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MedPerform Low Formulary July 2017

Foreword FORMULARY This document represents the efforts of the MedImpact Healthcare Systems EXCLUDED THERAPEUTIC THERAPEUTIC DRUG CLASS Pharmacy and Therapeutics (P & T) and Formulary Committees to provide DRUGS physicians and pharmacists with a method to evaluate the safety, efficacy and cost- ALTERNATIVES effectiveness of commercially available drug products. A structured approach to the /tretinoin, VELTIN ACNE AGENTS, TOPICAL drug selection process is essential in ensuring continuing patient access to rational ZIANA 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 ER, ANALGESICS, prescribing decisions that reflect the most current clinical consensus associated KADIAN with drug therapy decisions. NUCYNTA, NUCYNTA NARCOTICS ER This is accomplished through the auspices of the MedImpact P & T and Formulary ANALGESICS, 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, ANALGESICS, LAZANDA, fentanyl citrate lozenge As you use this Formulary, you are encouraged to review the information and NARCOTICS provide your input and comments to the MedImpact P & T and Formulary ONSOLIS, Committees. SUBSYS 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 KIT, gabapentin &  Comparison of relevant therapeutic benefits to current formulary agents of SMARTRX lidocaine/menthol topical, ANTICONVULSANTS similar use, and to minimize therapeutic duplication where possible GABA-V KIT,  Cost-effectiveness relative to comparable therapies or capsaicin/methyl SMART RX salicylate/menthol topical GABA KIT How to Use the Formulary The Formulary is a list of medications available to MedImpact members under their ANTICONVULSANTS pharmacy benefit. All drugs are listed by their generic names and most common immediate-release (RESTLESS LEG proprietary (branded) name. The Formulary may be accessed by using the index, HORIZANT gabapentin, SYNDROME/POST either by generic or proprietary name (in capital letters) and by therapeutic drug ropinirole, pramipexole category. In situations where an FDA approved generic equivalent is available, HERPETIC NEURALGIA) brand names are listed for reference purposes only, and do not denote coverage FORFIVO XL bupropion ER ANTIDEPRESSANTS 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 IRENKA duloxetine ANTIDEPRESSANTS Non-Formulary drug. desvenlafaxine succinate KHEDEZLA ER, desvenlafaxine ER ANTIDEPRESSANTS All drugs are listed in each category in alphabetical order by generic name. Where an FDA approved generic is available for the listed generic name, the generic name (Ranbaxy) is bolded. PEXEVA paroxetine ANTIDEPRESSANTS

For certain agents within the Formulary, a recommended prescribing guideline may ZUPLENZ ondansetron ODT ANTIEMETIC AGENTS apply. These are denoted throughout the document using the following symbols: NYATA topical ANTI-INFECTIVE AGE Age Edit Coverage may depend on patient age CU Concurrent Use Edit Coverage or lack thereof may depend upon DAXBIA cephalexin ANTI-INFECTIVE concurrent use of another drug MD Physician Specialty Edit Coverage may depend on prescribing ZIPSOR, ANTI-INFLAMMATORY diclofenac physician’s ZORVOLEX NON-STEROIDAL specialty or board certification PA Prior Authorization Requires specific physician request process QL Quantity Limit Coverage may be limited to specific quantities ANTI-INFLAMMATORY NAPRELAN naproxen per prescription and/or time period NON-STEROIDAL ST Step Therapy Coverage may depend on previous use of another drug ANTI-INFLAMMATORY VIVLODEX meloxicam Please refer to the prescribing guideline appendix within this document for details NON-STEROIDAL regarding specific agents. ANTI-INFLAMMATORY TIVORBEX indomethacin Benefit Coverage and Limitations NON-STEROIDAL This printed Formulary does not provide information regarding the specific coverage and limitations an individual member may be subject to. Many members naproxen & have specific benefit inclusions, exclusions, copays, or a lack of coverage, which esomeprazole ANTI-INFLAMMATORY are not reflected in the Formulary. magnesium, VIMOVO NON-STEROIDAL lansoprazole, The Formulary applies only to outpatient drugs provided to members, and does not COMBINATION AGENTS apply to medications used in inpatient settings. If a member has any specific omeprazole, or questions regarding their coverage, they should contact their Plan Sponsor or pantoprazole MedImpact at (800) 788-2949. ANTI-INFLAMMATORY DUEXIS famotidine & ibuprofen NON-STEROIDAL Excluded Agents COMBINATION AGENTS As new drugs become available, they will be considered for coverage under the ANTI-INFLAMMATORY MedPerform Formulary. The plan administrator has the right to decide what drugs are covered and to what extent, as well as the right to modify coverage including celecoxib & NON-STEROIDAL the exclusion of any prescription drugs. Please note that prescribing guidelines CAPXIB capsaicin/menthol topical CYCLOOXYGENASE-2 such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to patch (COX-2) SELECTIVE Formulary Therapeutic Alternatives. INHIBITOR immediate-release ANTI-INFLAMMATORY RAYOS prednisone STEROIDAL 37010 MedPerform Low Formulary – July 2017 i

MedPerform LOW Formulary

FORMULARY FORMULARY EXCLUDED THERAPEUTIC DRUG EXCLUDED THERAPEUTIC DRUG THERAPEUTIC THERAPEUTIC DRUGS CLASS DRUGS CLASS ALTERNATIVES ALTERNATIVES LEVITRA, DRUGS TO TREAT STENDRA, VIAGRA ZONACORT, dexamethasone ANTI-INFLAMMATORY IMPOTENCY STAXYN LOCORT 1.5mg tab STEROIDAL EMERGENCY diphenoxylate/atropi epinephrine 0.3mg MOTOFEN ANTI-MOTILITY TREATMENT OF ne AUVI-Q or 0.15mg auto- ALLERGIC REACTIONS codeine/pseudoephe injector HYCOFENIX ANTITUSSIVES (TYPE 1) drine/guaifenesin sol GENOTROPIN, APTENSIO XR, dextroamphetamine/ ATTENTION DEFICIT- HUMATROPE, ADZENYS XR amphetamine, HYPERACTIVITY NUTROPIN, ODT methylphenidate (ADHD)/NARCOLEPSY NUTROPIN AQ, OMNITROPE, GROWTH HORMONES HUMIRA, ENBREL, NUTROPIN AQ NORDITROPIN COSENTYX, NUSPIN, STELARA, CIMZIA, SAIZEN, XELJANZ/XR, KEVZARA, ZOMACTON OTEZLA, *SIMPONI AUTOIMMUNE DISEASE SIMPONI 50mg, VIEKIRA PAK, HARVONI, 100mg (*for HEPATITIS C TALTZ DAKLINZA EPCLUSA diagnosis of ESTROGEL DIVIGEL HORMONAL DEFICIENCY ulcerative colitis only) NATESTO, TESTIM, ANDROGEL, alendronate 70mg, BONE RESORPTION HORMONAL DEFICIENCY BINOSTO VOGELXO, AXIRON ibandronate INHIBITORS FORTESTA aspirin (OTC), amlodipine and DURLAZA CARDIOLOGY PRESTALIA HYPERTENSION clopidogrel benazepril hcl YOSPRALA aspirin (OTC) CARDIOLOGY APIDRA, GONITRO nitroglycerin CARDIOLOGY APIDRA SOLOSTAR, KELOCOTE, HUMALOG INSULINS BEAU RX DERMATOLOGY NOVOLOG, RECEDO NOVOLOG DERMAPAK tretinoin topical DERMATOLOGY FLEXPLEN PLUS LEVEMIR, ACCUCAINE lidocaine topical DERMATOLOGY BASAGLAR, LANTUS, TOUJEO INSULINS PEDIPAK DERMATOLOGY TRESIBA OTC EMOLLIENTS NOVOLIN HUMULIN INSULINS (EUCERIN, atorvastatin, lovastatin, SYNERDERM CETAPHIL, DERMATOLOGY ALTOPREV, pravastatin, LIPID IRREGULARITY VASELINE, LESCOL XL AQUAPHOR) simvastatin, URE-K, rosuvastatin KERALAC, fenofibrate/ UTOPIC, ANTARA micronized/ LIPOTROPICS urea 40%, urea 50% DERMATOLOGY UREVAZ, nanocrystallized DERMASORB balsalazide LOWER XM DELZICOL, disodium, APRISO, GASTROINTESTINAL diclofenac sodium DERMATOLOGY - DIPENTUM LIALDA, PENTASA, PENNSAID DISORDERS 1% topical ANTIINFLAMMATORY sulfasalazine ADLYXIN, ONZETRA, BYDUREON, TRULICITY, ZEMBRACE DIABETES sumatriptan MIGRAINE BYETTA, VICTOZA SYMTOUCH, TANZEUM TREXIMET TRULICITY, REBIF, GILENYA, XULTOPHY, VICTOZA, LANTUS, DIABETES PLEGRIDY, SOLIQUA TECFIDERA, TOUJEO EXTAVIA MULTIPLE SCLEROSIS INVOKANA, AVONEX, INVOKAMET,INVOK GLATOPA, FARXIGA, AMET XR, AUBAGIO DIABETES Individual vitamin MULTIVITAMIN XIGDUO XR JARDIANCE, METHAVER SYNJARDY, components PREPARATIONS SYNJARDY XR Nasal triamcinolone, GLUMETZA metformin ER DIABETES OMNARIS, flunisolide, ZETONNA, fluticasone, NASAL ANTI- NESINA, JENTADUETO, BECONASE AQ, budesonide, INFLAMMATORY KAZANO, JENTADUETO XR, TICANASE mometasone, OSENI, TRADJENTA, DIABETES QNASL ONGLYZA, JANUVIA, NASAL ANTI- Azelastine & KOMBIGLYZE JANUMET, INFLAMMATORY/ANTI- TICALAST fluticasone nasal XR JANUMET XR sprays ALL OTHER COMBINATION MANUFACTUR ABBOTT phentermine & ERS OF (PRECISION AND DIABETIC SUPPLIES QSYMIA OBESITY AGENTS DIABETIC TEST FREESTYLE (TEST STRIPS, METERS) topiramate STRIPS AND BRAND) METERS

37010 MedPerform Low Formulary – July 2017 ii MedPerform LOW Formulary

FORMULARY EXCLUDED THERAPEUTIC DRUG THERAPEUTIC DRUGS CLASS ALTERNATIVES

latanoprost, travoprost, OPHTHALMIC ZIOPTAN LUMIGAN, GLAUCOMA TRAVATAN Z

NARCAN NASAL OPIOID REVERSAL EVZIO SPRAY

LASTACAFT, BEPREVE, PATADAY, OPHTHALMIC EMADINE, olopatadine ANTIHISTAMINES PAZEO ORAL/PHARYNGEAL ARESTIN N/A DISORDERS lipase/protease/amyl PANCREAZE, ase, CREON, PANCREATIC ENZYMES PERTZYE ZENPEP AIRDUO RESPICLICK AND AUTHORIZED ADVAIR, BREO GENERIC ELIPTA, RESPIRATORY ASTHMA FLUTICASONE/ SYMBICORT, SALMETEROL DULERA (55/14mcg, 113/14mcg, and 232/14mcg) UTIBRON, STIOLTO RESPIRATORY COPD BEVESPI ASMANEX HFA, ALVESCO, ASMANEX FLOVENT TWISTHALER, RESPIRATORY ASTHMA DISKUS, PULMICORT FLOVENT HFA FLEXHALER, QVAR PROVENTIL PROAIR HFA, RESPIRATORY ASTHMA HFA, VENTOLIN HFA AND COPD levalbuterol HFA TUDORZA SPIRIVA PRESSAIR, HANDIHALER, RESPIRATORY COPD SEEBRI SPIRIVIA NEOHALER RESPIMAT ROSACEA AGENTS, NORITATE 0.75% cream, gel or TOPICAL lotion EDLUAR, INTERMEZZO, eszopiclone, SEDATIVE-HYPNOTICS, ROZEREM, zaleplon, zolpidem NON-BARBITURATE ZOLPIMIST AMRIX, cyclobenzaprine FEXMID, 5mg or 10mg RELAXANTS FLEXEPAX butalbital/acetamino ALLZITAL TENSION HEADACHE phen TIROSINT levothyroxine THYROID HORMONES

Please note that prescribing guidelines such as Prior Authorization, Step Therapy, Quantity Limit, etc., may still apply to Formulary Therapeutic Alternatives.

37010 MedPerform Low Formulary – July 2017 iii MedPerform LOW Formulary

Depending upon a member’s specific benefit parameters, the following topics generally not available for drugs that are specifically excluded by benefit may apply: design.

1. Generic Substitution 4. General Exclusions When available, FDA approved generic drugs are to be used in all situations, A. Over the Counter (OTC) medications or their equivalents, unless regardless of the brand name indicated. The generic names are bolded in the otherwise specified in the Formulary listing. formulary listing wherever an FDA approved generic drug product is available. B. Smoking Cessation products (i.e., transdermal nicotine, Greater economy is realized through the use of generic equivalents. This nicotine gum, nicotine inhaler). policy is not meant to preclude or supplant any state statutes that may exist. C. Drugs specifically listed as not covered. All drugs that are or become available generically are subject to review by D. Any drug products used for cosmetic purposes. MedImpact’s Pharmacy and Therapeutics Committee. MedImpact approves E. Experimental drug products or any drug product used in an such multi-source drugs for addition to the MAC list based on the following experimental manner. criteria: F. Replacement of lost or stolen medication.  A multi-source drug product manufactured by at least one (1) nationally G. Non self-administered injectable drug products unless otherwise marketed company. specified in the Formulary listing.  At least one (1) of the generic manufacturer’s products must have an H. Foreign sourced drugs or drugs not approved by the United States “A” rating or the generic product has been determined to be Food & Drug Administration. unassociated with efficacy, safety or bioequivalency concerns by the MedImpact P & T Committee. The P & T and Formulary Committees recognize that not all medical needs can be met with this document and encourage inquiries about alternative Drug product will be approved for generic substitution by the  therapies. MedImpact P & T Committee.

5. Pharmacist and Physician Communication This list is reviewed and updated periodically based on the clinical literature The Formulary is a tool to promote cost-effective prescription drug use. The and pharmacokinetic characteristics of currently available versions of these P & T and Formulary Committees have made every attempt to create a drug products. document that meets all therapeutic needs; however, the art of medicine

makes this a formidable task. MedImpact welcomes the participation of If a member or physician requests a brand name product in lieu of an physicians, pharmacists, and ancillary medical providers, in this dynamic approved generic, the member, based upon their coverage, will typically be process. Physicians and pharmacists are highly encouraged to direct any required to pay the difference in cost between the brand and the generic. If a suggestions, comments or formulary additions to MedImpact at the following physician determines that there is a documented medical need for the brand address: equivalent, a request for coverage may be made using the medication

request process. Chairperson, Pharmacy & Therapeutics Committee

MedImpact Healthcare Systems, Inc. 2. Three Tier Benefit 10181 Scripps Gateway Court The Formulary may be applied to a three tier benefit design, where the San Diego, CA 92131 member shares the cost of prescription drug therapy at three levels of

copayment. In most instances, generically available drugs will be covered under the first or lowest copay tier, branded drugs listed on the Formulary will

be covered under the second copay tier, and branded drugs not on the Formulary will be covered under the third or highest copay tier.

3. Medication Request Process Depending upon plan benefit design, a medication request process may apply as follows: A. Formulary Agents Drugs that are listed in the Formulary with associated Prior Authorization (PA) require evaluation, per MedImpact P & T Committee Prior Authorization guidelines prior to dispensing at a network pharmacy. Each request will be reviewed on an individual patient need basis. If the request does not meet the guidelines established by the P & T Committee, the request will not be approved and alternative therapy may be recommended. B. Non-Formulary Agents Any drug not found in the Formulary listing, or any Formulary updates published by MedImpact, shall be considered a Non-Formulary drug. 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 pharmacist, the pharmacist will evaluate the patient’s drug history and contact the physician to determine if there is a reasonable medical need for a non-formulary drug. Each request will be reviewed on an individual patient need basis. Approval will be given if a documented medical need exists. The following basic guidelines are used:  The use of Formulary Drugs is contraindicated in the patient.  The patient has failed an appropriate trial of Formulary or related agents.  The choices available in the Formulary are not suited for the present patient care need, and the drug selected is required for patient safety.  The use of a Formulary drug may provoke an underlying condition, which would be detrimental to patient care.

If the request does not meet the guidelines established by the P & T Committee, the request will not be approved and alternative therapy may be recommended. C. Obtaining Coverage Coverage, questions or information regarding the medication request or formulary process may be obtained by: 1. Faxing a completed Medication Request Form to MedImpact at (858) 790-7100. 2. Contacting MedImpact at (800) 788-2949 and providing all necessary information requested.

MedImpact will provide an authorization number, specific for the medical need, for all approved requests. Non-approved requests may be appealed. The prescriber must provide information to support the appeal on the basis of medical necessity. Prior Authorization is

37010 MedPerform Low Formulary – July 2017 iii MedPerform LOW Formulary

Foreword ...... i Antihyperlipidemic – PCSK9 Inhibitors ...... 3 ALLERGY ...... 1 Bile Salt Sequestrants ...... 3 Allergenic extracts ...... 1 Lipotropics ...... 3 2nd Generation Antihistamine & Decongestant Combinations ...... 1 Preparations ...... 4 Antihistamines - 1st Generation ...... 1 CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ...... 4 Antihistamines - 2nd Generation ...... 1 Adrenergic Vasopressor Agents ...... 4 Nasal Anti-Inflammatory ...... 1 Antianginal & Anti-Ischemic Agents, Non-Hemodynamic ...... 4 Nasal Antihistamines ...... 1 Antihyperlipidemic - HMG-CoA & Calcium Channel Blocker Combinations ..... 4 ANTIEMESIS/ANTIVERTIGO ...... 1 Heart Rate Reducing, Selective I(F) Current Inhib...... 4 Antiemetic/Antivertigo Agents ...... 1 CARDIOVASCULAR DISEASE - VASODILATION ...... 4 ASTHMA ...... 1 Vasodilators, Combination ...... 4 Beta-Adrenergic Agents ...... 1 Vasodilators, Coronary ...... 4 Beta-Adrenergic & Anticholinergic Combinations ...... 1 CONTRACEPTION/OXYTOCICS ...... 4 Beta-Adrenergic & Glucocorticoid Combinations ...... 1 Contraceptives, Intravaginal, Systemic ...... 4 General Bronchodilator Agents ...... 1 Contraceptives, Oral ...... 4 Leukotriene Receptor Antagonists ...... 1 Contraceptives, Transdermal ...... 4 Mast Stabilizers ...... 1 Oxytocics ...... 4 Oral Inhaled Corticosteroids ...... 1 COUGH AND COLD ...... 4 Phosphodiesterase-4 (PDE4) Inhibitors ...... 1 1st Generation Antihistamine & Decongestant Combinations...... 4 Xanthines ...... 1 Narcotic Antitussive-1st Generation Antihistamine-Decongestants ...... 4 AUTONOMIC NERVOUS SYSTEM DISORDERS ...... 1 Narcotic Antitussive-1st Generation Antihistamines ...... 4 Alzheimer's Therapy, Nmda Receptor Antagonists ...... 1 Narcotic Antitussive-Anticholinergic Comb...... 4 Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines Inhibitors ...... 1 Non-Narcotic Antitussive-1st Generation Antihistamine Combinations...... 4 Cholinesterase Inhibitors ...... 1 DERMATOLOGY - ACNE ...... 4 BEHAVIORAL HEALTH - ANTIDEPRESSANTS ...... 1 Acne Agents, Systemic ...... 4 Alpha-2 Receptor Antagonist Antidepressants ...... 1 Acne Agents, Topical ...... 4 MAOIs - Non-Selective & Irreversible...... 1 Keratolytic-Glucocorticoid Combinations ...... 4 & Reuptake Inhibitors (NDRIs) ...... 1 Keratolytics ...... 4 Selective Reuptake Inhibitors (SSRIs) ...... 1 Rosacea Agents, Topical ...... 4 Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs)...... 1 Vitamin A Derivatives ...... 4 SSRI & Antipsych, Atyp, Dopamine & Serotonin Antag Comb ...... 1 DERMATOLOGY - ANTIINFECTIVE ...... 4 SSRI & 5HT1A Partial Agonist Antidepressants ...... 1 Topical ...... 4 SSRI, Serotonin Receptor Modulator Antidepressants ...... 1 Topical ...... 4 Serotonin-Norepinephrine Reuptake-Inhibitors (SNRIs) ...... 1 Topical ...... 5 Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib ...... 1 Topical Antivirals ...... 5 BEHAVIORAL HEALTH - OTHER ...... 2 Topical Sulfonamides ...... 5 Adrenergics, Aromatic, Non-Catecholamine ...... 2 DERMATOLOGY - ANTIINFLAMMATORY ...... 5 Anti-Alcoholic Preparations ...... 2 Topical Anti-Inflammatory Steroidal ...... 5 Anti-Anxiety Drugs ...... 2 Topical Anti-Inflammatory, NSAIDs ...... 5 Anti-Mania Drugs ...... 2 Topical Antibiotics/Antiinflammatory, Steroidal ...... 5 Anti-Psychotics, Phenothiazines ...... 2 DERMATOLOGY - MISCELLANEOUS ...... 5 Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed ...... 2 Antiperspirants ...... 5 Antipsychotics, Atypical, D3/D2 Partial Agonist/5HT Mixed ...... 2 Antiseborrheic Agents ...... 5 Antipsychotics, Dopamine & Serotonin Antagonists ...... 2 Topical Antineoplastic & Premalignant Lesion Agents ...... 5 Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists ...... 2 Topical Local Anesthetics ...... 5 Antipsychotics, Dopamine Antagonists, Thioxanthenes ...... 2 DERMATOLOGY - PIGMENTATION DISORDERS ...... 5 Antipsychotics, Dopamine Antagonists, Butyrophenones ...... 2 Topical Hyperpigmentation Agents ...... 5 Barbiturates ...... 2 DERMATOLOGY - PSORIASIS/ECZEMA ...... 5 Narcolepsy and Sleep Disorder Therapy Agents ...... 2 Antipsoriatic Agents, Systemic ...... 5 Narcotic Antagonists ...... 2 Antipsoriatics Agents ...... 5 Sedative-Hypnotics, Non-Barbiturate ...... 2 Topical Immunosuppressive Agents ...... 5 Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy ...... 2 Topical Phosphodiesterase (PDE-4) Inhibitor ...... 5 Treatment for Attention Deficit-Hyperactivity (ADHD), NRI-Type ...... 2 DIABETES ...... 5 CARDIOVASCULAR DISEASE - ARRHYTHMIA ...... 2 Antihyperglycemics, Incretin Mimetics (GLP-1 Receptor Agonists) ...... 5 Antiarrhythmics ...... 2 Antihyperglycemics, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea) ...... 5 CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS ...... 2 Antihyperglycemics, Amylin Analog-Type ...... 5 Digitalis Glycosides ...... 2 Antihyperglycemics, DPP-4 Inhibitors ...... 5 CARDIOVASCULAR DISEASE - HYPERTENSION ...... 2 Antihyperglycemics, (DPP-4) Inhibitor & Biguanide Combinations ...... 5 ACE Inhibitor/Calcium Channel Blocker Combinations ...... 2 Antihyperglycemics, Insulin-Release Stimulant Type ...... 5 ACE Inhibitor/Thiazide & Thiazide-Like Diuretic ...... 2 Antihyperglycemic, Insulin-Response Enhancers (Non-Sulfonylurea) ...... 5 Alpha-Adrenergic Blocking Agents ...... 2 Antihyperglycemics, Biguanide Type (Non-Sulfonylurea) ...... 6 Alpha/Beta-Adrenergic Blocking Agents ...... 3 Antihyperglycemics, Insulin-Rel Stim. & Biguanide Combinations ...... 6 Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Antihyperglycemic, Insulin-Response & Release Combinationsination ...... 6 Combinations ...... 3 Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations ...... 6 Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations ...... 3 Antihyperglycemic-Glucocorticoid Receptor Blocker ...... 6 Angiotensin II Receptor Blocker-Beta Blocker Comb...... 3 Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors ...... 6 Angiotensin Receptor Antagonists & Calcium Channel Blockers ...... 3 Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Antihypertensives, ACE Inhibitors ...... 3 Biguanide Combination ...... 6 Antihypertensives, Angiotensin Receptor Antagonists ...... 3 Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination ...... 6 Antihypertensives, Sympatholytic ...... 3 Diabetic Supplies ...... 6 Antihypertensives, Vasodilators ...... 3 Diabetic Ulcer Preparations, Topical ...... 6 Beta-Adrenergic Blocking Agents ...... 3 Hyperglycemics ...... 6 Beta-Adrenergic Blocking Agents/Thiazide & Related ...... 3 Insulins ...... 6 Calcium Channel Blocking Agents ...... 3 Syringes & Accessories ...... 6 Loop Diuretics ...... 3 EAR - GENERAL DISORDERS ...... 6 Potassium Sparing Diuretics ...... 3 Ear Preparations, Miscellaneous Anti-Infectives ...... 6 Potassium Sparing Diuretics in Combination ...... 3 Ear Preparations, Antibiotics ...... 6 Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors ...... 3 Otic Preparations, Anti-Inflammatory-Antibiotics ...... 6 Pulmonary Anti-HTN, Endothelin Receptor Antagonists ...... 3 Otic Preparations, Local Anesthetics ...... 6 Pulmonary Anti-HTN, Prostacyclin-Type ...... 3 ELECTROLYTE REGULATION ...... 6 Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulator ...... 3 Electrolyte Depleters ...... 6 Thiazide & Related Diuretics ...... 3 Potassium Replacement ...... 6 CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ...... 3 ENDOCRINE DISORDER - FERTILITY ...... 6 Antihyperlipidemic - APO B-100 Synthesis Inhibitor ...... 3 Drugs to Treat Impotency ...... 6 Antihyperlipidemic - HMG CoA Reductase Inhibitors ...... 3 Fertility Stimulating Preparations, Non-FSH ...... 6 Antihyperlipidemic - MTP Inhibitors ...... 3 Follicle Stimulating/Luteinizing Hormones ...... 6

