Scripps Health Formulary July 2016

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

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

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

the difference in cost between the brand and the generic. If a physician The MedImpact P & T and Formulary Committees use the following criteria in the determines that there is a documented medical need for the brand equivalent, a evaluation of drug selection for the Portfolio Formulary: request for coverage may be made using the medication request process.  Drug safety profile  Drug efficacy 2. Three Tier Benefit  Comparison of relevant therapeutic benefits to current formulary agents of The Formulary may be applied to a three tier benefit design, where the member similar use, and to minimize therapeutic duplication where possible shares the cost of prescription drug therapy at three levels of copayment. In  Cost-effectiveness relative to comparable therapies most instances, generically available drugs will be covered under the first or lowest copay tier, branded drugs listed on the Formulary will be covered under How to Use the Formulary the second copay tier, and branded drugs not on the Formulary will be covered The Formulary is a list of medications available to MedImpact members under their under the third or highest copay tier. pharmacy benefit. All drugs are listed by their generic names and most common 3. Medication Request Process proprietary (branded) name. The Formulary may be accessed by using the index, Depending upon plan benefit design, a medication request process may apply either by generic or proprietary name (in capital letters) and by therapeutic drug as follows: category. In situations where an FDA approved generic equivalent is available, brand A. Formulary Agents names are listed for reference purposes only, and do not denote coverage for the Drugs that are listed in the Formulary with associated Prior Authorization brand, unless specifically noted. Any drug not found in this Formulary listing, or any (PA) require evaluation, per MedImpact P & T Committee Prior Formulary updates published by MedImpact shall be considered a Non-Formulary Authorization guidelines prior to dispensing at a network pharmacy. Each drug. request will be reviewed on an individual patient need basis. If the request does not meet the guidelines established by the P & T Committee, the All drugs are listed in each category in alphabetical order by generic name. Where an request will not be approved and alternative therapy may be FDA approved generic is available for the listed generic name, the generic name is recommended. bolded. B. Non-Formulary Agents For certain agents within the Formulary, a recommended prescribing guideline may Any drug not found in the Formulary listing, or any Formulary updates apply. These are denoted throughout the document using the following symbols: published by MedImpact, shall be considered a Non-Formulary drug. Coverage for non-formulary agents may be applied for in advance. When AGE Age Edit Coverage may depend on patient age a member gives a prescription order for a non-formulary drug to a CU Concurrent Coverage or lack thereof may depend upon pharmacist, the pharmacist will evaluate the patient’s drug history and Use Edit concurrent use of another drug contact the physician to determine if there is a reasonable medical need G Gender Edit Coverage may depend on patient gender for a non-formulary drug. Each request will be reviewed on an individual MD Physician Coverage may depend on prescribing physician’s patient need basis. Approval will be given if a documented medical need Specialty specialty or board certification exists. The following basic guidelines are used: Edit  The use of Formulary Drugs is contraindicated in the patient. PA Prior Requires specific physician request process  The patient has failed an appropriate trial of Formulary or related Authorization agents.  The choices available in the Formulary are not suited for the present QL Quantity Coverage may be limited to specific quantities patient care need, and the drug selected is required for patient Limit per prescription and/or time period safety. ST Step Coverage may depend on previous use of another  The use of a Formulary drug may provoke an underlying condition, Therapy drug which would be detrimental to patient care.

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

804 Portfolio High Formulary – July 2016 1 Portfolio High Formulary

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

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

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

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

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Foreword ...... i Antihyperlipidemic –PCSK9 Inhibitors ...... 8 1. Generic Substitution ...... i Bile Salt Sequestrants ...... 8 2. Three Tier Benefit ...... i Lipotropics ...... 9 3. Medication Request Process ...... i Niacin Preparations ...... 9 4. General Exclusions ...... i CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS ...... 9 5. Pharmacist and Physician Communication ...... ii Adrenergic Vasopressor Agents ...... 9 ALLERGY ...... 6 Antianginal & Anti-Ischemic Agents, Non-Hemodynamic ...... 9 Allergenic extracts ...... 6 Antihyperlipidemia - HMG-CoA & Calcium Channel Blocker Combinations ..... 9 2nd Geneneration Antihistamine & Decongestant Combinations ...... 6 Heart Rate Reducing, Selective I(F) Current Inhib...... 9 Antihistamines - 1st Generation ...... 6 CARDIOVASCULAR DISEASE - VASODILATION ...... 9 Antihistamines - 2nd Generation ...... 6 Vasodilators, Combination ...... 9 Nasal Anti-Inflammatory Steroids ...... 6 Vasodilators, Coronary ...... 9 Nasal Antihistamine ...... 6 CONTRACEPTION/OXYTOCICS ...... 9 ANTIEMESIS/ANTIVERTIGO ...... 6 Contraceptives, Intravaginal, Systemic ...... 9 Antiemetic/Antivertigo Agents ...... 6 Contraceptives, Oral ...... 9 ASTHMA ...... 6 Contraceptives, Transdermal ...... 9 Beta-Adrenergic Agents ...... 6 Oxytocics ...... 9 Beta-Adrenergic & Anticholinergic Combinations ...... 6 COUGH AND COLD ...... 9 Beta-Adrenergic & Glucocorticoid Combinations ...... 6 1st Generation Antihistamine & Decongestant Combinations...... 9 General Bronchodilator Agents ...... 6 Narcotic Antitussive-1st Geneneration Antihistamine-Decongestants ...... 9 Leukotriene Receptor Antagonists ...... 6 Narcotic Antitussive-1st Generation Antihistamines ...... 9 Mast Cell Stabilizers ...... 6 Narcotic Antitussive-Anticholinergic Comb...... 9 Oral Inhaled Corticosteroids ...... 6 Non-Narcotic Antitussive-1st Generation Antihistamine Combinations ...... 9 Phosphodiesterase-4 (PDE4) Inhibitors ...... 6 DERMATOLOGY - ACNE ...... 9 Xanthines ...... 6 Acne Agents, Systemic ...... 9 AUTONOMIC NERVOUS SYSTEM DISORDERS ...... 6 Acne Agents, Topical ...... 9 Alzheimer's Therapy, Nmda Receptor Antagonists ...... 6 Keratolytic-Glucocorticoid Combinations ...... 9 Alzheimer's Therapy, Nmda Receptor Antagonists & Cholines Inhibitors ...... 6 Keratolytics ...... 9 Cholinesterase Inhibitors ...... 6 Rosacea Agents, Topical ...... 9 BEHAVIORAL HEALTH - ANTIDEPRESSANTS ...... 6 Vitamin A Derivatives ...... 9 Alpha-2 Receptor Antagonist Antidepressants ...... 6 DERMATOLOGY - ANTIINFECTIVE ...... 9 Maois - Non-Selective & Irreversible ...... 6 Topical Antibiotics ...... 9 Norepinephrine & Dopamine Reuptake Inhibitors (NDRIs) ...... 6 Topical Antifungals ...... 10 Selective Serotonin Reuptake Inhibitors (SSRIs) ...... 6 Topical Antiparasitics ...... 10 SSRI & Antipsycho, Atyp, Dopamine & Serotonin Antag Comb ...... 6 Topical Antivirals ...... 10 Serotonin-2 Antagonist/Reuptake Inhibitors (SARIs)...... 6 Topical Sulfonamides ...... 10 Serotonin-Norepinephrine Reuptake-Inhib (SNRIs) ...... 6 DERMATOLOGY - ANTIINFLAMMATORY ...... 10 Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib ...... 7 Topical Anti-Inflammatory Steroidal ...... 10 BEHAVIORAL HEALTH - OTHER ...... 7 Topical Anti-Inflammatory, NSAIDs ...... 10 Adrenergics, Aromatic, Non-Catecholamine ...... 7 Topical Antibiotics/Antiinflammatory, Steroidal ...... 10 Anti-Alcoholic Preparations ...... 7 DERMATOLOGY - MISCELLANEOUS ...... 10 Anti-Anxiety Drugs ...... 7 Antiperspirants ...... 10 Anti-Mania Drugs ...... 7 Antiseborrheic Agents ...... 10 Antipsychotics, Phenothiazines ...... 7 Topical Antineoplastic & Premalignant Lesion Agents ...... 10 Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed ...... 7 Topical Local Anesthetics ...... 10 Antipsychotics, Dopamine & Serotonin Antagonists ...... 7 DERMATOLOGY - PIGMENTATION DISORDERS ...... 10 Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists ...... 7 Topical Hyperpigmentation Agents ...... 10 Antipsychotics, Dopamine Antagonists, Thioxanthenes ...... 7 DERMATOLOGY - PSORIASIS/ECZEMA ...... 10 Antipsychotics, Dopamine Antagonists, Butyrophenones ...... 7 Antipsoriatic Agents, Systemic ...... 10 Barbiturates ...... 7 Antipsoriatics Agents ...... 10 Narcolepsy and Sleep Disorder Therapy Agents ...... 7 Topical Immunosuppressive Agents ...... 10 Narcotic Antagonists ...... 7 DIABETES ...... 10 Sedative-Hypnotics, Non-Barbiturate ...... 7 Antihyperglycemic, Alpha-Glucosidase Inhibitors (Non-Sulfonylurea) ...... 10 Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy ...... 7 Antihyperglycemic, Amylin Analog-Type ...... 10 Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type ...... 7 Antihyperglycemic, DPP-4 Inhibitors ...... 10 CARDIOVASCULAR DISEASE - ARRHYTHMIA ...... 7 Antihyperglycemic, DPP-4 Inhibitor & Biguanide Combinations ...... 10 Antiarrhythmics ...... 7 Antihyperglycemic, Incretin Mimetic (GLP-1 Receptor Agonists) ...... 10 CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS ...... 7 Antihyperglycemic, Insulin-Release Stimulant Type ...... 10 Digitalis Glycosides ...... 7 Antihyperglycemic, Insulin-Response Enhancer (Non-Sulfonylurea) ...... 11 CARDIOVASCULAR DISEASE - HYPERTENSION ...... 7 Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) ...... 11 ACE Inhibitor/Calcium Channel Blocker Combinations ...... 7 Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations ...... 11 ACE Inhibitor/Thiazide & Thiazide-Like Diuretics ...... 7 Antihyperglycemic, Insulin-Response & Release Combinations ...... 11 Alpha-Adrenergic Blocking Agents ...... 8 Antihyperglycemic Insul-Resp. Enhancer & Biguanide Combinations ...... 11 Alpha/Beta-Adrenergic Blocking Agents ...... 8 Antihyperglycemic-Glucocorticoid Receptor Blockers...... 11 Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors ...... 11 Combinations ...... 8 Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) Inhibitor and Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations ...... 8 Biguanide Combination ...... 11 Angiotensin Receptor Antagonist & Calcium Channel Blockers ...... 8 Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination ...... 11 Antihypertensives, ACE Inhibitors ...... 8 Diabetic Supplies ...... 11 Antihypertensives, Angiotensin Receptor Antagonist ...... 8 Diabetic Ulcer Preparations, Topical ...... 11 Antihypertensives, Sympatholytic ...... 8 Hyperglycemics ...... 11 Antihypertensives, Vasodilators ...... 8 Insulins ...... 11 Beta-Adrenergic Blocking Agents ...... 8 Syringes & Accessories ...... 11 Beta-Adrenergic Blocking Agents/Thiazide & Related ...... 8 EAR - GENERAL DISORDERS ...... 11 Calcium Channel Blocking Agents ...... 8 Ear Preparations, Misc. Anti-Infectives ...... 11 Loop Diuretics ...... 8 Ear Preparations, Antibiotics ...... 11 Potassium Sparing Diuretics ...... 8 Otic Preparations, Anti-Inflammatory-Antibiotics ...... 11 Potassium Sparing Diuretics in Combination ...... 8 Otic Preparations, Local anesthetics ...... 11 Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 Inhibitors ...... 8 ELECTROLYTE REGULATION ...... 11 Pulmonary Anti-HTN, Endothelin Receptor Antagonists ...... 8 Electrolyte Depleters ...... 11 Pulmonary Anti-HTN, Prostacyclin-Type ...... 8 Potassium Replacement ...... 11 Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators ...... 8 ENDOCRINE DISORDER - FERTILITY ...... 11 Thiazide & Related Diuretics ...... 8 Drugs to Treat Impotency ...... 11 CARDIOVASCULAR DISEASE - LIPID IRREGULARITY ...... 8 Fertility Stimulating Preparations, Non-FSH ...... 11 Antihyperlipidemic - APO B-100 Synthesis Inhibitor ...... 8 Follicle Stimulating / Luteinizing Hormones ...... 11 Antihyperlipidemic - HMG CoA Reductase Inhibitors ...... 8 Pregnancy Facilitating/Maintaining Agents, Hormonal...... 11 Antihyperlipidemic - MTP Inhibitors ...... 8 ENDOCRINE DISORDER - OTHER ...... 11

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Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants ...... 11 Antivirals, HIV-Specific, Fusion Inhibitors ...... 14 Antidiuretic & Vasopressor Hormones ...... 11 Antivirals, HIV-Specific, Non-Nucleoside, RTI ...... 14 Bone Formation Stim. Agents - Parathyroid Hormone ...... 11 Antivirals, HIV-Specific, Nucleoside Analog, RTI ...... 14 Bone Resorption Inhibitor & Vitamin D Combinations ...... 11 Antivirals, HIV-Specific, Nucleotide Analog, RTI ...... 15 Bone Resorption Inhibitors ...... 11 Antivirals, HIV-Specific, Protease Inhibitor Comb ...... 15 Growth Hormone Receptor Antagonists ...... 12 Antivirals, HIV-Specific, Protease Inhibitors ...... 15 Growth Hormones ...... 12 Antivirals, HIV-1 Integrase Strand Transfer Inhibtors...... 15 Hyperparathyroid Tx Agent, Vitamin D Analog-Type ...... 12 Antiviral Combination Nucleoside, Nucleotide & Non-Nucleoside RTI ...... 15 LHRH (GnRH) Antagonist, Pituitary Suppressant Agents ...... 12 Cytochrome P450 Inhibitors ...... 15 Luteinizing Hormone Releasing Hormone –LHRH (GnRH) ...... 12 Hepatitis B Treatment Agents ...... 15 Pituitary Suppressive Agents ...... 12 Hepatitis C Combination Agents...... 15 ENDOCRINE DISORDER - THYROID ...... 12 Hepatitis C Treatment Agents ...... 15 Antithyroid Preparations ...... 12 INFLAMMATORY DISEASE ...... 15 Iodine Containing Agents ...... 12 Anti-Arthritic & Chelating Agents ...... 15 Thyroid Hormones ...... 12 Anti-Arthritic, Folate Antagonist Agents ...... 15 EYE - GENERAL DISORDERS ...... 12 Anti-Inflammatory Tumor Necrosis Factor Inhibitor ...... 15 Eye Antibiotic-Corticoid Combinations ...... 12 Anti-Inflammatory, Pyrimidine Synthesis Inhibitors ...... 15 Eye Antihistamines ...... 12 Bradykinin B2 Receptor Antagonists ...... 15 Eye Antiinflammatory Agents ...... 12 Glucocorticoids ...... 15 Eye Antivirals ...... 12 Mineralocorticoids ...... 15 Eye Sulfonamides ...... 12 Monoclonal antibody-human interleukin ...... 15 EYE - MISCELLANEOUS ...... 12 NSAIDs, Cyclooxygenase Inhibitor-Type ...... 15 Ophthalmic Cystine Delpleting Agents ...... 12 LOCAL ANESTHESIA ...... 15 Ophthalmic Anti-Inflammatory Immunomodulator-Type ...... 12 Local Anesthetics ...... 15 Ophthalmic Antibiotics ...... 12 LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT ...... 15 Ophthalmic Mast Cell Stabilizers ...... 12 Bowel Antiinflamatory Agents ...... 15 EYE - GLAUCOMA ...... 12 Chronic Inflam. Colon Dx, 5-A-Salicylat, Rectal Tx ...... 15 Carbonic Anhydrase Inhibitors ...... 12 Drug Tx-Chronic Inflam. Colon Dx, 5-Aminosalicylat ...... 15 Miotics/Other Intraoccula Pressure Reducers ...... 12 Hemorrhoidal Preparations ...... 15 Mydriatics ...... 12 Rectal Preparations ...... 15 GOUT AND RELATED DISEASES ...... 13 Rectal/Lower Bowel Prep., Glucocort. (Non-Hemorr) ...... 15 Colchicine ...... 13 LOWER GASTROINTESTINAL DISORDERS - OTHER ...... 15 Hyperuricemia Treatment - Purine Inhibitors ...... 13 Ammonia Inhibitors ...... 16 Uricosuric Agents ...... 13 Antidiarrheals ...... 16 HEMATOLOGICAL DISORDERS ...... 13 Bile Salts ...... 16 Anticoagulants, Coumarin Type ...... 13 Laxatives & Cathartics ...... 16 Hematinics, Other ...... 13 Narcotic Antagonists, Peripherally-Acting ...... 16 Hemorrheologic Agents ...... 13 MISCELLANEOUS AGENTS ...... 16 Heparin & Related Preparations ...... 13 Anaphylaxis Therapy Agents ...... 16 Leukocyte (WBC) Stimulants ...... 13 Parasympathetic Agents ...... 16 Platelet Aggregation Inhibitors ...... 13 Pku Tx Agent-Cofactor Of Phenylalanine Hydroxylase...... 16 Platelet Reducing Agents ...... 13 NEOPLASTIC DISEASE ...... 16 Thrombopoietin Receptor Agonists ...... 13 Alkylating Agents...... 16 Vitamin K Preparations ...... 13 Antiandrogenic Agents ...... 16 HORMONAL DEFICIENCY...... 13 Antimetabolites ...... 16 Androgenic Agents ...... 13 Antineoplastic - Aromatase Inhibitors ...... 16 Estrogen/Androgen Combinations ...... 13 Antineoplastic -B Cell Lymphoma-2(bcl-2) Inhibitors ...... 16 Estrogenic Agents ...... 13 Antineoplastic – Hedgehog Pathway Inhibitors...... 16 Progestational Agents ...... 13 Antineoplastic – Janus Kinase (JAK) Inhibitors ...... 16 IMMUNOSUPPRESSION/MODULATION...... 13 Antineoplastic - MEK1 and MEK2 Kinase Inhibitors ...... 16 Immunomodulators ...... 13 Antineoplastic - Topoisomerase I Inhibitors ...... 16 Immunosuppressives ...... 13 Antineoplastic - Immunomodulator Agents ...... 16 INFECTIOUS DISEASE - BACTERIAL ...... 13 Antineoplastic - Systemic Enzyme Inhibitors ...... 16 Absorbable Sulfonamides ...... 13 Antineoplastic, Histone Deacetylase Inhibitors, HDIS ...... 16 Betalactams ...... 13 Antineoplastics, Miscellaneous ...... 16 Cephalosporins - 1st Generation ...... 13 Chemotherapy Rescue/Antidote Agents ...... 16 Cephalosporins - 2nd Generation ...... 13 Selective Estrogen Receptor Modulators (SERM) ...... 16 Cephalosporins - 3rd Generation ...... 13 Selective Retinoid X Receptor Agonists (RXR) ...... 17 Chemotherapeutics, Antibacterial, Miscellaneous ...... 13 Steroid Antineoplastics ...... 17 Ketolides ...... 13 NEUROLOGICAL DISEASE - MISCELLANEOUS ...... 17 Lincosamides ...... 13 Agents to Treat Multiple Sclerosis ...... 17 Macrolides ...... 13 Fibromyalgia Agents, Serotonin-Norepineph RU Inhibitor ...... 17 Nitrofuran Derivatives ...... 14 Movement Disorders (Drug Therapy) ...... 17 Oxazolidinones ...... 14 ORAL/PHARYNGEAL DISORDERS ...... 17 Penicillins ...... 14 Dental Aids & Preparations ...... 17 Quinolones ...... 14 Nose Preparations, Antibiotics ...... 17 Tetracyclines ...... 14 Nose Preparations, Miscellaneous (Rx) ...... 17 INFECTIOUS DISEASE - FUNGAL ...... 14 OTHER DRUGS ...... 17 Antifungal Agents ...... 14 Appetite Stimulators for Anorexia, Cachexia, Wasting Syndrome ...... 17 Antifungal Antibiotics ...... 14 General Inhalation Agents ...... 17 INFECTIOUS DISEASE - MISCELLANEOUS ...... 14 Metabolic disease enzyme replace, hypophosphatasia ...... 17 Aminoglycosides ...... 14 Needles/Needleless Devices ...... 17 Anti-Mycobacterium Agents ...... 14 Nucleic Acid/Nucleotide Supplements ...... 17 Antileprotics ...... 14 OTHER RESPIRATORY DISORDERS ...... 17 Antitubercular Antibiotics ...... 14 Antifibrotic Therapy – Pyridone Analogs ...... 17 Rifamycins and Related Derivative Antibiotics ...... 14 Cystic Fibrosis-Cftr Potentiator & Corrector Comb...... 17 Vancomycin & Derivatives ...... 14 Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) Potentiators INFECTIOUS DISEASE - PARASITIC ...... 14 ...... 17 Amebacides ...... 14 Mucolytics ...... 17 Anaerobic Antiprotozoal-Antibacterial Agents ...... 14 Pulmonary Fibrosis – Systemic Enzyme Inhibitors ...... 17 Anthelmintics ...... 14 PAIN MANAGEMENT - ANALGESICS ...... 17 Antimalarial Drugs ...... 14 Analgesic, Non-Salicylate & Barbiturate Combinations ...... 17 Antiprotozoal Drugs, Miscellaneous ...... 14 Analgesic, Salicylate, Barbiturate & Xanthine Combinations ...... 17 INFECTIOUS DISEASE - VIRAL ...... 14 Analgesic, Non-Salicylate, Barbiturate & Xanthine Combinations ...... 17 Antivirals, HIV-Spec, Non-Peptidic Protease Inhib ...... 14 Analgesic/Antipyretics, Salicylates ...... 17 Antivirals, HIV-Spec, Nucleoside-Nucleotide Analog ...... 14 Analgesics, Narcotics ...... 17 Antivirals, HIV-Spec., Nucleoside Analog, RTI Comb ...... 14 Antimigraine Preparations ...... 17 Antivirals, HIV-Specific, CCR5 Co-Receptor Antag...... 14 Narcotic & Non-Salicylate Analgesic, Barbiturate & Xanthine Combinations . 17

