMAVERT ...... 15 PROTOPIC ...... 13 RITALIN LA ...... 10 SONATA ...... 10 PROVERA ...... 16 RITALIN-SR...... 10 sonidegib phosphate ...... 19 PROVIGIL...... 10 ritonavir ...... 18 sorafenib tosylate ...... 19 PROZAC ...... 9 rivaroxaban ...... 16 SORIATANE ...... 13 PROZAC WEEKLY ...... 9 rivastigmine ...... 9 sotalol hcl ...... 11 PULMICORT FLEXHALER ...... 9 rivastigmine tartrate ...... 9 SOTRET ...... 12 PULMICORT RESPULES ...... 9 rizatriptan benzoate ...... 20 SPIRIVA ...... 9 PULMOZYME ...... 20 ROBAXIN ...... 21 SPIRIVA RESPIMAT ...... 9 PURINETHOL ...... 19 ROBAXIN-750 ...... 21 spironolactone ...... 11 PURIXAN ...... 19 ROCALTROL ...... 22 SPORANOX ...... 17 pyrazinamide ...... 17 roflumilast ...... 9 SPRYCEL ...... 19

37012 MedPerform Medium Formulary – July 2017 39 MedPerform Medium Formulary INDEX

STAGESIC-10 ...... 20 testosterone 1% ...... 16 TRIDERM ...... 13 STALEVO ...... 21 testosterone cypionate ...... 16 TRIDESILON ...... 13 STARLIX ...... 14 testosterone gel 1.62% ...... 16 trifluoperazine hcl ...... 10 stavudine ...... 18 testosterone solution ...... 16 trifluridine ...... 15 STELARA ...... 18 TESTRED ...... 16 trifluridine/tipiracil hcl ...... 19 STELAZINE ...... 10 tetrabenazine ...... 20 TRIGLIDE 160MG ...... 12 STIOLTO RESPIMAT...... 9 tetracycline hcl ...... 17 TRIGLIDE 50MG ...... 12 STIVARGA ...... 19 TEXACORT ...... 13 trihexyphenidyl hcl...... 21 STRATTERA ...... 10 thalidomide ...... 17 TRILAFON ...... 10 STRENSIQ ...... 20 THALITONE ...... 11 TRILEPTAL ...... 21 STRIBILD ...... 17 THALOMID ...... 17 trimethoprim ...... 16 STRIVERDI RESPIMAT ...... 9 THEO-24 ...... 9 TRI-NORINYL ...... 12 sucralfate...... 21 theophylline anhydrous ...... 9 TRINTELLIX ...... 9 sulconazole nitrate ...... 13 THERMAZENE ...... 13 TRIUMEQ ...... 17 SULFAC ...... 15 thioguanine ...... 19 TRI-VI-FLOR W/IRON ...... 22 sulfacetamide sodium...... 12, 13, 15 THIOGUANINE ...... 19 TRIZIVIR ...... 17 sulfadiazine ...... 16 thioridazine hcl ...... 10 TROKENDI ...... 21 SULFADIAZINE ...... 16 thiothixene ...... 10 TRUSOPT ...... 15 sulfamethoxazole/trimethoprim ...... 16 THORAZINE ...... 10 TRUVADA ...... 17 sulfanilamide...... 22 thyroid, pork ...... 15 TUSSIONEX ...... 12 sulfasalazine ...... 18 TIAZAC ...... 11 TYBOST ...... 18 sulfisoxazole acetyl ...... 16 ticagrelor ...... 16 TYKERB ...... 19 sulindac ...... 18 TIKOSYN ...... 10 TYLENOL-CODEINE ...... 20 sumatriptan ...... 20 timolol ...... 15 TYZEKA ...... 18 sumatriptan succinate ...... 20 timolol maleate ...... 11, 15 ULORIC ...... 16 sunitinib malate ...... 19 TIMOPTIC ...... 15 ULTRACET...... 20 SUPRAX ...... 16 TIMOPTIC-XE ...... 15 ULTRAM ...... 20 SUSTIVA ...... 17 timothy grass pollen extract ...... 9 ULTRASE ...... 21 SUTENT ...... 19 tiotropium br/olodaterol hcl ...... 9 ULTRASE MT ...... 21 suvorexant ...... 10 tiotropium bromide ...... 9 ULTRAVATE ...... 13 SYEDA ...... 12 tipranavir ...... 17 UNIPHYL ...... 9 SYMBICORT ...... 9 tipranavir/vitamin e tpgs ...... 17 UNIRETIC ...... 11 SYMBYAX ...... 9 TIVICAY ...... 18 UNIVASC ...... 11 SYMLIN ...... 13 tizanidine hcl ...... 21 UPTRAVI ...... 11 SYMLINPEN 120 ...... 13 TOBI ...... 17 URECHOLINE ...... 19 SYMLINPEN 60 ...... 13 TOBRADEX ...... 15 URETRON D-S ...... 16 SYMMETREL ...... 21 tobramycin for inhalation ...... 17 uridine triacetate ...... 