37010 MedPerform Low Formulary – July 2017 iv MedPerform LOW Formulary

Pregnancy Facilitating/Maintaining Agents, Hormonal ...... 6 Antivirals, HIV-Spec, Non-Peptidic Protease Inhibitors ...... 9 ENDOCRINE DISORDER - OTHER ...... 6 Antivirals, HIV-Spec, Nucleoside-Nucleotide Analogs ...... 9 Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants ...... 6 Antivirals, HIV-Spec, Nucleoside Analog, RTI Combinations...... 9 Antidiuretic & Vasopressor Hormones ...... 6 Antivirals, HIV-Specific, CCR5 Co-Receptor Antagonists ...... 9 Bone Formation Stim. Agents - Parathyroid Hormone ...... 6 Antivirals, HIV-Specific, Fusion Inhibitors ...... 9 Bone Resorption Inhibitor & Vitamin D Combinations ...... 6 Antivirals, HIV-Specific, Non-Nucleoside, RTI ...... 9 Bone Resorption Inhibitors ...... 6 Antivirals, HIV-Specific, Nucleoside Analog, RTI ...... 9 Growth Hormone Receptor Antagonists ...... 6 Antivirals, HIV-Specific, Nucleotide Analog, RTI ...... 9 Growth Hormones ...... 6 Antivirals, HIV-Specific, Protease Inhibitor Combinations ...... 9 Hyperparathyroid Tx Agents, Vitamin D Analog-Type ...... 6 Antivirals, HIV-Specific, Protease Inhibitors ...... 9 LHRH (GnRH) Antagonist, Pituitary Suppressant Agents ...... 6 Antivirals, HIV-1 Integrase Strand Transfer Inhibitors ...... 9 Luteinizing Hormone Releasing Hormone –LHRH (GnRH) ...... 6 Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI ...... 9 Pituitary Suppressive Agents ...... 7 Cytochrome P450 Inhibitors ...... 10 ENDOCRINE DISORDER - THYROID ...... 7 Hepatitis B Treatment Agents ...... 10 Antithyroid Preparations ...... 7 Hepatitis C Combination Agents...... 10 Iodine Containing Agents ...... 7 Hepatitis C Treatment Agents ...... 10 Thyroid Hormones ...... 7 INFLAMMATORY DISEASE ...... 10 EYE - GENERAL DISORDERS ...... 7 Anti-Arthritic & Chelating Agents ...... 10 Eye -Corticoid Combinations ...... 7 Anti-Arthritic, Folate Antagonist Agents ...... 10 Eye Antihistamines ...... 7 Anti-Inflammatory Tumor Necrosis Factor Inhibitors ...... 10 Eye Antiinflammatory Agents ...... 7 Anti-Inflammatory, Pyrimidine Synthesis Inhibitors ...... 10 Eye Antivirals ...... 7 Bradykinin B2 Receptor Antagonists ...... 10 Eye Sulfonamides ...... 7 Glucocorticoids ...... 10 EYE - MISCELLANEOUS ...... 7 Mineralocorticoids ...... 10 Ophthalmic Cystine Delpleting Agents ...... 7 Monoclonal antibody-human interleukin ...... 10 Ophthalmic Anti-Inflammatory Immunomodulator-Type ...... 7 NSAIDs, Cyclooxygenase Inhibitor-Type ...... 10 Ophthalmic Antibiotics ...... 7 LOCAL ANESTHESIA ...... 10 Ophthalmic Mast Cell Stabilizers ...... 7 Local Anesthetics ...... 10 EYE - GLAUCOMA ...... 7 LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMATORY ...... 10 Carbonic Anhydrase Inhibitors ...... 7 Bowel Antiinflamatory Agents ...... 10 Miotics/Other Intraocular Pressure Reducers...... 7 Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx ...... 10 Mydriatics ...... 7 Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat ...... 10 Hyperuricemia Treatments - Purine Inhibitors ...... 7 Hemorrhoidal Preparations ...... 10 Uricosuric Agents ...... 7 Rectal Preparations ...... 10 HEMATOLOGICAL DISORDERS ...... 7 Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) ...... 10 Anticoagulants, Coumarin Type ...... 7 LOWER GASTROINTESTINAL DISORDERS - OTHER ...... 10 Direct Factor XA Inhibitors ...... 7 Ammonia Inhibitors ...... 10 Hematinics, Other ...... 7 Antidiarrheals ...... 10 Hemorrheologic Agents ...... 7 Bile Salts ...... 10 Heparin & Related Preparations ...... 7 Laxatives & Cathartics ...... 10 Leukocyte (WBC) Stimulants ...... 8 Narcotic Antagonists, Peripherally-Acting ...... 10 Platelet Aggregation Inhibitors ...... 8 Hydroxylase Inhibitor ...... 10 Platelet Reducing Agents ...... 8 Glucagon-Like Peptide (GLP-2) Analogs ...... 10 Thrombopoietin Receptor Agonists ...... 8 MISCELLANEOUS AGENTS ...... 10 Vitamin K Preparations ...... 8 Anaphylaxis Therapy Agents ...... 10 HORMONAL DEFICIENCY...... 8 Parasympathetic Agents ...... 11 Androgenic Agents ...... 8 Pku Tx Agent-Cofactor Of Hydroxylase...... 11 / Combinations ...... 8 NEOPLASTIC DISEASE ...... 11 Estrogenic Agents ...... 8 Alkylating Agents...... 11 Progestational Agents ...... 8 Antiandrogenic Agents ...... 11 IMMUNOSUPPRESSION/MODULATION...... 8 Antimetabolites ...... 11 Immunomodulators ...... 8 Antineoplastic - Aromatase Inhibitors ...... 11 Immunosuppressives ...... 8 Antineoplastic – B Cell Lymphoma 2(BCL-2) Inhibitors ...... 11 INFECTIOUS DISEASE - BACTERIAL ...... 8 Antineoplastic – Hedgehog Pathway Inhibitors...... 11 Absorbable Sulfonamides ...... 8 Antineoplastic – Janus Kinase (JAK) Inhibitors ...... 11 Betalactams ...... 8 Antineoplastic – MEK1 and MEK2 Kinase Inhibitors ...... 11 Cephalosporins - 1st Generation ...... 8 Antineoplastic - Topoisomerase I Inhibitors ...... 11 Cephalosporins - 2nd Generation ...... 8 Antineoplastic - Immunomodulator Agents ...... 11 Cephalosporins - 3rd Generation ...... 8 Antineoplastic - Systemic Enzyme Inhibitors ...... 11 Chemotherapeutics, Antibacterial, Miscellaneous...... 8 Antineoplastic, Histone Deacetylase Inhibitors, HDIS ...... 11 Ketolides ...... 8 Antineoplastics, Miscellaneous ...... 11 Lincosamides ...... 8 Antineoplastic mTOR Kinase Inhibitors ...... 11 Macrolides ...... 8 Chemotherapy Rescue/Antidote Agents ...... 11 Derivatives ...... 8 Selective Modulators (SERM) ...... 11 Oxazolidinones ...... 8 Selective Retinoid X Receptor Agonists (RXR) ...... 11 Penicillins ...... 8 Antineoplastics ...... 11 Quinolones ...... 8 NEUROLOGICAL DISEASE - MISCELLANEOUS ...... 11 ...... 9 Agents to Treat Multiple Sclerosis ...... 11 INFECTIOUS DISEASE - FUNGAL ...... 9 Fibromyalgia Agents, Serotonin-Norepinephrine Reuptake Inhibitors ...... 11 Agents ...... 9 Movement Disorders (Drug Therapy) ...... 11 Antifungal Antibiotics ...... 9 ORAL/PHARYNGEAL DISORDERS ...... 11 INFECTIOUS DISEASE - MISCELLANEOUS ...... 9 Dental Aids & Preparations ...... 12 Aminoglycosides ...... 9 Nose Preparations, Antibiotics ...... 12 Anti-Mycobacterium Agents ...... 9 Nose Preparations, Miscellaneous (Rx) ...... 12 Antileprotics ...... 9 OTHER DRUGS ...... 12 Antitubercular Antibiotics ...... 9 Appetite Stim. For Anorexia, Cachexia, Wasting Synd...... 12 and Related Derivative Antibiotics ...... 9 General Inhalation Agents ...... 12 Vancomycin & Derivatives ...... 9 Metabolic disease enzyme replace, hypophosphatasia ...... 12 INFECTIOUS DISEASE - PARASITIC ...... 9 Needles/Needleless Devices ...... 12 Amebacides ...... 9 Nucleic Acid/Nucleotide Supplements ...... 12 Anaerobic -Antibacterial Agents ...... 9 Somatostatic Agents ...... 12 Anthelmintics ...... 9 Drugs to treat hereditary tyrosinemia ...... 12 Antimalarial Drugs ...... 9 OTHER RESPIRATORY DISORDERS ...... 12 Antiprotozoal Drugs, Miscellaneous ...... 9 Antifibrotic Therapy – Pyridone Analogs ...... 12 INFECTIOUS DISEASE - VIRAL ...... 9 Cystic Fibrosis-Cftr Potentiator & Corrector Comb...... 12 Antiretroviral Combination, Integrase Inhibitors ...... 9 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiator12 Antivirals, General ...... 9 Mucolytics ...... 12

37010 MedPerform Low Formulary – July 2017 v MedPerform LOW Formulary

Pulmonary Fibrosis – Systemic Enzyme Inhibitors ...... 12 PAIN MANAGEMENT - ANALGESICS ...... 12 Analgesic, Non-Salicylate & Barbiturate Combinations...... 12 Analgesic, Salicylate, Barbiturate & Xanthine Comb ...... 12 Analgesic, Non-Salicylate, Barbiturate & Xanthine Comb ...... 12 Analgesic/Antipyretics, Salicylates ...... 12 Analgesics, Narcotics ...... 12 Antimigraine Preparations ...... 12 Narcoctic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations 12 Narcotic & Salicylate Analgesics, Barbiturate & Xanthine ...... 12 Narcotic Analgesic & Non-Salicylate Analgesic Combinations ...... 12 Narcotic Withdrawal Therapy Agents ...... 12 PARKINSON’S DISEASE ...... 12 Antiparkinsonism Drugs, Anticholinergic ...... 12 Antiparkinsonism Drugs, Other ...... 12 Decarboxylase Inhibitors ...... 13 SEIZURE DISORDER ...... 13 Anticonvulsants...... 13 SKELETAL MUSCLE DISORDER ...... 13 Agents To Treat Periodic Paralysis ...... 13 Skeletal Muscle Relaxants ...... 13 UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ...... 13 Pancreatic Enzymes ...... 13 UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE ...... 13 Anticholinergics/Antispasmodics ...... 13 Belladonna Alkaloids ...... 13 UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ...... 13 Anti-Ulcer Preparations ...... 13 Anti-Ulcer-H.pylori Agents ...... 13 Anticholinergics, Quaternary Ammonium ...... 13 Histamine H2-Receptor Inhibitors ...... 13 Intestinal Motility Stimulants ...... 13 Proton-Pump Inhibitors ...... 13 URINARY TRACT - FUNCTIONAL DISORDERS ...... 13 Benign Prostatic Hypertrophy/Micturition Agents ...... 13 Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag comb agents ...... 13 Kidney Stone Agents ...... 13

Overactive Bladder Agents, Beta-3 Adrenergic Recep ...... 13 Urinary Tract Analgesic Agents ...... 13 Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) ...... 13 Urinary Tract Antispasmodic, M(3) Selective Antagonists...... 13 Urinary Tract Antispasmodic/Antiincontinence Agent ...... 13 VAGINAL DISORDERS ...... 13 Vaginal Antibiotics ...... 13 Vaginal Antifungals ...... 13 Preparations ...... 13 Vaginal Sulfonamides ...... 13 VITAMIN AND/OR MINERAL DEFICIENCY ...... 13 Fluoride Preparations ...... 13 Folic Acid Preparations ...... 13 Multivitamin Preparations ...... 13 Pediatric Vitamin Preparations ...... 14 Prenatal Vitamin Preparations ...... 14 Vitamin B Preparations ...... 14 Vitamin D Preparations ...... 14 SPECIALTY INJECTABLE CROSS REFERENCE LISTING ...... 15

37010 MedPerform Low Formulary – July 2017 vi MedPerform LOW Formulary

ALLERGY Allergenic extracts Mast Cell Stabilizers PA 5-grass pollen extract ORALAIR cromolyn sodium INTAL PA short ragweed pollen extract RAGWITEK Oral Inhaled Corticosteroids PA timothy grass pollen extract GRASTEK QL budesonide PULMICORT RESPULES 2nd Generation Antihistamine & Decongestant Combinations QL beclomethasone dipropionate QVAR p-ephed hcl/cetirizine hcl (OTC) ZYRTEC-D (OTC) QL budesonide PULMICORT p-ephed sul/loratadine CLARITIN-D 12 HOUR FLEXHALER CLARITIN-D 24 HOUR 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 fluticasone propionate FLONASE QL memantine hcl NAMENDA QL triamcinolone acetonide NASACORT AQ QL memantine hcl NAMENDA XR QL beclomethasone dipropionate QNASL Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines QL QNASL CHILDREN Inhibitors QL mometasone furoate NASONEX QL memantine hcl/donepezil hcl NAMZARIC QL NAMZARIC TITIRATION Nasal Antihistamines PACK QL azelastine hcl ASTELIN Cholinesterase Inhibitors QL ASTEPRO donepezil hcl ARICEPT ANTIEMESIS/ANTIVERTIGO ARICEPT ODT Antiemetic/Antivertigo Agents QL galantamine hydrobromide RAZADYNE QL dronabinol MARINOL QL RAZADYNE ER meclizine hcl ANTIVERT pyridostigmine bromide MESTINON ondansetron ZOFRAN ODT QL rivastigmine EXELON PATCH ondansetron hcl ZOFRAN rivastigmine tartrate EXELON QL ondansetron hcl solution ZOFRAN 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 terbutaline sulfate BRETHINE WELLBUTRIN XL albuterol sulfate PROAIR HFA Selective Serotonin Reuptake Inhibitors (SSRIs) PROAIR RESPICLICK citalopram hydrobromide CELEXA VENTOLIN HFA escitalopram oxalate LEXAPRO QL formoterol fumarate PERFOROMIST fluoxetine er PROZAC WEEKLY QL olodaterol hcl STRIVERDI RESPIMAT fluoxetine hcl PROZAC QL salmeterol xinafoate SEREVENT DISKUS paroxetine hcl PAXIL Beta-Adrenergic & Anticholinergic Combinations sertraline hcl ZOLOFT ipratropium/albuterol sulfate DUONEB Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs) ipratropium/albuterol sulfate COMBIVENT trazodone hcl DESYREL 300MG COMBIVENT RESPIMAT SSRI & Antipsych, Atyp, Dopamine & Serotonin Antag Comb QL tiotropium br/olodaterol hcl STIOLTO RESPIMAT QL olanzapine/fluoxetine SYMBYAX Beta-Adrenergic & Glucocorticoid Combinations SSRI & 5HT1A Partial Agonist Antidepressants QL fluticasone/salmeterol ADVAIR DISKUS QL vilazodone hcl VIIBRYD QL ADVAIR HFA SSRI, Serotonin Receptor Modulator Antidepressants QL fluticasone/vilanterol BREO ELLIPTA QL vortioxetine hydrobromide TRINTELLIX QL mometasone/formoterol DULERA QL budesonide/formoterol fumarate SYMBICORT Serotonin-Norepinephrine Reuptake-Inhibitors (SNRIs) General Bronchodilator Agents QL desvenlafaxine ER (Ranbaxy DESVENLAFAXINE ER Brand) (RANBAXY BRAND) ipratropium bromide ATROVENT QL desvenlafaxine succinate PRISTIQ QL ipratropium bromide ATROVENT HFA QL levomilnacipran hcl FETZIMA QL tiotropium bromide SPIRIVA venlafaxine hcl EFFEXOR, EFFEXOR XR QL tiotropium bromide SPIRIVA RESPIMAT Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib Leukotriene Receptor Antagonists amitriptyline hcl ELAVIL montelukast sodium SINGULAIR

37010 MedPerform Low Formulary – July 2017 1 MedPerform LOW Formulary

amoxapine ASENDIN Barbiturates clomipramine hcl ANAFRANIL phenobarbital PHENOBARBITAL desipramine hcl NORPRAMIN Narcolepsy and Sleep Disorder Therapy Agents doxepin hcl SINEQUAN QL modafinil PROVIGIL imipramine hcl TOFRANIL Narcotic Antagonists maprotiline hcl LUDIOMIL naltrexone hcl NARCAN nortriptyline hcl PAMELOR naltrexone hcl REVIA BEHAVIORAL HEALTH - OTHER Sedative-Hypnotics, Non-Barbiturate Adrenergics, Aromatic, Non-Catecholamine chloral hydrate NOCTEC QL amphet asp/amphet/d-amphet ADDERALL QL doxepin hcl SILENOR QL ADDERALL XR estazolam PROSOM QL dextroamphetamine sulfate DEXEDRINE QL eszopiclone LUNESTA QL DEXEDRINE SPANSULE flurazepam hcl DALMANE QL ZENZEDI (5mg, 10mg) QL suvorexant BELSOMRA QL dextroamphetamine tablet (2.5mg, ZENZEDI temazepam RESTORIL 7.5mg, 15mg, 20mg, 30mg) triazolam HALCION QL lisdexamfetamine dimesylate VYVANSE QL zaleplon SONATA Anti-Alcoholic Preparations QL zolpidem tartrate AMBIEN ANTABUSE AMBIEN CR Anti-Anxiety Drugs Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy alprazolam XANAX QL dexmethylphenidate hcl FOCALIN ALPRAZOLAM QL FOCALIN XR INTENSOL QL methylphenidate hcl CONCERTA buspirone hcl BUSPAR QL METADATE CD VANSPAR QL+ METADATE ER chlordiazepoxide hcl LIBRIUM AGE clorazepate dipotassium TRANXENE T-TAB QL+ METHYLIN CHEW TAB diazepam VALIUM AGE METHYLIN SOLN QL RITALIN lorazepam ATIVAN QL+ RITALIN LA LORAZEPAM INTENSOL AGE RITALT meprobamate MILTOWN QL methylphenidate hcl QUILLICHEW ER oxazepam SERAX QL methylphenidate ER QUILLIVANT XR Anti-Mania Drugs Treatment for Attention Deficit-Hyperactivity (ADHD), NRI-Type lithium carbonate ESKALITH QL atomoxetine hcl STRATTERA LITHOBID CARDIOVASCULAR DISEASE - ARRHYTHMIA lithium citrate CIBALITH-S Antiarrhythmics Anti-Psychotics, Phenothiazines amiodarone hcl CORDARONE hcl THORAZINE disopyramide NORPACE fluphenazine hcl PROLIXIN flecainide acetate TAMBOCOR perphenazine TRILAFON mexiletine hcl MEXITIL thioridazine hcl MELLARIL procainamide hcl PRONESTYL trifluoperazine hcl STELAZINE propafenone hcl RYTHMOL Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed quinidine gluconate QUINAGLUTE QL aripiprazole ABILIFY SOLUTION quinidine sulfate QUINIDEX QL aripiprazole ABILIFY TABLET disopyramide phosphate NORPACE CR QL aripiprazole ODT ABILIFY DISCMELT QL brexpiprazole REXULTI dofetilide TIKOSYN Antipsychotics, Atypical, D3/D2 Partial Agonist/5HT Mixed dronedarone hcl MULTAQ QL cariprazine hcl VRAYLAR propafenone hcl RYTHMOL SR Antipsychotics, Dopamine & Serotonin Antagonists CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS loxapine succinate LOXITANE Digitalis Glycosides 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 hcl LATUDA amlodipine besylate/benazepril LOTREL QL olanzapine ZYPREXA ACE Inhibitor/Thiazide & Thiazide-Like Diuretic 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 QL ziprasidone hcl GEODON ZESTORETIC Antipsychotics, Dopamine Antagonists, Thioxanthenes moexipril/hydrochlorothiazide UNIRETIC thiothixene NAVANE quinapril/hydrochlorothiazide ACCURETIC Antipsychotics, Dopamine Antagonists, Butyrophenones Alpha-Adrenergic Blocking Agents HALDOL doxazosin mesylate CARDURA haloperidol lactate HALDOL ORAL CONC. phenoxybenzamine hcl DIBENZYLINE prazosin hcl MINIPRESS