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Narcotic & Salicylate Analgesics, Barbiturates & Xanthines ...... 17 Narcotic Analgesic & Non-Salicylate Analgesic Combinations ...... 17 PARKINSON’S DISEASE ...... 18 Antiparkinsonism Drugs, Anticholinergic ...... 18 Antiparkinsonism Drugs, Other ...... 18 Decarboxylase Inhibitors ...... 18 SEIZURE DISORDER ...... 18 Anticonvulsants...... 18 SKELETAL MUSCLE DISORDER ...... 18 Agents To Treat Periodic Paralysis ...... 18 Skeletal Muscle Relaxants ...... 18 UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE ...... 18 Pancreatic Enzymes ...... 18 UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE ...... 18 Anticholinergics/Antispasmodics ...... 18 Belladonna Alkaloids ...... 18 UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ...... 18 Anti-Ulcer Preparations ...... 18 Anti-Ulcer-H.pylori Agents ...... 18 Anticholinergics, Quaternary Ammonium ...... 18 Histamine H2-Receptor Inhibitors ...... 18 Intestinal Motility Stimulants ...... 18 Proton-Pump Inhibitors ...... 18 URINARY TRACT - FUNCTIONAL DISORDERS ...... 18 Benign Prostatic Hypertrophy/Micturition Agents ...... 18 Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag comb agents ...... 18 Kidney Stone Agents ...... 18 Overactive Bladder Agents, Beta-3 Adrenergic Recep ...... 18 Urinary Tract Analgesic Agents ...... 18 Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) ...... 18 Urinary Tract Antispasmodic, M(3) Selective Antagonists ...... 18 Urinary Tract Antispasmodic/Antiincontinence Agents ...... 18 VAGINAL DISORDERS ...... 19 Vaginal Antibiotics ...... 19 Vaginal Antifungals ...... 19 Vaginal Estrogen Preparations ...... 19 Vaginal Sulfonamides ...... 19

VITAMIN AND/OR MINERAL DEFICIENCY ...... 19 Fluoride Preparations ...... 19 Folic Acid Preparations ...... 19 Multivitamin Preparations ...... 19 Pediatric Vitamin Preparations ...... 19 Prenatal Vitamin Preparations ...... 19 Vitamin B Preparations ...... 19 Vitamin D Preparations ...... 19 SPECIALTY INJECTABLE CROSS REFERENCE LISTING ...... 19

Portfolio High Formulary – July 2016 5 Portfolio High Formulary

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

Portfolio High Formulary – July 2016 6 Portfolio High Formulary

Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib Antipsychotics, Dopamine Antagonists, Thioxanthenes amitriptyline hcl ELAVIL thiothixene NAVANE amoxapine ASENDIN Antipsychotics, Dopamine Antagonists, Butyrophenones clomipramine hcl ANAFRANIL haloperidol HALDOL desipramine hcl NORPRAMIN haloperidol lactate HALDOL ORAL CONC. doxepin hcl SINEQUAN Barbiturates imipramine hcl TOFRANIL phenobarbital PHENOBARBITAL maprotiline hcl LUDIOMIL Narcolepsy and Sleep Disorder Therapy Agents nortriptyline hcl PAMELOR PA modafinil PROVIGIL BEHAVIORAL HEALTH - OTHER Narcotic Antagonists Adrenergics, Aromatic, Non-Catecholamine naltrexone hcl REVIA QL amphet asp/amphet/d-amphet ADDERALL QL naloxone hcl NARCAN NASAL QL ADDERALL XR Sedative-Hypnotics, Non-Barbiturate QL dextroamphetamine sulfate DEXEDRINE chloral hydrate NOCTEC QL dextroamphetamine capsule DEXEDRINE SPANSULE estazolam PROSOM QL dextroamphetamine tablet (5mg, ZENZEDI QL eszopiclone LUNESTA 10mg) flurazepam hcl DALMANE QL + dextroamphetamine tablet (2.5mg, ZENZEDI ST 7.5mg) temazepam RESTORIL QL dextroamphetamine tablet (15mg, ZENZEDI triazolam HALCION 20mg, 30mg) QL zaleplon SONATA QL + lisdexamfetamine dimesylate VYVANSE QL zolpidem tartrate AMBIEN ST QL + AMBIEN CR Anti-Alcoholic Preparations ST ZOLPIDEM TARTRATE ER disulfiram ANTABUSE Treatment for Attention Deficit-Hyperactivity (ADHD)/Narcolepsy Anti-Anxiety Drugs QL dexmethylphenidate hcl FOCALIN alprazolam XANAX QL FOCALIN XR ALPRAZOLAM INTENSOL QL + methylphenidate hcl CONCERTA AGE 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 lorazepam ATIVAN QL RITALIN LORAZEPAM INTENSOL QL+ RITALIN LA meprobamate MILTOWN AGE RITALIN SR

oxazepam SERAX QL + methylphenidate ER Susp QUILLIVANT XR Anti-Mania Drugs ST lithium carbonate ESKALITH Treatment for Attention Deficit-Hyperactivity (ADHD), Nri-Type LITHOBID QL atomoxetine hcl STRATTERA lithium citrate CIBALITH-S CARDIOVASCULAR DISEASE - ARRHYTHMIA Antipsychotics, Phenothiazines Antiarrhythmics chlorpromazine hcl THORAZINE amiodarone hcl CORDARONE fluphenazine hcl PROLIXIN disopyramide phosphate NORPACE perphenazine TRILAFON flecainide acetate TAMBOCOR thioridazine hcl MELLARIL mexiletine hcl MEXITIL trifluoperazine hcl STELAZINE procainamide hcl PRONESTYL Antipsychotics, Atypical, D2 Partial Agonist/5HT Mixed propafenone hcl RYTHMOL ST + aripiprazole ABILIFY SOLUTION QL quinidine gluconate QUINAGLUTE QL aripiprazole ABILIFY TABLET quinidine sulfate QUINIDEX ST + aripiprazole ABILIFY DISCMELT disopyramide phosphate NORPACE CR QL dofetilide TIKOSYN Antipsychotics, Dopamine & Serotonin Antagonists dronedarone hcl MULTAQ loxapine succinate LOXITANE propafenone hcl RYTHMOL SR Antipsychotics, Atypical, Dopamine, & Serotonin Antagonists CARDIOVASCULAR DISEASE - CARDIAC STIMULANTS QL clozapine CLOZARIL Digitalis Glycosides QL olanzapine ZYPREXA digoxin LANOXIN QL olanzapine ODT ZYPREXA ZYDIS DIGOXIN ORAL SOLN. QL quetiapine fumarate SEROQUEL CARDIOVASCULAR DISEASE - HYPERTENSION QL risperidone RISPERDAL ACE Inhibitor/Calcium Channel Blocker Combinations QL risperidone ODT RISPERDAL M-TAB amlodipine besylate/benazepril LOTREL QL ziprasidone hcl GEODON ACE Inhibitor/Thiazide & Thiazide-Like Diuretics benazepril/hydrochlorothiazide LOTENSIN HCT captopril/hydrochlorothiazide CAPOZIDE enalapril/hydrochlorothiazide VASERETIC fosinopril/hydrochlorothiazide MONOPRIL HCT lisinopril/hydrochlorothiazide PRINZIDE

Portfolio High Formulary – July 2016 7 Portfolio High Formulary

ZESTORETIC Calcium Channel Blocking Agents moexipril/hydrochlorothiazide UNIRETIC amlodipine besylate NORVASC quinapril/hydrochlorothiazide ACCURETIC diltiazem hcl CARDIZEM Alpha-Adrenergic Blocking Agents CARDIZEM CD doxazosin mesylate CARDURA DILACOR XR TIAZAC phenoxybenzamine hcl DIBENZYLINE felodipine PLENDIL prazosin hcl MINIPRESS isradipine IR capsules DYNACIRC terazosin hcl HYTRIN nicardipine hcl CARDENE Alpha/Beta-Adrenergic Blocking Agents nifedipine ADALAT CC carvedilol COREG PROCARDIA labetalol hcl TRANDATE PROCARDIA XL carvedilol phosphate COREG CR nimodipine NIMOTOP Angiotensin Receptor Antagonist/Calcium Channel Blocker/Thiazide Combinations verapamil hcl CALAN ST amlodipine/valsartan/hctz EXFORGE HCT VERELAN ST olmesartan/amlodipin/hcthiazid TRIBENZOR verapamil hcl ER CALAN SR Angiotensin Receptor Antagonist/Thiazide Diuretic Combinations VERELAN PM irbesartan/hydrochlorithiazide AVALIDE Loop Diuretics losartan/hydrochlorothiazide HYZAAR bumetanide BUMEX valsartan/hydrochlorothiazide DIOVAN HCT furosemide LASIX ST olmesartan/hydrochlorothiazide BENICAR HCT torsemide DEMADEX Angiotensin Receptor Antagonist & Calcium Channel Blockers Potassium Sparing Diuretics ST amlodipine/valsartan EXFORGE eplerenone INSPRA ST amlodipine bes/olmesartan med AZOR spironolactone ALDACTONE Antihypertensives, ACE Inhibitors Potassium Sparing Diuretics in Combination benazepril hcl LOTENSIN triamterene/hydrochlorothiazide DYAZIDE captopril CAPOTEN MAXZIDE enalapril maleate VASOTEC MAXZIDE-25MG fosinopril sodium MONOPRIL Pulmonary Anti-HTN, Sel. C-GMP Phosphodiesterase T5 lisinopril PRINIVIL Inhibitors ZESTRIL PA sildenafil citrate REVATIO TABLET moexipril hcl UNIVASC PA tadalafil ADCIRCA quinapril hcl ACCUPRIL Pulmonary Anti-HTN, Endothelin Receptor Antagonists ramipril ALTACE PA ambrisentan LETAIRIS trandolapril MAVIK PA bosentan TRACLEER Antihypertensives, Angiotensin Receptor Antagonist PA macitentan OPSUMIT irbesartan AVAPRO Pulmonary Anti-HTN, Prostacyclin-Type losartan potassium COZAAR PA selexipag UPTRAVI valsartan DIOVAN Pulmonary Anti-HTN, Soluble Guanylate Cyclase Stimulators ST olmesartan medoxomil BENICAR PA riociguat ADEMPAS Antihypertensives, Sympatholytic Thiazide & Related Diuretics clonidine hcl CATAPRES chlorthalidone HYGROTON guanfacine hcl TENEX hydrochlorothiazide MICROZIDE methyldopa ALDOMET indapamide LOZOL reserpine SERPASIL metolazone ZAROXOLYN Antihypertensives, Vasodilators chlorthalidone THALITONE hydralazine hcl APRESOLINE CARDIOVASCULAR DISEASE - LIPID IRREGULARITY Beta-Adrenergic Blocking Agents Antihyperlipidemic - APO B-100 Synthesis Inhibitor acebutolol hcl SECTRAL PA mipomersen sodium KYNAMRO atenolol TENORMIN Antihyperlipidemic - HMG CoA Reductase Inhibitors bisoprolol fumarate ZEBETA atorvastatin calcium LIPITOR metoprolol succinate TOPROL XL lovastatin MEVACOR metoprolol tartrate LOPRESSOR pravastatin sodium PRAVACHOL nadolol CORGARD simvastatin ZOCOR pindolol VISKEN ST simvastatin (80mg only) propranolol hcl INDERAL LA QL rosuvastatin calcium CRESTOR sotalol hcl BETAPACE Antihyperlipidemic - MTP Inhibitors BETAPACE AF lomitapide JUXTAPID PA + timolol maleate BLOCADREN QL nebivolol hcl BYSTOLIC Beta-Adrenergic Blocking Agents/Thiazide & Related Antihyperlipidemic –PCSK9 Inhibitors atenolol/chlorthalidone TENORETIC 100 PA alirocumab PRALUENT TENORETIC 50 PA evolocumab REPATHA bisoprolol fumarate/hctz ZIAC Bile Salt Sequestrants metoprolol/hctz LOPRESSOR HCT cholestyramine/aspartame QUESTRAN LIGHT propranolol/hydrochlorothiazide INDERIDE-40/25 cholestyramine/sucrose QUESTRAN colesevelam hcl WELCHOL

Portfolio High Formulary – July 2016 8 Portfolio High Formulary

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

Portfolio High Formulary – July 2016 9 Portfolio High Formulary

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

Portfolio High Formulary – July 2016 10 Portfolio High Formulary

tolbutamide ORINASE QL insulin nph hum/reg insulin hm HUMULIN 70-30 glyburide DIABETA QL insulin nph human isophane HUMULIN N Antihyperglycemic, Insulin-Response Enhancer (Non- QL insulin npl/insulin lispro HUMALOG MIX 50-50 Sulfonylurea) QL HUMALOG MIX 75-25 pioglitazone hcl ACTOS QL insulin regular, human HUMULIN R Antihyperglycemic, Biguanide Type (Non-Sulfonylurea) insulin regular, human HUMULIN R U-500 metformin hcl GLUCOPHAGE Syringes & Accessories GLUCOPHAGE XR syringes & needles ALL COMMERCIALLY metformin hcl RIOMET AVAILABLE SYRINGES Antihyperglycemic, Insulin-Rel Stim.& Biguanide Combinations AND NEEDLES glyburide, micro/metformin hcl GLUCOVANCE EAR - GENERAL DISORDERS repaglinide/metformin hcl PRANDIMET Ear Preparations, Misc. Anti-Infectives Antihyperglycemic, Insulin-Response & Release Combinations acetic acid VOSOL ST pioglitazone/glimepiride DUETACT acetic acid/aluminum acetate DOMEBORO Antihyperglycemic Insul-Resp. Enhancer & Biguanide acetic acid/hydrocortisone VOSOL HC Combinations Ear Preparations, Antibiotics ST pioglitazone hcl/metformin hcl ACTOPLUS MET neomy sulf/polymyx b sulf/hc CORTISPORIN OTIC ST pioglitazone hcl/metformin hcl ACTOPLUS MET XR OTICIN HC Antihyperglycemic-Glucocorticoid Receptor Blockers ofloxacin FLOXIN PA mifepristone KORLYM Otic Preparations, Anti-Inflammatory-Antibiotics Antihyperglycemic-Sod/Gluc Cotransport2 (SGLT2) Inhibitors ciprofloxacin hcl/dexameth CIPRODEX QL + canagliflozin INVOKANA Otic Preparations, Local anesthetics ST antipyrine/benzocaine otic BENZOTIC QL + empagliflozin JARDIANCE ELECTROLYTE REGULATION ST Electrolyte Depleters Antihyperglycemic, Sodium/Glucose Cotransport-2 (SGLT2) calcium acetate PHOSLO Inhibitor and Biguanide Combination sodium polystyrene sulfonate KAYEXALATE QL + canagliflozin/metformin hcl INVOKAMET sevelamer carbonate RENVELA ST sevelamer hcl RENAGEL QL + empagliflozin/metformin hcl SYNJARDY Potassium Replacement ST potassium chloride K-DUR Antihyperglycemic, SGLT-2 & DPP-4 Inhibitor Combination K-TAB QL + empagliflozin/linagliptin GLYXAMBI MICRO-K ST ENDOCRINE DISORDER - FERTILITY Diabetic Supplies Drugs to Treat Impotency blood-glucose calib. control PREFERRED ABBOTT CONTROL PRODUCTS G + sildenafil citrate VIAGRA (e.g., FREESTYLE, QL PRECISION) G + tadalafil CIALIS QL PREFERRED LIFESCAN Fertility Stimulating Preparations, Non-FSH CONTROL PRODUCTS clomiphene citrate CLOMID (e.g., ONETOUCH) SEROPHENE blood-glucose meter ALL ABBOTT Follicle Stimulating / Luteinizing Hormones METERS(e.g., follitropin alpha, recomb GONAL-F FREESTYLE, GONAL-F RFF PRECISION) follitropin beta, recomb FOLLISTIM AQ

gonadotropin,chorionic, human NOVAREL PREFERRED LIFESCAN PREGNYL METERS (e.g., PROFASI ONETOUCH) hcg alpha, recombinant OVIDREL blood sugar diagnostics PREFERRED ABBOTT TEST STRIPS (e.g., menotropins MENOPUR FREESTYLE, REPRONEX PRECISION) urofollitropin (fsh) BRAVELLE FERTINEX PREFERRED LIFESCAN Pregnancy Facilitating/Maintaining Agents, Hormonal TEST STRIPS (e.g., progesterone, micronized CRINONE ONETOUCH) ENDOMETRIN lancing device/lancets PREFERRED ABBOTT PROCHIEVE AND LIFESCAN (e.g., ENDOCRINE DISORDER - OTHER ONETOUCH) LANCETS Antineoplastic LHRH (GNRH) Agonists, Pituitary Suppressants Diabetic Ulcer Preparations, Topical PA leuprolide ELIGARD becaplermin REGRANEX Antidiuretic & Vasopressor Hormones Hyperglycemics desmopressin (nonrefrigerated) DDAVP glucagon,human recombinant GLUCAGON Bone Formation Stim. Agents - Parathyroid Hormone EMERGENCY KIT QL teriparatide FORTEO Insulins Bone Resorption Inhibitor & Vitamin D Combinations QL insulin glargine,hum.rec.anlog LANTUS alendronate sodium/vitamin d3 FOSAMAX PLUS D QL TOUJEO Bone Resorption Inhibitors QL insulin lispro HUMALOG alendronate sodium tablet FOSAMAX

Portfolio High Formulary – July 2016 11 Portfolio High Formulary

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

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

Portfolio High Formulary – July 2016 13 Portfolio High Formulary

PCE erythromycin ethylsuccinate ERYPED 200 ERYPED 400 Vancomycin & Derivatives QL + fidaxomicin DIFICID QL vancomycin hcl VANCOCIN HCL ST INFECTIOUS DISEASE - PARASITIC Nitrofuran Derivatives Amebacides nitrofurantoin macrocrystal MACRODANTIN paromomycin sulfate HUMATIN nitrofurantoin/nitrofuran mac MACROBID iodoquinol YODOXIN furazolidone FUROXONE Anaerobic Antiprotozoal-Antibacterial Agents nitrofurantoin FURADANTIN metronidazole FLAGYL Oxazolidinones metronidazole FLAGYL ER PA linezolid ZYVOX Anthelmintics PA tedizolid phosphate tablet SIVEXTRO TABLET