20 SYNALAR ...... 13 tobramycin sulfate ...... 15 URIN D.S...... 16 SYNJARDY ...... 14 tobramycin sulfate/dexameth ...... 15 UROXATRAL ...... 21 SYNJARDY XR ...... 14 tobramycin/lotepred etab ...... 15 URSO ...... 19 SYNTHROID ...... 15 TOBREX ...... 15 URSO FORTE ...... 19 syringes & needles ...... 14 tofacitinib ...... 19 ursodiol ...... 19 tacrolimus ...... 13 tofacitinib XR ...... 19 ustekinumab ...... 18 tacrolimus anhydrous ...... 16 TOFRANIL ...... 10 VAGIFEM ...... 22 tadalafil ...... 11 tolazamide ...... 14 valacyclovir hcl ...... 17 TAFINLAR ...... 19 tolbutamide ...... 14 VALCHLOR ...... 13 TAGAMET ...... 21 TOLECTIN 600 ...... 18 VALISONE...... 13 TAGRISSO ...... 19 TOLINASE ...... 14 VALIUM ...... 10 TAKE ACTION ...... 12 tolmetin sodium ...... 18 valproate sodium ...... 21 TALADINE ...... 21 tolterodine tartrate ...... 22 valproic acid ...... 21 TAMBOCOR ...... 10 TOPAMAX ...... 21 valsartan ...... 11 TAMIFLU ...... 17 TOPAMAX SPRINKLE ...... 21 valsartan/hydrochlorothiazide ...... 11 tamoxifen citrate ...... 19 TOPICORT ...... 13 VALTREX ...... 17 tamsulosin hcl ...... 21 TOPICORT LP ...... 13 VANCOCIN HCL ...... 17 TAPAZOLE ...... 15 topiramate...... 21 vancomycin hcl ...... 17 tapentadol ...... 20 topotecan hcl ...... 19 VANDAZOLE ...... 22 tapentadol hcl ER ...... 20 TOPROL XL ...... 11 VANOXIDE-HC ...... 12 TARCEVA...... 19 TORADOL ...... 18 VANSPAR ...... 10 TARGRETIN ...... 13, 19 toremifene citrate ...... 19 VANTIN ...... 16 TASIGNA ...... 19 torsemide ...... 11 VASCEPA...... 12 tazarotene...... 13 TOUJEO ...... 14 VASERETIC ...... 10 TAZORAC ...... 13 TOVIAZ ...... 22 VASOCIDIN ...... 15 tazorotene foam ...... 12 TRACLEER ...... 11 VASOTEC ...... 11 TECFIDERA ...... 20 TRADJENTA ...... 13 V-CILLIN K ...... 17 tedizolid phosphate ...... 17 tramadol hcl ...... 20 VECTICAL ...... 22 teduglutide [rDNA origin] ...... 19 tramadol hcl/acetaminophen ...... 20 vemurafenib ...... 19 TEGRETOL ...... 21 trametinib dimethyl sulfoxide ...... 19 VENCLEXTA ...... 19 TEGRETOL XR ...... 21 TRANDATE ...... 11 venetoclax ...... 19 telbivudine ...... 18 trandolapril ...... 11 venlafaxine hcl ...... 10 telithromycin ...... 16 TRANXENE T-TAB ...... 10 VENTOLIN HFA ...... 9 telotristat ...... 19 tranylcypromine sulfate ...... 9 VEPESID ...... 19 temazepam ...... 10 TRAVATAN ...... 15 verapamil hcl ...... 11 TEMODAR...... 19 TRAVATAN Z ...... 15 VERELAN ...... 11 TEMOVATE ...... 13 travoprost ...... 15 VERELAN PM ...... 11 TEMOVATE EMOLLIENT ...... 13 travoprost (benzalkonium) ...... 15 VESANOID ...... 19 temozolomide ...... 19 trazodone hcl ...... 9 VESICARE ...... 22 TENEX ...... 11 TRENTAL ...... 16 VESTURA...... 12 tenofovir disoproxil fumarate ...... 18 tretinoin ...... 19 VFEND ...... 17 TENORETIC 100 ...... 11 TREXALL ...... 19 VIAGRA ...... 14 TENORETIC 50 ...... 11 TRIADVANCE ...... 22 VIBRAMYCIN ...... 17 TENORMIN ...... 11 triamcinolone acetonide ...... 9, 13, 20 VIBRAMYCIN 100MG CAPSULE ...... 17 terazosin hcl ...... 11 triamterene/hydrochlorothiazid ...... 11 VIBRAMYCIN SYRUP...... 17 terbinafine hcl ...... 13, 17 TRIAZ ...... 12 VIBRA-TABS ...... 17 terbutaline sulfate ...... 9 triazolam ...... 10 VICODIN ...... 20 teriparatide...... 14 TRIBENZOR ...... 11 VICODIN ES ...... 20 testosterone ...... 16 TRICOR ...... 12 VICODIN HP...... 20