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terazosin hcl HYTRIN CARDIZEM CD Alpha/Beta-Adrenergic Blocking Agents DILACOR XR carvedilol COREG TIAZAC labetalol hcl TRANDATE felodipine PLENDIL carvedilol phosphate COREG CR isradipine IR capsules ISRADIPINE Angiotensin Receptor Antagonist/Calcium Channel nicardipine hcl NICARDIPINE Blocker/Thiazide Combinations nifedipine ADALAT CC amlodipine/valsartan/hctz EXFORGE HCT PROCARDIA PROCARDIA XL olmesartan/amlodipin/hctz TRIBENZOR nimodipine NIMOTOP Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations verapamil hcl CALAN VERELAN azilsartan med/chlorthalidone EDARBYCLOR irbesartan/hydrochlorithiazide AVALIDE verapamil hcl ER CALAN SR 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 Antagonists & Calcium Channel Blockers eplerenone INSPRA amlodipine/valsartan EXFORGE ALDACTONE amlodipine bes/olmesartan med AZOR Potassium Sparing Diuretics in Combination Antihypertensives, ACE Inhibitors triamterene/hydrochlorothiazid DYAZIDE benazepril hcl LOTENSIN MAXZIDE MAXZIDE-25MG captopril CAPOTEN Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 enalapril maleate VASOTEC Inhibitors fosinopril sodium MONOPRIL PA sildenafil citrate REVATIO TABLET lisinopril PRINIVIL PA tadalafil ADCIRCA ZESTRIL Pulmonary Anti-HTN, Endothelin Receptor Antagonists moexipril hcl UNIVASC PA ambrisentan LETAIRIS quinapril hcl ACCUPRIL PA bosentan TRACLEER ramipril ALTACE PA macitentan OPSUMIT trandolapril MAVIK Pulmonary Anti-HTN, Prostacyclin-Type Antihypertensives, Angiotensin Receptor Antagonists PA selexipag UPTRAVI azilsartan EDARBI irbesartan AVAPRO Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulator 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 PA mipomersen sodium KYNAMRO Beta-Adrenergic Blocking Agents Antihyperlipidemic - HMG CoA Reductase Inhibitors acebutolol hcl SECTRAL atorvastatin calcium LIPITOR atenolol TENORMIN lovastatin MEVACOR bisoprolol fumarate ZEBETA QL pitavastatin LIVALO metoprolol succinate TOPROL XL pravastatin sodium PRAVACHOL metoprolol tartrate LOPRESSOR simvastatin ZOCOR ST simvastatin (80mg only) nadolol CORGARD QL rosuvastatin calcium CRESTOR pindolol VISKEN Antihyperlipidemic - MTP Inhibitors propranolol hcl INDERAL LA PA + lomitapide JUXTAPID sotalol hcl BETAPACE QL BETAPACE AF Antihyperlipidemic – PCSK9 Inhibitors timolol maleate BLOCADREN PA alirocumab PRALUENT nebivolol hcl BYSTOLIC PA evolocumab REPATHA Beta-Adrenergic Blocking Agents/Thiazide & Related Bile Salt Sequestrants atenolol/chlorthalidone TENORETIC 100 cholestyramine/aspartame QUESTRAN LIGHT TENORETIC 50 cholestyramine/sucrose QUESTRAN bisoprolol fumarate/hctz ZIAC colesevelam hcl WELCHOL metoprolol/hctz LOPRESSOR HCT WELCHOL POWDER propranolol/hydrochlorothiazid INDERIDE-40/25 PACKETS Calcium Channel Blocking Agents colestipol COLESTID amlodipine besylate NORVASC COLESTID GRANULES diltiazem hcl CARDIZEM Lipotropics

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fenofibrate FENOGLIDE norethindrone a-e LOESTRIN LOFIBRA TABS norethindrone-ethinyl estrad NORINYL 1+35 fenofibrate, micronized LOFIBRA CAPS ORTHO-NOVUM fenofibrate nanocrystallized TRICOR TRI-NORINYL gemfibrozil LOPID norethindrone- NORINYL 1+50 ST niacin NIASPAN norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN QL omega-3 acid ethyl LOVAZA ORTHO-CYCLEN QL ezetimibe ZETIA norgestrel-ethinyl estradiol LO-OVRAL-28 fenofibrate TRIGLIDE norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO QL icosapent ethyl VASCEPA noreth a-et estra/fe fumarate LO LOESTRIN FE Niacin Preparations Contraceptives, Transdermal niacin SLO-NIACIN QL norelgestromin/ethin.estradiol ORTHO EVRA CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS Oxytocics Adrenergic Vasopressor Agents methylergonovine maleate METHERGINE midodrine hcl PROAMATINE COUGH AND COLD Angiotensin Recept-Neprilysin Inhibitor Comb(ARNI) 1st Generation Antihistamine & Decongestant Combinations QL sacubitril/valsartan ENTRESTO phenylephrine hcl/prometh hcl PHENERGAN VC Antianginal & Anti-Ischemic Agents, Non-Hemodynamic Narcotic Antitussive-1st Generation Antihistamine- Decongestants QL ranolazine RANEXA phenylephrine hcl/cod/prometh PHENERGAN VC Antihyperlipidemic - 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 hydrocodone/homatrop me-br HYCODAN 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 isotretinoin AMNESTEEM ISMO CLARAVIS MONOKET MYORISAN nitroglycerin transdermal patch NITRO-DUR SOTRET nitroglycerin transdermal ointment NITRO-BID ZENATANE nitroglycerin sublingual solution NITROLINGUAL Acne Agents, Topical nitroglycerin sublingual tablet NITROSTAT AGE adapalene/benzoyl peroxide EPIDUO, EPIDUO CONTRACEPTION/OXYTOCICS FORTE Contraceptives, Intravaginal, Systemic clindamycin phos/benzoyl peroxide ONEXTON QL etonogestrel/ethinyl estradiol NUVARING clindamycin/Tretinoin ZIANA Contraceptives, Oral sodium KLARON desog-et estra/ethin estra MIRCETTE Keratolytic-Glucocorticoid Combinations desogestrel-ethinyl estradiol CYCLESSA benzoyl peroxide/hydrocortison VANOXIDE-HC DESOGEN Keratolytics ORTHO-CEPT benzoyl peroxide BREVOXYL-4 ST ethinyl estradiol/drospirenone GIANVI BREVOXYL-8 ST LORYNA TRIAZ ST OCELLA podofilox CONDYLOX ST SYEDA Rosacea Agents, Topical ST VESTURA metronidazole METROCREAM ST YASMIN 28 METROLOTION ST YAZ ST ZARAH Vitamin A Derivatives ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 AGE adapalene DIFFERIN levonorgestrel AFTERA AGE tazarotene 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 AVIANE-28 erythromycin base/ EMGEL LESSINA ERYGEL LUTERA gentamicin sulfate GARAMYCIN ORSYTHIA SRONYX mupirocin BACTROBAN CENTANY noreth a-et estra/fe fumarate LOESTRIN FE LOESTRIN 24FE clindamycin phosphate EVOCLIN norethindrone NOR-Q-D erythromycin base/benz per BENZAMYCIN PAK ORTHO MICRONOR mupirocin calcium BACTROBAN Topical Antifungals

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

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Sulfonylurea) Ear Preparations, Antibiotics pioglitazone hcl ACTOS neomy sulf/polymyx b sulf/hc CORTISPORIN OTIC Antihyperglycemics, Biguanide Type (Non-Sulfonylurea) OTICIN HC metformin hcl GLUCOPHAGE FLOXIN GLUCOPHAGE XR Otic Preparations, Anti-Inflammatory-Antibiotics metformin hcl RIOMET hcl/dexameth CIPRODEX Antihyperglycemics, Insulin-Rel Stim. & Biguanide Combinations Otic Preparations, Local Anesthetics glyburide, micro/metformin hcl GLUCOVANCE antipyrine/benzocaine otic BENZOTIC repaglinide/metformin hcl PRANDIMET ELECTROLYTE REGULATION Antihyperglycemic, Insulin-Response & Release Electrolyte Depleters Combinationsination calcium acetate PHOSLO pioglitazone/glimepiride DUETACT sodium polystyrene sulfonate KAYEXALATE Antihyperglycemic Insul-Resp. Enhancer & Biguanide sevelamer carbonate RENVELA Combinations sevelamer hcl RENAGEL pioglitazone hcl/metformin hcl ACTOPLUS MET Potassium Replacement ACTOPLUS MET XR potassium chloride K-DUR Antihyperglycemic-Glucocorticoid Receptor Blocker K-TAB PA mifepristone KORLYM MICRO-K Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors ENDOCRINE DISORDER - FERTILITY QL canagliflozin INVOKANA Drugs to Treat Impotency QL empagliflozin JARDIANCE QL sildenafil citrate VIAGRA Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Fertility Stimulating Preparations, Non-FSH Inhibitor and Biguanide Combination clomiphene citrate CLOMID QL canagliflozin/metformin hcl INVOKAMET SEROPHENE QL canagliflozin/metformin hcl XR INVOKAMET XR Follicle Stimulating/Luteinizing Hormones QL empagliflozin/metformin hcl SYNJARDY follitropin alpha, recomb GONAL-F QL empagliflozin/metformin XR SYNJARDY XR GONAL-F RFF Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination ,chorionic, human NOVAREL QL empagliflozin/linagliptin GLYXAMBI PREGNYL Diabetic Supplies PROFASI blood glucose calib. control ABBOTT CONTROL hcg alpha, recombinant OVIDREL PRODUCTS (e.g., menotropins MENOPUR FREESTYLE, REPRONEX PRECISION) Pregnancy Facilitating/Maintaining Agents, Hormonal

progesterone, micronized CRINONE blood-glucose meter ABBOTT METERS (e.g., ENDOMETRIN FREESTYLE, PROCHIEVE PRECISION) ENDOCRINE DISORDER - OTHER

Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants blood sugar diagnostics ABBOTT TEST STRIPS (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 alendronate sodium tablet FOSAMAX TABLET EMERGENCY KIT QL alendronate sodium solution FOSAMAX SOLUTION Insulins etidronate disodium DIDRONEL QL insulin glargine,hum.rec.anlog LANTUS ibandronate BONIVA QL TOUJEO QL hcl EVISTA QL insulin lispro HUMALOG Growth Hormone Receptor Antagonists QL insulin nph hum/reg insulin hm HUMULIN 70-30 pegvisomant SOMAVERT QL insulin nph human isophane HUMULIN N Growth Hormones QL insulin npl/insulin lispro HUMALOG MIX 50-50 PA somatropin NORDITROPIN QL HUMALOG MIX 75-25 NORDITROPIN QL insulin regular, human HUMULIN R FLEXPRO QL insulin regular, human HUMULIN R U-500 KWIK NORDITROPIN PEN NORDIFLEX Syringes & Accessories PA somatropin OMNITROPE syringes & needles ALL COMMERCIALLY Hyperparathyroid Tx Agents, Vitamin D Analog-Type AVAILABLE SYRINGES QL calcifediol RAYALDEE AND NEEDLES paricalcitol ZEMPLAR EAR - GENERAL DISORDERS LHRH (GnRH) Antagonist, Pituitary Suppressant Agents Ear Preparations, Miscellaneous Anti-Infectives acetate CETROTIDE VOSOL ganirelix acetate GANIRELIX ACETATE acetic acid/aluminum acetate DOMEBORO Luteinizing Hormone Releasing Hormone –LHRH (GnRH) acetic acid/hydrocortisone VOSOL HC

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Pituitary Suppressive Agents erythromycin base ROMYCIN cabergoline DOSTINEX ZYMAXID DANOCRINE gentamicin sulfate GARAMYCIN ENDOCRINE DISORDER - THYROID neomycin/bacitracin/polymyxin NEOSPORIN OPHTH Antithyroid Preparations OINTMENT methimazole TAPAZOLE neomycin/polymyxn NEOSPORIN OPHTH propylthiouracil PROPYLTHIOURACIL b/gramicidin DROPS Iodine Containing Agents ofloxacin OCUFLOX potassium iodide POTASSIUM IODIDE polymyxin b sulfate/tmp POLYTRIM Thyroid Hormones tobramycin sulfate TOBREX levothyroxine sodium LEVOTHROID hcl drops susp 0.6% BESIVANCE LEVOXYL hcl VIGAMOX SYNTHROID Ophthalmic Mast Cell Stabilizers liothyronine sodium CYTOMEL cromolyn sodium OPTICROM thyroid, pork ARMOUR THYROID lodoxamide tromethamine ALOMIDE NATURE-THROID nedocromil sodium ALOCRIL WESTHROID pemirolast potassium ALAMAST EYE - GENERAL DISORDERS EYE - GLAUCOMA Eye Antibiotic-Corticoid Combinations Carbonic Anhydrase Inhibitors neo/polymyx b sulf/dexameth MAXITROL acetazolamide DIAMOX SEQUELS neomy sulf/bacitrac zn/poly/hc NEO-POLYCIN HC methazolamide NEPTAZANE OPHTH OINTMENT Miotics/Other Intraocular Pressure Reducers neomy sulf/polymyx b sulf/hc CORTISPORIN OPHTH betaxolol hcl BETOPTIC SUSPENSION QL bimatoprost 0.03% LUMIGAN tobramycin sulfate/dexameth TOBRADEX brimonidine tartrate ALPHAGAN P tobramycin/lotepred etab ZYLET carteolol hcl OCUPRESS Eye Antihistamines dorzolamide hcl TRUSOPT azelastine hcl OPTIVAR dorzolamide hcl/timolol maleat COSOPT ketotifen fumarate (OTC) ALAWAY (OTC) latanoprost XALATAN QL olopatadine hcl PATADAY PATANOL levobunolol hcl BETAGAN Eye Antiinflammatory Agents metipranolol OPTIPRANOLOL diclofenac sodium VOLTAREN pilocarpine hcl ISOPTO CARPINE fluorometholone FML timolol maleate TIMOPTIC (except Ocudose) flurbiprofen sodium OCUFEN TIMOPTIC-XE ketorolac tromethamine ACULAR QL travoprost (benzalkonium) TRAVATAN ACULAR LS betaxolol hcl BETOPTIC S prednisolone acetate OMNIPRED PRED FORTE QL bimatoprost 0.01% LUMIGAN prednisolone sod phosphate PREDNISOL brimonidine/timolol COMBIGAN difluprednate DUREZOL brinzolamide AZOPT fluorometholone FML FORTE brinzolamide/brimonidine SIMBRINZA FML S.O.P. carbachol ISOPTO CARBACHOL fluorometholone acetate FLAREX timolol BETIMOL loteprednol etabonate ALREX QL travoprost TRAVATAN Z LOTEMAX Mydriatics nepafenac ILEVRO atropine sulfate ISOPTO ATROPINE NEVANAC cyclopentolate hcl CYCLOGYL prednisolone acetate PRED MILD homatropine hbr ISOPTO HOMATROPINE Eye Antivirals dipivefrin hcl PROPINE trifluridine VIROPTIC Hyperuricemia Treatments - Purine Inhibitors ganciclovir ZIRGAN allopurinol ZYLOPRIM Eye Sulfonamides QL febuxostat ULORIC na sulfacetm/prednis sp VASOCIDIN Uricosuric Agents sulfacetamide sodium SULFAC QL lesinurad ZURAMPIC na sulfacetm/prednisol ac BLEPHAMIDE probenecid BENEMID BLEPHAMIDE S.O.P. HEMATOLOGICAL DISORDERS EYE - MISCELLANEOUS Anticoagulants, Coumarin Type Ophthalmic Cystine Delpleting Agents warfarin sodium COUMADIN PA cysteamine CYSTARAN Direct Factor XA Inhibitors Ophthalmic Anti-Inflammatory Immunomodulator-Type QL apixaban ELIQUIS QL cyclosporine RESTASIS SINGLE QL rivaroxaban XARELTO DOSE Hematinics, Other QL RESTASIS MULTIDOSE PA epoetin alfa PROCRIT QL lifitegrast XIIDRA Hemorrheologic Agents Ophthalmic Antibiotics pentoxifylline TRENTAL bacitracin AK-TRACIN Heparin & Related Preparations bacitracin/polymyxin b sulfate POLYCIN-B QL enoxaparin sodium LOVENOX ciprofloxacin hcl CILOXAN

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QL fondaparinux sodium ARIXTRA INFECTIOUS DISEASE - BACTERIAL heparin sodium, porcine HEP-LOCK Absorbable Sulfonamides HEPARIN LOCK sulfadiazine SULFADIAZINE heparin sodium, porcine/pf HEP-LOCK / BACTRIM DS QL dalteparin sodium, porcine FRAGMIN SEPTRA Leukocyte (WBC) Stimulants SEPTRA DS PA filgrastim NEUPOGEN sulfisoxazole acetyl GANTRISIN PA pegfilgrastim NEULASTA Betalactams PA sargramostim LEUKINE PA aztreonam lysine CAYSTON Platelet Aggregation Inhibitors Cephalosporins - 1st Generation cilostazol PLETAL cefadroxil hydrate DURICEF clopidogrel bisulfate 75mg PLAVIX 75MG cephalexin monohydrate KEFLEX QL clopidogrel bisulfate 300mg PLAVIX 300MG Cephalosporins - 2nd Generation dipyridamole PERSANTINE cefaclor CECLOR QL prasugrel hcl EFFIENT cefprozil CEFZIL QL ticagrelor BRILINTA cefuroxime axetil CEFTIN Platelet Reducing Agents Cephalosporins - 3rd Generation anagrelide hcl AGRYLIN cefdinir OMNICEF Thrombopoietin Receptor Agonists cefixime SUPRAX PA + eltrombopag olamine PROMACTA cefpodoxime proxetil VANTIN QL Chemotherapeutics, Antibacterial, Miscellaneous. Vitamin K Preparations trimethoprim PROLOPRIM phytonadione MEPHYTON meth/meth blue/ba/salicy/hyos PROSED-DS HORMONAL DEFICIENCY mth/me blue/salicy/na phos/hyo URETRON D-S Androgenic Agents URIN D.S. QL ANDROXY trimethoprim PRIMSOL ANDROID Ketolides PA 1% ANDROGEL telithromycin KETEK PA + testosterone cypionate DEPO-TESTOSTERONE Lincosamides QL clindamycin palmitate solution CLEOCIN PALMITATE PA testosterone enantate DELATESTRYL clindamycin hcl capsules CLEOCIN HCL methyltestosterone Macrolides METHITEST azithromycin ZITHROMAX PA testosterone gel 1.62% ANDROGEL ZITHROMAX TRI-PAK PA testosterone solution AXIRON clarithromycin BIAXIN Estrogen/Androgen Combinations BIAXIN XL estrogen, /me-testosterone ESTRATEST H.S. ery e-succ/sulfisoxazole PEDIAZOLE Estrogenic Agents erythromycin base ERYC estradiol CLIMARA erythromycin ethylsuccinate ERYPED 200 ESTRACE erythromycin stearate ERYTHROCIN QL VIVELLE-DOT STEARATE OGEN azithromycin ZMAX norethindrone ac-eth estradiol FEMHRT ZMAX PEDIATRIC estradiol ALORA erythromycin base ERY-TAB ESTRADERM PCE QL estradiol/noreth ac COMBIPATCH erythromycin ethylsuccinate ERYPED 200 , conj/ DUAVEE ERYPED 400 estrogen, con/m-progest acet PREMPHASE QL DIFICID PREMPRO Nitrofuran Derivatives estrogens, conjugated PREMARIN macrocrystal MACRODANTIN estrogens, esterified MENEST nitrofurantoin/nitrofuran mac MACROBID Progestational Agents furazolidone FUROXONE medroxyprogesterone acet PROVERA nitrofurantoin FURADANTIN norethindrone acetate AYGESTIN Oxazolidinones progesterone, micronized PROMETRIUM PA ZYVOX IMMUNOSUPPRESSION/MODULATION PA tedizolid phosphate tablet SIVEXTRO TABLET Immunomodulators Penicillins PA + imiquimod ALDARA amox tr/potassium clavulanate AUGMENTIN QL AUGMENTIN ES-600 PA interferon alfa-2b, recomb. INTRON A AUGMENTIN XR Immunosuppressives amoxicillin trihydrate AMOXIL azathioprine IMURAN ampicillin trihydrate POLYCILLIN cyclosporine SANDIMMUNE dicloxacillin sodium PATHOCIL cyclosporine, modified NEORAL penicillin v potassium V-CILLIN K mycophenolate mofetil CELLCEPT Quinolones sirolimus RAPAMUNE ciprofloxacin CIPRO ORAL SUSPENSION tacrolimus anhydrous PROGRAF ciprofloxacin hcl CIPRO everolimus ZORTRESS

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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 TABLET acyclovir ZOVIRAX minocycline hcl DYNACIN ganciclovir CYTOVENE 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 Inhibitors 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 Analogs terbinafine hcl LAMISIL QL emtricitabine/tenofov alafenam DESCOVY voriconazole VFEND QL emtricitabine/tenofovir TRUVADA terbinafine hcl LAMISIL GRANULES Antivirals, HIV-Spec, Nucleoside Analog, RTI Combinations 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 Antivirals, HIV-Specific, CCR5 Co-Receptor Antagonists 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 NYDRAZID SUSTIVA pyrazinamide PYRAZINAMIDE QL etravirine INTELENCE Antileprotics QL rilpivirine EDURANT AVLOSULFON Antivirals, HIV-Specific, Nucleoside Analog, RTI PA thalidomide THALOMID QL abacavir sulfate ZIAGEN Antitubercular Antibiotics QL didanosine VIDEX EC rifampin RIFADIN QL lamivudine EPIVIR rifampin/isoniazid RIFAMATE QL stavudine ZERIT Rifamycins and Related Derivative Antibiotics QL zidovudine RETROVIR PA XIFAXAN 550MG QL didanosine VIDEX SOLUTION Vancomycin & Derivatives QL emtricitabine EMTRIVA QL vancomycin hcl VANCOCIN Antivirals, HIV-Specific, Nucleotide Analog, RTI INFECTIOUS DISEASE - PARASITIC QL tenofovir disoproxil fumarate VIREAD Amebacides Antivirals, HIV-Specific, Protease Inhibitor Combinations sulfate HUMATIN QL lopinavir/ritonavir KALETRA iodoquinol YODOXIN Antivirals, HIV-Specific, Protease Inhibitors Anaerobic Antiprotozoal-Antibacterial Agents QL atazanavir sulfate REYATAZ metronidazole FLAGYL QL atazanavir sulfate/cobicistat EVOTAZ metronidazole FLAGYL ER QL fosamprenavir calcium LEXIVA Anthelmintics indinavir sulfate CRIXIVAN praziquantel BILTRICIDE nelfinavir mesylate VIRACEPT PA mebendazole EMVERM QL ritonavir NORVIR Antimalarial Drugs QL saquinavir mesylate INVIRASE chloroquine phosphate ARALEN PHOSPHATE Antivirals, HIV-1 Integrase Strand Transfer Inhibitors hydroxychloroquine sulfate PLAQUENIL QL dolutegravir TIVICAY mefloquine hcl LARIAM QL raltegravir potassium ISENTRESS quinine sulfate QUALAQUIN Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside primaquine phosphate PRIMAQUINE RTI PA pyrimethamine DARAPRIM QL efavirenz/emtricitab/tenofovir ATRIPLA

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QL rilpivirine/ emtricitabine/ tenofovir COMPLERA NAPROSYN disoproxil fumarate naproxen sodium ANAPROX QL emtricitab/rilpiviri/tenof ala ODEFSEY ANAPROX DS Cytochrome P450 Inhibitors oxaprozin DAYPRO QL cobicistat TYBOST piroxicam FELDENE Hepatitis B Treatment Agents sulindac CLINORIL QL adefovir dipivoxil HEPSERA tolmetin sodium TOLECTIN 600 QL entecavir BARACLUDE fenoprofen calcium NALFON CAPSULES QL lamivudine EPIVIR HBV TABLET indomethacin INDOCIN SUPPOS. QL lamivudine EPIVIR HBV SOLUTION INDOCIN ORAL SUSP. telbivudine TYZEKA LOCAL ANESTHESIA Hepatitis C Combination Agents Local Anesthetics PA ledipasvir/sofosbuvir HARVONI lidocaine hcl XYLOCAINE PA sofosbuvir/velpatasvir EPCLUSA LOWER GASTROINTESTINAL DISORDERS - BOWEL Hepatitis C Treatment Agents INFLAMMATORY ribavirin 200mg COPEGUS Bowel Antiinflamatory Agents REBETOL CAPSULE sulfasalazine AZULFIDINE PA peginterferon alfa-2a PEGASYS Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx PA peginterferon alfa-2a PEGASYS PROCLICK mesalamine SFROWASA ribavirin REBETOL SOLUTION mesalamine w/cleansing wipes ROWASA INFLAMMATORY DISEASE mesalamine CANASA Anti-Arthritic & Chelating Agents Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat penicillamine DEPEN balsalazide disodium COLAZAL Anti-Arthritic, Folate Antagonist Agents mesalamine APRISO methotrexate sodium RHEUMATREX LIALDA QL methotrexate OTREXUP PENTASA Anti-Inflammatory Tumor Necrosis Factor Inhibitors Hemorrhoidal Preparations PA adalimumab HUMIRA hc acetate/pramoxine hcl ANALPRAM HC PA etanercept ENBREL Irritable Bowel Agents, Guanylate Cylase-C Agonists Anti-Inflammatory, Pyrimidine Synthesis Inhibitors QL linaclotide LINZESS leflunomide ARAVA Rectal Preparations Bradykinin B2 Receptor Antagonists hydrocortisone PROCTO-KIT PROCTOCORT CREAM PA icatibant acetate FIRAZYR PROCTOCREAM-HC Glucocorticoids hydrocortisone acetate ANUSOL-HC budesonide BUDESONIDE PROCTOCORT SUPPOS. cortisone acetate CORTONE ACETATE hc acetate/pramoxine hcl PROCTOFOAM-HC dexamethasone tablet, elixir DECADRON Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) hydrocortisone CORTEF hydrocortisone CORTENEMA methylprednisolone MEDROL LOWER GASTROINTESTINAL DISORDERS - OTHER prednisolone MILLIPRED Ammonia Inhibitors MILLIPRED DP lactulose CHRONULAC prednisolone sod phosphate ORAPRED sodium phenylbutyrate BUPHENYL POWDER PEDIAPRED sodium phenylbutyrate BUPHENYL TABLET prednisone DELTASONE Antidiarrheals PREDNISONE INTENSOL diphenoxylate hcl/atrop sulf LOMOTIL

budesonide ENTOCORT EC Bile Salts Mineralocorticoids ursodiol ACTIGALL fludrocortisone acetate FLORINEF ACETATE URSO Monoclonal antibody-human interleukin URSO FORTE PA ustekinumab STELARA SC Laxatives & Cathartics NSAIDs, Cyclooxygenase Inhibitor-Type peg 3350/na sulf,bicarb,cl/kcl COLYTE WITH FLAVOR celecoxib CELEBREX PACKETS diclofenac sodium VOLTAREN polyethylene glycol 3350 MIRALAX VOLTAREN-XR sod chloride/nahco3/kcl/peg's NULYTELY WITH etodolac LODINE FLAVOR PACKS fenoprofen calcium NALFON TABLETS lactulose KRISTALOSE flurbiprofen ANSAID peg 3350/na sulf,bicarb,cl/kcl GOLYTELY OCL ibuprofen MOTRIN Narcotic Antagonists, Peripherally-Acting indomethacin INDOCIN INDOCIN SR QL naloxegol oxalate MOVANTIK ketoprofen ORUVAIL Inhibitor QL ketorolac tromethamine TORADOL PA telotristat XERMELO meclofenamate sodium MECLOMEN Glucagon-Like Peptide (GLP-2) Analogs meloxicam MOBIC QL teduglutide [rDNA origin] GATTEX nabumetone RELAFEN MISCELLANEOUS AGENTS naproxen EC-NAPROSYN Anaphylaxis Therapy Agents epinephrine EPIPEN