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

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

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Ammonia Inhibitors PA venetoclax VENCLEXTA lactulose CHRONULAC Antineoplastic – Hedgehog Pathway Inhibitors sodium phenylbutyrate BUPHENYL POWDER PA vismodegib ERIVEDGE

sodium phenylbutyrate BUPHENYL TABLET PA sonidegib phosphate ODOMZO

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

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

Portfolio High Formulary – July 2016 17 Portfolio High Formulary

TYLENOL-CODEINE NO.4 acetaminophen and codeine CAPITAL AND CODEINE UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE PARKINSON’S DISEASE Pancreatic Enzymes Antiparkinsonism Drugs, Anticholinergic amylase/lipase/protease PANCRELIPASE 5,000 benztropine mesylate COGENTIN amylase/lipase/protease CREON trihexyphenidyl hcl ARTANE ULTRASE Antiparkinsonism Drugs, Other ULTRASE MT ZENPEP amantadine hcl SYMMETREL UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE bromocriptine mesylate PARLODEL Anticholinergics/Antispasmodics carbidopa/levodopa PARCOPA SINEMET 25-100 dicyclomine hcl BENTYL SINEMET CR Belladonna Alkaloids carbidopa/levodopa/entacapone STALEVO belladonna alkaloids/phenobarb DONNATAL entacapone COMTAN hyoscyamine sulfate ANASPAZ pramipexole di-hcl MIRAPEX LEVBID LEVSIN-SL ropinirole hcl REQUIP QL + REQUIP XL UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE ST Anti-Ulcer Preparations selegiline hcl ELDEPRYL misoprostol CYTOTEC QL rasagiline mesylate AZILECT sucralfate CARAFATE QL + rotigotine NEUPRO Anti-Ulcer-H.pylori Agents ST lansoprazole/amox tr/clarith PREVPAC Decarboxylase Inhibitors Anticholinergics, Quaternary Ammonium carbidopa LODOSYN chlordiazepoxide/clidinium br LIBRAX SEIZURE DISORDER Histamine H2-Receptor Inhibitors Anticonvulsants cimetidine hcl TAGAMET carbamazepine CARBATROL famotidine PEPCID TEGRETOL nizatidine AXID TEGRETOL XR ranitidine hcl ZANTAC clonazepam KLONOPIN Intestinal Motility Stimulants QL diazepam DIASTAT metoclopramide hcl REGLAN divalproex sodium DEPAKOTE Proton-Pump Inhibitors DEPAKOTE ER QL + esomeprazole magnesium NEXIUM DEPAKOTE SPRINKLE ST ethosuximide ZARONTIN lansoprazole PREVACID RX gabapentin NEURONTIN omeprazole capsules (RX) PRILOSEC CAPSULES lamotrigine LAMICTAL (RX) levetiracetam KEPPRA omeprazole magnesium tablets PRILOSEC OTC oxcarbazepine TRILEPTAL (OTC) TABLETS (OTC) phenytoin DILANTIN-125 pantoprazole sodium PROTONIX DILANTIN CHEW TAB ST lansoprazole PREVACID SOLUTABS phenytoin sodium extended DILANTIN ST pantoprazole sodium suspension PROTONIX SUSP PHENYTEK URINARY TRACT - FUNCTIONAL DISORDERS primidone MYSOLINE Benign Prostatic Hypertrophy/Micturition Agents topiramate TOPAMAX alfuzosin UROXATRAL TOPAMAX SPRINKLE G + dutasteride AVODART valproate sodium DEPAKENE SYRUP ST valproic acid DEPAKENE CAPSULES finasteride PROSCAR zonisamide ZONEGRAN tamsulosin hcl FLOMAX pregabalin LYRICA Benign Prostatic Hypertrophy, 5-alpha red. Inhib & alpha-1 antag SKELETAL MUSCLE DISORDER comb agents Agents To Treat Periodic Paralysis G + dutasteride/tamsulosin hcl JALYN PA dichlorphenamide KEVEYIS ST Skeletal Muscle Relaxants Kidney Stone Agents baclofen LIORESAL PA cysteamine bitartrate PROCYSBI carisoprodol SOMA Overactive Bladder Agents, Beta-3 Adrenergic Recep carisoprodol/aspirin SOMA COMPOUND ST mirabegron MYRBETRIQ chlorzoxazone PARAFON FORTE DSC Urinary Tract Analgesic Agents cyclobenzaprine hcl FLEXERIL pentosan polysulfate sodium ELMIRON dantrolene sodium DANTRIUM Urinary Tract Anesthetic/Analgesic Agents (Azo-Dye) metaxalone SKELAXIN phenazopyridine hcl PYRIDIUM methocarbamol ROBAXIN Urinary Tract Antispasmodic, M(3) Selective Antagonists ROBAXIN-750 ST solifenacin succinate VESICARE orphenadrine citrate NORFLEX Urinary Tract Antispasmodic/Antiincontinence Agents orphenadrine/aspirin/caffeine NORGESIC FORTE oxybutynin chloride DITROPAN XL tizanidine hcl ZANAFLEX ST trospium chloride SANCTURA

ST tolterodine tartrate DETROL

Portfolio High Formulary – July 2016 18 Portfolio High Formulary

ST DETROL LA ST fesoterodine fumarate TOVIAZ VAGINAL DISORDERS MEDICATION PRESCRIBING LIMITATIONS

Vaginal Antibiotics 1. AGE RESTRICTIONS (FORMULARY)- Covered for ages: metronidazole METROGEL-VAGINAL  Concerta ≤ 18 years old VANDAZOLE  Differin ≤ 25 years old Vaginal Antifungals  Fabior ≥ 12 years old miconazole nitrate MONISTAT 3  Metadate ER ≤ 18 years old butoconazole nitrate GYNAZOLE-1  Protopic Vaginal Estrogen Preparations 0.03% ≥ 2 years old estradiol ESTRACE 0.1% ≥ 15 years old VAGIFEM  Ritalin LA 60mg ≤ 18 years old estrogens, conjugated PREMARIN  Ritalin SR ≤ 18 years old Vaginal Sulfonamides 2. AGE RESTRICTIONS (NON FORMULARY)- Covered for ages: sulfanilamide AVC  All carbinoxamine containing products ≥ 2 years old VITAMIN AND/OR MINERAL DEFICIENCY (i.e., Palgic, Tussafed, etc.) Fluoride Preparations  Aptensio XR ≤ 18 years old sodium fluoride FLUORITAB  Atralin ≤ 25 years old FLURA-DROPS  Avita ≤ 25 years old FLURA-TABS  Elidel ≥ 2 years old LURIDE  Epaned < 12 years old Folic Acid Preparations  Epaned (Step Therapy applies) ≥ 12 years old folic acid FOLIC ACID  Epiduo ≤ 25 years old Multivitamin Preparations  Epiduo Forte ≤ 25 years old folic acid/mu-vits-min th VICON FORTE  Oracea ≥ 18 years old Pediatric Vitamin Preparations  Refissa ≤ 25 years old fluoride ion/iron/vit a,c&d TRI-VI-FLOR W/IRON  Renova ≤ 25 years old fluoride ion/multivitamins POLY-VI-FLOR  Retin-A ≤ 25 years old ≤ 25 years old fluoride ion/multivits w-fe POLY-VI-FLOR W/IRON  Retin-A Micro  Retin-A Micro Pump ≤ 25 years old fluoride ion/vit a,c&d FLUORABON BASIC  Solodyn ≥ 12 years old Prenatal Vitamin Preparations  Tretin-X ≤ 25 years old prenatal vit 15/iron cb/fa/dss TRIADVANCE prenatal vit 16/iron cb/fa/dss VINATE GT 3. QUANTITY RESTRICTIONS (FORMULARY) prenatal vit 18/iron cb/fa/dss VINATE ULTRA  Abilify prenatal vit 95/fe fum/fa PRENAVITE tablets 30 tablets per 30 days Vitamin B Preparations solution 900mL per 30 days

cyanocobalamin/fa/pyridoxine FOLGARD RX  Abilify Discmelt 10mg 90 tablets per 30 days Vitamin D Preparations 15mg 60 tablets per 30 days calcitriol ROCALTROL  Adderall 60 tablets per 30 days ST VECTICAL  Adderall XR ergocalciferol DRISDOL 5mg, 10mg, 15mg 30 capsules per 30 days 20mg, 25mg, 30mg 60 capsules per 30 days  Advair Diskus 60 units per 30 days SPECIALTY INJECTABLE CROSS REFERENCE LISTING  Advair HFA 12g (1 inhaler) per 30 days  Afinitor 30 tablets per 30 days The following cross reference is being provided as a guide to  Akynzeo 1 capsule per 28 days formulary choices within prominent “specialty” injectable drug  Aldara 24 packets per 30 days categories. General specialty categories are cross referenced to  Alecensa 240 capsules per 30 days their corresponding formulary classification status and page  Alendronate solution 300mL per 28 days number. This cross reference is not meant to be all-inclusive.  Ambien / Ambien CR 30 tablets per 30 days Please refer to the Table of Contents or Index to determine  Amerge 18 tablets per 30 days formulary status of injectable medications not listed in this cross  Amitiza 60 capsules per 30 days reference (e.g., Antineoplastics, Leukocyte Stimulants, etc.).  Androxy 120 tablets per 30 days  Anoro Ellipta 60 blister packs per 30 days EPO  Arixtra Hematinics, Other Page 7 2.5mg/0.5mL 5mL (10 syringes) per 30 5mg/0.4mL days HEPATITIS C 7.5mg/0.6mL 4mL (10 syringes) per 30 Hepatitis C Treatment Agents Page 9 10mg/0.8mL days 6mL (10 syringes) per 30 HUMAN GROWTH FACTORS days Growth Hormones Page 6 8mL (10 syringes) per 30 days LOW MOLECULAR WEIGHT HEPARINS  Asmanex 1 inhaler per 30 days Heparin and Related Preparations Page 7  Asmanex HFA 13 grams per 30 days  Astelin 60mL (2 bottles) per 30 days MULTIPLE SCLEROSIS  Astepro 60mL (2 bottles) per 30 days Agents to Treat Multiple Sclerosis Page 10  Atripla 30 tablets per 30 days

2 inhalers per 28 days RHEUMATOID ARTHRITIS  Atrovent HFA Anti-Inflammatory, Pyrimidine Synthesis Inhibitors  Avinza

Portfolio High Formulary – July 2016 19 Portfolio High Formulary

30mg, 45mg, 60mg, days 75mg, 90mg 1 capsule per day 7.2mL (10 syringes) per 30 120mg 2 capsules per day days  Azilect 30 tablets per 30 days 7.6mL (2 vials) per 30 days  Breo Ellipta 60 units per 30 days  Fuzeon 1 kit per 30 days  Brilinta 60 tablets per 30 days  Genvoya 30 tablets per 30 days  Butrans 4 patches per 28 days  Geodon (oral) 60 capsules per 30 days  Caduet 30 tablets per 30 days  Glyxambi 30 tablets per 30 days  Cafergot 40 tablets 28 days  Humulin N  Cialis vial 40mL (4 vials) per 28 days 2.5mg, 5mg 30 tablets per 30 days Kwikpen 30mL (10 pens) per 28 days 10mg, 20mg 6 tablets per 30 days  Humulin R  Climara 4 patches per 28 days 100u/mL 40mL (4 vials) per 28 days  Clozaril 90 tablets per 30 day 500u/mL 40mL (2 vials) per 28 days  Colcrys 120 tablets per 30 days  Humulin R U-500  Combipatch 8 patches per 30 days Kwikpen 8 pens (4 boxes of 2 pens)  Combivir 60 tablets per 30 days per 28 days  Complera 30 tablets per 30 days  Humulin 70/30 40mL (4 vials) per 28 days  Concerta vial 30mL (10 pens) per 28 days 18mg, 27mg, 54mg 30 tablets per 30 days Kwikpen 36mg 60 tablets per 30 days  Humalog 40mL (4 vials) per 28 days  Corlanor 60 tablets per 30 days vial pen/cartridge 30mL (10 pens/cartridges) per  Cotellic 63 tablets per 28 days 28 days  Crestor 30 tablets per 30 days  Humalog Mix 50/50 / 75/25 60 capsules per 30 days  Cymbalta vial 40mL (4 vials) per 28 days  Daliresp 30 tablets per 30 days Kwikpen 30mL (10 pens) per 28 days  Depo-Testosterone 10mL per 30 days  Hydrocodone bit/acetaminophen (maximum of 4gm of  Descovy 30 tablets per 30 days acetaminophen per day):  Desvenlavaxine ER 30 tablets per 30 days 250mg 16 tablets per 1 day supply (Ranbaxy Brand) 300mg 13 tablets per 1 day supply  Dexedrine Spansule 325mg 12 tablets per 1 day supply 5mg, 10mg 60 capsules per 30 days 300mg/15ml soln 200ml per 1 day supply 15mg 120 capsules per 30 days 325mg/15ml elixir 184ml per 1 day supply  Diastat 1 kit per copay  Hysingla ER 30 tablets per 30 days  Dificid 20 tablets per 30 days  Dulera 13g (1 inhaler) per 30 days  Imitrex  Duragesic 10 patches per 30 days tablets (all strengths) 18 tablets per 30 days  Effient 30 tablets per 30 days nasal spray 12 units per 30 days  Eliquis 60 tablets per 30 days injection (kits and vials):  Emend 6mg/0.5ml vial 4 vials per 30 days 40mg 1 capsules per 21 days 6mg/0.5ml kit/refill kit 2 kits per 30 days 80mg 2 capsules per 21 days 4mg/0.5ml kit/refill kit 2 kits per 30 days 125mg 1 capsule per 21 days  Invirase  Emend Trifold Pack 1 packet per 21 days 200mg capsules 300 capsules per 30 days  Emtriva 500mg tablets 120 tablets per 30 days 10mg/mL oral solution 720mL per 30 days  Invokamet 60 tablets per 30 days 200mg capsules 30 capsules per 30 days  Invokana 30 tablets per 30 days  Epivir  Janumet 60 tablets per 30 days 10mg/mL oral solution 900mL per 30 days  Janumet XR 150mg tablets 60 tablets per 30 days 100-1000mg 30 tablets per 30 days 300mg tablets 30 tablets per 30 days 50-1000mg 60 tablets per 30 days  Epzicom 30 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  Flonase 16gm (1 bottle) per 30 days  Juxtapid 30 capsules per 30 days  Flunisolide 25mL (1 bottle) per 30 days  Kaletra  Focalin 60 tablets per 30 days oral solution 390mL per 30 days  Focalin XR 30 capsules per 30 days 100/25mg tablets 300 tablets per 30 days  Forteo 2.4mL (1 pen) per 28 days 200/50mg tablets 120 tablets per 30 days with a max duration of 2 years  Lantus per lifetime vial 40mL (4 vials) per 28 days  Fragmin Solostar 30mL (10 pens) per 28 days 2500 units/0.2mL 2mL (10 syringes) per 30  Linzess 30 capsules per 30 days 5000 units/0.2mL days  Lovaza 120 capsules per 30 days 7500 units/0.3mL 2mL (10 syringes) per 30  Lovenox 10,000 units/1mL days 30mg/0.3mL 6mL (20 syringes) per 30 12,500 units/0.5mL 3mL (10 syringes) per 30 40mg/0.4mL days 15,000 units/0.6mL days 60mg/0.6mL 8mL (20 syringes) per 30 18,000 units/0.72mL 10mL (10 syringes) per 30 80mg/0.8mL days 25,000 units/ml days 100mg/1mL 12mL (20 syringes) per 30 5mL (10 syringes) per 30 120mg/0.8mL days days 150mg/1mL 16mL (20 syringes) per 30 6mL (10 syringes) per 30 300mg/3mL days

Portfolio High Formulary – July 2016 20 Portfolio High Formulary

20mL (20 syringes) per 30  Pulmicort Flexhaler 1 inhaler per 30 days days  Pulmicort Respules 60mL (30 respules) per 30 16mL (20 syringes) per 30 days days  Qnasl 8.7g (1 canister) per 30 days 20mL (20 syringes) per 30  Qnasl Children 4.9g (1 canister) per 30 days days  Quillivant XR 30mL (10 vials) per 30 days 60mL 60mL (1 bottle) per 30 days  Lumigan 2.5ml per 30 days 120mL 240mL (2 bottles) per 30 days  Lunesta 30 tablets per 30 days 150mL 300mL (2 bottles) per 30 days  Lynparza 16 capsules per day 180mL 360mL (2 bottles) per 30 days  Marinol 60 capsules per 30 days  QVAR 17.4g (2 inhalers) per 30 days  Maxalt/ 18 tablets per 30 days  Ranexa Maxalt MLT 500mg 120 tablets per 30 days  Metadate CD 1000mg 60 tablets per 30 days 30mg 60 tablets per 30 days  Requip XL 30 tablets per 30 days 10mg, 20mg, 40mg,  Restasis 64 vials per 30 days 60mg 30 tablets per 30 days  Retrovir  Metadate ER 90 tablets per 30 days syrup 1800mL per 30 days  Methylin chewable tablet 90 tablets per 30 days capsules 180 capsules per 30 days  Migergot 20 units per 28 days tablets 60 tablets per 30 days  Movantik 30 tablets per 30 days  Revlimid 30 capsules per 30 days  MS Contin 90 tablets per 30 days  Risperdal  Namenda tablets/ODT 60 tablets per 30 days tablets 60 tablets per 30 days solution 240ml per 30 days titration pack 49 tablets per 28 days  Ritalin 90 tablets per 30 days solution 300mLper 30 days  Ritalin LA  Namenda XR 10mg, 20mg, 40mg, 30 capsules per 30 days capsules 30 capsules per 30 days 60mg titration pack 28 capsules per 28 days 30mg 60 capsules per 30 days  Namzaric 30 capsules per 30 days  Ritalin SR 90 tablets per 30 days  Narcan Nasal 2 boxes (4 nasal sprays per  Seasonale 91 tablets per 84 days 30 days  Serevent 60 doses (1 diskus) per 30  Nasacort AQ 16.5g (1 canister) per 30 days days  Nasarel 25ml (1 bottle) per 30 days  Seroquel 90 tablets per 30 days  Nasonex 17g (1 canister) per 30 days  Spiriva 30 capsules per 30 days  Neupro 30 patches per 30 days  Spiriva Respimat 1 inhaler per 30 days  Nexium  Sonata 30 capsules per 30 days capsules 30 capsules per 30 days  Stiolto Respimat 4g (60 inhalations) per 30 packets 30 packets per 30 days days  Nilandron 150mg tablet 60 tablets for first 30 days,  Strattera then 30 tablets per 30 days 10mg, 18mg, 25mg, thereafter 40mg 60 capsules per 30 days  Norvir 60mg, 80mg, 100mg 30 capsules per 30 days oral solution 450mL per 30 days  Stribild 30 tablets per 30 days capsules/tablets 360 capsules/tablets per 30  Striverdi Respimat 4g (60 inhalations) per 30 days days  Nucynta 180 tablets per 30 days  Symbyax 30 capsules per 30 days  Nucynta ER 60 tablets per 30 days  Synjardy 60 capsules per 30 days  Nuvaring 1 ring per 28 days  Tagrisso 1 tablet per day  Odefsey 30 tablets per 30 days  Tamiflu  Ortho Evra 3 patches per 28 days 30mg tablets 40 tablets per 183 days  Otrexup 1.6mL per 28 days 45mg, 75mg tablets 20 tablets per 183 days  Oxycodone hcl/acetaminophen (maximum of 4gm suspension 360mL per 183 days acetaminophen per day): NOTE: The FDA recommends a maximum of 5 days of therapy 325mg 12 tablets per 1 day supply with this drug 325mg/5ml soln 61mL per 1 day supply  Toradol 20 tablets per fill  Oxycontin  Tradjenta 30 tablets per 30 days 10mg, 15mg, 20mg, 30mg,  Travatan/Travatan Z 2.5ml per 30 days 40mg, 60mg 60 tablets per 30 days  Triumeq 30 tablets per 30 days 80mg 120 tablets per 30 days  Trulicity 2mL (4 pens) per 28 days  Perforomist 120mL per 30 days  Truvada 30 tablets per 30 days  Picato  Toujeo 13.5mL (9 prefilled pens) per 0.015% gel 3 tubes per 56 days 28 days 0.05% gel 2 tubes per 56 days  Uloric 30 tablets per 30 days  Plavix 300mg tablet 4 tablets per 30 days  Vascepa 120 capsules per 30 days  Prezcobix 30 tablets per 30 days  Vancocin Oral  Prezista 125mg and 250mg 40 capsules per 30 days oral suspension 240mL per 30 days  Viagra 6 tablets per 30 days capsules 180 capsules per 30 days  Vibramycin 60 capsules per 30 days 75mg tablets 480 tablets per 30 days  Vibra-Tabs 60 tablets per 30 days 150mg tablets 240 tablets per 30 days  Victoza 9mL (3 pens) per 30 days 60 tablets per 30 days 400mg, 600mg tablets  Videx 30 tablets per 30 days 800mg tablets solution 1200mL per 30 days  Pristiq 30 tablets per 30 days capsules 60 capsules per 30 days  Promacta 30 tablets per 30 days