37012 MedPerform Medium Formulary – July 2017 40 MedPerform Medium Formulary INDEX

VICON FORTE ...... 22 WESTCORT ...... 13 ZIAC ...... 11 VICTOZA ...... 13 WESTHROID...... 15 ZIAGEN ...... 18 VIDEX ...... 18 XALATAN ...... 15 ZIANA ...... 12 VIDEX EC ...... 18 XALKORI ...... 19 zidovudine ...... 18 VIDEX SOLUTION ...... 18 XANAX ...... 10 ziprasidone hcl ...... 10 VIGAMOX ...... 15 XARELTO ...... 16 ZIRGAN ...... 15 VIIBRYD ...... 9 XELJANZ ...... 19 ZITHROMAX ...... 16 VIMPAT ...... 21 XELJANZ XR ...... 19 ZITHROMAX TRI-PAK ...... 16 VINATE GT...... 22 XELODA ...... 19 ZMAX ...... 16 VINATE ULTRA ...... 22 XENAZINE...... 20 ZMAX PEDIATRIC ...... 16 VIRACEPT...... 18 XENAZINE...... 20 ZOCOR ...... 11 VIRAMUNE...... 17 XERMELO ...... 19 ZOFRAN ...... 9 VIRAMUNE XR ...... 17 XIFAXAN 550MG ...... 17 ZOFRAN ODT ...... 9 VIRAZOLE ...... 17 XIIDRA ...... 15 ZOLINZA ...... 19 VIREAD ...... 18 XODOL 10-300 ...... 20 zolmitriptan ...... 20 VIROPTIC...... 15 XTANDI ...... 19 ZOLOFT ...... 9 VISKEN ...... 11 XURIDEN ...... 20 zolpidem tartrate ...... 10 vismodegib ...... 19 XYLOCAINE ...... 18 ZOMIG ...... 20 VISTARIL ...... 9 XYZAL TABS ...... 9 ZOMIG ZMT ...... 20 VISTOGARD ...... 19 YASMIN 28 ...... 12 ZONEGRAN ...... 21 VIVELLE-DOT ...... 16 YAZ ...... 12 zonisamide ...... 21 VOLTAREN ...... 15, 18 YODOXIN ...... 17 ZORTRESS ...... 16 VOLTAREN GEL ...... 13 zaleplon ...... 10 ZOVIRAX ...... 17 VOLTAREN-XR ...... 18 ZANAFLEX ...... 21 ZOVIRAX CREAM ...... 13 voriconazole ...... 17 ZANTAC ...... 21 ZOVIRAX OINTMENT ...... 13 vorinostat ...... 19 ZARAH ...... 12 ZUBSOLV ...... 21 VOSOL ...... 14 ZARONTIN ...... 21 ZURAMPIC ...... 16 VOSOL HC ...... 14 ZAROXOLYN ...... 11 ZYDELIG ...... 19 VOTRIENT ...... 19 ZEBETA ...... 11 ZYKADIA ...... 19 VRAYLAR ...... 10 ZELBORAF...... 19 ZYLET ...... 15 vridine triacetate ...... 19 ZEMPLAR...... 15 ZYLOPRIM ...... 16 VYVANSE...... 10 ZENATANE ...... 12 ZYMAXID ...... 15 warfarin sodium ...... 16 ZENPEP ...... 21 ZYPREXA ...... 10 WELCHOL ...... 12 ZENZEDI ...... 10 ZYPREXA ZYDIS ...... 10 WELCHOL POWDER PACKETS ...... 12 ZERIT ...... 18 ZYRTEC (OTC) ...... 9 WELLBUTRIN ...... 9 ZESTORETIC ...... 10 ZYRTEC-D (OTC) ...... 9 WELLBUTRIN SR ...... 9 ZESTRIL ...... 11 ZYTIGA ...... 19 WELLBUTRIN XL ...... 9 ZETIA ...... 12 ZYVOX ...... 17

37012 MedPerform Medium Formulary – July 2017 41