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epinephrine EPIPEN JR QL Parasympathetic Agents PA dabrafanib TAFINLAR bethanechol chloride URECHOLINE PA dasatinib SPRYCEL cevimeline hcl EVOXAC PA+ erlotinib hcl TARCEVA pilocarpine hcl SALAGEN QL Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase PA gefitinib IRESSA PA sapropterin dihydrochloride KUVAN PA ibrutinib IMBRUVICA NEOPLASTIC DISEASE PA idelalisib ZYDELIG Alkylating Agents PA imatinib mesylate GLEEVEC cyclophosphamide CYTOXAN PA ixazomib citrate NINLARO hydroxyurea HYDREA PA lapatinib ditosylate TYKERB lomustine CEENU PA lenvatinib mesylate LENVIMA PA temozolomide TEMODAR PA nilotinib hydrochloride TASIGNA altretamine HEXALEN PA olaparib LYNPARZA busulfan MYLERAN PA + osimertinib mesylate TAGRISSO QL chlorambucil LEUKERAN PA pazopanib hydrochloride VOTRIENT melphalan ALKERAN PA palbociclib IBRANCE Antiandrogenic Agents PA ponatinib ICLUSIG CASODEX PA regorafenib STIVARGA flutamide EULEXIN PA ribociclib succinate KISQALI PA ZYTIGA PA sorafenib tosylate NEXAVAR PA enzalutamide XTANDI PA sunitinib malate SUTENT QL nilutamide 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 mitotane LYSODREN mercaptopurine PURIXAN hcl MATULANE methotrexate sodium TREXALL tretinoin VESANOID PA trifluridine/tipiracil hcl LONSURF Antineoplastic mTOR Kinase Inhibitors Antineoplastic - Aromatase Inhibitors PA everolimus AFINITOR ARIMIDEX QL AROMASIN PA AFINITOR DISPERZ FEMARA Chemotherapy Rescue/Antidote Agents Antineoplastic – B Cell Lymphoma 2(BCL-2) Inhibitors leucovorin calcium LEUCOVORIN CALCIUM PA venetoclax VENCLEXTA QL vridine triacetate VISTOGARD Antineoplastic – Hedgehog Pathway Inhibitors Selective Estrogen Receptor Modulators (SERM) PA vismodegib ERIVEDGE citrate NOLVADEX PA sonidegib phosphate ODOMZO PA citrate FARESTON Antineoplastic – Janus Kinase (JAK) Inhibitors Selective Retinoid X Receptor Agonists (RXR) PA ruxolitinib JAKAFI PA bexarotene TARGRETIN PA tofacitinib XELJANZ PA tofacitinib XR XELJANZ XR Steroid Antineoplastics PA ruxolitinib JAKAFI MEGACE Antineoplastic – MEK1 and MEK2 Kinase Inhibitors phosphate sodium EMCYT PA + cobimetinib fumarate COTELLIC NEUROLOGICAL DISEASE - MISCELLANEOUS QL Agents to Treat Multiple Sclerosis Antineoplastic - Topoisomerase I Inhibitors PA glatiramer acetate COPAXONE topotecan hcl HYCAMTIN PA dimethyl fumarate TECFIDERA Antineoplastic - Immunomodulator Agents PA fingolimod hcl GILENYA PA + lenalidomide REVLIMID PA interferon beta-1a AVONEX QL PA interferon beta-1a/albumin AVONEX PA pomalidamide POMALYST ADMINISTRATION PACK Antineoplastic - Systemic Enzyme Inhibitors PA REBIF PA REBIF REBIDOSE PA afatinib GILOTRIF PA peginterferon beta-1a PLEGRIDY PA + alectinib hydrochloride ALECENSA PA PLEGRIDY PEN QL PA teriflunomide AUBAGIO PA+ axitinib INLYTA Fibromyalgia Agents, Serotonin-Norepinephrine Reuptake QL Inhibitors PA bosutinib BOSULIF milnacipran hcl SAVELLA PA cabozanitinib COMETRIQ PA cabozantinib s-malate CABOMETYX Movement Disorders (Drug Therapy) PA ceritinib ZYKADIA PA tetrabenazine XENAZINE PA crizotinib XALKORI ORAL/PHARYNGEAL DISORDERS

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

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

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folic acid/mu-vits-min th VICON FORTE Pediatric Vitamin Preparations fluoride ion/iron/vit a,c&d TRI-VI-FLOR W/IRON fluoride ion/multivitamins POLY-VI-FLOR fluoride ion/multivits w-fe POLY-VI-FLOR W/IRON fluoride ion/vit a,c&d FLUORABON BASIC Prenatal Vitamin Preparations prenatal vit 15/iron cb/fa/dss TRIADVANCE prenatal vit 16/iron cb/fa/dss VINATE GT prenatal vit 18/iron cb/fa/dss VINATE ULTRA prenatal vit 95/fe fum/fa PRENAVITE Vitamin B Preparations cyanocobalamin/fa/pyridoxine FOLGARD RX Vitamin D Preparations calcitriol ROCALTROL calcitriol VECTICAL ergocalciferol DRISDOL

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SPECIALTY INJECTABLE CROSS REFERENCE LISTING  Androxy 120 tablets per 30 days  Anoro Ellipta 60 blister packs per 30 days The following cross reference is being provided as a guide to  Aptivus formulary choices within prominent “specialty” injectable drug capsule 120 capsules per 30 days categories. General specialty categories are cross referenced to solution 380mL (4 bottles) per 30 days their corresponding formulary classification status and page number. This cross reference is not meant to be all-inclusive.  Arixtra 5mL (10 syringes) per 30 days Please refer to the Table of Contents or Index to determine 2.5mg/0.5mL 4mL (10 syringes) per 30 days formulary status of injectable medications not listed in this cross 5mg/0.4mL 6mL (10 syringes) per 30 days reference (e.g., Antineoplastics, Leukocyte Stimulants, etc.). 7.5mg/0.6mL 8mL (10 syringes) per 30 days 10mg/0.8mL EPO  Asmanex 1 inhaler per 30 days Hematinics, Other Page 7  Asmanex HFA 13g (1 inhaler) per 30 days  Astelin 60mL (2 bottles) per 30 days HEPATITIS C  Astepro 60mL (2 bottles) per 30 days Hepatitis C Treatment Agents Page 9  Atripla 30 tablets per 30 days  Atrovent HFA 25.8g (2 inhalers) per 28 days HUMAN GROWTH FACTORS  Avinza Growth Hormones Page 6 30mg, 45mg, 60mg, 75mg, 90mg 30 capsules per 30 days LOW MOLECULAR WEIGHT HEPARINS 120mg 60 capsules per 30 days Heparin and Related Preparations Page 7  Azilect 30 tablets per 30 days  Baraclude MULTIPLE SCLEROSIS 0.5mg, 1mg 30 tablets per 30 days Agents to Treat Multiple Sclerosis Page 10 0.05mg/5mL oral 630mL (3 bottles) per 30 days Solution RHEUMATOID ARTHRITIS  Belsomra 30 tablets per 30 days Anti-Inflammatory Pyrimidine Synthesis Inhibitors Page 9  Breo Ellipta 60 units per 30 days  Brilinta 60 tablets per 30 days MEDICATION PRESCRIBING LIMITATIONS  Butrans 4 patches per 28 days  Caduet 30 tablets per 30 days 1. AGE RESTRICTIONS (FORMULARY) Covered for ages:  Cafergot 40 tablets per 28 days  Differin ≤ 25 years old  Climara 4 patches per 28 days  Epiduo ≤ 25 years old  Clozaril 90 tablets per 30 days  Epiduo Forte ≤ 25 years old  Colcrys 120 tablets per 30 days  Fabior ≥ 12 years old  Combipatch 8 patches per 28 days  Ritalin LA 60mg ≤ 18 years old  Combivir 60 tablets per 30 days  Ritalin SR ≤ 18 years old  Complera 30 tablets per 30 days  Concerta 2. AGE RESTRICTIONS (NON FORMULARY) Covered for ages: 18mg, 27mg, 54mg 30 tablets per 30 days  All carbinoxamine ≥ 2 years old 36mg 60 tablets per 30 days containing products (i.e.,  Corlanor 60 tablets per 30 days Palgic, Tussafed, etc.)  Cotellic 63 tablets per 28 days  Atralin ≤ 25 years old  Crestor 30 tablets per 30 days  Avita ≤ 25 years old  Cymbalta 60 capsules per 30 days  Oracea ≥ 18 years old  Daliresp 30 tablets per 30 days  Refissa ≤ 25 years old  Depo-Testosterone 10mL per 30 days  Renova ≤ 25 years old  Descovy 30 tablets per 30 days  Retin-A ≤ 25 years old  Desvenlafaxine ER 30 tablets per 30 days  Retin-A Micro ≤ 25 years old (Ranbaxy Brand)  Retin-A Micro Pump ≤ 25 years old  Dexedrine Spansule  Solodyn ≥ 12 years old 5mg, 10mg 60 capsules per 30 days  Tretin-X ≤ 25 years old 15mg 120 capsules per 30 days  Diastat 1 kit per copay  Dificid 20 tablets per 30 days 3. QUANTITY RESTRICTIONS (FORMULARY)  Dulera 13g (1 inhaler) per 30 days  Abilify 10 patches per 30 days tablets 30 tablets per 30 days  Duragesic solution 900mL per 30 days  Edurant 30 tablets per 30 days  Abilify Discmelt  Effient 30 tablets per 30 days 10mg 90 tablets per 30 days  Eliquis 60 tablets per 30 days 15mg 60 tablets per 30 days  Emend  Adderall 60 tablets per 30 days 40mg capsule 1 capsules per 28 days  Adderall XR 80mg capsule 2 capsules per 21 days 5mg, 10mg, 15mg 30 capsules per 30 days 125mg capsule 1 capsule per -21 days 20mg, 25mg, 30mg 60 capsules per 30 days  Emend Trifold Pack 1 packet (3 capsules) per -21 days  Advair Diskus 60 units per 30 days  Emtriva  Advair HFA 12g (1 inhaler) per 30 days 10mg/mL oral solution 850mL (5 bottles) per 30 days 30 capsules per 30 days  Afinitor 30 per 30 days 200mg capsules

 Akynzeo 1 capsule per 28 days  Epivir 150mg tablets 60 tablets per 30 days  Aldara 24 packets per 30 days 300mg tablets 30 tablets per 30 days  Alecensa 240 capsules per 30 days 10mg/mL oral solution 960mL (4 bottles) per 30 days  Alendronate solution 300mL per 28 days  Epivir HBV 30 tablets per 30 days  Ambien/Ambien CR 100mg 30 tablets per 30 days  Amerge 18 tablets per 30 days oral solution 720ml (3 bottles) per 30 days

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 Epzicom 30 tablets per 30 days 50-1000mg 60 tablets per 30 days  Entresto 60 tablets per 30 days 50-500mg 60 tablets per 30 days  Evista 30 tablets per 30 days  Januvia 30 tablets per 30 days  Evotaz 30 tablets per 30 days  Jentadueto 60 tablets per 30 days  Exelon patch 30 patches per 30 days  Jardiance 30 tablets per 30 days  Fetzima 30 capsules per 30 days  Juxtapid  Flonase 16g (1 bottle) per 30 days 5mg, 10mg, 30mg, 40mg,  Focalin 60 tablets per 30 days 60mg 30 capsules per 30 days  Focalin XR 30 capsules per 30 days 20mg 90 capsules per 30 days  Forteo 2.4mL (1 pen) per 28 days with a  Kaletra max duration of 2 years per lifetime 100-25mg tablets 60 tablets per 30 days  Fragmin 200-50mg tablets 120 tablets per 30 days 2500 units/0.2mL 2mL (10 syringes) per 30 days oral solution 480mL (3 bottles) per 30 days 5000 units/0.2mL 2mL (10 syringes) per 30 days  Lantus 7500 units/0.3mL 3mL (10 syringes) per 30 days vial 40mL (4 vials) per 28 days 10,000 units/1mL 10mL (10 syringes) per 30 days Solostar 30mL (10 pens) per 28 days 12,500 units/0.5mL 5mL (10 syringes) per 30 days  Latuda 15,000 units/0.6mL 6mL (10 syringes) per 30 days 20mg, 40mg, 60mg, 30 tablets per 30 days 18,000 units/0.72mL 7.2mL (10 syringes) per 30 days 120mg 25,000 units/ml 7.6ml (2 vials) per 30 days 80mg 60 tablets per 30 days  Fuzeon 60 vials per 30 days  Lexiva  Genvoya 30 tablets per 30 days suspension 1800mL (8 bottles) per 30 days  Geodon 60 capsules per 30 days tablet 120 tablets per 30 days  Glyxambi 30 tablets per 30 days  Linzess 30 capsules per 30 days  Hepsera 30 tablets per 30 days  Livalo 30 tablets per 30 days  Humulin N  Lovaza 120 capsules per 30 days vial 40mL (4 vials) per 28 days  Lovenox Kwikpen 30mL (10 pens) per 28 days 30mg/0.3mL 6mL (20 syringes) per 30 days  Humulin R 40mg/0.4mL 8mL (20 syringes) per 30 days 100u/mL 40mL (4 vials) per 28 days 60mg/0.6mL 12mL (20 syringes) per 30 days 500u/mL 40mL (2 vials) per 28 days 80mg/0.8mL 16mL (20 syringes) per 30 days  Humulin R U-500 100mg/1mL 20mL (20 syringes) per 30 days Kwikpen 8 pens (4 boxes of 2 pens) per 28 120mg/0.8mL 16mL (20 syringes) per 30 days days 150mg/1mL 20mL (20 syringes) per 30 days  Humulin 70/30 300mg/3mL 30mL (10 vials) per 30 days vial 40mL (4 vials) per 28 days  Lumigan 2.5mL per 30 days Kwikpen 30mL (10 pens) per 28 days  Lunesta 30 tablets per 30 days  Humalog  Lynparza 16 capsules per day vial 40mL (4 vials) per 28 days  Marinol 60 capsules per 30 days pen/cartridge 30mL (10 pens/cartridges) per 28  Maxalt/Maxalt MLT 18 tablets per 30 days days  Metadate CD  Humalog Mix 50/50 / 75/25 10mg, 20mg, 40mg, 30 tablets per 30 days vial 40mL (4 vials) per 28 days 60mg Kwikpen 30mL (10 pens) per 28 days 30mg 60 tablets per 30 days  Hydrocodone bit/acetaminophen (maximum of 4gm of  Metadate ER 90 tablets per 30 days acetaminophen per day):  Methadone HCl injection 120mL (6 vials) per 30 days 250mg 16 tablets per 1 day supply solution 300mg 13 tablets per 1 day supply  Methylin chewable tablet 90 tablets per 30 days 325mg 12 tablets per 1 day supply  Migergot 20 units per 28 days 300mg/15ml soln 200mL per 1 day supply  Morgidox 325mg/15ml elixir 184mL per 1 day supply 50mg, 100mg 60 capsules per 30 days 30 tablets per 30 days  Hysingla ER

 Imitrex  Movantik 30 tablets per 30 days tablet 18 tablets per 30 days  MS Contin 90 tablets per 30 days nasal spray 12 units per 30 days  Namenda injection 4 units per 28 days tablet 60 tablets per 30 days  Inlyta titration pack 49 tablets per 28 days 1mg 180 tablets per 30 days solution 300mL per 30 days 5mg 120 tablets per 30 days  Namenda XR  Intelence capsules 30 capsules per 30 days 25mg, 100mg 120 tablets per 30 days titration pack 28 capsules per 28 days 200mg 60 tablets per 30 days  Namzaric  Invirase capsules 30 capsules per 30 days 200mg 300 capsules per 30 days titration pack 28 capsules per 28 days 500mg 120 tablets per 30 days  Narcan 2 boxes (4 nasal sprays) per 30 60 tablets per 30 days  Invokamet days 60 tablets per 30 days  Invokamet XR  Nasacort AQ 16.5g (1 canister) per 30 days 30 tablets per 30 days  Invokana  Nasarel 25mL (1 bottle) per 30 days

 Isentress  Nasonex 17g (1 canister) per 30 days 400 mg tablets 60 tablets per 30 days  Neupro 30 patches per 30 days 25mg, 100mg tablets 180 chewable tablets per 30 days  Nexium 100mg powder 60 packets per 30 days capsules 30 capsules per 30 days  Janumet 60 tablets per 30 days packets 30 packets per 30 days  Janumet XR  Nilandron 60 tablets for the first 30 days, then 30 tablets per 30 days 100-1000mg 30 tablets per 30 days

37010 MedPerform Low Formulary – July 2017 16 MedPerform LOW Formulary

 Norvir 10mg, 20mg, 40mg, 30 capsules per 30 days oral solution 480mL (2 bottles) per 30 days 60mg capsules/tablets 360 capsules/tablets per 30 days 30mg 60 capsules per 30 days  Nucynta 180 tablets per 30 days  Ritalin SR 90 tablets per 30 days  Nucynta ER 60 tablets per 30 days  Saphris 60 tablets per 30 days  Nuvaring 1 ring per 28 days  Seasonale 91 tablets per 84 days  Odefsey 30 tablets per 30 days Extra copay for every 31 days  Ortho Evra 3 patches per 28 days  Selzentry  Otrexup 1.6mL per 28 days 75mg, 150mg 60 tablets per 30 days  Oxycodone hcl/acetaminophen (maximum of 4g acetaminophen 25mg, 300mg 120 tablets per 30 days per day):  Serevent Diskus 60 doses (1 Diskus) per 30 days 325mg 12 tablets per 1 day supply  Seroquel 90 tablets per 30 days 500mg 8 tablets/capsules per 1 day supply  Silenor 30 tablets per 30 days 650mg 6 tablets per 1 day supply  Sonata 30 capsules per 30 days 325mg/5mL soln 61mL per 1 day supply  Spiriva 30 inh capsules per 30 days  Oxycontin  Spiriva Respimat 1 inhaler per 30 days 10mg, 15mg, 20mg,  Stiolto Respimat 4g (60 inhalations) per 30 days 30mg, 40mg, 60mg 60 tablets per 30 days  Strattera 80mg 120 tablets per 30 days 10mg, 18mg, 25mg,  Perforomist 120mL per 30 days 40mg 60 capsules per 30 days  Picato 60mg, 80mg, 100mg 30 capsules per 30 days 0.015% 3 tubes per 56 days  Stribild 30 tablets per 30 days 0.05% 2 tubes per 56 days  Striverdi Respimat 4g (60 inhalations) per 30 days  Plavix 300mg tablet 4 tablets per 30 days  Suboxone  Potiga 2/0.5mg, 4/1mg 30 films per 30 days 50mg 270 tablets per 30 days 8/2mg, 12/3mg 60 films per 30 days 200mg, 300mg, 400mg 90 tablets per 30 days Tablets 90 tablets per 30 days  Prezcobix 30 tablets per 30 days  Subutex 90 tablets per 30 days  Prezista  Symbicort 1 inhaler per 30 days (10.2 grams) suspension 400mL per 30 days  Symbyax 30 capsules per 30 days 75mg 480 tablets per 30 days  Synjardy 60 tablets per 30 days 150mg 240 tablets per 30 days  Synjardy XR 400mg, 600mg 60 tablets per 30 days 5/1000mg,12.5/1000mg 2 tablets per day 800mg 30 tablets per 30 days 10/1000mg, 25/1000mg 1 tablet per day  Pristiq 30 tablets per 30 days  Tagrisso 1 tablet per day  Promacta 30 tablets per 30 days  Tamiflu  Provigil 60 tablets per 30 days suspension 360mL per 183 days  Pulmicort Flexhaler 1 inhaler per 30 days 30mg 40 tablets per 183 days  Pulmicort Respules 60mL (30 respules) per 30 days 45mg, 75mg 20 tablets per 183 days  Qnasl 8.7g (1 canister) per 30 days  Tarceva 30 tablets per 30 days  Qnasl Children 4.9g (1 canister) per 30 days  Tivicay 30 tablets per 30 days  Quillichew ER  Toradol 20 tablets per fill 20mg, 40mg 30 tablets 30 per days  Trintellix 30 tablets per 30 days 30mg 60 tablets per 30 days  Viibryd 30 tablets per 30 days  Quillivant XR  Vimpat 60mL 60mL (1 bottle) per 30 days 50mg, 100mg, 120mL 240mL (2 bottles) per 30 days 150mg, 200mg 60 tablets per 30 days 150mL 300mL (2 bottles) per 30 days 10mg/ml oral solution 1200mL per 30 days 180mL 360mL (2 bottles) per 30 days  Vraylar  QVAR 17.4g (2 inhalers) per 30 days All Strengths 30 capsules per 30 days  Ranexa Titration Pack 7 blisters (1 dose-pack) per 28 days 500mg 120 tablets per 30 days 1000mg 60 tablets per 30 days  Vyvanse  Rayaldee 60 capsules per 30 days 30 capsules/tablets per 30 days  Zubsolv  Razadyne 0.7mg/0.18mg solution 200mL (2 bottles) per 30 days 30 sublingual tablets per 30 days 1.4/0.36mg tablets 60 tablets per 30 days 2.9/0.71mg  Razadyne ER 30 capsules per 30 days 5.7/1.4mg  Requip XL 30 tablets per 30 days 11.4/2.9mg 60 sublingual tablets per 30 days 60 single use vials per 30 days  Restasis SDV 8.6/2.1mg 1 multidose vial per 30 days  Restasis MDV  Retrovir NOTE: The FDA recommends a maximum of 5 days of therapy syrup 1920mL (8 bottles) per 30 days with this drug capsules 180 capsules per 30 days tablets 60 tablets per 30 days  Toujeo 13.5mL (9 pens) per 28 days  Revlimid 30 capsules per 30 days  Tradjenta 30 tablets per 30 days 30 tablets per 30 days  Rexulti  Travatan 2.5mL per 30 days  Reyataz  Travatan Z 2.5mL per 30 days 60 capsules per 30 days 150mg, 200mg  Triumeq 30 tablets per 30 days 300mg 30 capsules per 30 days  Trizivir 60 tablets per 30 days 50mg 150 packets per 30 days  Trokendi XR Risperdal/Risperdal M-tab 60 tablets per 30 days  25mg, 50mg, 100mg 30 capsules per 30 days 240mL per 30 days  Risperdal solution 200mg 60 capsules per 30 days 90 tablets per 30 days  Ritalin  Trulicity 2mL (4 pens) per 28 days  Ritalin LA