Portfolio High Formulary – July 2016 21 Portfolio High Formulary

 Viramune vial 40mL (4 vials) per 28 days solution 1200mL per 30 days Solostar/cartridge 30mL (10 pens/cartridges) per tablets 60 tablets per 30 days 28 days  Aplenzin 30 tablets per 30 days  Viread  Aptensio XR 30 capsules per 30 days powder 225g powder per 30 days  Aptiom tablets 30 tablets per 30 days 200, 400 30 tablets per 30 days  Vistogard 600mg, 800mg 60 tablets per 30 days granules 24 packets per 14 days  Arcapta 30 capsules per 30 days  Vivelle Dot 8 patches per 30 days  Arnuity Ellipta 30 blister packs per 30 days  Vitekta 30 tablets per 30 days  Atelvia 4 tablets per 28 days  Vyvanse 30 capsules per 30 days  Auryxia 12 tablets per day  Xalkori 60 capsules per 30 days  Avidoxy 60 tablets per 30 days  Xarelto  Avidoxy DK 1 kit per 30 days 10mg, 20mg 30 tablets per 30 days  Axert 12 tablets per 30 days 15mg loading dose 42 tablets per 21 days,  Banzel followed by 30 tablets per 30 200mg 480 tablets per 30 days days 400mg 240 tablets per 30 days  Zenzedi 40mg/ml suspension 2400ml per 30 days 2.5mg, 5mg, 7.5mg,  Basaglar 30mL (10 pens) per 28 days 15mg 90 tablets per 30 days  Beau Rx 30g (1 tube) per 30 days 180 tablets per 30 days 10mg  Beconase AQ 25g (1 bottle) per 30 days 20mg, 30mg 60 tablets per 30 days  Belbuca 2 buccal films per day  Zerit  Belsomra 30 tablets per 30 days oral solution 2400mL per 30 days  Benoxyldoxy 1 kit per 30 days capsules 60 tablets per 30 days  Bepreve 10mL (1 bottle) per 30 days  Zetia 30 tablets per 30 days  Binosto 4 tablets per 28 days  Ziagen 30 tablets per 30 days solution 900mL per 30 days  Trintellix tablets 60 tablets per 30 days  Brisdelle 30 capsules per 30 days  Zofran oral solution  Brovana 120mL per 30 days 4mg/5ml oral solution 50ml per 15 days  Bupap 180 tablets per 30 days  Zomig/Zomig ZMT  Bydureon/Bydureon Pen 4 vials/pens per 28 days Tablets 12 tablets per 30 days  Byetta Nasal Spray 12 units per 30 days 5mcg 1.2mL (1 pen) per 30 days  Zyprexa/Zyprexa Zydis 30 tablets per 30 days 10mcg 2.4mL (1 pen) per 30 days  Cambia 9 packets per 30 days 4. QUANTITY RESTRICTIONS (NON FORMULARY)  Caverject 1 dose per 5 days  Abstral 120 tablets per 30 days  Cesamet 180 capsules per 30 days  Aciphex 30 tablets per 30 days  Chantix 56 tablets per 28 days  Aciphex Sprinkle 30 capsules per 30 days  Clarinex  Acticlate 60 tablets per 30 days 2.5mg, 5mg reditab 30 tablets per 30 days 5mg 30 tablets per 30 days  Actonel 5mg/10ml syrup 300ml per 30 days 5mg, 30mg 30 tablets per 30 days  Clarinex-D 12 hour 60 tablets per 30 days 35mg 4 tablets per 28 days  Clarinex-D 24 hour 30 tablets per 30 days 150mg 1 tablet per 28 days  Climara Pro 4 patches per 30 days  Adoxa  Conzip 30 capsules per 30 days 50mg, 75mg, 100mg 60 tablets per 30 days  Cosopt PF 60 droperettes per 30 days 150mg 60 capsules per 30 days  Daytrana 30 patches per 30 days  Adoxa Pak 100mg, 150mg 60 tablets per 30 days  Demerol solution 900mL per 30 days  Adzenys XR-ODT 30 tablets per 30 days tablets 180 tablets per 30 days  Aerospan 17.8g (2 inhalers) per 30 days  Depo-Provera 1mL per 84 days  Afrezza  Depo-subQ Provera 104 0.65mL per 84 days 4 unit 180 cartridges (2 kits) per 28  DermacinRx Silapak 1 kit per 30 days 30-4 unit + 60-8 unit days  DermasilkRx SDS 1 kit per 30 days 60-4 unit + 30-8 unit 360 cartridges (4 kits) per 28  Desoxyn 150 tablets per 30 days 60-8 unit + 30-12 unit days  Desvenlafaxine ER 30 tablets per 30 days 360 cartridges (4 kits) per 28 (fumarate) days  Dexilant 30 capsules per 30 days 360 cartridges (4 kits) per 28  D.H.E.45 30 ampules per 28 days days  Diclegis 120 tablets per 30 days  Allegra  Doryx 30mg/5ml oral susp 300ml per 30 days 50mg, 75mg 60 tablets per 30 days 360 tablets per 30 days  Allzital 100mg 60 tablets/capsules per 30  Alsuma 4 units per 28 days 150mg, 200mg days  Altoprev 30 tablets per 30 days 30 tablets per 30 days  Alvesco 12.2gms (2 inhalers) per 25  Duexis 90 tablets per 30 days days  Dyanavel XR 240mL per 30 days  Anoro Ellipta 60 blister packs per 30 days  Dymista 23g (1 bottle) per 30 days  Anzemet  Edex 1 dose per 5 days 8 tablets per fill 50mg  Edluar 30 tablets per 30 days 100mg 4 tablets per fill  Emadine 10mL (2 bottles) per 30 days  Apidra  Embeda

Portfolio High Formulary – July 2016 22 Portfolio High Formulary

20-0.8mg, 30-1.2mg, 200mg 60 capsules per 30 days 50-2mg, 60-2.4mg, 120 capsules per 30 days 80-3.2mg 2 capsules per day  Kapvay 120 tablets per 30 days 100-4mg 4 capsules per day  Karbinal ER 960mL (2 bottles) per 30 days  Emsam 30 patches per 30 days  Kazano 60 tablets per 30 days  Entresto 60 tablets per 30 days  Khedezla 30 tablets per 30 days  Epaned 1200mL per 30 days  Kombiglyze XR  Epiduo 45g (1 tube) per 30 days 2.5-1000mg 60 tablets per 30 days  Epduo Forte 45g (1 tube) per 30 days 5-500mg, 5-1000mg 30 tablets per 30 days  Ergomar SL 40 tablets per 28 days  Kytril 8 tablets per 30 days  Esomeprazole Strontium  Lamictal ODT 24.65mg 30 capsules per 30 days 25mg, 50mg 180 tablets per 30 days 49.3mg 120 capsules per 30 days 100mg 90 tablets per 30 days  Estring 1 ring per 90 days 200mg 60 tablets per 30 days  Evzio 0.8mL (2 syringes) per 365  Lamictal XR days 25mg, 50mg 180 tablets per 30 days  Fanapt 100mg 90 tablets per 30 days Tablets 60 tablets per 30 days 200mg, 250mg, 300mg 60 tablets per 30 days Titration Pack 1 pack per 28 days  Lastacft 3mL (1 bottle) per 30 days  Farxiga 30 tablets per 30 days  Latuda  Fazaclo 90 tablets per 30 days 20mg, 40mg, 60mg 30 tablets per 30 days  Felbatol 80mg 60 tablets per 30 days 400mg 270 tablets per 30 days  Lazanda 15 bottles per 30 days 600mg 180 tablets per 30 days  Lescol 60 tablets per 30 days 600mg/5ml solution 900mL per 30 days  Lescol XL 30 tablets per 30 days  Fentora 120 tablets per 30 days  Levemir  Fetzima 30 capsules per 30 days vial 40mL (4 vials) per 28 days  Firmagon 80mg/vial 1 vial per 30 days Flextouch 30mL (10 pens) per 28 days  Firmagon 120mg/vial 2 vials per 365 days  Levitra 6 tablets per 30 days  Flovent Diskus  Liptruzet 30 tablets per 30 days 50mcg, 100mcg 250mcg 60 units (1 diskus) per 30  Livalo 30 tablets per 30 days days  LoSeasonique 91 tablets per 84 days 120 units (2 diskus) per 30  Luvox CR 60 capsules per 30 days days  Luzu 60g (1 tube) per 28 days  Flovent HFA  Menostar 4 patches per 30 days 44mcg 21.2g (2 inhalers) per 30 days  Migranal 8 vials per 28 days 110mcg 12g (1 inhaler) per 30 days  Mirapex ER 30 tablets per 30 days 24g (2 inhalers) per 30 days 220mcg  Mirvaso 30g (1 tube) per 30 days 60 capsules per 30 days  Foradil  Mitigare 60 capsules per 30 days 30 capsules per 30 days  Forfivo XL  Moban  Frova 18 tablets per 30 days 25mg 270 tablets per 30 days  Fulyzaq 60 tablets per 30 days 10mg 240 tablets per 30 days  Fycompa 5mg 120 tablets per 30 days 2mg 120 tablets per 30 days  Morgidox 1 kit per 30 days 4mg, 6mg 60 tablets per 30 days  Muse 1 dose per 5 days 30 tablets per 30 days 8mg, 10mg, 12mg  Myalept 11.3mg vial 30 vials per 30 days

 Gabitril  Nesina 30 tablets per 30 days 2mg, 4mg, 12mg 120 tablets per 30 days  Nicotrol cartridge 1008 cartridges (6 inhalers) 90 tablets per 30 days 16mg per 90 days

 Gralise  Nicotrol NS 160mL (4 packs) per 90 days 300mg, 600mg 90 tablets per 30 days  Novolin N/Novolin R/ 40mL (4 vials) per 28 days Starter Pack 78 tablets per 30 days Novolin 70/30  Granisol solution 60mL per 30 days  Novolog 360mL (3 bottles) per 30 days  Hemangeol vial 40mL (4 vials) per 28 days  Horizant Flexpen/cartridge 30mL (10 pens/cartridges) per 300mg 30 tablets per 30 days 28 days 600mg 60 tablets per 30 days  Novolog Mix 70/30  Hydrocodone bit/ (max 4gm per day) vial 40mL (4 vials) per 28 days acetaminophen Kwikpen 30mL (10 pens) per 28 days Xodol 5-300mg 13 tablets per 1 day supply  Obredon 600mL per 10 days 184mL per 1 day supply Zamicet Soln 325mg/15ml  Oleptro ER  Hycofenix 473mL (1 bottle) per 30 days 150mg 45 tablets per 30 days 300mg 30 tablets per 30 days  Incruse Ellipta 30 blisters per 30 days  Omnaris 12.5g (1 bottle) per 30 days  Intermezzo 30 tablets per 30 days  Onfi  Intuniv 30 tablets per 30 days Tablets 60 tablets per 30 days  Invega Suspension 480mL per 30 days 1.5mg, 3mg, 9mg 30 tablets per 30 days  Onglyza 30 tablets per 30 days 6mg 60 tablets per 30 days  Onsolis 120 films per 30 days  Iprivask 6 syringes per 30 days  Onzetra Xsail 16 nose pieces (one dose-kit)  Irenka 30 capsules per 30 days per 30 days  Kadian  Opana ER 10mg, 20mg, 30mg, 40mg, 5mg, 7.5mg, 10mg, 15mg, 50mg, 60mg, 70mg, 80mg, 20mg 60 tablets per 30 days 100mg, 130mg, 150mg

Portfolio High Formulary – July 2016 23 Portfolio High Formulary

30mg, 40mg 120 tablets per 30 day 250mL 2000mL (8 bottles) per 30  Oseni 30 tablets per 30 days 480mL days  Osphena 30 tablets per 30 days 3840mL (8 bottles) per 30 days

 Oxycodone hcl/acetaminophen (maximum of 4gm  Spritam acetaminophen per day): 250/500/750mg 120 tablets per 30 days 300mg 13 tablets per 1 day supply 1000mg 60 tablets per 30 days 325mg 12 tablets per 1 day supply  Sprix 5 bottles per 30 days  Oxtellar XR  Staxyn ODT 6 tablets per 30 days 150mg, 300mg 30 tablets per 30 days  Stendra 6 tablets per 30 days 600mg 120 tablets per 30 days  Sumavel DosePro 4 units per 28 days  Patanase 30.5g (1 bottle) per 30 days  Subsys 120 sprays per 30 days  Pazeo 2.5mL (1 bottle) per 30 days  Symbicort 10.2g (1 inhaler) per 30 days  Pexeva 30 tablets per 30 days  Tanzeum 4 pens per 28 days  Potiga  Tasmar 90 tablets per 30 days 50mg 270 tablets per 30 days  Testim 300g (60 x 5g tubes) per 30 200mg, 300mg, 400mg 90 tablets per 30 days days  Pradaxa 60 capsules per 30 days  Timoptic Ocudose 60 droperettes per 30 days  Prestalia 30 tablets per 30 days  Tivorbex 90 capsules per 30 days  Procentra 1800mL per 30 days  Tresiba (100 U) 30 mL (10 pens) per 28 days  Qudexy XR  Tresiba (200 U) 18 mL (6 pens) per 28 days 25mg, 50mg, 100mg 30 capsules per 30 days  Trezix 10 capsules per day 150mg, 200mg 60 capsules per 30 days  Treximet 9 tablets per 30 days  Quillichew  Trokendi XR 20mg, 40mg 1 tablet per day 25mg, 50mg, 100mg 30 capsules per 30 days 30mg 2 tablets per day 200mg 60 capsules per 30 days  Rasuvo  Tudorza Pressair 1 inhaler per 30 days 7.5mg/0.15mL 1.6mL (4 syringes) per 28  Tuzistra XR 600mL per 30 days 10mg/0.2mL days  Utibron Neohaler 60 blister packs (Utibron 12.5mg/0.25mL 0.8mL (4 syringes) per 28 Inhaler) per 30 days 15mg/0.3mL days  Varubi 2 tablets per 14 days 1mL (4 syringes) per 28 days 17.5mg/0.35mL  Veramyst 10g (1 bottle) per 30 days 22.5mg/0.46mL 1.2mL (4 syringes) per 28  Versacloz 540mL per 30 day 25mg/0.5mL days  Viibryd 30 tablets per 30 days 27.5mg/0.55mL 1.4mL (4 syringes) per 28

30mg/0.6mL days  Vimpat 1.8mL (4 syringes) per 28 Tablets 60 tablets per 30 days days Solution 1200mL per 30 days 2mL (4 syringes) per 28 days  Vivlodex 1 capsule per day 2.2mL (4 syringes) per 28  Vraylar days All strengths 30 capsules per 30 days 2.4mL (4 syringes) per 28 Tritration Pack 7 blisters (1 dose-pack) per 28 days days  Razadyne  Vytorin 30 tablets per 30 days Tablets 60 tablets per 30 days  Xartemis XR 360 tablets per 30 days Solution 200mL (2 bottles) per 30 days  Xerese 10gm (2 tubes) per 365 days  Razadyne ER 30 capsules per 30 days  Xifaxan 200mg 9 tablets per fill  Relenza 2 boxes (#20 diskhalers/box)  Xigduo XR 60 tablets per 30 days per 183 days  Xyzal solution 300mL per 30 days  Relpax 12 tablets per 30 days  Zecuity 1 carton per 28 days  Rescula 10mL (2 bottles) per 30 days  Zegerid  Rexulti 30 tablets per 30 days Packets 30 packets per 30 days  Rhinocort Aqua 17.2g (2 canisters) per 30 Capsules 30 capsules per 30 days days  Zelapar 60 tablets per 30 days  Risperdal/Risperdal M-Tab 60 tablets per 30 days  Zembrace Symtouch 8mL (16 auto-injectors) per 30  Rozerem 30 tablets per 30 days days  Rytary 300 capsules per 30 days  Zetonna 6.1g (1 bottle) per 30 days  Ryzodeg 70/30 30mL (10 pens) per 28 days  Zioptan 30 droperettes per 30 days  Sabril 180 tablets per 30 days  Zipsor 120 capsules per 30 days  Samsca  Zohydro ER 60 capsules per 30 days 15mg tablets 30 tablets per 365 days  Zolpimist 7.7mL (1 pump) per 30 days 30mg tablets 60 tablets per 365 days  Zontivity 30 tablets per 30 days  SanadermRX 1 kit per 30 days  Zorvolex 90 capsules per 30 days  Sancuso 4 patches per 28 days  Zuplenz  Saphris 60 tablets per 30 days 4mg 20 films per 30 days  Savaysa 30 tablets per 30 days 8mg 10 films per 30 days  Seasonique 91 tablets per 84 days  Zyclara 2.5%: 7.5 grams (1 bottle) per  Seebri Neohaler 60 blister packs (1 Seebri 28 days. inhaler) per 30 days 3.75% pump:7.5 grams (1  Seroquel XR 30 tablets per 30 days bottle) per 28 days  Silenor 30 tablets per 30 days 3.75% packet: 28 packets per  Sitavig 4 tablets per 365 days 28 days