37010 MedPerform Low Formulary – July 2017 17 MedPerform LOW Formulary

 Truvada 30 tablets per 30 days 50mg 8 tablets per fill  Tybost 30 tablets per 30 days 100mg 4 tablets per fill  Uloric 30 tablets per 30 days  Aplenzin 30 tablets per 30 days  Vancocin 40 capsules per 30 days  Aptiom  Vascepa 200, 400 30 tablets per 30 days 0.5g 240 capsules per 30 days 600mg, 800mg 60 tablets per 30 days 1g 120 capsules per 30 days  Arcapta 30 capsules per 30 days  Viagra 6 tablets per 30 days  Arnuity Ellipta 30 blister packs per 30 days  Vibramycin 100mg 60 capsules per 30 days  Atelvia 4 tablets per 28 days  Vibra-Tabs 60 tablets per 30 days  Auryxia 12 tablets per day  Victoza 9mL (3 pens) per 30 days  Avidoxy 60 tablets per 30 days  Videx Solution 600mL (six 2g bottles or three 4g bottles) per 30 days  Axert 12 tablets per 30 days  Videx EC 125 mg, 200 mg 60 capsules per 30 days  Banzel 250 mg, 400 mg 30 capsules per 30 days 200mg 480 tablets per 30days  Viramune 400mg 240 tablets per 30 days solution 1200mL (5 bottles) per 30 days solution 2400mL per 30 days tablets 60 tablets per 30 days  Viramune XR  Benoxyldoxy 1 kit per 30 days 100mg 90 tablets per 30 days  Brisdelle 30 capsules per 30 days 400mg 30 tablets per 30 days  Briviact  Viread tablet 60 tablets per 30 days powder 240g powder per 30 days oral solution 600ml per 30 days tablets 30 tablets per 30 days  Brovana 120mL per 30 days  Vistogard  Bunavail granules 24 packets per 14 days 2.1/0.3mg 30 films per 30 days  Vivelle-Dot 8 patches per 28 days 4.2/0.7mg, 6.3/1mg 60 films 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 2.5mg, 5mg reditab 30 tablets per 30 days 20mg, 30mg 60 tablets per 30 days 5mg 30 tablets per 30 days  Zerit syrup 300mL per 30 days oral solution 2400mL (12 bottles) per 30 days  Clarinex D 12 hour 60 tablets per 30 days capsules 60 tablets per 30 days  Clarinex D 24 hour 30 tablets per 30 days  Zetia 30 tablets per 30 days  Climara Pro 4 patches per 28 days  Ziagen  Clozapine ODT 90 tablets per 30 days solution 960mL (4 bottles) per 30 days  Conzip 30 capsules per 30 days tablets 60 tablets per 30 days  Cosopt PF 60 droperettes per 30 days  Zofran solution 50mL per 15 days  Daytrana 30 patches per 30 days  Zomig/Zomig ZMT  Demerol tablet 12 tablets per 30 days solution 900mL per 30 days nasal spray 12 units per 30 days tablets 180 tablets per 30 days  Zurampic 30 tablets per 30 days  Depo-Provera 1mL per 84 days  Zyprexa 30 tablets per 30 days  Depo-subQ Provera 104 0.65mL per 84 days  Zyprexa Zydis 30 tablets per 30 days  Desoxyn 150 tablets per 30 days  Desvenlafaxine ER 30 tablets per 30 days 4. QUANTITY RESTRICTIONS (NON FORMULARY) (Fumarate)  Aciphex  Dexilant 30 capsules per 30 days 30 capsules per 30 days sprinkle  D.H.E. 45 30 ampules per 28 days delayed-release tablets 30 tablets per 30 days  Diclegis 120 tablets per 30 days  Acticlate 75mg, 150mg 60 tablets per 30 days  Doryx

 Actonel 50mg 60 tablets per 30 days 30 tablets per 30 days 5mg, 30mg 200mg 30 tablets per 30 days 35mg 4 tablets per 28 days  Doryx MPC 120mg 60 tablets per 30 days 150mg 1 tablet per 28 days  Dutoprol  Aerospan 17.8g (2 inhalers) per 30 days 25-12.5mg, 50-12.5mg 30 tablets per 30 days

 Afrezza 100-12.5mg 60 tablets per 30 days 4 unit 180 cartridges (2 kits) per 28 days  Dyanavel XR 240mL per 30 days 30-4 unit + 60-8 unit 360 cartridges (4 kits) per 28 days  Dymista 23g (1 bottle) per 30 days 60-4 unit + 30-8 unit 360 cartridges (4 kits) per 28 days 1 dose per 5 days 60-8 unit + 30-12 unit 360 cartridges (4 kits) per 28 days  Edex Titration pack 180 cartridges (1 kit) per 28 days  Embeda

 Allegra suspension 300mL per 30 days 20-0.8mg, 30-1.2mg, 50-2mg, 60-2.4mg,  Alsuma 4 units per 28 days 80-3.2mg 2 capsules per day  Amitiza 60 capsules per 30 days 100-4mg 4 capsules per day  Anoro Ellipta 60 blister packs per 30 days  Emsam 30 patches per 30 days  Anzemet  Epaned 1200mL per 30 days

37010 MedPerform Low Formulary – July 2017 18 MedPerform LOW Formulary

 Ergomar SL 40 tablets per 28 days Suspension  Esomeprazole Strontium  Opana ER 24.65mg 30 capsules per 30 days 5mg, 7.5mg, 10mg, 49.3mg 120 capsules per 30 days 15mg, 20mg 60 tablets per 30 days  Estring 1 ring per 90 days 30mg, 40mg 120 tablets per 30 days  Fanapt 60 tablets per 30 days  Oracea 30 capsules per 30 days  Fanapt Titration Pack 8 tablets (1 pack) per 28 days  Osphena 30 tablets per 30 days  Fazaclo 90 tablets per 30 days  Oxtellar XR  Felbatol 150mg, 300mg 30 tablets per 30 days 400mg 270 tablets per 30 days 600mg 120 tablets per 30 days 600mg 180 tablets per 30 days  Oxycodone HCl/acetaminophen 600mg/5ml solution 900mL per 30 days (maximum of 4g acetaminophen per day)  Firmagon 80mg/vial 1 vial per 30 days  Patanase 30.5g (1 bottle) per 30 days  Firmagon 120mg/vial 2 vials per 365 days  Pataday 2.5ml (1 bottle) per 30 days  Foradil 60 capsules per 30 days  Pradaxa 60 capsules per 30 days  Frova 18 tablets per 30 days  Procentra 1800mL per 30 days  Fulyzaq 60 tablets per 30 days  Qbrelis 1200ml (8 bottles) per 30 days  Qudexy XR  Fycompa 25mg, 50mg, 100mg 30 capsules per 30 days 2mg 120 tablets per 30 days 150mg, 200mg 60 capsules per 30 days 4mg, 6mg 60 tablets per 30 days  Rasuvo 8mg, 10mg, 12mg 30 tablets per 30 days 7.5mg/0.15mL 1.6mL (4 syringes) per 28 days 0.5mg/mL suspension 680mL (2 bottles) per 28 daysy 10mg/0.2mL 0.8mL (4 syringes) per 28 days  Gabitril 12.5mg/0.25mL 1mL (4 syringes) per 28 days 2mg, 4mg, 12mg 120 tablets per 30 days 15mg/0.3mL 1.2mL (4 syringes) per 28 days 16mg 90 tablets per 30 days 17.5mg/0.35mL 1.4mL (4 syringes) per 28 days  Granisol solution 60mL per 30 days 22.5mg/0.46mL 1.8mL (4 syringes) per 28 days  Hemangeol 360mL (3 bottles) per 30 days 25mg/0.5mL 2mL (4 syringes) per 28 days  Hydrocodone bit/ 27.5mg/0.55mL 2.2mL (4 syringes) per 28 days acetaminophen (max 4gm per day) 30mg/0.6mL 2.4mL (4 syringes) per 28 days  Incruse Ellipta 30 blisters per 30 days Relenza 40 disk inhalers per 183 days  Intuniv 30 tablets per 30 days  Relpax 12 tablets per 30 days  Invega 1.5mg, 3mg, 9mg 30 tablets per 30 days  Rescula 10mL (2 bottles) per 30 days  Invega 6mg 60 tablets per 30 days  Rhinocort Aqua 17.2g (2 canisters) per 30 days  Iprivask 6 syringes per 30 days  Rubraca 120 tablets per 30 days  Kapvay 120 tablets per 30 days  Rytary 300 capsules per 30 days  Karbinal ER 960mL (2 bottles) per 30 days  Ryzodeg 70/30 30ml (10 pens) per 28 days  Kytril 8 tablets per 30 days  Sabril 180 tablets per 30 days  Lamictal ODT  Samsca 25mg, 50mg 180 tablets per 30 days 15mg tablets 30 tablets per 365 days 100mg 90 tablets per 30 days  30mg tablets 60 tablets per 365 days 200mg 60 tablets per 30 days Sancuso 4 patches per 28 days  Lamictal XR  Savaysa 30 tablets per 30 days 25mg, 50mg 180 tablets per 30 days  Seasonique 91 tablets per 84 days 100mg 90 tablets per 30 days  Seroquel XR 30 tablets per 30 days 200mg, 250mg, 300mg 60 tablets per 30 days   Lescol 60 tablets per 30 days Sitavig 4 tablets per 365 days  Liptruzet 30 tablets per 30 days  Solaraze 100g per fill  LoSeasonique 91 tablets per 84 days  Solodyn 30 tablets per 30 days  Luvox CR 60 capsules per 30 days  Sotylize  Luzu 60g (1 tube) per 28 days 250mL 2000mL (8 bottles) per 30 days  Magnacet 400mg 10 tablets per 1 day supply  480mL 3840mL (8 bottles) per 30 days  Menostar 4 patches per 30 days  Spritam  Migranal 8 vials per 28 days 250mg, 500mg,750mg 120 tablets per 30 days  Mirapex ER 30 tablets per 30 days 1000mg 60 tablets per 30 days  Mitigare 60 capsules per 30 days Sprix 5 bottles per 30 days  Mondoxyne NL  Sumavel DosePro 4 units per 28 days 50mg, 75mg, 100mg 60 capsules per 30 days  Targadox 120 tablets per 30 days  Monodox  Tasmar 90 tablets per 30 days 50mg, 75mg, 100mg 60 capsules per 30 days  Timoptic Ocudose 60 droperettes per 30 days  Muse 1 dose per 5 days  Trezix 10 capsules per day  Myalept 11.3mg vial 30 vials per 30 days  Trulance 30 tablets per 30 days  Nicotrol cartridge 1008 cartridges (6 inhalers) per 90  Tuzistra XR 600mL per 30 days days  Varubi 2 tablets per 14 days  Nicotrol NS 160mL (4 Packs) per 90 days  Veltassa 1 packet per day  Nuvigil  Vemlidy 30 tablets per 30 days 50mg 90 tablets per 30 days  Versacloz 540mL per 30 day 150mg, 200mg, 250mg 30 tablets per 30 days  Vytorin 30 tablets per 30 days  Obredon 600mL per 10 days  Xartemis XR 360 tablets per 30 days  Oleptro ER  Xerese 10gm (2 tubes) per 365 days 150mg 45 tablets per 30 days  Xifaxan 200mg 9 tablets per fill 300mg 30 tablets per 30 days  Xodol 5-300mg 13 tablets per 1 day supply  Onfi  Xolox 500mg 8 tablets per 1 day supply Tablets 60 tablets per 30 days  Xyzal solution 300mL per 30 days 480mL per 30 days

37010 MedPerform Low Formulary – July 2017 19 MedPerform LOW Formulary

 Zamicet Soln 325mg/15ml 184mL per 1 day supply  Zarah Trial of two different non-  Zegerid 30 packets per 30 days drospirenone oral contraceptives Packets 30 capsules per 30 days (containing levonorgestrel,  Capsules norethindrone, norgestimate, Zelapar 60 tablets per 30 days norgestrel, desogestrel, or  Zohydro ER 60 capsules per 30 days ethinynodiol ace.) within the past  Zontivity 30 tablets per 30 days 365 days.  Zyclara  Zenzedi (2.5mg, 7.5mg) Trial of a multisource 2.5% 7.5 grams (1 bottle) per 28 days dextroamphetamine sulfate tablet 3.75% pump 7.5 grams (1 bottle) per 28 days or dextroamphetamine solution  3.75% packet 28 packets per 28 days within the past 120 days  Zocor (80mg only) Trial of simvastatin 80mg or Vytorin  Zyclara 10/80mg within the past 365 days 2.5% 7.5 grams (1 bottle) per 28 days 3.75% pump 7.5 grams (1 bottle) per 28 days  Zocor (80mg only) Trial of simvastatin 80mg or Vytorin 3.75% packet 28 packets per 28 days 10/80mg within the past 365 days

5. STEP THERAPY EDITS (FORMULARY) Daliresp6. STEP THERAPY EDITSTrial (NON of Spiriva,FORMULARY) Serevent,Breo Ellipta, Advair, or Dulera within the past 120 days  Gianvi Trial of two different non-  Aerospan Trial of at least two of the following: drospirenone oral contraceptives QVAR, Asmanex or Pulmicort (containing levonorgestrel, within the past 365 days norethindrone, norgestimate,  Amitiza Trial of Linzess or Movantik within norgestrel, desogestrel, or the past 120 days. ethinynodiol ace.) within the past  Anoro Ellipta Trial of Stiolto Respimat and one of 365 days. the following: Spiriva, Striverdi or  Loryna Trial of two different non- Serevent within the past 365 days drospirenone oral contraceptives  Arcapta Trial of Serevent Diskus or Striverdi (containing levonorgestrel, Respimat within the past 120 days norethindrone, norgestimate,  Arnuity Ellipta Trial of at least two of the following: norgestrel, desogestrel, or QVAR, Asmanex or Pulmicort ethinynodiol ace.) within the past within the past 365 days 365 days.  Avandia/ Trial of metformin (IR/ER), a  Methadone HCl injection Trial of lower strength oral Avandaryl/ sulfonylurea, pioglitazone, or a solution methadone tablets or solution  Avandamet combination product containing any within the past 120 days. two of the three agents above within the past 120 days.  Niaspan Trial of generic/multisource statin (atorvastatin, lovastatin,  Beyaz Trial of 2 generic/multisource oral pravastatin, or simvastatin), or contraceptives within the past 365 generic/multisource gemfibrozil or days fenofibrate within the past 365 days Bravelle Trial of Gonal-F or Gonal-F-RFF required within the past 120 days  Ocella Trial of two different non- drospirenone oral contraceptives  Follistim AQ Trial of Gonal-F or Gonal-F-RFF (containing levonorgestrel,  required within the past 120 days norethindrone, norgestimate, Foradil Trial of Serevent Diskus or Striverdi norgestrel, desogestrel, or Respimat within the past 120 days ethinynodiol ace.) within the past  Giazo Trial of balsalazide or Apriso within 365 days. the past 120 days  Syeda Trial of two different non-  Incruse Ellipta Trial of preferred LAMA (Spiriva) drospirenone oral contraceptives within the past 120 days (containing levonorgestrel,  Neo-Synalar Trial of fluocinolone and bacitracin norethindrone, norgestimate, within the past 365 days norgestrel, desogestrel, or  Novantrone Trial of an antineoplastic agent ethinynodiol ace.) within the past within the past 120 days. If step not 365 days. met, follow prior authorization  Vestura Trial of two different non- guideline. drospirenone oral contraceptives  Pradaxa Trial of Eliquis and Xarelto within (containing levonorgestrel, the past 365 days norethindrone, norgestimate,  Rasuvo Trial of Otrexup and methotrexate norgestrel, desogestrel, or tablet or solution for injection within ethinynodiol ace.) within the past the past 365 days. 365 days.  Ryzodeg 70/30 Trial of preferred long acting insulin  Yasmin 28 Trial of two different non- and preferred pre-mixed insulin) drospirenone oral contraceptives within the past 365 days (containing levonorgestrel,  Safyral Trial of two different non- norethindrone, norgestimate, drospirenone oral contraceptives norgestrel, desogestrel, or (containing levonorgestrel, ethinynodiol ace.) within the past norethindrone, norgestimate, 365 days. norgestrel, desogestrel, or  Yaz Trial of two different non- ethinynodiol ace.) within the past drospirenone oral contraceptives 365 days. (containing levonorgestrel,  Savaysa Trial Eliquis and Xarelto within the norethindrone, norgestimate, past 365 days norgestrel, desogestrel, or  Sitavig Trial of oral acyclovir, valacyclovir ethinynodiol ace.) within the past or famciclovir within the past 120 365 days. days

37010 MedPerform Low Formulary – July 2017 20 MedPerform LOW Formulary

 Trulance Trial of Linzess within the past 120  Oralair days.  Orfadin  Uceris tablet Trial of balsalazide within the past  Orkambi 120 days  Otezla  Vytorin (10/80mg only) Trial of simvastatin 80mg or Vytorin  Pegasys 10/80mg within the past 365 days  Pegasys Proclick  Xerese Trial of oral acyclovir, valacyclovir  Plegridy or famciclovir within the past 120  Plegridy Pen days  Pomalyst  Xerese Trial of oral acyclovir, valacyclovir or famciclovir within the past 120  Praluent days  Procrit  Procysbi  Promacta  Pulmozyme  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  Xuriden  Juxtapid  Zelboraf  Kalydeco  Zydelig  Keveyis  Zykadia  Kisqali  Zytiga  Korlym  Zyvox  Kynamro

 Lenvima

 Letairis  Leukine  Lonsurf

 Lynparza 8. PRIOR AUTHORIZATION RESTRICTIONS (NON-FORMULARY)  Mekinist  Abraxane*  Neulasta  Actemra SC  Neupogen  Actemra IV*  Nexavar  Adcetris*  Ninlaro  Addyi  Norditropin  Afrezza  Odomzo  Alimta*  Ofev  Ampyra  Omnitrope  Amturnide  Opsumit  Anadrol-50

37010 MedPerform Low Formulary – July 2017 21 MedPerform LOW Formulary

 Androderm  Jublia  Apokyn  Kadcyla*  Aranesp  Kalbitor*  Arzerra*  Kanuma*  Austedo  Keytruda*  Avastin*  Kineret  Bavencio*  Kitabis Pak  Beleodaq*  Kyprolis*  Belviq  Lartruvo*  Belviq XR  Lemtrada*  Berinert  Lucentis*  Bethkis  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  Nuedexta  Cyramza*  Nuplazid  Darzalex*  Nymalize  Duopa  Ocaliva  Dysport*  Octagam*  Egrifta  Ocrevus*  Elelyso*  Olysio  Elspar*  Oncaspar*  Emflaza  Onivyde*  Empliciti*  Opdivo*  Entyvio*  Orencia IV*  Epogen  Orencia SC  Erbitux*  Orenitram ER  Erwinaze*  Orthovisc*  Euflexxa*  Oxandrin  Evekeo  Pegintron  Exalgo  Pegintron Redipen  Exondys 51*  Perjeta*  Eylea*  Photofrin*  Faslodex*  Portrazza*  Flebogamma DIF*  Privigen*  Flolan*  Prolia*  Gamastan S-D*  Qutenza  Gammagard Liquid  Ravicti  Gammagard S-D*  Relistor  Gammaked  Remicade*  Gammaplex*  Remodulin  Gamunex-C  Revatio Vial*  Gazyva*  Revatio suspension  Gel-One*  Rituxan*  Gleostine  Rubraca  Granix*  Saxenda  Halaven*  Serostim  Herceptin*  Signifor  Hetlioz  Siliq  Hizentra  Simponi SC  H.P. Acthar*  Simponi Aria IV*  Hyalgan*  Sirturo  Hymovis*  Solaraze  Hyqvia IG component  Soliris*  Ilaris*  Spinraza*  Imlygic*  Stelara IV*  Incivek  Striant  Increlex  Sucraid  Inflectra*  Supartz*  Ingrezza  Suprenza ODT  Iprivask  Sylvant*  Istodax*  Synagis*  Ixempra*  Synribo*

37010 MedPerform Low Formulary – July 2017 22 MedPerform LOW Formulary

 Synvisc*  Yondelis*  Synvisc-One*  Zaltrap*  Tecentriq*  Zarxio  Technivie  Zavesca  Tekamlo  Zepatier  Tekturna  Zinbryta  Tekturna HCT  Zoladex*  Temodar vial*  Zorbtive  Testred  Zyclara  Tev-Tropin  Translarna *=Dependent on plan benefit. If covered under pharmacy benefit then  Thyrogen* nonformulary with prior authorization.  Torisel*  Tymlos 9. CONCURRENT USE EDITS (FORMULARY)  Tysabri*  Suboxone  Tyvaso  Subutex  Unituxin*  Zubsolv  Valturna  Vecamyl 10. CONCURRENT USE EDITS (NON-FORMULARY)  Vectibix*  Bunavail  Velcade*

 Veletri*  Veltassa  Ventavis  Viberzi  Vimizim  Vogelxo  Vpriv*  Xeomin*  Xgeva*  Xolair*  Xyrem  Yervoy*

37010 MedPerform Low Formulary – July 2017 23 MedPerform Low Formulary INDEX

5-grass pollen extract...... 1 aminophylline ...... 1 AXIRON ...... 8 8-MOP ...... 5 amiodarone hcl ...... 2 axitinib ...... 11 abacavir sulfate ...... 9 amitriptyline hcl ...... 1 AYGESTIN...... 8 abacavir sulfate/lamivudine ...... 9 amlodipine bes/olmesartan med ...... 3 azathioprine ...... 8 abacavir/dolutegravir/lamivudine ...... 9 amlodipine besylate ...... 3 azelastine hcl ...... 1, 7 abacavir/lamivudine/zidovudine ...... 9 amlodipine besylate/benazepril ...... 2 AZILECT ...... 13 ABBOTT DIABETIC SUPPLIES ...... 6 amlodipine/atorvast cal ...... 4 azilsartan med/chlorthalidone ...... 3 ABILIFY DISCMELT ...... 2 amlodipine/valsartan ...... 3 azilsartanl ...... 3 ABILIFY SOLUTION ...... 2 amlodipine/valsartan/hctz ...... 3 azithromycin ...... 8 ABILIFY TABLET ...... 2 AMNESTEEM ...... 4 AZOPT ...... 7 abiraterone acetate ...... 11 amox tr/potassium clavulanate ...... 8 AZOR ...... 3 acarbose ...... 5 amoxapine ...... 2 aztreonam lysine ...... 8 ACCUPRIL ...... 3 amoxicillin trihydrate ...... 8 AZULFIDINE ...... 10 ACCURETIC ...... 2 AMOXIL ...... 8 bacitracin ...... 7 acebutolol hcl ...... 3 amphet asp/amphet/d-amphet ...... 2 bacitracin/polymyxin b sulfate ...... 7 acetaminophen with codeine ...... 12 ampicillin trihydrate ...... 8 baclofen ...... 13 acetazolamide ...... 7 amylase/lipase/protease ...... 13 BACTRIM DS ...... 8 acetic acid ...... 6 ANAFRANIL...... 2 BACTROBAN ...... 4 acetic acid/aluminum acetate ...... 6 anagrelide hcl ...... 8 BACTROBAN NASAL ...... 12 acetic acid/hydrocortisone ...... 6 ANALPRAM HC ...... 10 balsalazide disodium ...... 10 acetylcysteine ...... 12 ANAPROX ...... 10 BARACLUDE ...... 10 acitretin ...... 5 ANAPROX DS ...... 10 becaplermin ...... 6 ACLOVATE ...... 5 ANASPAZ ...... 13 beclomethasone dipropionate ...... 1 ACTIGALL ...... 10 anastrozole ...... 11 belladonna alkaloids/phenobarb ...... 13 ACTIQ ...... 12 ANDROGEL...... 8 BELSOMRA ...... 2 ACTOPLUS MET ...... 6 ANDROID ...... 8 benazepril hcl ...... 3 ACTOPLUS MET XR ...... 6 ANDROXY ...... 8 benazepril/hydrochlorothiazide ...... 2 ACTOS ...... 6 ANSAID ...... 10 BENEMID ...... 7 ACULAR ...... 7 ANTABUSE ...... 2 BENICAR ...... 3 ACULAR LS ...... 7 anthralin ...... 5 BENICAR HCT ...... 3 acyclovir ...... 5, 9 Antipsychotics, Atypical, D3/D2 Partial BENTYL ...... 13 ADALAT CC ...... 3 Agonist/5HT Mixed ...... 2 BENZAMYCIN ...... 4 adalimumab ...... 10 antipyrine/benzocaine otic ...... 6 BENZAMYCIN PAK ...... 4 adapalene ...... 4 ANTIVERT ...... 1 BENZOTIC...... 6 ADCIRCA ...... 3 ANUSOL-HC ...... 10 benzoyl peroxide...... 4 ADDERALL ...... 2 APEXICON ...... 5 benzoyl peroxide/hydrocortison ...... 4 ADDERALL XR ...... 2 APEXICON E ...... 5 benztropine mesylate ...... 12 adefovir dipivoxil ...... 10 apixaban ...... 7 besifloxacin hcl drops susp 0.6% ...... 7 ADEMPAS ...... 3 aprepitant ...... 1 BESIVANCE ...... 7 ADVAIR DISKUS ...... 1 APRESOLINE ...... 3 BETAGAN ...... 7 ADVAIR HFA ...... 1 APRISO ...... 10 Betalactams ...... 8 afatinib ...... 11 APTIVUS ...... 9 betamet diprop/prop gly ...... 5 AFINITOR ...... 11 ARALEN PHOSPHATE ...... 9 betamethasone dipropionate ...... 5 AFINITOR DISPERZ ...... 11 ARAVA ...... 10 betamethasone valerate ...... 5 AFTERA ...... 4 ARICEPT ...... 1 BETAPACE ...... 3 AGRYLIN ...... 8 ARICEPT ODT ...... 1 BETAPACE AF ...... 3 AK-TRACIN ...... 7 ARIMIDEX ...... 11 betaxolol hcl ...... 7 AKYNZEO ...... 1 aripiprazole...... 2 bethanechol chloride ...... 11 ALAMAST ...... 7 ARIXTRA ...... 8 BETIMOL ...... 7 ALA-TET ...... 9 ARMOUR THYROID ...... 7 BETOPTIC ...... 7 ALAWAY OTC ...... 7 AROMASIN...... 11 BETOPTIC S ...... 7 albuterol sulfate ...... 1 ARTANE ...... 12 bexarotene ...... 5, 11 ALBUTEROL SULFATE ...... 1 ASENDIN ...... 2 BIAXIN ...... 8 alclometasone dipropionate ...... 5 asfotase alfa ...... 12 BIAXIN XL ...... 8 ALDACTONE ...... 3 ASMANEX ...... 1 bicalutamide ...... 11 ALDARA ...... 8 ASMANEX HFA ...... 1 BIDIL ...... 4 ALDOMET ...... 3 ASTELIN ...... 1 BILTRICIDE ...... 9 ALECENSA ...... 11 ASTEPRO ...... 1 bimatoprost ...... 7 alectinib hydrochloride ...... 11 ATARAX ...... 1 bisoprolol fumarate ...... 3 alendronate sodium ...... 6 atazanavir sulfate ...... 9 bisoprolol fumarate/hctz ...... 3 alendronate sodium solution ...... 6 atazanavir sulfate/cobicistat ...... 9 BLEPHAMIDE ...... 7 alendronate sodium/vitamin d3 ...... 6 atenolol ...... 3 BLEPHAMIDE S.O.P...... 7 alfuzosin ...... 13 atenolol/chlorthalidone ...... 3 BLOCADREN ...... 3 alirocumab ...... 3 ATIVAN ...... 2 blood sugar diagnostic ...... 6 ALKERAN ...... 11 atomoxetine hcl ...... 2 blood-glucose calib. control ...... 6 allopurinol ...... 7 atorvastatin calcium ...... 3 blood-glucose meter ...... 6 ALOCRIL ...... 7 ATRIPLA ...... 9 BONIVA ...... 6 ALOMIDE ...... 7 atropine sulfate ...... 7 bosentan ...... 3 ALORA ...... 8 ATROVENT ...... 1, 12 BOSULIF ...... 11 ALPHAGAN P ...... 7 ATROVENT HFA ...... 1 bosutinib ...... 11 alprazolam ...... 2 AUBAGIO ...... 11 BREO ELLIPTA ...... 1 ALPRAZOLAM INTENSOL ...... 2 AUGMENTIN ...... 8 BRETHINE...... 1 ALREX ...... 7 AUGMENTIN ES-600 ...... 8 BREVOXYL-4 ...... 4 ALTACE ...... 3 AUGMENTIN XR ...... 8 BREVOXYL-8 ...... 4 altretamine ...... 11 AVALIDE ...... 3 BRILINTA ...... 8 aluminum chloride ...... 5 AVAPRO ...... 3 brimonidine tartrate ...... 7 ALUPENT ...... 1 AVC ...... 13 brimonidine/timolol ...... 7 amantadine hcl ...... 12 AVELOX ...... 9 brinzolamide ...... 7 AMARYL ...... 5 AVELOX ABC PACK ...... 9 brinzolamide/brimonidine ...... 7 AMBIEN ...... 2 AVIANE-28 ...... 4 bromocriptine mesylate...... 12 AMBIEN CR ...... 2 AVINZA ...... 12 budesonide ...... 1, 10 ambrisentan ...... 3 AVLOSULFON ...... 9 BUDESONIDE ...... 10 amcinonide ...... 5 AVONEX ...... 11 bumetanide ...... 3 AMERGE ...... 12 AVONEX ADMINISTRATION PACK ...... 11 BUMEX ...... 3 AMINOPHYLLIN ...... 1 AXID ...... 13 BUPHENYL POWDER ...... 10

37010 MedPerform Low Formulary – July 2017 24 MedPerform Low Formulary INDEX

BUPHENYL TABLET ...... 10 CICLODAN ...... 5 COZAAR ...... 3 buprenorphine ...... 12 ciclopirox 8% solution ...... 5 CREON ...... 13 bupropion hcl ...... 1 ciclopirox olamine ...... 5 CREON 36K ...... 13 BUSPAR ...... 2 cilostazol ...... 8 CRESTOR ...... 3 buspirone hcl ...... 2 CILOXAN ...... 7 CRINONE ...... 6 busulfan ...... 11 cimetidine hcl ...... 13 crisaborole ...... 5 butalb/acetaminophen/caffeine ...... 12 CIPRO ...... 8 CRIXIVAN ...... 9 butalbital/acetaminophen ...... 12 CIPRO ORAL SUSPENSION ...... 8 crizotinib ...... 11 butalbital/aspirin/caffeine ...... 12 CIPRODEX ...... 6 cromolyn sodium ...... 1, 7 butoconazole nitrate ...... 13 ciprofloxacin ...... 8 crotamiton ...... 5 BUTRANS ...... 12 ciprofloxacin hcl ...... 7, 8 CUPRIMINE ...... 10 BYSTOLIC ...... 3 ciprofloxacin hcl/dexameth ...... 6 CUTIVATE ...... 5 BYVALSON ...... 3 citalopram hydrobromide ...... 1 cyanocobalamin/fa/pyridoxine ...... 14 cabergoline ...... 7 CLARAVIS ...... 4 CYCLESSA ...... 4 CABOMETYX ...... 11 clarithromycin ...... 8 cyclobenzaprine hcl ...... 13 cabozanitinib ...... 11 CLARITIN (OTC) ...... 1 CYCLOCORT ...... 5 cabozantinib s-malate ...... 11 CLARITIN-D 12 HOUR ...... 1 CYCLOGYL ...... 7 CADUET ...... 4 CLARITIN-D 24 HOUR ...... 1 cyclopentolate hcl ...... 7 CAFERGOT ...... 12 CLEOCIN ...... 8 cyclophosphamide ...... 11 CALAN ...... 3 CLEOCIN PALMITATE ...... 8 cyclosporine ...... 7, 8 CALAN SR ...... 3 CLEOCIN T...... 4 cyclosporine, modified ...... 8 calcipotriene...... 5 CLIMARA ...... 8 CYSTARAN ...... 7 calcitriol ...... 14 clindamycin hcl ...... 8 cysteamine...... 7 calcium acetate ...... 6 clindamycin palmitate solution ...... 8 cysteamine bitartrate ...... 13 canagliflozin ...... 6 clindamycin phosphate ...... 4 CYTOMEL ...... 7 canagliflozin/metformin hcl ...... 6 clindamycin/tretinoin ...... 4 CYTOTEC...... 13 CANASA ...... 10 CLINORIL ...... 10 CYTOVENE ...... 9 capecitabine ...... 11 clobetasol propionate ...... 5 CYTOXAN ...... 11 CAPITAL W-CODEINE ...... 12 clobetasol propionate/emoll ...... 5 dabrafanib ...... 11 CAPOTEN ...... 3 CLOBEX ...... 5 DALIRESP ...... 1 CAPOZIDE ...... 2 CLOMID ...... 6 DALMANE ...... 2 captopril ...... 3 clomiphene citrate ...... 6 dalteparin sodium,porcine ...... 8 captopril/hydrochlorothiazide ...... 2 clomipramine hcl ...... 2 danazol ...... 7 CARAFATE ...... 13 clonazepam ...... 13 DANOCRINE ...... 7 carbachol ...... 7 clonidine hcl ...... 3 DANTRIUM ...... 13 carbamazepine ...... 13 clopidogrel bisulfate ...... 8 dantrolene sodium ...... 13 CARBATROL ...... 13 clorazepate dipotassium ...... 2 dapsone ...... 9 carbidopa ...... 13 clotrimazole ...... 9 DARAPRIM ...... 9 carbidopa/levodopa ...... 12 clotrimazole/betamet diprop ...... 5 darunavir ethanolate ...... 9 carbidopa/levodopa/entacapone ...... 12 clozapine ...... 2 darunavir/cobicistat ...... 9 CARDIZEM ...... 3 CLOZARIL ...... 2 dasatinib ...... 11 CARDIZEM CD ...... 3 cobicistat ...... 10 DAYPRO ...... 10 CARDURA ...... 2 cobimetinib fumarate ...... 11 DDAVP ...... 6 carisoprodol ...... 13 codeine phos/carisoprodol/asa ...... 12 DECADRON ...... 10 carisoprodol/aspirin ...... 13 codeine/butalbit/acetamin/caff ...... 12 DELATESTRYL ...... 8 CARMOL HC ...... 5 codeine/butalbital/asa/caffein ...... 12 delavirdine mesylate ...... 9 carteolol hcl...... 7 codeine/promethazine hcl ...... 4 DEL-BETA ...... 5 carvedilol ...... 3 COGENTIN ...... 12 DELTASONE ...... 10 carvedilol phosphate ...... 3 COLAZAL ...... 10 DEMADEX ...... 3 CASODEX ...... 11 colesevelam hcl ...... 3 DEMULEN 1-50-21 ...... 4 CATAPRES ...... 3 COLESTID ...... 3 DEPAKENE CAPSULES ...... 13 CAYSTON ...... 8 COLESTID GRANULES ...... 3 DEPAKENE SYRUP ...... 13 CECLOR ...... 8 colestipol ...... 3 DEPAKOTE ...... 13 CEENU ...... 11 COLYTE WITH FLAVOR PACKETS ...... 10 DEPAKOTE ER ...... 13 cefaclor ...... 8 COMBIGAN ...... 7 DEPAKOTE SPRINKLE ...... 13 cefadroxil hydrate ...... 8 COMBIPATCH ...... 8 DEPEN ...... 10 cefdinir ...... 8 COMBIVENT ...... 1 DEPO-TESTOSTERONE ...... 8 cefixime ...... 8 COMBIVENT RESPIMAT ...... 1 DESCOVY ...... 9 cefpodoxime proxetil ...... 8 COMBIVIR ...... 9 desipramine hcl ...... 2 cefprozil ...... 8 COMETRIQ ...... 11 desmopressin ...... 6 CEFTIN ...... 8 COMPAZINE ...... 1 DESOGEN ...... 4 cefuroxime axetil ...... 8 COMPAZINE SYRUP ...... 1 desogestrel-ethinyl estradiol ...... 4 CEFZIL ...... 8 COMPLERA...... 10 desog-et estra/ethin estra ...... 4 CELEBREX ...... 10 COMTAN ...... 12 desonide ...... 5 celecoxib ...... 10 CONCERTA...... 2 DESOWEN ...... 5 CELEXA ...... 1 CONDYLOX...... 4 desoximetasone ...... 5 CELLCEPT ...... 8 COPAXONE ...... 11 desvenlafaxine ER (Ranbaxy Brand) ...... 1 CENTANY ...... 4 COPEGUS ...... 10 DESVENLAFAXINE ER (RANBAXY BRAND) .... 1 cephalexin monohydrate ...... 8 CORDARONE ...... 2 desvenlafaxine succinate ...... 1 ceritinib ...... 11 CORDRAN ...... 5 DESYREL ...... 1 cetirizine hcl (OTC) ...... 1 CORDRAN SP ...... 5 DETROL ...... 13 cetrorelix acetate ...... 6 COREG ...... 3 DETROL LA ...... 13 CETROTIDE ...... 6 COREG CR ...... 3 dexamethasone ...... 10 cevimeline hcl ...... 11 CORGARD ...... 3 DEXEDRINE ...... 2 chloral hydrate ...... 2 CORLANOR ...... 4 DEXEDRINE SPANSULE ...... 2 chlorambucil ...... 11 CORTEF ...... 10 dexmethylphenidate hcl ...... 2 chlordiazepoxide hcl ...... 2 CORTENEMA ...... 10 dextroamphetamine sulfate ...... 2 chlordiazepoxide/clidinium br ...... 13 cortisone acetate ...... 10 dextroamphetamine tablet...... 2 chlorhexidine gluconate ...... 12 CORTISPORIN CREAM ...... 5 DIABETA ...... 5 chloroquine phosphate ...... 9 CORTISPORIN OINTMENT ...... 5 DIABINESE ...... 5 chlorpromazine hcl ...... 2 CORTISPORIN OPHTH SUSPENSION ...... 7 DIAMOX SEQUELS ...... 7 chlorpropamide ...... 5 CORTISPORIN OTIC ...... 6 DIASTAT ...... 13 chlorthalidone ...... 3 CORTONE ACETATE ...... 10 diazepam ...... 2, 13 chlorzoxazone ...... 13 COSENTYX ...... 5 DIBENZYLINE ...... 2 cholestyramine/aspartame ...... 3 COSOPT ...... 7 dichlorphenamide ...... 13 CHRONULAC ...... 10 COTELLIC ...... 11 diclofenac sodium ...... 5, 7, 10 CIBALITH-S ...... 2 COUMADIN ...... 7 dicloxacillin sodium ...... 8

37010 MedPerform Low Formulary – July 2017 25 MedPerform Low Formulary INDEX dicyclomine hcl ...... 13 elvitegravir/ cobicistat/emtricitabine/tenofovir EVISTA ...... 6 didanosine ...... 9 disoproxil fumarate ...... 9 EVOCLIN ...... 4 DIDRONEL ...... 6 EMCYT ...... 11 evolocumab ...... 3 DIFFERIN ...... 4 EMEND ...... 1 EVOTAZ ...... 9 DIFICID ...... 8 EMGEL ...... 4 EVOXAC ...... 11 diflorasone diacetate ...... 5 empagliflozin ...... 6 EXELDERM ...... 5 diflorasone diacetate/emoll ...... 5 empagliflozin/linagliptin ...... 6 EXELON CAPSULE ...... 1 DIFLUCAN ...... 9 empagliflozin/metformin hcl ...... 6 EXELON PATCH ...... 1 diflunisal ...... 12 empagliflozin/metformin XR ...... 6 exemestane ...... 11 difluprednate ...... 7 emtricitab/rilpiviri/tenof ala...... 10 EXFORGE ...... 3 digoxin ...... 2 emtricitab/rilpivirine/tenofovir ...... 10 EXFORGE HCT ...... 3 DIGOXIN ORAL SOLN ...... 2 emtricitabine ...... 9 ezetimibe ...... 4 DILACOR XR ...... 3 emtricitabine/tenofov alafenam ...... 9 FABIOR ...... 4 DILANTIN ...... 13 emtricitabine/tenofovir ...... 9 famotidine...... 13 DILANTIN CHEW TAB ...... 13 EMTRIVA ...... 9 FARESTON ...... 11 DILANTIN-125 ...... 13 EMVERM ...... 9 FARYDAK ...... 11 DILAUDID ...... 12 enalapril maleate ...... 3 febuxostat ...... 7 DILAUDID-5 ...... 12 enalapril/hydrochlorothiazide ...... 2 FELDENE ...... 10 diltiazem hcl ...... 3 ENBREL ...... 10 felodipine ...... 3 dimethyl fumarate ...... 11 ENDOMETRIN ...... 6 FEMARA ...... 11 DIOVAN ...... 3 enfuvirtide ...... 9 FEMHRT ...... 8 DIOVAN HCT ...... 3 enoxaparin sodium ...... 7 fenofibrate ...... 4 diphenoxylate hcl/atrop sulf ...... 10 entacapone ...... 12 fenofibrate nanocrystallized ...... 4 dipivefrin hcl ...... 7 entecavir ...... 10 fenofibrate, micronized...... 4 DIPROLENE ...... 5 ENTOCORT EC ...... 10 FENOGLIDE ...... 4 DIPROLENE AF ...... 5 ENTRESTO ...... 4 fenoprofen calcium ...... 10 DIPROSONE ...... 5 enzalutamide ...... 11 fentanyl ...... 12 dipyridamole ...... 8 EPCLUSA ...... 10 fentanyl citrate lozenge ...... 12 DISALCID ...... 12 EPIDUO ...... 4 fesoterodine fumarate ...... 13 disopyramide phosphate ...... 2 EPIDUO FORTE ...... 4 FETZIMA ...... 1 disulfiram ...... 2 epinephrine ...... 10, 11 fidaxomicin ...... 8 DITROPAN XL ...... 13 EPIPEN ...... 10 filgrastim ...... 8 divalproex sodium ...... 13 EPIPEN JR ...... 11 finasteride...... 13 d-methorphan hb/prometh hcl ...... 4 EPIVIR ...... 9 fingolimod hcl ...... 11 dofetilide ...... 2 EPIVIR HBV SOLUTION ...... 10 FIORICET ...... 12 DOLOBID ...... 12 EPIVIR HBV TABLET ...... 10 FIORICET WITH CODEINE ...... 12 DOLOPHINE HCL ...... 12 eplerenone...... 3 FIORINAL ...... 12 dolutegravir ...... 9 epoetin alfa ...... 7 FIORINAL WITH CODEINE ...... 12 DOMEBORO ...... 6 EPZICOM ...... 9 FIRAZYR ...... 10 donepezil hcl ...... 1 ergocalciferol ...... 14 FIRST-HYDROCORTISONE ...... 5 DONNATAL ...... 13 ergotamine tartrate/caffeine ...... 12 FLAGYL ...... 9 dornase alfa ...... 12 erlotinib hcl ...... 11 FLAGYL ER ...... 9 dorzolamide hcl ...... 7 ery e-succ/sulfisoxazole ...... 8 FLAREX ...... 7 dorzolamide hcl/timolol maleat ...... 7 ERYC ...... 8 flecainide acetate ...... 2 DOSTINEX ...... 7 ERYGEL ...... 4 FLEXERIL ...... 13 DOVONEX ...... 5 ERYPED 200 ...... 8 FLOMAX ...... 13 doxazosin mesylate ...... 2 ERYPED 400 ...... 8 FLONASE ...... 1 doxepin hcl ...... 2 ERY-TAB ...... 8 FLORINEF ACETATE ...... 10 doxycycline calcium ...... 9 ERYTHROCIN STEARATE ...... 8 FLOXIN ...... 6, 9 doxycycline hyclate ...... 9 erythromycin base ...... 7, 8 fluconazole ...... 9 DOXYCYCLINE HYCLATE 100MG TABLET ...... 9 erythromycin base/benz per ...... 4 fludarabine phosphate ...... 11 DOXYCYCLINE MONOHYDRATE 150MG erythromycin base/ethanol ...... 4 fludrocortisone acetate ...... 10 TABLET ...... 9 erythromycin ethylsuccinate ...... 8 flunisolide ...... 1 DRISDOL ...... 14 erythromycin stearate ...... 8 fluocinolone acetonide ...... 5 DRITHOCREME HP ...... 5 ESBRIET ...... 12 fluocinonide ...... 5 DRITHO-SCALP ...... 5 escitalopram oxalate ...... 1 fluocinonide/emollient ...... 5 dronabinol ...... 1 ESGIC ...... 12 FLUORABON BASIC ...... 14 dronedarone hcl ...... 2 ESKALITH ...... 2 fluoride ion/iron/vit a,c&d ...... 14 DRYSOL ...... 5 esomeprazole magnesium ...... 13 fluoride ion/multivitamins ...... 14 DUAVEE ...... 8 estazolam ...... 2 fluoride ion/multivits w-fe ...... 14 DUETACT ...... 6 ESTRACE ...... 8, 13 fluoride ion/vit a,c&d ...... 14 DULERA ...... 1 ESTRADERM ...... 8 FLUORITAB ...... 13 DUONEB ...... 1 estradiol ...... 8, 13 fluorometholone...... 7 DURAGESIC ...... 12 estradiol/noreth ac ...... 8 fluorometholone acetate ...... 7 DUREZOL ...... 7 sodium ...... 11 fluorouracil ...... 5 DURICEF ...... 8 ESTRATEST H.S...... 8 fluoxetine er ...... 1 dutasetride/tamsulosin ...... 13 estrogen, con/m-progest acet ...... 8 fluoxetine hcl ...... 1 DYAZIDE ...... 3 estrogen, ester/me-testosterone...... 8 fluoxymesterone ...... 8 DYNACIN ...... 9 estrogens, conj/bazedoxifene ...... 8 fluphenazine hcl ...... 2 EC-NAPROSYN ...... 10 estrogens, conjugated ...... 8, 13 FLURA-DROPS ...... 13 EDARBI ...... 3 estrogens, esterified...... 8 flurandrenolide ...... 5 EDARBYCLOR ...... 3 estropipate ...... 8 FLURA-TABS ...... 13 EDURANT ...... 9 eszopiclone ...... 2 flurazepam hcl ...... 2 efavirenz ...... 9 etanercept ...... 10 flurbiprofen ...... 10 efavirenz/emtricitab/tenofovir ...... 9 ethambutol hcl ...... 9 flurbiprofen sodium ...... 7 EFFIENT ...... 8 ethinyl estradiol/drospirenone ...... 4 flutamide ...... 11 EFUDEX ...... 5 ethosuximide ...... 13 fluticasone propionate ...... 1, 5 ELAVIL ...... 1 ethynodiol d-ethinyl estradiol ...... 4 fluticasone/salmeterol ...... 1 ELDEPRYL ...... 13 etidronate disodium ...... 6 fluticasone/vilanterol ...... 1 ELIDEL ...... 5 etodolac ...... 10 FML ...... 7 ELIGARD ...... 6 etonogestrel/ethinyl estradiol ...... 4 FML FORTE ...... 7 ELIMITE ...... 5 etoposide ...... 11 FML S.O.P...... 7 ELIQUIS ...... 7 etravirine ...... 9 FOCALIN ...... 2 ELMIRON ...... 13 EUCRISA ...... 5 FOCALIN XR ...... 2 ELOCON ...... 5 EULEXIN ...... 11 FOLGARD RX ...... 14 eltrombopag olamine ...... 8 EURAX ...... 5 folic acid ...... 13 elviteg/cobi/emtric/tenofo ala ...... 9 everolimus ...... 8, 11 FOLIC ACID ...... 13