 Solodyn 30 tablets per 30 days

 Sotylize

Portfolio High Formulary – July 2016 24 Portfolio High Formulary

the past 120 days.  Invokana Trial of metformin (IR/ER), a sulfonylurea, pioglitazone or a combination product containing any two of the three agents above within the past 120 days. 6. STEP THERAPY EDITS (FORMULARY)  Jalyn Trial of finasteride 5mg, alfuzosin,  Abilify Discmelt Trial of two generic SSRI’s, SNRIs or doxazosin, prazosin,tamsulosin or Abilify solution generic atypical anti-psychotics terazosin within the past 120 days (risperidone, olanzapine, ziprasidone,  Jardiance Trial of metformin (IR/ER), a quetiapine, or aripiprazole tablets) sulfonylurea, pioglitazone, or a within the past 365 days. combination product containing any  Actoplus Met Trial of metformin, metformin ER, two of the three agents above within Actoplus Met XR sulfonylurea (e.g., glyburide, glipizide) the past 120 days. or pioglitazone within the past 120  Loestrin FE Trial of one generic contraceptive days within the past 120 days  Ambien CR Trial of Ambien IR within the past 180  Loestrin FE24 Trial of two generic oral contraceptives days within the past 365 days  Astepro Trial of Astelin (azelastine) within the  Lo Loestrin FE Trial of two generic oral contraceptives past 120 days within the past 365 days  Avodart Trial of Proscar, alfuzosin, doxazosin,  Loryna Trial of two different non-drospirenone prazosin, silodosin, tamsulosin or oral contraceptives (containing terazosin within the past 120 days levonorgestrel, norethindrone,  Azor Trial of ACE inhibitor, ACE inhibitor norgestimate, norgestrel, desogestrel, combination, formulary generic ARB, or ethinynodiol ace.) within the past or formulary generic ARB combination 365 days. within the past 120 days  Marinol Trial of ondansetron, corticosteroids  Benicar Trial of ACE inhibitor, ACE inhibitor and Emend within the past 365 days Benicar HCT combination, formulary generic ARB,  Myrbetriq Trial of oxybutynin IR/ER within the or formulary generic ARB combination past 120 days within the past 120 days  Neupro Trial of pramipexole IR or ropinirole IR  Daliresp Trial of Spiriva, Serevent,Breo Ellipta, within the past 120 days Advair Diskus, or Dulera within the  Nexium Trial of omeprazole, lansoprazole or past 120 days Nexium Suspension pantoprazole within the past 120 days  Desvenlafaxine ER Trial of two of the following: paroxetine,  Namzaric Trial of donepezil and memantine (Ranbaxy Brand) fluoxetine, citalopram, sertraline, within the past 365 days escitalopram, mirtazapine,  Niaspan Trial of generic/multisource statin bupropion, venlafaxine IR/ER within (atorvastatin, lovastatin, pravastatin, or the past 365 days simvastatin), or generic/multisource  Detrol Trial of oxybutynin or oxybutynin ER gemfibrozil or fenofibrate within the Detrol LA within the past 120 days past 365 days  Dificid Trial of vancomycin capsules within the  Ocella Trial of two different non-drospirenone past 120 days oral contraceptives (containing  Dovonex Trial of a topical corticosteroid within levonorgestrel, norethindrone, the past 120 days norgestimate, norgestrel, desogestrel,  Drithocreme HP Trial of a topical corticosteroid within or ethinynodiol ace.) within the past the past 120 days 365 days.  Duetact Trial of metformin, metformin ER,  Otrexup Trial of methotrexate tablet or solution sulfonylurea (e.g., glyburide, glipizide) for injection within the past 120 days or pioglitazone within the past 120  Prevacid Solutabs Trial of lansoprazole, omeprazole or days pantoprazole within the past 120 days  Exforge Trial of ACE inhibitor, ACE inhibitor  Pristiq Trial of two of the following: generic Exforge HCT combination, formulary generic ARB, paroxetine, fluoxetine, citalopram, or formulary generic ARB combination sertraline, escitalopram, mirtazapine, within the past 120 days bupropion, or venlafaxine IR/ER within  Fenoglide Trial of gemifibrozil or generic the past 365 days fenofibrate within the past 120 days  Protonix Suspension Trial of Prilosec OTC or omeprazole  Fuzeon Trial of any antiretroviral medication within the past 120 days within the past 30 days  Protopic Trial of a topical corticosteroid within  Gianvi Trial of two different non-drospirenone the past 120 days oral contraceptives (containing  Purixan Trial of mercaptopurine tablet within levonorgestrel, norethindrone, the past 120 days norgestimate, norgestrel, desogestrel,  Qnasl Trial of fluticasone or flunisolide within or ethinynodiol ace.) within the past the past 120 days 365 days.  Qnasl Children Trial of fluticasone or flunisolide within  Glyxambi Trial of metformin (IR/ER), a the past 120 days sulfonylurea, pioglitazone or a  Quillivant XR Trial of Metadate CD or Ritalin LA combination product containing any within the past 120 days two of the three agents above within  Retin-A Micro Pump Trial of generic tretinoin microspheres the past 120 days. 0.04% AND tretinoin gel 0.10% within  Invirase Trial of Isentress, Reyataz, Prezista, the past 365 days Sustiva or Atripla within the past 120  Requip XL Trial of pramipexole IR or ropinirole IR days within the past 120 days  Invokamet Trial of metformin (IR/ER), a  Sanctura Trial of oxybutynin or oxybutynin ER sulfonylurea, pioglitazone or a within the past 120 days combination product containing any  Syeda Trial of two different non-drospirenone two of the three agents above within oral contraceptives (containing

Portfolio High Formulary – July 2016 25 Portfolio High Formulary

levonorgestrel, norethindrone, days. norgestimate, norgestrel, desogestrel,  Zomig Trial of sumatriptan or rizatriptan within or ethinynodiol ace.) within the past Zomig ZMT the past 180 days 365 days.

 Synjardy Trial of metformin (IR/ER), a 7. STEP THERAPY EDITS (NON FORMULARY) sulfonylurea, pioglitazone, or a  Absorica Trial of generic isotretinoin within the combination product containing any past 120 days two of the three agents above within  Aciphex Trial of two of the following; the past 120 days. omeprazole, lansoprazole or  Tribenzor Trial of ACE inhibitor, ACE inhibitor pantoprazole or rabeprazole within the combination, formulary generic ARB or past 365 days ARB combination within the past 120  Aciphex Sprinkle Trial of two of the following; days omeprazole, lansoprazole,  Toviaz Trial of oxybutynin or oxybutynin ER pantoprazole or rabeprazole within the within the past 120 days past 365 days  Triglide Trial of gemifibrozil or generic  Acticlate Trial of generic doxycycline fenofibrate within the past 120 days monohydrate tablets within the past  Trulicity Trial of metformin (IR/ER), a 120 days sulfonylurea, pioglitazone or a  Actonel Trial of alendronate and ibandronate combination product containing any within the past 365 days two of the three agents above within  Adrenaclick Trial of Epipen within the past 120 the past 120 days. days.  Uloric Trial of allopurinol within the past 120  Adzenys XR-ODT Trial of Adderall XR in the past 120 days days  Vectical Trial of a topical corticosteroid within  Aerospan Trial of at least two of the following: the past 120 days QVAR, Asmanex or Pulmicort within  Vesicare Trial of oxybutynin or oxybutynin ER the past 365 days within the past 120 days  Allzital Trial of generic  Vestura Trial of two different non-drospirenone butalbital/acetaminophen combination oral contraceptives (containing product required levonorgestrel, norethindrone,  Altoprev Trial of two of the following: norgestimate, norgestrel, desogestrel, atorvastatin, lovastatin, pravastatin or or ethinynodiol ace.) within the past simvastatin within the past 365 days 365 days.  Alvesco Trial of at least two of the following:  Vibramycin/Vibra-Tabs Trial of generic doxycycline QVAR, Asmanex or Pulmicort within monohydrate capsules within the past the past 365 days 120 days  Anoro Ellipta Trial of Stiolto Respimat and one of  Victoza Trial of metformin (IR/ER), a the following: Spiriva, Striverdi or sulfonylurea, pioglitazone or a Serevent within the past 365 days combination product containing any  Antara Trial of gemifibrozil or generic two of the three agents above within fenofibrate within the past 120 days the past 120 days.  Anzemet Trial of ondansetron tablets or ODT  Vitekta Trial of previous HIV anti-retroviral within the past 120 days therapy within the past 120 days  Apidra Trial of Humalog within the past 120  Vyvanse Trial of one of the following: SSRI days (sertraline, escitalopram, citalopram,  Aplenzin Trial of bupropion hcl SR or XL within fluoxetine, fluvoxamine, paroxetine), the past 120 days topiramate, generic/multisource mixed  Aptensio XR Trial of methylphenidate IR, amphetamine salts (Adderall IR/XR), or generic/multisource mixed methylphenidate (IR, ER, LA, CD) amphetamine salts (Adderall) or long- within the past 120 days. acting formulation of methylphenidate  Yasmin 28 Trial of two different non-drospirenone (ER, LA, CD) within the past 120 days oral contraceptives (containing  Aptiom Trial of two of the following; levonorgestrel, norethindrone, carbamazepine, gabapentin, norgestimate, norgestrel, desogestrel, lamotrigine, levetiracetam IR or ER, or ethinynodiol ace.) within the past oxcarbazepine, valproic acid or 365 days. divalproex, topiramate, or zonisamide  Yaz Trial of two different non-drospirenone within the past 365 days oral contraceptives (containing  Arcapta Trial of Serevent Diskus or Striverdi levonorgestrel, norethindrone, Respimat within the past 120 days norgestimate, norgestrel, desogestrel,  Arnuity Ellipta Trial of at least two of the following: or ethinynodiol ace.) within the past Asmanex, Pulmicort, or QVAR within 365 days. the past 365 days  Zarah Trial of two different non-drospirenone  Asacol HD Trial of balsalazide, Lialda, Pentasa or oral contraceptives (containing Apriso within the past 120 days levonorgestrel, norethindrone,  Atelvia Trial of alendronate and ibandronate norgestimate, norgestrel, desogestrel, within the past 365 days or ethinynodiol ace.) within the past  Auvi-Q Trial of Epipen within the past 120 365 days. days  Zenzedi (2.5mg, 7.5mg) Trial of a multisource  Avandia/ Trial of metformin (IR/ER), a dextroamphetamine sulfate tablet or Avandaryl/ sulfonylurea, pioglitazone, or a dextroamphetamine solution within the Avandamet combination product containing any past 120 days two of the three agents above within  Zocor (80mg only) Trial of simvastatin 80mg or Vytorin the past 120 days. 10/80mg within the past 365 days  Avidoxy/Avidoxy DK Trial of generic doxycycline  Zolpidem ER Trial of zolpidem IR within the past 120 monohydrate 100mg capsules within

Portfolio High Formulary – July 2016 26 Portfolio High Formulary

the past 120 days 5% (OTC) and silicone tape (OTC)  Axert Trial of sumatriptan or rizatriptan within the past 365 days within the past 180 days  DermasilkRx SDS Trial of all three individual ingredients:  Banzel Trial of lamotrigine, valproic acid or triamcinolone 0.1% (RX), dimethicone topiramate within the past 120 days 5% (OTC) and silicone tape (OTC)  Basaglar Trial of preferred long acting insulin within the past 365 days within the past 120 days  Desvenlafaxine ER Trial of two of the following; generic  Beconase AQ Trial of fluticasone or flunisolide within fumarate paroxetine, fluoxetine, citalopram, the past 365 days sertraline, escitalopram, venlafaxine  Belbuca Trial of Butrans (buprenorphine ER or IR, mirtazapine or bupropion transdermal) patch within the past 120 within the past 365 days days  Dexilant Trial of omeprazole, pantoprazole, or  Belsomra Trial of zolpidem IR (Ambien), lansoprazole within the past 120 days zaleplon (Sonata) or eszopiclone  Diabetes blood glucose Trial of 1) one FreeStyle or Precision (Lunesta) within the past 120 days test strips, Bayer brands brand test strip and 2) one OneTouch  Benoxyldoxy Trial of generic doxycycline (Contour, Breeze) test strip within the past 365 days monohydrate 100mg capsules within  Diabetes blood glucose Trial of 1) one FreeStyle or Precision the past 120 days test strips, Roche brands brand test strip and 2) one OneTouch  Beau Rx Trial of Kelo-cote or Recedo within the (Accu-chek, ChemStrip) test strip within the past 365 days past 120 days  Dipentum Trial of balsalazide, Lialda, Pentasa  Bepreve Trial of generic ophthalmic or Apriso within the past 120 days antihistamine (epinastine, azelastine,  Doryx 50mg tabs Trial of generic doxycycline or olapatadine) AND Pataday monohydrate 50mg capsules within (olapatadine 0.2%) within the past 365 the past 120 days days  Doryx 75mg tabs Trial of generic doxycycline  Beyaz Trial of two different non-drospirenone monohydrate 75mg tablets within the oral contraceptives (containing past 120 days levonorgestrel, norethindrone,  Doryx 100mg tabs/caps Trial of generic doxycycline norgestimate, norgestrel, desogestrel, monohydrate 100mg capsules within or ethinynodiol ace.) within the past the past 120 day 365 days  Doryx 150mg tabs Trial of generic doxycycline  Binosto Trial of generic alendronate and monohydrate 150mg tablets within the ibandronate within the past 365 days past 120 days  Trintellix Trial of two of the following  Doryx 200mg tabs Trial of generic doxycycline generic/multisource products: monohydrate 100mg capsules within paroxetine, venlafaxine ER or IR, the past 120 days fluoxetine, citalopram, sertraline,  Duexis Trial of generic Rx IBU 400, 600mg escitalopram, mirtazapine or required within the past 120 days bupropion within the past 365 days  Dyanavel XR Trial of extended-release  Brisdelle Trial of paroxetine or venlafaxine amphetamine/dextroamphetamine oral within the past 120 days capsules within the past 120 days  Bupap Trial of generic  Dymista Trial of fluticasone or flunisolide within butalbital/acetaminophen combination the past 365 days product required  Edarbi Trial of ACE inhibitor, ACE inhibitor  Bydureon Trial of metformin (IR/ER), a combination, formulary generic ARB, sulfonylurea, pioglitazone, or a or formulary generic ARB combination combination product containing any within the past 120 days two of the three agents above and  Edarbyclor Trial of ACE inhibitor, ACE inhibitor Trulicity or Victoza within the past 365 combination, formulary generic ARB, days. or formulary generic ARB combination  Byetta Trial of metformin (IR/ER), a within the past 120 days sulfonylurea, pioglitazone, or a  Edluar Trial of zolpidem immediate-release combination product containing any tablets within the past 120 days two of the three agents above and  Elidel Trial of a topical corticosteroid within Trulicity or Victoza within the past 365 the past 120 days days.  Emadine Trial of generic ophthalmic  Cesamet Trial of ondansetron tablet or ODT antihistamine (epinastine, azelastine, within the past 120 days or olapatadine) AND Pataday  Clarinex Reditabs/ Trial of desloratadine or levocetirizine (olapatadine 0.2%) within the past 365 Clarinex syrup/ tablet within the past 120 days days Clarinex D  Enstilar Trial of topical corticosteroid within the  Conzip Trial of tramadol ER (Ultram ER) past 120 days within the past 120 days  Epaned If age ≥ 12 years, trial of enalapril  Cosopt PF Trial of dorzolamide/timolol within the tablets within the past 120 days past 120 days  Epiduo Trial of adapalene 0.1% gel within the  Cycloset Trial of metformin (Glucophage), past 120 days metformin ER, glyburide/metformin  Epiduo Forte Trial of adapalene 0.1% gel within the (Glucovance), or glipizide/metformin past 120 days (Metaglip) within the past 180 days  Esomeprazole Strontium Trial of omeprazole, lansoprazole or  Daytrana Trial of methylphenidate CD, ER, or pantoprazole within the past 120 days LA formulation or methylphenidate  Evzio Trial of Narcan nasal spray within the suspension/solution within the past past 120 days 120 days  Fanapt Trial of two generic atypical  Delzicol Trial of balsalazide, Lialda, Pentasa antipsychotics within the past 365 or Apriso within the past 120 days days  DermacinRx Silapak Trial of all three individual ingredients:  Farxiga Trial of metformin (IR/ER), a triamcinolone 0.1% (RX), dimethicone sulfonylurea, pioglitazone, or a

Portfolio High Formulary – July 2016 27 Portfolio High Formulary

combination product containing any 120 days two of the three agents above and  Khedezla Trial of two of the following generic Invokana, Invokamet, Jardiance or products: paroxetine, venlafaxine ER/ Synjardy within the past 365 days IR, fluoxetine, citalopram, sertraline, escitalopram, mirtazapine or  Fazaclo Trial of two generic atypical bupropion within the past 365 days antipsychotics within the past 365  Kombiglyze XR Trial of a formulary DPP4 days inhibitor(s)/combination (Januvia,  Felbatol Trial of lamotrigine or topiramate Janumet, Janumet XR, Tradjenta, or within the past 120 days Jentadueto within the past 120 days  Fetzima Trial of two of the following;  Lastacaft Trial of generic ophthalmic paroxetine, fluoxetine, citalopram, antihistamine (epinastine, azelastine, sertraline, escitalopram, mirtazapine, or olapatadine) AND Pataday bupropion or venlafaxine IR/ER within (olapatadine 0.2%) within the past 365 the past 365 days days  Flovent Diskus/HFA Trial of two of the following: QVAR,  Kytril Trial of ondansetron tablets or ODT Pulmicort or Asmanex within the past within the past 120 days 365 days  Lamictal ODT/XR Trial of lamotrigine IR within the past  Foradil Trial of Serevent Diskus or Striverdi 120 days Respimat within the past 120 days  Latuda Trial of two generic atypical anti-  Forfivo XL Trial of generic bupropion within the psychotics, risperidone, olanzapine, past 120 days ziprasidone, quetiapine, clozapine, or  Fortamet Trial of generic metformin ER aripiprazole in the past 365 days (Glucophage XR) within the past 120  Lescol/XL Trial of two of the following: days atorvastatin, lovastatin, pravastatin or  Frova Trial of sumatriptan or rizatriptan simvastatin within the past 365 days within the past 180 days  Levemir Trial of Lantus or Toujeo within the  Fulyzaq Trial of antiretroviral therapy within the past 120 days past 120 days  Levitra Trial of Cialis and Viagra within the  Fycompa Trial of two of the following: past 365 days carbamazepine, gabapentin,  Liptruzet lamotrigine, levetiracetam IR or ER, 10/10mg Trial of 2 of the following: atorvastatin, oxcarbazepine, valproic acid, simvastatin, pravastatin or lovastatin divalproex, topiramate or zonisamide within the past 365 days within the past 365 days 10/20mg, 10/40mg, Trial of 40mg atorvastatin or 80mg  Gabitril Trial of two of the following: 10/80mg atorvastatin within the past 120 days carbamazepine, gabapentin,  Livalo Trial of two of the following: lamotrigine, levetiracetam IR or ER, atorvastatin, lovastatin, pravastatin or oxcarbazepine, valproic acid, simvastatin within the past 365 days divalproex, topiramate or zonisamide  Loestrin 24 Fe Trial of two generic oral contraceptives within the past 365 days within the past 365 days  Giazo Trial of balsalazide or Apriso within the  Luvox CR Trial of generic paroxetine, fluoxetine, past 120 days citalopram, sertraline, escitalopram,  Glumetza Trial of generic metformin ER mirtazapine, or fluvoxamine IR within (Glucophage XR) within the past 120 the past 120 days days  Luzu Trial of ketoconazole and clotrimazole  Gralise Trial of gabapentin (Neurontin) within cream within the past 365 days the past 120 days  Mirapex ER Trial of pramipexole IR or ropinirole IR  Hemangeol For age over 1 year, trial of generic within the past 120 days propranolol oral solution within the  Moderiba Dosepak Trial of ribavirin 200mg capsule or past 120 days tablet within the past 120 days  Horizant Trial of pramiprexole (Mirapex),  Monodox 75mg caps Trial of generic doxycycline ropinirole IR (Requip) or generic monohydrate 75mg tabs within the gabapentin (Neurontin) within the past past 120 days 120 days  Morgidox Trial of generic doxycycline  Hycofenix Trial of monohydrate 100mg cap within the codine/pseudoephedrine/guaifenesin past 120 days within the past 120 days  Natazia Trial of two generic oral contraceptives  Incruse Ellipta Trial of preferred LAMA (Spiriva) within the past 365 days within the past 120 days  Neo-Synalar Trial of fluocinolone and bacitracin  Inderal XL Trial of Inderal LA within the past 120 within the past 365 days days  Nesina Trial of a formulary DPP4  Innopran XL Trial of Inderal LA within the past 120 inhibitor(s)/combination (Januvia, days Janumet, Janumet XR, Tradjenta, or  Intermezzo Trial of zolpidem immediate-release Jentadueto within the past 120 days tablets within the past 120 days  Novolin N Trial of Humulin N within the past 120  Invega Trial of two generic atypical days antipsychotics within the past 365  Novolin R Trial of Humulin R within the past 120 days. days  Irenka Trial of generic duloxetine 20mg  Novolin 70/30 Trial of Humulin 70/30 within the past capsules within the past 120 days 120 days  Kazano Trial of a formulary DPP4  Novolog Trial of Humalog within the past 120 inhibitor(s)/combination (Januvia, days Janumet, Janumet XR, Tradjenta, or  Novolog Mix 70/30 Trial of Humalog Mix 75/25 within the Jentadueto within the past 120 days past 120 days  Karbinal ER Trial of generic immediate-release  Obredon Trial of hydrocodone/homatropine carbinoxamine maleate within the past methylbromide within the past 120