37010 MedPerform Low Formulary – July 2017 26 MedPerform Low Formulary INDEX folic acid/mu-vits-min th ...... 14 HYCODAN ...... 4 ISOPTO CARPINE ...... 7 follitropin alpha,recomb ...... 6 hydralazine hcl ...... 3 ISOPTO HOMATROPINE ...... 7 fondaparinux sodium ...... 8 HYDREA ...... 11 ISORDIL ...... 4 formoterol fumarate ...... 1 hydrochlorothiazide ...... 3 ISORDIL TITRADOSE ...... 4 FORTEO ...... 6 hydrocodone bit/acetaminophen ...... 12 isosorb dinit/hydralazine hcl ...... 4 FOSAMAX ...... 6 hydrocodone bit/acetaminophen oral elixir .. 12 isosorbide dinitrate ...... 4 FOSAMAX PLUS D ...... 6 hydrocodone bit/acetaminophen oral solution ... 12 isosorbide mononitrate ...... 4 FOSAMAX TABLET ...... 6 hydrocodone bit/homatrop me-br ...... 4 isotretinoin ...... 4 fosamprenavir calcium ...... 9 hydrocodone bitartrate ...... 12 ISRADIPINE ...... 3 fosinopril sodium ...... 3 hydrocodone/chlorphen p-stirex ...... 4 isradipine IR ...... 3 fosinopril/hydrochlorothiazide ...... 2 hydrocort/sal acid/sulf/shmp#1 ...... 5 itraconazole ...... 9 FRAGMIN ...... 8 hydrocortisone ...... 5, 10 ivabradine hcl ...... 4 FURADANTIN ...... 8 hydrocortisone acetate ...... 10 ivacaftor ...... 12 furazolidone ...... 8 hydrocortisone acetate/urea ...... 5 ixazomib citrate ...... 11 furosemide ...... 3 hydrocortisone butyrate ...... 5 JALYN ...... 13 FUROXONE ...... 8 hydrocortisone butyrate/emoll ...... 5 JANUMET XR ...... 5 FUZEON ...... 9 hydrocortisone probutate ...... 5 JANUVIA ...... 5 gabapentin ...... 13 hydrocortisone valerate ...... 5 JARDIANCE ...... 6 galantamine ...... 1 hydromorphone hcl ...... 12 JUXTAPID ...... 3 ganciclovir ...... 7, 9 hydroxychloroquine sulfate ...... 9 KALETRA ...... 9 ganirelix acetate ...... 6 hydroxyurea ...... 11 KALYDECO ...... 12 GANIRELIX ACETATE ...... 6 hydroxyzine hcl ...... 1 KAYEXALATE ...... 6 GANTRISIN ...... 8 hydroxyzine pamoate ...... 1 K-DUR ...... 6 GARAMYCIN ...... 4, 7 HYGROTON ...... 3 KEFLEX ...... 8 gatifloxacin ...... 7 hyoscyamine sulfate ...... 13 KENALOG ...... 5 GATTEX ...... 10 HYPER-SAL 7% ...... 12 KENALOG IN ORABASE ...... 12 gefitinib ...... 11 HYSINGLA ER ...... 12 KEPPRA ...... 13 gemfibrozil ...... 4 HYTRIN ...... 3 KETEK ...... 8 gentamicin sulfate ...... 4, 7 HYZAAR ...... 3 ketoconazole ...... 5, 9 Genvoya ...... 9 ibandronate ...... 6 ketoprofen ...... 10 GEODON ...... 2 IBRANCE ...... 11 ketorolac tromethamine ...... 7, 10 GIANVI ...... 4 ibrutinib ...... 11 ketotifen fumarate (OTC) ...... 7 GILENYA ...... 11 ibuprofen ...... 10 KEVEYIS ...... 13 GILOTRIF ...... 11 icatibant acetate ...... 10 KISQALI ...... 11 glatiramer acetate ...... 11 ICLUSIG ...... 11 KLARON ...... 4 glimepiride ...... 5 icosapent ethyl ...... 4 KLONOPIN ...... 13 glipizide ...... 5 idelalisib ...... 11 KORLYM ...... 6 glipizide/metformin hcl ...... 5 ILEVRO ...... 7 KRISTALOSE ...... 10 GLUCAGON EMERGENCY KIT ...... 6 IMBRUVICA ...... 11 K-TAB ...... 6 glucagon,human recombinant ...... 6 IMDUR ...... 4 KURIC ...... 5 GLUCOPHAGE ...... 6 imipramine hcl ...... 2 KUVAN ...... 11 GLUCOPHAGE XR ...... 6 imiquimod ...... 8 KWELL ...... 5 GLUCOTROL ...... 5 IMITREX INJECTION ...... 12 KYNAMRO...... 3 GLUCOTROL XL ...... 5 IMITREX NASAL SPRAY ...... 12 labetalol hcl ...... 3 GLUCOVANCE ...... 6 IMITREX TABLET ...... 12 LACTICARE-HC ...... 5 glyburide ...... 5 IMPAVIDO ...... 9 lactulose ...... 10 glyburide, micro/metformin hcl ...... 6 IMURAN ...... 8 LAMICTAL ...... 13 GLYXAMBI ...... 6 indapamide ...... 3 LAMISIL ...... 5, 9 GOLYTELY ...... 10 INDERAL LA ...... 3 LAMISIL GRANULES ...... 9 gonadotropin,chorionic, human ...... 6 INDERIDE-40/25 ...... 3 lamivudine ...... 9, 10 GONAL-F ...... 6 indinavir sulfate ...... 9 lamivudine/zidovudine ...... 9 GONAL-F RFF ...... 6 INDOCIN ...... 10 lamotrigine ...... 13 GRASTEK ...... 1 INDOCIN ORAL SUSP...... 10 lancing device/lancets ...... 6 griseofulvin suspension ...... 9 INDOCIN SR ...... 10 LANOXIN ...... 2 griseofulvin ultramicrosize ...... 9 INDOCIN SUPPOS ...... 10 lansoprazole ...... 13 GRISEOFULVIN V ...... 9 indomethacin ...... 10 lansoprazole/amox tr/clarith ...... 13 GRIS-PEG ...... 9 ingenol ...... 5 LANTUS ...... 6 guanfacine hcl ...... 3 INLYTA ...... 11 lapatinib ditosylate ...... 11 GYNAZOLE-1 ...... 13 INSPRA ...... 3 LARIAM ...... 9 HALCION ...... 2 insulin glargine,hum.rec.anlog ...... 6 LASIX ...... 3 HALDOL ...... 2 insulin lispro ...... 6 latanoprost ...... 7 HALDOL ORAL CONC ...... 2 insulin nph hum/reg insulin hm ...... 6 LATUDA ...... 2 halobetasol propionate ...... 5 insulin nph human isophane ...... 6 ledipasvir/sofosbuvir ...... 10 haloperidol ...... 2 insulin npl/insulin lispro ...... 6 leflunomide ...... 10 haloperidol lactate ...... 2 insulin regular, human ...... 6 lenalidomide ...... 11 HARVONI ...... 10 INTAL ...... 1 lenvatinib mesylate ...... 11 hc acetate/pramoxine ...... 5 INTELENCE...... 9 LENVIMA ...... 11 hc acetate/pramoxine hcl ...... 10 interferon alfa-2b, recomb...... 8 LESSINA ...... 4 hcg alpha, recombinant ...... 6 interferon beta-1a ...... 11 LETAIRIS ...... 3 HEPARIN LOCK ...... 8 interferon beta-1a/albumin ...... 11 letrozole ...... 11 heparin sodium, porcine ...... 8 INTRON A ...... 8 leucovorin calcium ...... 11 heparin sodium, porcine/pf ...... 8 INVIRASE ...... 9 LEUCOVORIN CALCIUM ...... 11 HEP-LOCK ...... 8 INVOKAMET ...... 6 LEUKERAN ...... 11 HEPSERA ...... 10 INVOKANA ...... 6 LEUKINE ...... 8 HEXALEN ...... 11 iodoquinol ...... 9 leuprolide ...... 6 homatropine hbr ...... 7 ipratropium bromide ...... 1, 12 LEVAQUIN...... 9 HUMALOG ...... 6 ipratropium/albuterol sulfate ...... 1 LEVBID ...... 13 HUMALOG MIX 50-50 ...... 6 irbesartan ...... 3 levetiracetam ...... 13 HUMALOG MIX 75-25 ...... 6 irbesartan/hydrochlorithiazide ...... 3 levobunolol hcl ...... 7 HUMATIN ...... 9 IRESSA ...... 11 levocetirizine ...... 1 HUMIRA ...... 10 ISENTRESS ...... 9 levofloxacin ...... 9 HUMULIN 70-30 ...... 6 ISMO ...... 4 levonorgestrel ...... 4 HUMULIN N ...... 6 ISOCHRON ...... 4 levonorgestrel-eth estra ...... 4 HUMULIN R ...... 6 isomethept/acetaminop/dichlphn ...... 12 LEVOTHROID ...... 7 HUMULIN R U-500 KWIK PEN ...... 6 isoniazid ...... 9 levothyroxine sodium ...... 7 HYCAMTIN ...... 11 ISOPTO ATROPINE ...... 7 LEVOXYL ...... 7 HYCET ...... 12 ISOPTO CARBACHOL ...... 7 LEVSIN-SL ...... 13

37010 MedPerform Low Formulary – July 2017 27 MedPerform Low Formulary INDEX

LEXAPRO ...... 1 MAXITROL ...... 7 mirabegron...... 13 LEXIVA ...... 9 MAXZIDE ...... 3 MIRALAX ...... 10 LIBRAX ...... 13 MAXZIDE-25MG ...... 3 MIRAPEX ...... 12 LIBRIUM ...... 2 mebendazole ...... 9 MIRCETTE ...... 4 LIDEX ...... 5 mechlorethamine gel ...... 5 mirtazapine ...... 1 LIDEX-E ...... 5 meclizine hcl ...... 1 misoprostol ...... 13 lidocaine hcl ...... 10 meclofenamate sodium ...... 10 mitotane ...... 11 linaclotide ...... 10 MECLOMEN ...... 10 MOBIC ...... 10 linagliptin ...... 5 MEDROL ...... 10 modafinil ...... 2 Lincosamides ...... 8 medroxyprogesterone acet ...... 8 moexipril hcl ...... 3 lindane ...... 5 mefloquine hcl ...... 9 moexipril/hydrochlorothiazide ...... 2 linezolid ...... 8 MEGACE ...... 11, 12 mometasone furoate ...... 1, 5 LINZESS ...... 10 megestrol acetate ...... 11, 12 mometasone/formoterol ...... 1 LIORESAL ...... 13 MEKINIST ...... 11 MONISTAT 3 ...... 13 liothyronine sodium ...... 7 MELLARIL ...... 2 MONOKET...... 4 LIPITOR ...... 3 meloxicam ...... 10 MONOPRIL ...... 3 liraglutide ...... 5 melphalan ...... 11 MONOPRIL HCT ...... 2 lisdexamfetamine dimesylate ...... 2 memantine hcl ...... 1 montelukast sodium ...... 1 lisinopril ...... 3 memantine hcl ER ...... 1 MORGIDOX ...... 9 lisinopril/hydrochlorothiazide ...... 2 memantine hcl/donepezil hcl ...... 1 MORGIDOX 100MG CAPSULE ...... 9 lithium carbonate ...... 2 MENEST ...... 8 MORGIDOX 50MG CAPSULE ...... 9 lithium citrate ...... 2 MENOPUR ...... 6 morphine sulfate ...... 12 LITHOBID ...... 2 menotropins ...... 6 MOTRIN ...... 10 LIVALO ...... 3 MEPHYTON ...... 8 MOVANTIK ...... 10 LO LOESTRIN FE ...... 4 meprobamate ...... 2 moxifloxacin hcl ...... 7, 9 LO MINASTRIN FE ...... 4 mercaptopurine ...... 11 MS CONTIN ...... 12 LOCOID ...... 5 mesalamine ...... 10 MSIR ...... 12 LOCOID LIPOCREAM ...... 5 mesalamine w/cleansing wipes ...... 10 mth/me blue/salicy/na phos/hyo ...... 8 LODINE ...... 10 MESTINON ...... 1 MUCOMYST-10 ...... 12 LODOSYN ...... 13 METADATE CD ...... 2 MULTAQ ...... 2 lodoxamide tromethamine ...... 7 METADATE ER ...... 2 mupirocin ...... 4 LOESTRIN ...... 4 METAGLIP ...... 5 mupirocin calcium ...... 4, 12 LOESTRIN 24FE ...... 4 metaproterenol sulfate ...... 1 MYAMBUTOL ...... 9 LOESTRIN FE ...... 4 metaxalone ...... 13 MYCELEX ...... 9 LOFIBRA ...... 4 metformin hcl ...... 6 MYCIFRADIN ...... 9 lomitapide ...... 3 meth/meth blue/ba/salicy/hyos ...... 8 MYCOLOG II ...... 5 LOMOTIL ...... 10 methadone hcl ...... 12 mycophenolate mofetil ...... 8 lomustine ...... 11 Methadone hcl ...... 12 MYCOSTATIN ...... 5, 9 LONSURF ...... 11 methadone hcl injection solution ...... 12 MYLERAN ...... 11 LO-OVRAL-28 ...... 4 methazolamide ...... 7 MYORISAN ...... 4 LOPID ...... 4 METHERGINE ...... 4 MYRBETRIQ ...... 13 lopinavir/ritonavir ...... 9 methimazole ...... 7 MYSOLINE ...... 13 LOPRESSOR ...... 3 METHITEST ...... 8 na sulfacetm/prednis sp ...... 7 LOPRESSOR HCT ...... 3 methocarbamol ...... 13 na sulfacetm/prednisol ac ...... 7 LOPROX ...... 5 methotrexate ...... 10 nabumetone ...... 10 loratadine (OTC ...... 1 methotrexate sodium ...... 10, 11 nadolol ...... 3 lorazepam ...... 2 METHOTREXATE TABLET ...... 11 naftifine hcl ...... 5 LORAZEPAM INTENSOL ...... 2 METHOTREXATE VIAL ...... 11 NAFTIN ...... 5 LORCET ...... 12 methoxsalen ...... 5 NALFON CAPSULES ...... 10 LORCET PLUS ...... 12 methoxsalen, rapid ...... 5 NALFON TABLETS ...... 10 LORTAB ...... 12 methyldopa...... 3 naloxegol oxalate ...... 10 LORTAB ELIXIR ...... 12 methylergonovine maleate ...... 4 naltrexone hcl ...... 2 LORYNA ...... 4 METHYLIN CHEW TAB ...... 2 NAMENDA ...... 1 losartan potassium ...... 3 METHYLIN SOLN ...... 2 NAMENDA XR ...... 1 losartan/hydrochlorothiazide ...... 3 methylphenidate ER suspension ...... 2 NAMZARIC ...... 1 LOTEMAX ...... 7 methylphenidate hcl ...... 2 NAPROSYN ...... 10 LOTENSIN ...... 3 methylprednisolone ...... 10 naproxen ...... 10 LOTENSIN HCT ...... 2 methyltestosterone ...... 8 naproxen sodium ...... 10 loteprednol etabonate ...... 7 metipranolol ...... 7 naratriptan ...... 12 LOTREL ...... 2 metolazone ...... 3 NARCAN ...... 2 LOTRISONE ...... 5 metoprolol succinate ...... 3 Narcotic Withdrawal Therapy Agents ...... 12 lovastatin ...... 3 metoprolol tartrate ...... 3 NARDIL ...... 1 LOVAZA ...... 4 metoprolol/hctz ...... 3 NASACORT AQ ...... 1 LOVENOX ...... 7 METROCREAM ...... 4 NASAREL ...... 1 loxapine succinate ...... 2 METROGEL-VAGINAL ...... 13 NASONEX ...... 1 LOXITANE ...... 2 METROLOTION ...... 4 nateglinide ...... 5 LOZOL ...... 3 metronidazole ...... 4, 9, 13 NATURE-THROID ...... 7 LUDIOMIL ...... 2 MEVACOR ...... 3 NAVANE ...... 2 lumacaftor/ivacaftor ...... 12 mexiletine hcl ...... 2 nebivolol hcl ...... 3 LUMIGAN ...... 7 MEXITIL ...... 2 NEBUPENT ...... 9 LUNESTA ...... 2 miconazole nitrate ...... 13 nedocromil sodium ...... 7 LURIDE ...... 13 MICRO-K ...... 6 needles, insulin disp., safety ...... 12 LUTERA ...... 4 MICRONASE ...... 5 nelfinavir mesylate ...... 9 LYNPARZA ...... 11 MICROZIDE...... 3 neo/polymyx b sulf/dexameth ...... 7 LYRICA ...... 13 midodrine hcl ...... 4 neomy sulf/bacitrac zn/poly/hc ...... 7 LYSODREN ...... 11 MIDRIN ...... 12 neomy sulf/polymyx b sulf/hc ...... 5, 6, 7 macitentan ...... 3 mifepristone ...... 6 neomycin sulfate...... 9 MACROBID ...... 8 MIGERGOT ...... 12 neomycin/bacitra/polymyxin/hc ...... 5 MACRODANTIN ...... 8 MILLIPRED ...... 10 neomycin/bacitracin/polymyxin ...... 7 malathion ...... 5 MILLIPRED DP ...... 10 neomycin/polymyxn b/gramicidin ...... 7 maprotiline hcl ...... 2 milnacipran hcl ...... 11 NEO-POLYCIN HC OPHTH OINTMENT ...... 7 maraviroc ...... 9 miltefoside ...... 9 NEORAL ...... 8 MARINOL ...... 1 MILTOWN ...... 2 NEOSPORIN OPHTH DROPS ...... 7 MATULANE ...... 11 MINIPRESS ...... 2 NEOSPORIN OPHTH OINTMENT ...... 7 MAVIK ...... 3 MINOCIN ...... 9 neostigmine bromide ...... 1 MAXALT ...... 12 minocycline hcl ...... 9 nepafenac ...... 7 MAXALT MLT ...... 12 mipomersen sodium ...... 3 NEPTAZANE ...... 7

37010 MedPerform Low Formulary – July 2017 28 MedPerform Low Formulary INDEX netupitant/palonosetron hcl ...... 1 olmesartan/hydrochlorothiazide ...... 3 PEPCID ...... 13 NEULASTA ...... 8 olodaterol hcl ...... 1 p-ephed hcl/cetirizine hcl (OTC) ...... 1 NEUPOGEN ...... 8 olopatadine hcl ...... 7 p-ephed sul/loratadine ...... 1 NEUPRO ...... 13 OLUX ...... 5 PERCOCET ...... 12 NEURONTIN ...... 13 omega-3 acid ethyl esters ...... 4 PERCODAN ...... 12 NEVANAC ...... 7 omeprazole ...... 13 PERCOLONE ...... 12 nevirapine ...... 9 omeprazole magnesium ...... 13 PERFOROMIST ...... 1 nevirapine ER ...... 9 OMNICEF ...... 8 PERIDEX ...... 12 NEXAVAR ...... 11 OMNIPRED ...... 7 PERISOL ...... 12 NEXIUM ...... 13 OMNITROPE ...... 6 permethrin ...... 5 niacin ...... 4 ondansetron ...... 1 perphenazine ...... 2 NIASPAN ...... 4 ondansetron hcl ...... 1 PERSANTINE ...... 8 NICARDIPINE ...... 3 ondansetron hcl solution ...... 1 phenazopyridine hcl ...... 13 nicardipine hcl ...... 3 ONEXTON ...... 4 phenelzine sulfate ...... 1 nifedipine ...... 3 OPSUMIT ...... 3 PHENERGAN ...... 1 NILANDRON...... 11 OPTICROM ...... 7 PHENERGAN VC ...... 4 nilotinib hydrochloride ...... 11 OPTIPRANOLOL ...... 7 PHENERGAN VC W/CODEINE ...... 4 nilutamide ...... 11 OPTIVAR ...... 7 PHENERGAN W/CODEINE ...... 4 nimodipine ...... 3 ORALAIR ...... 1 PHENERGAN W/DEXTROMETHORPHAN ...... 4 NIMOTOP ...... 3 ORAMORPH SR ...... 12 phenobarbital ...... 2 NINLARO ...... 11 ORAPRED ...... 10 PHENOBARBITAL ...... 2 nintedanib esylate ...... 12 ORFADIN ...... 12 phenoxybenzamine hcl ...... 2 NITRO-BID ...... 4 ORINASE ...... 5 phenylephrine hcl/cod/prometh ...... 4 NITRO-DUR ...... 4 ORKAMBI ...... 12 phenylephrine hcl/prometh hcl ...... 4 nitrofurantoin ...... 8 orphenadrine citrate ...... 13 PHENYTEK ...... 13 nitrofurantoin macrocrystal ...... 8 orphenadrine/aspirin/caffeine ...... 13 phenytoin...... 13 nitrofurantoin/nitrofuran mac ...... 8 ORSYTHIA ...... 4 phenytoin sodium extended ...... 13 nitroglycerin ...... 4 ORTHO EVRA ...... 4 PHOSLO ...... 6 NITROLINGUAL ...... 4 ORTHO MICRONOR ...... 4 PHRENILIN ...... 12 NITROSTAT ...... 4 ORTHO TRI-CYCLEN ...... 4 PHRENILIN FORTE ...... 12 nizatidine ...... 13 ORTHO TRI-CYCLEN LO ...... 4 phytonadione ...... 8 NIZORAL ...... 5, 9 ORTHO-CEPT ...... 4 PICATO ...... 5 NOCTEC ...... 2 ORTHO-CYCLEN ...... 4 pilocarpine hcl ...... 7, 11 NOLVADEX ...... 11 ORTHO-NOVUM ...... 4 pindolol ...... 3 NORCO ...... 12 ORUVAIL ...... 10 pioglitazone hcl ...... 6 NORDETTE-28 ...... 4 oseltamivir phosphate ...... 9 pioglitazone hcl/metformin hcl ...... 6 NORDITROPIN ...... 6 osimertinib mesylate ...... 11 pioglitazone/glimepiride ...... 6 NORDITROPIN FLEXPRO ...... 6 OTEZLA ...... 5 pirfenidone ...... 12 NORDITROPIN NORDIFLEX ...... 6 OTICIN HC ...... 6 piroxicam ...... 10 norelgestromin/ethin.estradiol ...... 4 OTREXUP ...... 10 PLAN B ONE-STEP ...... 4 noreth a-et estra/fe fumarate ...... 4 OVACE PLUS SUSPENSION ...... 5 PLAQUENIL ...... 9 norethindrone ...... 4 OVIDE ...... 5 PLAVIX ...... 8 norethindrone acetate ...... 8 OVIDREL ...... 6 PLAVIX 300MG ...... 8 norethindrone ac-eth estradiol ...... 8 oxaprozin ...... 10 PLEGRIDY...... 11 norethindrone a-e estradiol ...... 4 oxazepam ...... 2 PLEGRIDY PEN ...... 11 norethindrone-ethinyl estrad ...... 4 oxcarbazepine ...... 13 PLENDIL ...... 3 norethindrone-mestranol ...... 4 OXSORALEN ...... 5 PLETAL ...... 8 NORFLEX ...... 13 OXSORALEN-ULTRA ...... 5 podofilox ...... 4 NORGESIC FORTE...... 13 oxybutynin chloride ...... 13 POLYCILLIN ...... 8 norgestimate-ethinyl estradiol ...... 4 oxycodone hcl ...... 12 POLYCIN-B ...... 7 norgestrel-ethinyl estradiol ...... 4 oxycodone hcl/acetaminophen ...... 12 polyethylene glycol 3350 ...... 10 NORINYL 1+35 ...... 4 oxycodone hcl/aspirin ...... 12 polymyxin b sulfate/tmp ...... 7 NORINYL 1+50 ...... 4 OXYCONTIN ...... 12 POLYTRIM ...... 7 NORPACE ...... 2 palbociclib ...... 11 POLY-VI-FLOR ...... 14 NORPACE CR ...... 2 PAMELOR ...... 2 POLY-VI-FLOR W/IRON ...... 14 NORPRAMIN ...... 2 PANCRELIPASE ...... 13 pomalidamide ...... 11 NOR-Q-D ...... 4 PANDEL ...... 5 POMALYST ...... 11 nortriptyline hcl ...... 2 panobinostat lactate ...... 11 ponatinib ...... 11 NORVASC ...... 3 pantoprazole sodium ...... 13 potassium chloride ...... 6 NORVIR ...... 9 PARAFON FORTE DSC ...... 13 potassium iodide ...... 7 NOVAREL ...... 6 PARCOPA ...... 12 POTASSIUM IODIDE ...... 7 NOVOFINE 32 PEN NEEDLE ...... 12 paricalcitol ...... 6 POTIGA ...... 13 NUCYNTA ...... 12 PARLODEL...... 12 PRALUENT ...... 3 NUCYNTA ER ...... 12 PARNATE ...... 1 pramipexole di-hcl ...... 12 NULYTELY WITH FLAVOR PACKS ...... 10 paromomycin sulfate ...... 9 pramlintide acetate...... 5 NUVARING ...... 4 paroxetine hcl ...... 1 PRAMOSONE ...... 5 NYDRAZID ...... 9 PATADAY ...... 7 PRANDIMET ...... 6 nystatin ...... 5, 9 PATANOL ...... 7 PRANDIN ...... 5 nystatin/triamcin ...... 5 PATHOCIL ...... 8 prasugrel hcl ...... 8 OCELLA ...... 4 PAXIL ...... 1 PRAVACHOL ...... 3 OCL ...... 10 pazopanib hydrochloride ...... 11 pravastatin sodium ...... 3 octreotide acetate ...... 12 PCE ...... 8 praziquantel ...... 9 OCUFEN ...... 7 PEDIAPRED ...... 10 prazosin hcl ...... 2 OCUFLOX ...... 7 PEDIAZOLE...... 8 PRECOSE ...... 5 OCUPRESS ...... 7 peg 3350/na sulf,bicarb,cl/kcl ...... 10 PRED FORTE ...... 7 ODEFSEY ...... 10 PEGASYS ...... 10 PRED MILD ...... 7 ODOMZO ...... 11 PEGASYS PROCLICK ...... 10 PREDNISOL ...... 7 OFEV ...... 12 pegfilgrastim ...... 8 prednisolone ...... 10 ofloxacin ...... 6, 7, 9 peginterferon alfa-2a ...... 10 prednisolone acetate ...... 7 OFORTA ...... 11 peginterferon beta-1a ...... 11 prednisolone sod phosphate ...... 7, 10 OGEN ...... 8 pegvisomant ...... 6 prednisone ...... 10 olanzapine ...... 2 pemirolast potassium ...... 7 PREDNISONE INTENSOL ...... 10 olanzapine ODT ...... 2 penicillamine ...... 10 pregabalin ...... 13 olanzapine/fluoxetine ...... 1 penicillin v potassium ...... 8 PREGNYL ...... 6 olaparib ...... 11 pentamidine isethionate ...... 9 PREMARIN ...... 8, 13 olmesartan medoxomil ...... 3 pentosan polysulfate sodium ...... 13 PREMPHASE ...... 8 olmesartan/amlodipin/hcthiazid...... 3 pentoxifylline ...... 7 PREMPRO...... 8

37010 MedPerform Low Formulary – July 2017 29 MedPerform Low Formulary INDEX prenatal vit 15/iron cb/fa/dss ...... 14 ramipril ...... 3 SECTRAL ...... 3 prenatal vit 16/iron cb/fa/dss ...... 14 RANEXA ...... 4 secukinumab ...... 5 prenatal vit 18/iron cb/fa/dss ...... 14 ranitidine hcl ...... 13 selegiline hcl ...... 13 PRENAVITE ...... 14 ranolazine ...... 4 selenium sulfide ...... 5 PREVACID ...... 13 RAPAMUNE ...... 8 selexipag ...... 3 PREVPAC ...... 13 rasagiline mesylate ...... 13 SELSUN RX ...... 5 PREZCOBIX ...... 9 RAYALDEE...... 6 SELZENTRY ...... 9 PREZISTA ...... 9 RAZADYNE ...... 1 SEPTRA ...... 8 PRILOSEC ...... 13 RAZADYNE ER ...... 1 SEPTRA DS ...... 8 PRILOSEC OTC ...... 13 REBETOL ...... 10 SERAX ...... 2 PRIMAQUINE ...... 9 REBIF ...... 11 SEREVENT DISKUS ...... 1 primaquine phosphate ...... 9 REBIF REBIDOSE ...... 11 SEROPHENE ...... 6 primidone ...... 13 REDERM ...... 5 SEROQUEL ...... 2 PRIMSOL ...... 8 regorafenib ...... 11 SERPASIL ...... 3 PRINIVIL ...... 3 REGRANEX...... 6 sertraline hcl ...... 1 PRINZIDE ...... 2 RELAFEN ...... 10 sevelamer carbonate ...... 6 PRISTIQ ...... 1 REMERON ...... 1 sevelamer hcl ...... 6 PROAIR HFA ...... 1 RENAGEL ...... 6 SFROWASA ...... 10 PROAIR RESPICLICK ...... 1 RENVELA ...... 6 short ragweed pollen extract ...... 1 PROAMATINE ...... 4 repaglinide...... 5 sildenafil citrate ...... 3, 6 probenecid ...... 7 repaglinide/metformin hcl ...... 6 SILENOR ...... 2 procainamide hcl ...... 2 REPATHA ...... 3 SILVADENE ...... 5 procarbazine hcl ...... 11 REPRONEX...... 6 silver sulfadiazine ...... 5 PROCARDIA ...... 3 REQUIP ...... 13 SIMBRINZA ...... 7 PROCARDIA XL ...... 3 REQUIP XL...... 13 simvastatin ...... 3 PROCHIEVE...... 6 RESCRIPTOR ...... 9 simvastatin (80mg only) ...... 3 prochlorperazine edisylate ...... 1 reserpine ...... 3 SINEMET 25-100 ...... 12 prochlorperazine maleate ...... 1 RESTASIS ...... 7 SINEMET CR ...... 12 PROCRIT ...... 7 RESTASIS MULTIDOSE ...... 7 SINEQUAN ...... 2 PROCTOCORT ...... 10 RESTORIL ...... 2 SINGULAIR ...... 1 PROCTOCREAM-HC ...... 10 RETIN-A MICRO ...... 15 sirolimus ...... 8 PROCTOFOAM-HC ...... 10 RETROVIR ...... 9 sitagliptin phosphate ...... 5 PROCTO-KIT ...... 10 REVATIO TABLET...... 3 SIVEXTRO...... 8 PROCYSBI ...... 13 REVIA ...... 2 SKELAXIN ...... 13 PROFASI ...... 6 REVLIMID ...... 11 SLO-NIACIN ...... 4 progesterone, micronized ...... 6, 8 REXULTI ...... 2 sod chloride/nahco3/kcl/peg's ...... 10 PROGRAF ...... 8 REYATAZ ...... 9 sodium chloride for inhalation ...... 12 PROLIXIN ...... 2 RHEUMATREX ...... 10 sodium fluoride ...... 13 PROLOPRIM ...... 8 ribavirin ...... 9, 10 sodium phenylbutyrate ...... 10 PROMACTA ...... 8 RIFADIN ...... 9 sodium polystyrene sulfonate ...... 6 promethazine hcl ...... 1 RIFAMATE ...... 9 sofosbuvir/velpatasvir ...... 10 PROMETRIUM ...... 8 rifampin ...... 9 solifenacin succindate ...... 13 PRONESTYL ...... 2 rifampin/isoniazid ...... 9 SOMA ...... 13 propafenone hcl ...... 2 rifaximin ...... 9 SOMA COMPOUND ...... 13 PROPINE ...... 7 rilpivirine ...... 9 SOMA COMPOUND WITH CODEINE ...... 12 propranolol hcl ...... 3 riociguat ...... 3 somatropin ...... 6 propranolol/hydrochlorothiazid ...... 3 RIOMET ...... 6 SOMAVERT ...... 6 propylthiouracil ...... 7 RISPERDAL ...... 2 SONATA ...... 2 PROPYLTHIOURACIL ...... 7 RISPERDAL M-TAB ...... 2 sonidegib phosphate ...... 11 PROSCAR ...... 13 risperidone ...... 2 sorafenib tosylate ...... 11 PROSED-DS ...... 8 RITALIN ...... 2 SORIATANE ...... 5 PROSOM ...... 2 RITALIN LA...... 2 sotalol hcl ...... 3 PROSTIGMIN ...... 1 RITALIN-SR ...... 2 SOTRET ...... 4 PROTONIX ...... 13 ritonavir ...... 9 SPIRIVA ...... 1 PROTOPIC ...... 5 rivaroxaban ...... 7 SPIRIVA RESPIMAT ...... 1 PROVERA ...... 8 rivastigmine ...... 1 spironolactone ...... 3 PROVIGIL ...... 2 rivastigmine tartrate ...... 1 SPORANOX ...... 9 PROZAC ...... 1 rizatriptan benzoate ...... 12 SPRYCEL ...... 11 PROZAC WEEKLY ...... 1 ROBAXIN ...... 13 SRONYX ...... 4 PULMICORT FLEXHALER ...... 1 ROBAXIN-750 ...... 13 SSRI & 5HT1A Partial Agonist Antidepressants .. 1 PULMICORT RESPULES ...... 1 ROCALTROL ...... 14 SSRI, Serotonin Receptor Modulator PULMOZYME ...... 12 roflumilast ...... 1 Antidepressants ...... 1 PURINETHOL ...... 11 ROMYCIN ...... 7 STAGESIC-10 ...... 12 PURIXAN ...... 11 ropinirole hcl ...... 13 STALEVO ...... 12 pyrazinamide ...... 9 rosuvastatin calcium ...... 3 STARLIX ...... 5 PYRAZINAMIDE ...... 9 rotigotine ...... 13 stavudine ...... 9 PYRIDIUM ...... 13 ROWASA ...... 10 STELARA ...... 10 pyridostigmine bromide ...... 1 ROXANOL ...... 12 STELAZINE ...... 2 pyrimethamine ...... 9 ROXICET ...... 12 STIOLTO RESPIMAT ...... 1 QNASL ...... 1 ROXICODONE ...... 12 STIVARGA...... 11 QNASL CHILDREN ...... 1 ROXICODONE INTENSOL...... 12 STRATTERA ...... 2 QUALAQUIN...... 9 RYTHMOL ...... 2 STRENSIQ ...... 12 QUESTRAN LIGHT ...... 3 RYTHMOL SR ...... 2 STRIBILD ...... 9 quetiapine fumarate ...... 2 sacubitril/valsartan ...... 4 STRIVERDI RESPIMAT ...... 1 QUILLICHEW ER ...... 2 SALAGEN ...... 11 sucralfate ...... 13 QUILLIVANT XR ...... 2 salmeterol xinafoate ...... 1 sulconazole nitrate ...... 5 QUINAGLUTE ...... 2 salsalate ...... 12 SULFAC ...... 7 quinapril hcl ...... 3 SANDIMMUNE ...... 8 sulfacetamide sodium ...... 4, 5, 7 quinapril/hydrochlorothiazide ...... 2 SANDOSTATIN ...... 12 sulfadiazine ...... 8 QUINIDEX ...... 2 SAPHRIS ...... 2 SULFADIAZINE ...... 8 quinidine gluconate ...... 2 sapropterin dihydrochloride ...... 11 sulfamethoxazole/trimethoprim ...... 8 quinidine sulfate ...... 2 saquinavir mesylate ...... 9 sulfanilamide ...... 13 quinine sulfate ...... 9 sargramostim ...... 8 sulfasalazine ...... 10 QVAR ...... 1 SAVELLA ...... 11 sulfisoxazole acetyl ...... 8 RAGWITEK ...... 1 SCALACORT ...... 5 sulindac ...... 10 raloxifene hcl ...... 6 SCALACORT DK ...... 5 sumatriptan ...... 12 raltegravir potassium...... 9 SEASONALE ...... 4 sumatriptan succinate ...... 12

37010 MedPerform Low Formulary – July 2017 30 MedPerform Low Formulary INDEX sunitinib malate ...... 11 TIMOPTIC-XE ...... 7 ULTRASE MT ...... 13 SUPRAX ...... 8 timothy grass pollen extract ...... 1 ULTRAVATE ...... 5 SUSTIVA ...... 9 tiotropium br/olodaterol hcl ...... 1 UNIPHYL ...... 1 SUTENT ...... 11 tiotropium bromide ...... 1 UNIRETIC ...... 2 suvorexant ...... 2 tipranavir ...... 9 UNIVASC ...... 3 SYEDA ...... 4 tipranavir/vitamin e tpgs ...... 9 UPTRAVI ...... 3 SYMBICORT ...... 1 TIVICAY ...... 9 URECHOLINE ...... 11 SYMBYAX ...... 1 tizanidine hcl ...... 13 URETRON D-S ...... 8 SYMLIN ...... 5 TOBI ...... 9 uridine triacetate ...... 12 SYMLINPEN 120 ...... 5 TOBI PODHALER ...... 9 URIN D.S...... 8 SYMLINPEN 60 ...... 5 TOBRADEX ...... 7 UROXATRAL ...... 13 SYMMETREL ...... 12 tobramycin for inhalation ...... 9 URSO ...... 10 SYNALAR ...... 5 tobramycin sulfate ...... 7 URSO FORTE ...... 10 SYNJARDY ...... 6 tobramycin sulfate/dexameth ...... 7 ursodiol ...... 10 SYNJARDY XR ...... 6 tobramycin/lotepred etab ...... 7 ustekinumab ...... 10 SYNTHROID...... 7 TOBREX ...... 7 VAGIFEM ...... 13 syringes & needles ...... 6 tofacitinib ...... 11 valacyclovir hcl ...... 9 tacrolimus ...... 5 tofacitinib XR ...... 11 VALCHLOR ...... 5 tacrolimus anhydrous ...... 8 TOFRANIL ...... 2 VALISONE ...... 5 tadalafil ...... 3 tolazamide ...... 5 VALIUM ...... 2 TAFINLAR ...... 11 tolbutamide ...... 5 valproate sodium ...... 13 TAGAMET ...... 13 TOLECTIN 600 ...... 10 valproic acid ...... 13 TAGRISSO ...... 11 TOLINASE ...... 5 valsartan ...... 3 TAKE ACTION ...... 4 tolmetin sodium ...... 10 valsartan/hydrochlorothiazide ...... 3 TALADINE ...... 13 tolterodine tartrate ...... 13 VALTREX ...... 9 TAMBOCOR ...... 2 TOPAMAX ...... 13 VANCOCIN ...... 9 TAMIFLU ...... 9 TOPAMAX SPRINKLE ...... 13 vancomycin hcl ...... 9 tamoxifen citrate ...... 11 TOPICORT ...... 5 VANDAZOLE ...... 13 tamsulosin hcl ...... 13 TOPICORT LP ...... 5 VANOS ...... 5 TAPAZOLE ...... 7 topiramate ...... 13 VANOXIDE-HC ...... 4 tapentadol ...... 12 topotecan hcl ...... 11 VANSPAR ...... 2 tapentadol hcl ER ...... 12 TOPROL XL...... 3 VANTIN ...... 8 TARCEVA ...... 11 TORADOL ...... 10 VASCEPA ...... 4 TARGRETIN ...... 5, 11 toremifene citrate ...... 11 VASERETIC ...... 2 TASIGNA ...... 11 torsemide ...... 3 VASOCIDIN ...... 7 tazarotene ...... 5 TOUJEO ...... 6 VASOTEC ...... 3 TAZORAC ...... 5 TOVIAZ ...... 13 V-CILLIN K...... 8 tazorotene foam ...... 4 TRACLEER...... 3 VECTICAL ...... 14 TECFIDERA ...... 11 TRADJENTA ...... 5 vemurafenib ...... 11 tedizolid phosphate ...... 8 tramadol hcl ...... 12 VENCLEXTA ...... 11 teduglutide [rDNA origin] ...... 10 tramadol hcl/acetaminophen ...... 12 venetoclax ...... 11 TEGRETOL ...... 13 trametinib dimethyl sulfoxide ...... 11 VENTOLIN HFA ...... 1 TEGRETOL XR ...... 13 TRANDATE ...... 3 VEPESID ...... 11 telbivudine ...... 10 trandolapril ...... 3 verapamil hcl ...... 3 telithromycin ...... 8 TRANXENE T-TAB ...... 2 verapamil hcl ER ...... 3 telotristat ...... 10 tranylcypromine sulfate ...... 1 VERELAN ...... 3 temazepam ...... 2 TRAVATAN...... 7 VERELAN PM ...... 3 TEMODAR ...... 11 TRAVATAN Z ...... 7 VESANOID ...... 11 TEMOVATE ...... 5 travoprost ...... 7 VESICARE...... 13 TEMOVATE EMOLLIENT ...... 5 trazodone hcl ...... 1 VESTURA ...... 4 temozolomide ...... 11 TRENTAL ...... 7 VFEND ...... 9 TENEX ...... 3 tretinoin ...... 11 VIAGRA ...... 6 tenofovir disoproxil fumarate ...... 9 TREXALL ...... 11 VIBRAMYCIN ...... 9 TENORETIC 100 ...... 3 TRIADVANCE ...... 14 VIBRAMYCIN SYRUP ...... 9 TENORETIC 50 ...... 3 triamcinolone acetonide ...... 1, 5, 12 VIBRA-TABS ...... 9 TENORMIN ...... 3 triamterene/hydrochlorothiazid ...... 3 VICODIN ...... 12 terazosin hcl ...... 3 TRIAZ ...... 4 VICODIN ES ...... 12 terbinafine hcl ...... 5, 9 triazolam ...... 2 VICODIN HP ...... 12 terbutaline sulfate ...... 1 TRIBENZOR ...... 3 VICON FORTE ...... 14 teriparatide ...... 6 TRICOR ...... 4 VICTOZA ...... 5 testosterone 1% ...... 8 TRIDERM ...... 5 VIDEX ...... 9 testosterone cypionate ...... 8 TRIDESILON ...... 5 VIDEX EC ...... 9 testosterone enantate ...... 8 trifluoperazine hcl ...... 2 VIDEX SOLUTION ...... 9 testosterone gel 1.62% ...... 8 trifluridine ...... 7 VIGAMOX ...... 7 testosterone solution ...... 8 TRIGLIDE 160MG ...... 4 VIIBRYD ...... 1 TESTRED ...... 8 TRIGLIDE 50MG ...... 4 VIMPAT ...... 13 tetrabenazine ...... 11 trihexyphenidyl hcl ...... 12 VIMPAT ORAL SOLUTION ...... 13 tetracycline hcl ...... 9 TRILAFON ...... 2 VINATE GT ...... 14 TEXACORT ...... 5 TRILEPTAL...... 13 VINATE ULTRA ...... 14 thalidomide ...... 9 trimethoprim ...... 8 VIRACEPT ...... 9 THALITONE ...... 3 TRI-NORINYL ...... 4 VIRAMUNE ...... 9 THALOMID ...... 9 TRINTELLIX ...... 1 VIRAMUNE XR ...... 9 THEO-24 ...... 1 TRIUMEQ ...... 9 VIRAZOLE ...... 9 theophylline anhydrous ...... 1 TRI-VI-FLOR W/IRON ...... 14 VIREAD ...... 9 THERMAZENE ...... 5 TRIZIVIR ...... 9 VIROPTIC ...... 7 thioguanine ...... 11 TROKENDI XR ...... 13 VISKEN ...... 3 THIOGUANINE ...... 11 TRUSOPT ...... 7 VISTARIL ...... 1 thioridazine hcl ...... 2 TRUVADA ...... 9 VISTOGARD ...... 11 thiothixene ...... 2 TUSSIONEX ...... 4 VIVELLE-DOT ...... 8 THORAZINE ...... 2 TYBOST ...... 10 VOLTAREN ...... 7, 10 thyroid, pork ...... 7 TYKERB ...... 11 VOLTAREN GEL ...... 5 TIAZAC ...... 3 TYLENOL-CODEINE ...... 12 VOLTAREN-XR ...... 10 ticagrelor ...... 8 TYZEKA ...... 10 voriconazole ...... 9 TIKOSYN ...... 2 ULORIC ...... 7 vorinostat ...... 11 timolol ...... 7 ULTRACET ...... 12 VOSOL ...... 6 timolol maleate ...... 3, 7 ULTRAM ...... 12 VOSOL HC ...... 6 TIMOPTIC ...... 7 ULTRASE ...... 13 VOTRIENT...... 11

37010 MedPerform Low Formulary – July 2017 31 MedPerform Low Formulary INDEX

VRAYLAR ...... 2 YAZ ...... 4 ZOFRAN ...... 1 vridine triacetate ...... 11 YODOXIN ...... 9 ZOFRAN ODT ...... 1 VYVANSE ...... 2 zaleplon ...... 2 ZOFRAN SOLUTION ...... 1 warfarin sodium ...... 7 ZANAFLEX ...... 13 ZOLINZA ...... 11 WELCHOL ...... 3 ZANTAC ...... 13 zolmitriptan ...... 12 WELCHOL POWDER PACKETS ...... 3 ZARAH ...... 4 ZOLOFT ...... 1 WELLBUTRIN ...... 1 ZARONTIN ...... 13 zolpidem tartrate ...... 2 WELLBUTRIN SR ...... 1 ZAROXOLYN ...... 3 ZOMIG ...... 12 WELLBUTRIN XL ...... 1 ZEBETA ...... 3 ZOMIG ZMT ...... 12 WESTCORT ...... 5 ZELBORAF ...... 11 ZONEGRAN ...... 13 WESTHROID ...... 7 ZEMPLAR ...... 6 zonisamide ...... 13 XALATAN ...... 7 ZENATANE...... 4 ZORTRESS ...... 8 XALKORI ...... 11 ZENPEP ...... 13 ZOVIRAX ...... 9 XANAX ...... 2 ZENZEDI ...... 2 ZOVIRAX CREAM ...... 5 XARELTO ...... 7 ZERIT ...... 9 ZOVIRAX OINTMENT ...... 5 XELJANZ ...... 11 ZESTORETIC ...... 2 ZUBSOLV ...... 12 XELJANZ XR ...... 11 ZESTRIL ...... 3 Zurampic ...... 18 XELODA ...... 11 ZETIA ...... 4 ZURAMPIC ...... 7 XENAZINE ...... 11 ZIAC ...... 3 ZYDELIG ...... 11 XENAZINE ...... 11 ZIAGEN ...... 9 ZYKADIA ...... 11 XERMELO ...... 10 ZIANA ...... 4 ZYLET ...... 7 XIFAXAN 550MG ...... 9 zidovudine ...... 9 ZYLOPRIM ...... 7 XIIDRA ...... 7 ziprasidone hcl ...... 2 ZYMAXID ...... 7 XODOL 10-300 ...... 12 ZIRGAN ...... 7 ZYPREXA ...... 2 XTANDI ...... 11 ZITHROMAX ...... 8 ZYPREXA ZYDIS ...... 2 XURIDEN ...... 12 ZITHROMAX TRI-PAK ...... 8 ZYRTEC (OTC) ...... 1 XYLOCAINE ...... 10 ZMAX ...... 8 ZYRTEC-D (OTC) ...... 1 XYZAL TABS ...... 1 ZMAX PEDIATRIC ...... 8 ZYTIGA ...... 11 YASMIN 28 ...... 4 ZOCOR ...... 3 ZYVOX ...... 8

37010 MedPerform Low Formulary – July 2017 32