Portfolio High Formulary – July 2016 28 Portfolio High Formulary

days past 120 days  Oleptro ER Trial of immediate release trazodone  Ryzodeg 70/30 Trial of preferred long acting insulin within the past 120 days and preferred pre-mixed insulin) within  Omnaris Trial of fluticasone or flunisolide within the past 365 days the past 365 days  Onfi Trial of lamotrigine or topiramate  Safyral Trial of two different non-drospirenone within the past 120 days oral contraceptives (containing  Onglyza Trial of a formulary DPP4 levonorgestrel, norethindrone, inhibitor(s)/combination (Januvia, norgestimate, norgestrel, desogestrel, Janumet, Janumet XR, Tradjenta, or or ethinynodiol ace.) within the past Jentadueto within the past 120 days 365 days.  Onzetra Xsail Trial of sumatriptan nasal spray  Savaysa Trial of Eliquis and Xarelto within the  Oracea Trial of generic doxycycline past 365 days monohydrate 50mg capsule within the  SanadermRX Trial of all three individual ingredients: past 120 days triamcinolone 0.1% (RX), dimethicone  Oseni Trial of a formulary DPP4 5% (OTC) and silicone tape (OTC) inhibitor(s)/combination (Januvia, within the past 365 days Janumet, Janumet XR, Tradjenta, or  Seebri Neohaler Trial of preferred LAMA within the past Jentadueto within the past 120 days 120 days  Ovace Plus Lotion Trial of ketoconazole shampoo/cream  Sernivo Trial of Kenalog (triamcinolone or ciclopirox shampoo/gel within the acetonide) 0.147mg/g spray within the past 120 days past 120 days  Oxtellar XR Trial of two of the following:  Seroquel XR Trial of two generic atypical anti- carbamazepine, gabapentin, psychotics, SSRIs,or SNRIs within the lamotrigine, levetiracetam IR or ER, past 365 days oxcarbazepine, valproic acid,  Sancuso Trial of ondansetron tablet or ODT divalproex, topiramate, or zonisamide within the past 120 days within the past 365 days  Saphris Trial of two generic atypical  Patanase Trial of Astelin (azelastine) within the antipsychotics within the past 365 past 120 days days  Pazeo Trial of generic antihistamine and  Silenor Trial of zolpidem IR (Ambien), Pataday within the past 365 days zaleplon (Sonata) or eszopiclone  Pennsaid Trial of Voltaren gel within the past (Lunesta) within the past 120 days 120 days  Sitavig Trial of oral acyclovir, valacyclovir or  Pexeva Trial of paroxetine IR within the past famciclovir within the past 120 days 120 days  Staxyn ODT Trial of Cialis and Viagra within the  Potiga Trial of two of the following: past 365 days carbamazepine, gabapentin,  Stendra Trial of Cialis and Viagra within the lamotrigine, levetiracetam IR or ER, past 365 days oxcarbazepine, valproic acid,  Solodyn Trial of generic minocycline immediate divalproex, topiramate, or zonisamide release within the past 120 days within the past 365 days  Sorilux Trial of a topical corticosteroid within  Pradaxa Trial of Eliquis and Xarelto within the the past 120 days past 365 days  Sotylize Trial of sotolol tablets within the past  Prestalia Trial of amlodipine and ACE inhibitor 120 days (quinapril hcl, perindopril erbumine,  Spritam Trial of generic levetiracetam ramipril, benazepril hcl, captopril, 100mg/mL solution required within the enalapril maleate, fosinopril sodium, last 120 days lisinopril, trandolapril or moexipril hcl)  Stavzor Trial of generic valproic acid or within the past 365 days divalproex within the past 120 days  Qudexy XR Trial of topiramate immediate release  Sumavel Dose-Pro Trial of generic/multisource injectable within the past 120 days sumatriptan or nasal sumatriptan  Quillichew Trial of Ritalin LA or Metadate CD (Imitrex or equivalent) within the past within the past 120 days 180 days  Rapaflo Trial of finasteride 5mg, alfuzosin,  Symbicort Trial of Dulera, Advair or Breo Ellipta doxazosin, prazosin,tamsulosin or within the past 120 days terazosin within the past 120 days  Taclonex Trial of a topical corticosteroid within  Rasuvo Trial of Otrexup and methotrexate Taclonex Scalp the past 120 days tablet or solution for injection within  Tanzeum Trial of metformin (IR/ER), a the past 365 days. sulfonylurea, pioglitazone, or a  Rayos Trial of generic prednisone within the combination product containing any past 120 days two of the three agents above and  Relpax Trial of sumatriptan or rizatriptan Trulicity or Victoza within the past 365 within the past 180 days days.  Rescula Trial of latanoprost and Lumigan or  Tasmar Trial of Comtan within the past 120 Travatan Z within the past 365 days days  Rexulti Trial of two generic atypical  Teveten Trial of ACE inhibitor, ACE inhibitor antipsychotics , SSRIs or SNRIs within Teveten HCT combination, formulary generic ARB, the past 365 days or formulary generic ARB combination  Rhinocort Aqua Trial of fluticasone or flunisolide within within the past 120 days the past 365 days  Timoptic Ocudose Trial of timolol drops within the past  Ribasphere 400mg, Trial of ribavirin 200mg capsule or 120 days 600mg, RibaPak tablet within the past 120 days  Tivorbex Trial of generic indomethacin within  Rozerem Trial of zolpidem IR (Ambien), the past 120 days zaleplon (Sonata) or eszopiclone  Topicort Spray Trial of mometasone 0.1% ointment, (Lunesta) within the past 120 days fluocinonide 0.05% cream/ointment/  Rytary Trial of Sinemet IR or CR within the gel, desoximetasone 0.25% cream, or

Portfolio High Formulary – July 2016 29 Portfolio High Formulary

betamethasone dipropionate 0.05% Zithranol RR the past 120 days cream within the past 120 days  Zolpimist Trial of zolpidem immediate-release  Tresiba Trial of preferred long-acting insulin tablets within the past 120 days within the past 120 days  Zorvolex Trial of diclofenac sodium within the past 120 days  Treximet Trial of sumatriptan within the past 180  Zuplenz Trial of ondansetron tablet or ODT days within the past 120 days  Trokendi XR Trial of topiramate IR within the past 8. GENDER EDITS (FORMULARY) 120 days  Avodart Male only  Tudorza Pressair Trial of Spiriva within the past 120  Cialis Male only days  Jalyn Male only  Utibron Neohaler Trial of preferred LAMA or LABA and  Viagra Male only LAMA/LABA(s) within the past 365 days 8. GENDER EDITS (NON-FORMULARY)  Tuzistra XR Trial of promethazine with codeine  Levitra Male only syrup within the past 120 days  Rapaflo Male only  Uceris rectal foam Trial of mesalamine enema within the  Staxyn ODT Male only past 120 days  Stendra Male only  Uceris tablet Trial of balsalazide within the past 120 days 9. PRIOR AUTHORIZATION RESTRICTIONS (FORMULARY)  Veltin Trial of two preferred topical  Actiq combination acne agents (Ziana and  Adcirca Acanya) within the past 365 days  Adempas  Veramyst Trial of fluticasone or flunisolide within

the past 365 days  Afinitor /Afinitor Disperz

 Versacloz Trial of two generic atypical  Aldara antipsychotics within the past 365  Alecensa days.  Androgel  Viibryd Trial of two of the following:  Aptivus paroxetine, fluoxetine, citalopram,  Avonex sertraline, escitalopram, mirtazapine,  Avonex Admin Pack bupropion, venlafaxine IR/ER within  Axiron the past 365 days  Bosulif  Vimovo Trial of generic naproxen within the  Cabometyx past 120 days  Cayston  Vimpat Trial of two of the following:  Cometriq carbamazepine, gabapentin,  Complera lamotrigine, levetiracetam IR or ER,  Copaxone oxcarbazepine, valproic acid,  Corlanor divalproex, topiramate or zonisamide  Cosentyx within the past 365 days  Cotellic  Vivlodex Trial of generic meloxicam within the past 120 days  Cystaran  Vraylar Trial of two generic antypical  Daraprim antipsychotics within the past 365  Delatestryl days  Depen  Vytorin: Trial of two of the following:  Depo-Testosterone 10/10mg atorvastatin, lovastatin, pravastatin or  Duragesic simvastatin within the past 365 days  Edurant 10/20mg, 10/40mg Trial of atorvastatin 40mg or  Eligard atorvastatin 80mg within the past 120  Emverm days  Enbrel 10/80mg Trial of simvastatin 80mg or Vytorin  Erivedge 10/80mg within the past 365 days  Esbriet  Xerese Trial of oral acyclovir, valacyclovir or  Fareston famciclovir within the past 120 days  Farydak  Xigduo XR Trial of metformin (IR/ER), a  Firazyr sulfonylurea, pioglitazone, or a  Gattex combination product containing any  Gilenya two of the three agents above and

Invokana, Invokamet, Jardiance or  Gilotrif Synjardy within the past 365 days.  Gleevec  Xyzal Solution Trial of desloratadine or levocetirizine  Grastek tablet within the past 120 days  Harvoni  Zecuity Trial of generic/multisource  Humira sumatriptan and nasal sumatriptan  Ibrance within the past 365 days  Iclusig  Zegerid Trial of omeprazole, lansoprazole or  Imbruvica pantoprazole within the past 120 days  Impavido  Zembrace Symtouch Trial of sumatriptan injection  Inlyta  Zetonna Trial of fluticasone or flunisolide within  Intelence the past 365 days  Intron A  Zioptan Trial of latanoprost and Lumigan or  Iressa Travatan Z within the past 365 days  Jakafi  Zipsor Trial of diclofenac sodium within the  Juxtapid past 120 days  Kalydeco  Zithranol Trial of a topical corticosteroid within

Portfolio High Formulary – July 2016 30 Portfolio High Formulary

 Keveyis  Xenazine  Korlym  Xifaxan 550mg  Kynamro  Xtandi  Lenvima  Xuriden  Letairis  Zelboraf  Leukine  Zydelig  Lexiva  Zykadia  Lonsurf  Zytiga  Lynparza  Zyvox  Mekinist

 Neulasta 10. PRIOR AUTHORIZATION RESTRICTIONS (NON FORMULARY)

 Neupogen  Abraxane*

 Nexavar  Abstral  Ninlaro  Actemra IV*

 Norditropin  Actemra SC  Odefsey  Adcetris*

 Odomzo  Addyi

 Ofev  Afrezza

 Omnitrope  Alimta*

 Opsumit  Ampyra

 Oralair  Amturnide

 Orkambi  Anadrol-50

 Pegasys  Androderm

 Plegridy  Apokyn

 Plegridy Pen  Aranesp

 Pomalyst  Arzerra*  Praluent  Aubagio

 Procrit  Avastin*

 Procysbi  Beleodaq*

 Promacta  Belviq

 Provigil  Berinert

 Pulmozyme  Betaseron  Ragwitek  Bethkis  Rebif  Bivigam*  Rebif Rebidose  Blincyto*  Relistor  Botox*  Repatha  Bunavail

 Revatio tablets 

 Revlimid  Caprelsa

 Selzentry  Carimune NF Nanofiltered*

 Sivextro  Cerezyme*

 Sovaldi  Cholbam

 Sprycel  Cimzia

 Stivarga  Cinqair  Stelara  Cinryze  Strensiq  Contrave

 Suboxone  Cuprimine

 Subutex  Cyramza*

 Sutent  Daklinza

 Tafinlar  Darzalex*

 Tagrisso  Durlaza  Tarceva  Duopa  Targretin  Dysport*  Tasigna  Egrifta  Tecfidera  Elelyso*  Temodar capsules  Elspar*  Thalomid  Empliciti*  Tivicay  Entresto  Tobi  Entyvio*  Tobi Podhaler  Epogen  Tracleer  Erbitux*  Trizivir  Erwinase*  Tybost  Euflexxa*  Tykerb  Evekeo  Uptravi  Exalgo  Valchlor  Exondys 51*  Venclexta  Extavia  Votrient  Eylea*  Xalkori  Faslodex*  Xeljanz  Fentora  Xeljanz XR  Flebogamma DIF*  Xeloda  Flolan*

Portfolio High Formulary – July 2016 31 Portfolio High Formulary

 Fortesta  Orthovisc*  Gamastan S-D*  Otezla  Gammagard Liquid  Oxandrin  Gammagard S-D*  Pegintron  Gammaked  Pegintron Redipen  Gammaplex*  Perjeta*  Gamunex-C  Photofrin*  Gazyva*  Portrazza*  Gleostine  Privigen*  Gel-One*  Prolia*  Genotropin  PProvigil  Granix*  Qsymia  H.P. Acthar*  Qutenza  Halaven*  Ravicti  Herceptin*  Remicade*  Hetlioz  Remodulin  Hizentra  Revatio vial*  Humatrope  Revatio suspension  Hyalgan*  Rituxan*  Hymovis*  Saizen  Hyqvia IG Component  Saxenda  Ilaris*  Serostim  Imlygic*  Signifor  Incivek  Simponi SC  Increlex  Simponi Aria IV*  Inflectra*  Sirturo  Iprivask  Solaraze  Istodax*  Soliris*  Ixempra*  Stivarga  Jublia  Striant  Kadcyla*  Subsys  Kalbitor*  Sucraid  Kanuma*  Supartz*  Keytruda*  Suprenza ODT  Kineret  Sylatron  Kitabis Pak  Sylvant*  Kyprolis*  Synagis*  Lazanda  Synribo*  Lemtrada*  Synvisc*  Lucentis*  Synvisc-One*  Lumizyme*  Taltz  Macugen*  Technivie  Makena  Tekamlo  Marqibo*  Tekturna  Mircera  Tekturna HCT  Monovisc*  Temodar Vial*  Mozobil*  Testim  MMyobloc*  Testred  NNatesto  Tev-Tropin  NNatpara  Thyrogen*  NNeulasta Delivery Kit*  Torisel*  Northera  Translarna  Novantrone*  Tysabri*  Nucala*  Tyvaso  Nuedexta  Unituxin*  Nuplazid  Valturna  Nutropin  Vecamyl  Nutropin AQ  Vectibix*  Nutropin AQ NuSpin  Velcade*  Nuvigil  Veletri*  Nymalize  Veltassa  Ocaliva  Venclexta  Octagam*  Ventavis  Olysio  Viberzi  Omontys  Viekira Pak  Oncaspar*  Vimizim*  Onivyde*  Vogelxo  Onsolis  Vpriv*  Opdivo*  Xeomin*  Orencia IV*  Xgeva*  Orencia SC  Xolair*  Orenitram ER  Xyrem

Portfolio High Formulary – July 2016 32 Portfolio High Formulary

 Yervoy*  Yondelis*  Zaltrap*  Zarxio  Zavesca  Zepatier  Zoladex*  Zomacton  Zorbtive  Zubsolv  Zyclara

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

11. CONCURRENT USE EDITS (FORMULARY)  Suboxone  Subutex

12. CONCURRENT USE EDITS (NON FORMULARY)  Bunavail  Zubsolv

Portfolio High Formulary – July 2016 33 Portfolio High Formulary INDEX

5-grass pollen extract...... 6 aminophylline ...... 6 AXID ...... 18 8-MOP ...... 10 amiodarone hcl ...... 7 AXIRON ...... 13 abacavir sulfate ...... 14 AMITIZA ...... 16 axitinib ...... 16 abacavir sulfate/lamivudine ...... 14 amitriptyline hcl ...... 7 AYGESTIN...... 13 abacavir/dolutegravir/lamivudine ...... 14 amlodipine bes/olmesartan med ...... 8 azathioprine ...... 13 abacavir/lamivudine/zidovudine ...... 14 amlodipine besylate ...... 8 azelastine hcl ...... 6, 12 ABBOTT DIABETIC SUPPLIES ...... 11 amlodipine besylate/benazepril ...... 7 AZILECT ...... 18 ABILIFY DISCMELT ...... 7 amlodipine/atorvast cal ...... 9 azithromycin ...... 13 ABILIFY SOLUTION ...... 7 amlodipine/valsartan ...... 8 AZOPT ...... 12 ABILIFY TABLET ...... 7 amlodipine/valsartan/hctz ...... 8 AZOR ...... 8 abiraterone acetate ...... 16 AMNESTEEM ...... 9 aztreonam lysine ...... 13 ACANYA ...... 9 amox tr/potassium clavulanate ...... 14 AZULFIDINE ...... 15 acarbose ...... 10 amoxapine ...... 7 bacitracin ...... 12 ACCUPRIL ...... 8 amoxicillin trihydrate ...... 14 bacitracin/polymyxin b sulfate ...... 12 ACCURETIC ...... 8 AMOXIL ...... 14 baclofen ...... 18 acebutolol hcl ...... 8 amphet asp/amphet/d-amphet ...... 7 BACTRIM DS ...... 13 acetaminophen with codeine ...... 17, 18 ampicillin trihydrate ...... 14 BACTROBAN ...... 9, 10 acetazolamide ...... 12 amylase/lipase/protease ...... 18 BACTROBAN NASAL ...... 17 acetic acid ...... 11 ANAFRANIL...... 7 balsalazide disodium ...... 15 acetic acid/aluminum acetate ...... 11 anagrelide hcl ...... 13 BARACLUDE ...... 15 acetic acid/hydrocortisone ...... 11 ANALPRAM HC ...... 15 becaplermin ...... 11 acetylcysteine ...... 17 ANAPROX ...... 15 beclomethasone dipropionate ...... 6 acitretin ...... 10 ANAPROX DS ...... 15 belladonna alkaloids/phenobarb ...... 18 ACLOVATE ...... 10 ANASPAZ ...... 18 benazepril hcl ...... 8 ACTIGALL ...... 16 anastrozole ...... 16 benazepril/hydrochlorothiazide ...... 7 ACTIQ ...... 17 ANDROGEL...... 13 BENEMID ...... 13 ACTOPLUS MET ...... 11 ANDROID ...... 13 BENICAR ...... 8 ACTOPLUS MET XR ...... 11 ANDROXY ...... 13 BENICAR HCT ...... 8 ACTOS ...... 11 ANSAID ...... 15 BENTYL ...... 18 ACULAR ...... 12 ANTABUSE ...... 7 BENZACLIN ...... 9 ACULAR LS ...... 12 anthralin ...... 10 BENZAMYCIN ...... 9 acyclovir ...... 10, 14 antipyrine/benzocaine otic ...... 11 BENZAMYCIN PAK ...... 10 ADALAT CC ...... 8 ANTIVERT ...... 6 BENZOTIC...... 11 adalimumab ...... 15 ANUSOL-HC ...... 15 benzoyl peroxide...... 9 adapalene ...... 9 APEXICON ...... 10 benzoyl peroxide/hydrocortison ...... 9 ADCIRCA ...... 8 APEXICON E ...... 10 benztropine mesylate ...... 18 ADDERALL ...... 7 apixaban ...... 13 besifloxacin hcl drops susp 0.6% ...... 12 ADDERALL XR ...... 7 aprepitant ...... 6 BESIVANCE ...... 12 ADEMPAS ...... 8 APRESOLINE ...... 8 BETAGAN ...... 12 ADVAIR DISKUS ...... 6 APRISO ...... 15 betamet diprop/prop gly ...... 10 ADVAIR HFA ...... 6 APTIVUS ...... 14 betamethasone dipropionate ...... 6, 10 afatinib ...... 16 ARALEN PHOSPHATE ...... 14 betamethasone valerate ...... 10 AFINITOR ...... 16 ARAVA ...... 15 BETAPACE ...... 8 AFINITOR DISPERZ ...... 16 ARICEPT ...... 6 BETAPACE AF ...... 8 AFTERA ...... 9 ARICEPT ODT ...... 6 betaxolol hcl ...... 12 AGRYLIN ...... 13 ARIMIDEX ...... 16 bethanechol chloride ...... 16 AK-TRACIN ...... 12 aripiprazole...... 7 BETIMOL ...... 12 AKYNZEO ...... 6 ARIXTRA ...... 13 BETOPTIC ...... 12 ALAMAST ...... 12 ARMOUR THYROID ...... 12 BETOPTIC S ...... 12 ALA-TET ...... 14 AROMASIN...... 16 bexarotene ...... 10, 16 ALAWAY OTC ...... 12 ARTANE ...... 18 BIAXIN ...... 13 albuterol sulfate ...... 6 ASACOL ...... 15 BIAXIN XL ...... 13 ALBUTEROL SULFATE ...... 6 ASENDIN ...... 7 bicalutamide ...... 16 alclometasone dipropionate ...... 10 asfotase alfa., STRENSIQ ...... 17 BIDIL ...... 9 ALDACTONE ...... 8 ASMANEX ...... 6 BILTRICIDE ...... 14 ALDARA ...... 13 ASMANEX HFA ...... 6 bimatoprost 0.01% ...... 12 ALDOMET ...... 8 ASTELIN ...... 6 bimatoprost 0.03% ...... 12 ALECENSA ...... 16 ASTEPRO ...... 6 bimonidine/timolol ...... 12 alectinib hydrochloride ...... 16 ATARAX ...... 6 bisoprolol fumarate ...... 8 alendronate sodium ...... 11 atazanavir sulfate ...... 15 bisoprolol fumarate/hctz ...... 8 alendronate sodium solution ...... 12 atazanavir sulfate/cobicistat ...... 15 BLEPHAMIDE ...... 12 alendronate sodium/vitamin d3 ...... 11 atenolol ...... 8 BLEPHAMIDE S.O.P...... 12 alfuzosin ...... 18 atenolol/chlorthalidone ...... 8 BLOCADREN ...... 8 alirocumab ...... 8 ATIVAN ...... 7 blood sugar diagnostic ...... 11 ALKERAN ...... 16 atomoxetine hcl ...... 7 blood-glucose calib. control ...... 11 allopurinol ...... 13 atorvastatin calcium ...... 8 blood-glucose meter ...... 11 ALOCRIL ...... 12 ATRIPLA ...... 15 BONIVA ...... 12 ALOMIDE ...... 12 atropine sulfate ...... 12 bosentan ...... 8 ALORA ...... 13 ATROVENT ...... 6, 17 BOSULIF ...... 16 ALPHAGAN P ...... 12 ATROVENT HFA ...... 6 bosutinib ...... 16 alprazolam ...... 7 AUGMENTIN ...... 14 BRAVELLE ...... 11 ALPRAZOLAM INTENSOL ...... 7 AUGMENTIN ES-600 ...... 14 BREO ELLIPTA ...... 6 ALREX ...... 12 AUGMENTIN XR ...... 14 BRETHINE...... 6 ALTACE ...... 8 AVALIDE ...... 8 BREVOXYL-4 ...... 9 altretamine ...... 16 AVAPRO ...... 8 BREVOXYL-8 ...... 9 aluminum chloride ...... 10 AVC ...... 19 BRILINTA ...... 13 ALUPENT ...... 6 AVELOX ...... 14 brimonidine tartrate ...... 12 amantadine hcl ...... 18 AVELOX ABC PACK ...... 14 brinzolamide ...... 12 AMARYL ...... 10 AVIANE-28 ...... 9 brinzolamide/brimonidine ...... 12 AMBIEN ...... 7 AVINZA ...... 17 bromocriptine mesylate...... 18 ambrisentan ...... 8 AVLOSULFON ...... 14 budesonide ...... 6, 15 amcinonide ...... 10 AVODART ...... 18 BUDESONIDE ...... 15 AMERGE ...... 17 AVONEX ...... 17 bumetanide ...... 8 AMINOPHYLLIN ...... 6 AVONEX ADMINISTRATION PACK ...... 17 BUMEX ...... 8

Portfolio High Formulary – July 2016 34 Portfolio High Formulary INDEX

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

Portfolio High Formulary – July 2016 35 Portfolio High Formulary INDEX dexmethylphenidate hcl ...... 7 EDURANT ...... 14 ethambutol hcl ...... 14 dextroamphetamine capsule ...... 7 efavirenz ...... 14 ethinyl estradiol/drospirenone ...... 9 dextroamphetamine sulfate ...... 7 efavirenz/emtricitab/tenofovir ...... 15 ethosuximide ...... 18 dextroamphetamine tablet ...... 7 EFFEXOR ...... 6 ethynodiol d-ethinyl estradiol ...... 9 EFFEXOR XR ...... 6 etidronate disodium ...... 12 DIABETA ...... 11 EFFIENT ...... 13 etodolac ...... 15 DIABINESE ...... 10 EFUDEX ...... 10 etonogestrel/ethinyl estradiol ...... 9 DIAMOX SEQUELS ...... 12 ELAVIL ...... 7 etoposide ...... 16 DIASTAT ...... 18 ELDEPRYL ...... 18 etravirine ...... 14 diazepam ...... 7, 18 ELIGARD ...... 11 EULEXIN ...... 16 DIBENZYLINE ...... 8 ELIMITE ...... 10 EURAX ...... 10 dichlorphenamide ...... 18 ELIQUIS ...... 13 everolimus ...... 13, 16 diclofenac sodium ...... 10, 12, 15 ELMIRON ...... 18 EVISTA ...... 12 dicloxacillin sodium ...... 14 ELOCON ...... 10 EVOCLIN ...... 10 dicyclomine hcl ...... 18 eltrombopag olamine ...... 13 evolocumab ...... 8 didanosine ...... 14, 15 elviteg/cobi/emtric/tenofo ala ...... 14 EVOTAZ ...... 15 DIDRONEL ...... 12 elvitegravir ...... 15 EVOXAC ...... 16 DIFFERIN ...... 9 elvitegravir/cobicistat/emtricitabine/ tenofovir EXELDERM ...... 10 DIFICID ...... 14 disoproxil fumarate ...... 14 EXELON ...... 6 diflorasone diacetate ...... 10 EMCYT ...... 17 EXELON PATCH ...... 6 diflorasone diacetate/emoll ...... 10 EMEND ...... 6 exemestane ...... 16 DIFLUCAN ...... 14 EMGEL ...... 9 EXFORGE ...... 8 diflunisal ...... 17 empagliflozin ...... 11 EXFORGE HCT ...... 8 difluprednate ...... 12 empagliflozin/linagliptin ...... 11 ezetimibe ...... 9 digoxin ...... 7 empagliflozin/metformin hcl ...... 11 FABIOR ...... 9 DIGOXIN ORAL SOLN ...... 7 emtricitabine ...... 15 famotidine...... 18 dihydrotachysterol ...... 19 emtricitabine/tenofov alafenam ...... 14 FARESTON ...... 16 DILACOR XR ...... 8 emtricitabine/tenofovir ...... 14 FARYDAK ...... 16 DILANTIN ...... 18 emtrictab/rilpiviri/tenof ala ...... 15 febuxostat ...... 13 DILANTIN CHEW TAB ...... 18 EMTRIVA ...... 15 FELDENE ...... 15 DILANTIN-125 ...... 18 EMVERM……………………..……………………14 felodipine ...... 8 DILAUDID ...... 17 enalapril maleate ...... 8 FEMHRT ...... 13 DILAUDID-5 ...... 17 enalapril/hydrochlorothiazide ...... 7 fenofibrate ...... 9 diltiazem hcl ...... 8 ENBREL ...... 15 fenofibrate nanocrystallized ...... 9 dimethyl fumarate ...... 17 ENDOMETRIN ...... 11 fenofibrate, micronized...... 9 DIOVAN ...... 8 enfuvirtide ...... 14 fenoprofen calcium ...... 15 DIOVAN HCT ...... 8 enoxaparin sodium ...... 13 fentanyl ...... 17 diphenoxylate hcl/atrop sulf ...... 16 entacapone ...... 18 fentanyl citrate lozenge ...... 17 dipivefrin hcl ...... 12 entecavir ...... 15 FERTINEX ...... 11 DIPROLENE ...... 10 ENTOCORT EC ...... 15 fesoterodine fumarate ...... 18 DIPROLENE AF ...... 10 enzalutamide ...... 16 fidaxomicin ...... 14 DIPROSONE ...... 10 epinephrine ...... 16 filgrastim ...... 13 dipyridamole ...... 13 EPIPEN ...... 16 finasteride...... 18 DISALCID ...... 17 EPIPEN JR ...... 16 fingolimod hcl ...... 17 disopyramide phosphate ...... 7 EPIVIR ...... 15 FIORICET ...... 17 disulfiram ...... 7 EPIVIR HBV SOLUTION ...... 15 FIORICET WITH CODEINE ...... 17 DITROPAN XL ...... 18 EPIVIR HBV TABLET ...... 15 FIORINAL ...... 17 divalproex sodium ...... 18 eplerenone...... 8 FIORINAL WITH CODEINE ...... 17 d-methorphan hb/prometh hcl ...... 9 epoetin alfa ...... 13 FIRAZYR ...... 15 dofetilide ...... 7 EPZICOM ...... 14 FIRST-HYDROCORTISONE ...... 10 DOLOBID ...... 17 ergocalciferol ...... 19 FLAGYL ...... 14 DOLOPHINE HCL ...... 17 ergotamine tartrate/caffeine ...... 17 FLAGYL ER ...... 14 dolutegravir ...... 15 ERIVEDGE ...... 16 FLAREX ...... 12 DOMEBORO ...... 11 erlotinib hcl ...... 16 flecainide acetate ...... 7 donepezil hcl ...... 6 ery e-succ/sulfisoxazole ...... 13 FLEXERIL ...... 18 DONNATAL ...... 18 ERYC ...... 13 FLOMAX ...... 18 dornase alfa ...... 17 ERYGEL ...... 9 FLONASE ...... 6 dorzolamide hcl ...... 12 ERYPED 200 ...... 13, 14 FLORINEF ACETATE ...... 15 dorzolamide hcl/timolol maleat ...... 12 ERYPED 400 ...... 14 FLOXIN ...... 11, 14 DOSTINEX ...... 12 ERY-TAB ...... 13 fluconazole ...... 14 DOVONEX ...... 10 ERYTHROCIN STEARATE ...... 13 fludarabine phosphate ...... 16 doxazosin mesylate ...... 8 erythromycin base ...... 12, 13 fludrocortisone acetate ...... 15 doxepin hcl ...... 7 erythromycin base/benz per ...... 9, 10 flunisolide ...... 6 doxycycline calcium ...... 14 erythromycin base/ethanol ...... 9 fluocinolone acetonide ...... 10 doxycycline hyclate ...... 14 erythromycin ethylsuccinate ...... 13, 14 fluocinonide ...... 10 doxycycline monohydrate ...... 14 erythromycin stearate ...... 13 fluocinonide/emollient ...... 10 DRISDOL ...... 19 ESBRIET ...... 17 FLUORABON BASIC ...... 19 DRITHOCREME HP ...... 10 escitalopram oxalate ...... 6 fluoride ion/iron/vit a,c&d ...... 19 DRITHO-SCALP ...... 10 ESGIC ...... 17 fluoride ion/multivitamins ...... 19 dronabinol ...... 6 ESKALITH ...... 7 fluoride ion/multivits w-fe ...... 19 dronedarone hcl ...... 7 esomeprazole magnesium ...... 18 fluoride ion/vit a,c&d ...... 19 DRYSOL ...... 10 estazolam ...... 7 FLUORITAB ...... 19 DUAVEE ...... 13 ESTRACE ...... 13, 19 fluorometholone...... 12 DUETACT ...... 11 ESTRADERM ...... 13 fluorometholone acetate ...... 12 DULERA ...... 6 estradiol ...... 13, 19 fluorouracil ...... 10 duloxetine hcl ...... 6 estradiol/noreth ac ...... 13 fluoxetine er ...... 6 DUONEB ...... 6 estramustine phosphate sodium ...... 17 fluoxetine hcl ...... 6 DURAGESIC ...... 17 ESTRATEST H.S...... 13 fluoxymesterone ...... 13 DUREZOL ...... 12 estrogen, con/m-progest acet ...... 13 fluphenazine hcl ...... 7 DURICEF ...... 13 estrogen, ester/me-testosterone...... 13 FLURA-DROPS ...... 19 dutasteride ...... 18 estrogens, conj/bazedoxifene ...... 13 flurandrenolide ...... 10 dutasteride/tamsulosin ...... 18 estrogens, conjugated ...... 13, 19 FLURA-TABS ...... 19 DYAZIDE ...... 8 estrogens, esterified...... 13 flurazepam hcl ...... 7 DYNACIN ...... 14 estropipate ...... 13 flurbiprofen ...... 15 DYNACIRC ...... 8 eszopiclone ...... 7 flurbiprofen sodium ...... 12 EC-NAPROSYN ...... 15 etanercept ...... 15 flutamide ...... 16

Portfolio High Formulary – July 2016 36 Portfolio High Formulary INDEX fluticasone propionate ...... 6, 10 HEXALEN ...... 16 INVIRASE ...... 15 fluticasone/salmeterol ...... 6 homatropine hbr ...... 12 INVOKAMET ...... 11 fluticasone/vilanterol ...... 6 HUMALOG ...... 11 INVOKANA ...... 11 FML ...... 12 HUMALOG MIX 50-50 ...... 11 iodoquinol ...... 14 FML FORTE ...... 12 HUMALOG MIX 75-25 ...... 11 ipratropium bromide ...... 6, 17 FML S.O.P...... 12 HUMATIN ...... 14 ipratropium/albuterol sulfate ...... 6 FOCALIN ...... 7 HUMIRA ...... 15 irbesartan ...... 8 FOCALIN XR ...... 7 HUMULIN 70-30 ...... 11 irbesartan/hydrochlorithiazide ...... 8 FOLGARD RX ...... 19 HUMULIN N ...... 11 IRESSA ...... 16 folic acid ...... 19 HUMULIN R ...... 11 ISENTRESS ...... 15 FOLIC ACID ...... 19 HUMULIN R U-500 ...... 11 ISMO ...... 9 folic acid/mu-vits-min th ...... 19 HYCAMTIN ...... 16 ISOCHRON ...... 9 FOLLISTIM AQ ...... 11 HYCET ...... 17 isomethept/acetaminop/dichlphn ...... 17 follitropin alpha,recomb ...... 11 HYCODAN ...... 9 isoniazid ...... 14 follitropin beta,recomb ...... 11 hydralazine hcl ...... 8 ISOPTO ATROPINE ...... 12 fondaparinux sodium...... 13 HYDREA ...... 16 ISOPTO CARBACHOL ...... 12 formoterol fumarate ...... 6 hydrochlorothiazide ...... 8 ISOPTO CARPINE ...... 12 FORTEO ...... 11 hydrocodone bit/acetaminophen ...... 17 ISOPTO HOMATROPINE ...... 12 FOSAMAX ...... 11, 12 hydrocodone bit/acetaminophen oral elixir .. 17 ISORDIL ...... 9 FOSAMAX PLUS D ...... 11 hydrocodone bit/acetaminophen oral solution ISORDIL TITRADOSE ...... 9 fosamprenavir calcium ...... 15 ...... 17 isosorb dinit/hydralazine hcl ...... 9 fosinopril sodium ...... 8 hydrocodone bit/homatrop me-br ...... 9 isosorbide dinitrate ...... 9 fosinopril/hydrochlorothiazide ...... 7 hydrocodone bitartrate ...... 17 isosorbide mononitrate ...... 9 FRAGMIN ...... 13 hydrocodone/chlorphen p-stirex ...... 9 isotretinoin ...... 9 FURADANTIN ...... 14 hydrocort/sal acid/sulf/shmp#1 ...... 10 isradipine IR capsules ...... 8 furazolidone ...... 14 hydrocortisone ...... 10, 15 itraconazole ...... 14 furosemide ...... 8 hydrocortisone acetate ...... 15 ivabradine hcl ...... 9 FUROXONE ...... 14 hydrocortisone acetate/urea ...... 10 ivacaftor ...... 17 FUZEON ...... 14 hydrocortisone butyrate ...... 10 ixazomib citrate ...... 16 gabapentin ...... 18 hydrocortisone butyrate/emoll ...... 10 JAKAFI ...... 16 galantamine hbr ...... 6 hydrocortisone probutate ...... 10 JALYN ...... 18 ganciclovir ...... 12, 14 hydrocortisone valerate ...... 10 JANUMET ...... 10 ganirelix acetate ...... 12 hydromorphone hcl ...... 17 JANUMET XR ...... 10 GANIRELIX ACETATE ...... 12 hydroxychloroquine sulfate ...... 14 JANUVIA ...... 10 GANTRISIN ...... 13 hydroxyurea ...... 16 JARDIANCE ...... 11 GARAMYCIN ...... 9, 12 hydroxyzine hcl ...... 6 JENTADUETO ...... 10 gatifloxacin ...... 12 hydroxyzine pamoate ...... 6 JUXTAPID ...... 8 GATTEX ...... 16 HYGROTON ...... 8 KALETRA ...... 15 gefitinib ...... 16 hyoscyamine sulfate ...... 18 KALYDECO ...... 17 gemfibrozil ...... 9 HYPER-SAL 7% ...... 17 KAYEXALATE ...... 11 gentamicin sulfate ...... 9, 12 HYSINGLA ER ...... 17 K-DUR ...... 11 GENVOYA ...... 14 HYTRIN ...... 8 KEFLEX ...... 13 GEODON ...... 7 HYZAAR ...... 8 KENALOG ...... 10 GIANVI ...... 9 ibandronate ...... 12 KENALOG IN ORABASE ...... 17 GILENYA ...... 17 IBRANCE ...... 16 KEPPRA ...... 18 GILOTRIF ...... 16 ibrutinib ...... 16 KETEK ...... 13 glatiramer acetate ...... 17 ibuprofen ...... 15 ketoconazole ...... 10, 14 GLEEVEC ...... 16 icatibant ...... 15 ketoprofen ...... 15 glimepiride ...... 10 ICLUSIG ...... 16 ketorolac tromethamine ...... 12, 15 glipizide ...... 10 icosapent ethyl ...... 9 ketotifen fumarate (OTC) ...... 12 glipizide/metformin hcl ...... 10 idelalisib ...... 16 KEVEYIS ...... 18 glucagon ...... 11 ILEVRO ...... 12 KLARON ...... 9 GLUCAGON KIT ...... 11 imatinib mesylate ...... 16 KLONOPIN ...... 18 GLUCOPHAGE ...... 11 IMBRUVICA ...... 16 KORLYM ...... 11 GLUCOPHAGE XR ...... 11 IMDUR ...... 9 KRISTALOSE ...... 16 GLUCOTROL ...... 10 imipramine hcl ...... 7 K-TAB ...... 11 GLUCOTROL XL ...... 10 imiquimod ...... 13 KURIC ...... 10 GLUCOVANCE ...... 11 IMITREX INJECTION ...... 17 KUVAN ...... 16 glyburide ...... 10, 11 IMITREX NASAL SPRAY ...... 17 KWELL ...... 10 glyburide, micro/metformin hcl ...... 11 IMITREX TABLET ...... 17 KYNAMRO...... 8 GLYXAMBI ...... 11 IMPAVIDO ...... 14 labetalol hcl ...... 8 GOLYTELY ...... 16 IMURAN ...... 13 LACTICARE-HC ...... 10 gonadotropin,chorionic, human ...... 11 indapamide ...... 8 lactulose ...... 16 GONAL-F ...... 11 INDERAL LA ...... 8 LAMICTAL ...... 18 GONAL-F RFF ...... 11 INDERIDE-40/25 ...... 8 LAMISIL ...... 10, 14 GRASTEK ...... 6 indinavir sulfate ...... 15 LAMISIL GRANULES ...... 14 griseofulvin suspension ...... 14 INDOCIN ...... 15 lamivudine ...... 15 griseofulvin ultramicrosize ...... 14 INDOCIN ORAL SUSP...... 15 lamivudine/zidovudine ...... 14 GRISEOFULVIN V ...... 14 INDOCIN SR ...... 15 lamotrigine ...... 18 GRIS-PEG ...... 14 INDOCIN SUPPOS ...... 15 lancing device/lancets ...... 11 guanfacine hcl ...... 8 indomethacin ...... 15 LANOXIN ...... 7 GYNAZOLE-1 ...... 19 ingenol ...... 10 lansoprazole ...... 18 HALCION ...... 7 INLYTA ...... 16 lansoprazole/amox tr/clarith ...... 18 HALDOL ...... 7 INSPRA ...... 8 LANTUS ...... 11 HALDOL ORAL CONC ...... 7 insulin glargine,hum.rec.anlog ...... 11 lapatinib ditosylate ...... 16 halobetasol propionate ...... 10 insulin lispro ...... 11 LARIAM ...... 14 haloperidol ...... 7 insulin nph hum/reg insulin hm ...... 11 LASIX ...... 8 haloperidol lactate ...... 7 insulin nph human isophane ...... 11 latanoprost ...... 12 HARVONI ...... 15 insulin npl/insulin lispro ...... 11 ledipasvir/sofosbuvir ...... 15 hc acetate/pramoxine hcl ...... 10, 15 insulin regular, human ...... 11 leflunomide ...... 15 hcg alpha, recombinant ...... 11 INTAL ...... 6 lenalidomide ...... 16 HEPARIN LOCK ...... 13 INTELENCE...... 14 lenvatinib mesylate ...... 16 heparin sodium, porcine ...... 13 interferon alfa-2b, recomb...... 13 LENVIMA ...... 16 heparin sodium, porcine/pf ...... 13 interferon beta-1a ...... 17 LESSINA ...... 9 HEP-LOCK ...... 13 interferon beta-1a/albumin ...... 17 LETAIRIS ...... 8 HEPSERA ...... 15 INTRON A ...... 13 LEUKERAN ...... 16

Portfolio High Formulary – July 2016 37 Portfolio High Formulary INDEX

LEUKINE ...... 13 LURIDE ...... 19 miconazole nitrate ...... 19 leuprolide ...... 11 LUTERA ...... 9 MICRO-K ...... 11 LEVAQUIN ...... 14 LYNPARZA ...... 16 MICRONASE ...... 10 LEVBID ...... 18 LYRICA ...... 18 MICROZIDE ...... 8 levetiracetam ...... 18 LYSODREN ...... 16 midodrine hcl ...... 9 levobunolol hcl ...... 12 macitentan ...... 8 MIDRIN ...... 17 levocetirizine ...... 6 MACROBID ...... 14 mifepristone ...... 11 levofloxacin ...... 14 MACRODANTIN ...... 14 MIGERGOT ...... 17 levonorgestrel ...... 9 malathion ...... 10 MILLIPRED ...... 15 levonorgestrel-eth estra ...... 9 maprotiline hcl ...... 7 MILLIPRED DP ...... 15 LEVOTHROID ...... 12 maraviroc ...... 14 milnacipran hcl ...... 17 levothyroxine sodium ...... 12 MARINOL ...... 6 miltefosine ...... 14 LEVOXYL ...... 12 MATULANE ...... 16 MILTOWN ...... 7 LEVSIN-SL ...... 18 MAVIK ...... 8 MINIPRESS ...... 8 LEXAPRO ...... 6 MAXALT ...... 17 MINOCIN ...... 14 LEXIVA ...... 15 MAXALT MLT ...... 17 minocycline hcl ...... 14 LIBRAX ...... 18 MAXITROL ...... 12 mipomersen sodium ...... 8 LIBRIUM ...... 7 MAXZIDE ...... 8 mirabegron...... 18 LIDEX ...... 10 MAXZIDE-25MG ...... 8 MIRALAX ...... 16 LIDEX-E ...... 10 mebendazole ...... 14 MIRAPEX ...... 18 lidocaine hcl ...... 15 mechlorethamine ...... 10 MIRCETTE ...... 9 LIFESCAN DIABETIC SUPPLIES ...... 11 meclizine hcl ...... 6 mirtazapine ...... 6 linaclotide ...... 15 meclofenamate sodium ...... 15 misoprostol ...... 18 linagliptin ...... 10 MECLOMEN ...... 15 mitotane ...... 16 linagliptin/metformin hcl ...... 10 MEDROL ...... 15 MOBIC ...... 15 lindane ...... 10 medroxyprogesterone acet ...... 13 modafinil ...... 7 linezolid ...... 14 mefloquine hcl ...... 14 moexipril hcl ...... 8 LINZESS ...... 15 MEGACE ...... 17 moexipril/hydrochlorothiazide ...... 8 LIORESAL ...... 18 megestrol acetate ...... 17 mometasone furoate ...... 6, 10 liothyronine sodium ...... 12 MEKINIST ...... 16 mometasone/formoterol ...... 6 LIPITOR ...... 8 MELLARIL ...... 7 MONISTAT 3 ...... 19 liraglutide ...... 10 meloxicam ...... 15 MONOKET...... 9 lisdexamfetamine dimesylate ...... 7 melphalan ...... 16 MONOPRIL ...... 8 lisinopril ...... 8 memantine hcl ...... 6 MONOPRIL HCT ...... 7 lisinopril/hydrochlorothiazide ...... 7 memantine hcl/donepezil hcl ...... 6 montelukast sodium ...... 6 lithium carbonate ...... 7 MENEST ...... 13 morphine sulfate ...... 17 lithium citrate ...... 7 MENOPUR ...... 11 MOTRIN ...... 15 LITHOBID ...... 7 menotropins ...... 11 MOVANTIK ...... 16 LO LOESTRIN FE ...... 9 MEPHYTON ...... 13 moxifloxacin hcl ...... 12, 14 LO MINASTRIN FE ...... 9 meprobamate ...... 7 MSIR ...... 17 LOCOID ...... 10 mercaptopurine ...... 16 mth/me blue/salicy/na phos/hyo ...... 13 LOCOID LIPOCREAM ...... 10 mesalamine ...... 15 MUCOMYST-10 ...... 17 LODINE ...... 15 mesalamine w/cleansing wipes ...... 15 MULTAQ ...... 7 LODOSYN ...... 18 MESTINON ...... 6 mupirocin ...... 9 lodoxamide tromethamine ...... 12 METADATE CD ...... 7 mupirocin calcium ...... 10, 17 LOESTRIN ...... 9 METADATE ER ...... 7 MYAMBUTOL ...... 14 LOESTRIN FE ...... 9 METAGLIP ...... 10 MYCELEX ...... 14 LOESTRIN FE24 ...... 9 metaproterenol sulfate ...... 6 MYCIFRADIN ...... 14 LOFIBRA ...... 9 metaxalone ...... 18 MYCOLOG II ...... 10 lomitapide ...... 8 metformin hcl ...... 11 mycophenolate mofetil ...... 13 LOMOTIL ...... 16 meth/meth blue/ba/salicy/hyos ...... 13 MYCOSTATIN ...... 10, 14 lomustine ...... 16 methadone hcl ...... 17 MYLERAN ...... 16 LONSURF ...... 16 methazolamide ...... 12 MYORISAN ...... 9 LO-OVRAL-28 ...... 9 METHERGINE ...... 9 MYRBETRIQ ...... 18 LOPID ...... 9 methimazole ...... 12 MYSOLINE ...... 18 lopinavir/ritonavir ...... 15 METHITEST ...... 13 na sulfacetm/prednis sp ...... 12 LOPRESSOR ...... 8 METHLYIN SOLN ...... 7 na sulfacetm/prednisol ac ...... 12 LOPRESSOR HCT ...... 8 methocarbamol ...... 18 nabumetone ...... 15 LOPROX ...... 10 methotrexate ...... 15 nadolol ...... 8 loratadine (OTC) ...... 6 methotrexate sodium ...... 15, 16 naftifine hcl ...... 10 lorazepam ...... 7 METHOTREXATE TABLET ...... 16 NAFTIN ...... 10 LORAZEPAM INTENSOL ...... 7 METHOTREXATE VIAL ...... 16 NALFON CAPSULE ...... 15 LORCET ...... 17 methoxsalen ...... 10 NALFON TABLET ...... 15 LORCET PLUS ...... 17 methoxsalen, rapid ...... 10 naloxegol oxalate ...... 16 LORTAB ...... 17 methyldopa...... 8 naltrexone hcl ...... 7 LORTAB ELIXIR ...... 17 methylergonovine maleate ...... 9 NAMENDA ...... 6 LORYNA ...... 9 METHYLIN CHEW TAB ...... 7 NAMENDA XR ...... 6 losartan potassium ...... 8 methylnaltrexone bromide ...... 16 NAMZARIC ...... 6 losartan/hydrochlorothiazide ...... 8 methylphenidate ER Susp ...... 7 NAPROSYN ...... 15 LOTEMAX ...... 12 methylphenidate hcl ...... 7 naproxen ...... 15 LOTENSIN ...... 8 methylprednisolone ...... 15 naproxen sodium ...... 15 LOTENSIN HCT ...... 7 methyltestosterone ...... 13 naratriptan ...... 17 loteprednol etabonate ...... 12 metipranolol ...... 12 NARCAN NASAL ...... 7 LOTREL ...... 7 metoclopramide hcl ...... 18 NARDIL ...... 6 LOTRISONE ...... 10 METOCLOPRAMIDE HCL INTENSOL ...... 18 NASACORT AQ ...... 6 lovastatin ...... 8 metolazone ...... 8 NASAREL ...... 6 LOVAZA ...... 9 metoprolol succinate ...... 8 NASONEX ...... 6 LOVENOX ...... 13 metoprolol tartrate ...... 8 nateglinide ...... 10 loxapine succinate ...... 7 metoprolol/hctz ...... 8 NATURE-THROID ...... 12 LOXITANE ...... 7 METROCREAM ...... 9 NAVANE ...... 7 LOZOL ...... 8 METROGEL-VAGINAL ...... 19 nebivolol hcl ...... 8 lubiprostone ...... 16 METROLOTION ...... 9 NEBUPENT ...... 14 LUDIOMIL ...... 7 metronidazole ...... 9, 14, 19 nedocromil sodium ...... 12 lumacaftor/ivacaftor ...... 17 MEVACOR ...... 8 needles, insulin disp., safety ...... 17 LUMIGAN ...... 12 mexiletine hcl ...... 7 nelfinavir mesylate ...... 15 LUNESTA ...... 7 MEXITIL ...... 7 neo/polymyx b sulf/dexameth ...... 12

Portfolio High Formulary – July 2016 38 Portfolio High Formulary INDEX neomy sulf/bacitrac zn/poly/hc ...... 12 ODOMZO ...... 16 peginterferon alfa-2a ...... 15 neomy sulf/polymyx b sulf/hc ...... 10, 11, 12 OFEV ...... 17 peginterferon beta-1a ...... 17 neomy sulf/polymyx b sulf/pred ...... 12 ofloxacin ...... 11, 12, 14 pegvisomant ...... 12 neomycin sulfate ...... 14 OFORTA ...... 16 pemirolast potassium ...... 12 neomycin/bacitra/polymyxin/hc ...... 10 OGEN ...... 13 penicillamine ...... 15 neomycin/bacitracin/polymyxin ...... 12 olanzapine ...... 7 penicillin v potassium ...... 14 neomycin/polymyxn b/gramicidin ...... 12 olanzapine ODT ...... 7 pentamidine isethionate ...... 14 NEORAL ...... 13 olanzapine/fluoxetine ...... 6 pentosan polysulfate sodium ...... 18 NEOSPORIN OPHTH DROPS ...... 12 olaparib ...... 16 pentoxifylline ...... 13 NEOSPORIN OPHTH OINTMENT ...... 12 olmesartan medoxomil ...... 8 PEPCID ...... 18 neostigmine bromide...... 6 olmesartan/amlodipin/hcthiazid ...... 8 p-ephed hcl/cetirizine hcl (OTC) ...... 6 nepafenac ...... 12 olmesartan/hydrochlorothiazide ...... 8 p-ephed sul/loratadine ...... 6 NEPTAZANE ...... 12 olodaterol hcl ...... 6 PERCOCET ...... 17 netupitant/palonosetron hcl ...... 6 olopatadine hcl ...... 12 PERCODAN ...... 17 NEULASTA ...... 13 OLUX ...... 10 PERCOLONE ...... 17 NEUPOGEN ...... 13 omega-3 acid ethyl esters ...... 9 PERFOROMIST ...... 6 NEUPRO ...... 18 omeprazole ...... 18 PERIDEX ...... 17 NEURONTIN ...... 18 omeprazole magnesium ...... 18 PERISOL ...... 17 NEVANAC ...... 12 OMNICEF ...... 13 permethrin ...... 10 nevirapine ...... 14 OMNIPRED ...... 12 perphenazine ...... 7 nevirapine ER ...... 14 OMNITROPE ...... 12 PERSANTINE ...... 13 NEXAVAR ...... 16 ondansetron ...... 6 phenazopyridine hcl ...... 18 NEXIUM ...... 18 ondansetron hcl ...... 6 phenelzine sulfate ...... 6 niacin ...... 9 OPSUMIT ...... 8 PHENERGAN ...... 6 NIASPAN ...... 9 OPTICROM ...... 12 PHENERGAN VC ...... 9 nicardipine ...... 8 OPTIPRANOLOL ...... 12 PHENERGAN VC W/CODEINE ...... 9 nifedipine ...... 8 OPTIVAR ...... 12 PHENERGAN W/CODEINE ...... 9 NILANDRON...... 16 ORALAIR ...... 6 PHENERGAN W/DEXTROMETHORPHAN ...... 9 nilotinib hydrochloride ...... 16 ORAMORPH SR ...... 17 phenobarbital ...... 7 nilutamide ...... 16 ORAPRED ...... 15 PHENOBARBITAL ...... 7 nimodipine ...... 8 ORINASE ...... 11 phenoxybenzamine hcl ...... 8 NIMOTOP ...... 8 ORKAMBI ...... 17 phenylephrine hcl/cod/prometh ...... 9 NINLARO ...... 16 orphenadrine citrate ...... 18 phenylephrine hcl/prometh hcl ...... 9 nintedanib esylate ...... 17 orphenadrine/aspirin/caffeine ...... 18 PHENYTEK ...... 18 NITRO-BID ...... 9 ORSYTHIA ...... 9 phenytoin...... 18 NITRO-DUR ...... 9 ORTHO EVRA ...... 9 phenytoin sodium extended ...... 18 nitrofurantoin ...... 14 ORTHO MICRONOR ...... 9 PHOSLO ...... 11 nitrofurantoin macrocrystal ...... 14 ORTHO TRI-CYCLEN ...... 9 PHRENILIN ...... 17 nitrofurantoin/nitrofuran mac ...... 14 ORTHO TRI-CYCLEN LO ...... 9 PHRENILIN FORTE ...... 17 nitroglycerin ...... 9 ORTHO-CEPT ...... 9 phytonadione ...... 13 NITROLINGUAL ...... 9 ORTHO-CYCLEN ...... 9 PICATO ...... 10 NITROSTAT ...... 9 ORTHO-NOVUM ...... 9 pilocarpine hcl ...... 12, 16 nizatidine ...... 18 ORUVAIL ...... 15 pindolol ...... 8 NIZORAL ...... 10, 14 OSCELLA ...... 9 pioglitazone hcl ...... 11 NOCTEC ...... 7 oseltamivir phosphate ...... 14 pioglitazone hcl/metformin hcl ...... 11 NOLVADEX ...... 16 osimertinib mesylate ...... 16 pioglitazone/glimepiride ...... 11 NORCO ...... 17 OTICIN HC ...... 11 pirfenidone ...... 17 NORDETTE-28 ...... 9 OTREXUP ...... 15 piroxicam ...... 15 NORDITROPIN ...... 12 OVACE PLUS SUSPENSION ...... 10 PLAN B ONE-STEP ...... 9 NORDITROPIN FLEXPRO ...... 12 OVIDE ...... 10 PLAQUENIL ...... 14 NORDITROPIN NORDIFLEX ...... 12 OVIDREL ...... 11 PLAVIX ...... 13 norelgestromin/ethin.estradiol ...... 9 oxaprozin ...... 15 PLAVIX 300MG ...... 13 noreth a-et estra/fe fumarate ...... 9 oxazepam ...... 7 PLEGRIDY...... 17 norethindrone ...... 9 oxcarbazepine ...... 18 PLEGRIDY PEN ...... 17 norethindrone acetate ...... 13 OXSORALEN ...... 10 PLENDIL ...... 8 norethindrone ac-eth estradiol ...... 13 OXSORALEN-ULTRA ...... 10 PLETAL ...... 13 norethindrone a-e estradiol ...... 9 oxybutynin chloride ...... 18 PODHALER ...... 14 norethindrone-ethinyl estrad ...... 9 oxycodone hcl ...... 17 podofilox ...... 9 norethindrone-mestranol ...... 9 oxycodone hcl/acetaminophen ...... 17 POLYCILLIN ...... 14 NORFLEX ...... 18 oxycodone hcl/aspirin ...... 17 POLYCIN-B ...... 12 NORGESIC FORTE...... 18 OXYCONTIN ...... 17 polyethylene glycol 3350 ...... 16 norgestimate-ethinyl estradiol ...... 9 palbociclib ...... 16 polymyxin b sulfate/tmp ...... 12 norgestrel-ethinyl estradiol ...... 9 PAMELOR ...... 7 POLYTRIM ...... 12 NORINYL 1+35 ...... 9 PANCRELIPASE 5,000 ...... 18 POLY-VI-FLOR ...... 19 NORINYL 1+50 ...... 9 PANDEL ...... 10 POLY-VI-FLOR W/IRON ...... 19 NORPACE ...... 7 panobinostat lactate ...... 16 pomalidomide ...... 16 NORPACE CR ...... 7 pantoprazole sodium ...... 18 POMALYST ...... 16 NORPRAMIN ...... 7 PARAFON FORTE DSC ...... 18 ponatinib ...... 16 NOR-Q-D ...... 9 PARCOPA ...... 18 potassium chloride ...... 11 nortriptyline hcl ...... 7 paricalcitol ...... 12 potassium iodide ...... 12 NORVASC ...... 8 PARLODEL...... 18 POTASSIUM IODIDE ...... 12 NORVIR ...... 15 PARNATE ...... 6 PRALUENT ...... 8 NOVAREL ...... 11 paromomycin sulfate ...... 14 pramipexole di-hcl ...... 18 NUCYNTA ...... 17 paroxetine hcl ...... 6 pramlintide acetate...... 10 NUCYNTA ER ...... 17 PATADAY ...... 12 PRAMOSONE ...... 10 NULYTELY WITH FLAVOR PACKS ...... 16 PATANOL ...... 12 PRANDIMET ...... 11 NUVARING ...... 9 PATHOCIL ...... 14 PRANDIN ...... 10 NYDRAZID ...... 14 PAXIL ...... 6 prasugrel hcl ...... 13 nystatin ...... 10, 14 pazopanib hydrochloride ...... 16 PRAVACHOL ...... 8 nystatin/triamcin ...... 10 PCE ...... 13 pravastatin sodium ...... 8 OCL ...... 16 PEDIAPRED ...... 15 praziquantel ...... 14 octreotide acetate ...... 17 PEDIAZOLE...... 13 prazosin hcl ...... 8 OCUFEN ...... 12 peg 3350/na sulf,bicarb,cl/kcl ...... 16 PRECOSE ...... 10 OCUFLOX ...... 12 PEGASYS ...... 15 PRED FORTE ...... 12 OCUPRESS ...... 12 PEGASYS PROCLICK ...... 15 PRED MILD ...... 12 ODEFSEY ...... 15 pegfilgrastim ...... 13 PREDNISOL ...... 12

Portfolio High Formulary – July 2016 39 Portfolio High Formulary INDEX prednisolone ...... 15 QUESTRAN LIGHT ...... 8 RYTHMOL ...... 7 prednisolone acetate ...... 12 quetiapine fumarate ...... 7 RYTHMOL SR ...... 7 prednisolone sod phosphate ...... 12, 15 QUILLIVANT XR ...... 7 SALAGEN ...... 16 prednisone ...... 15 QUINAGLUTE ...... 7 salmeterol xinafoate ...... 6 PREDNISONE INTENSOL ...... 15 quinapril hcl ...... 8 salsalate ...... 17 pregabalin ...... 18 quinapril/hydrochlorothiazide ...... 8 SANDIMMUNE ...... 13 PREGNYL ...... 11 QUINIDEX ...... 7 SANDOSTATIN ...... 17 PREMARIN ...... 13, 19 quinidine gluconate ...... 7 sapropterin dihydrochloride ...... 16 PREMPHASE ...... 13 quinidine sulfate ...... 7 saquinavir mesylate ...... 15 PREMPRO ...... 13 quinine sulfate ...... 14 sargramostim ...... 13 prenatal vit 15/iron cb/fa/dss ...... 19 QVAR ...... 6 SAVELLA ...... 17 prenatal vit 16/iron cb/fa/dss ...... 19 RAGWITEK...... 6 SCALACORT ...... 10 prenatal vit 18/iron cb/fa/dss ...... 19 raloxifene hcl ...... 12 SCALACORT DK ...... 10 prenatal vit 95/fe fum/fa ...... 19 raltegravir potassium ...... 15 SEASONALE ...... 9 PRENATE GT ...... 19 ramipril ...... 8 SECTRAL ...... 8 PRENAVITE ...... 19 RANEXA ...... 9 secukinumab ...... 10 PREVACID ...... 18 ranitidine hcl ...... 18 selegiline hcl ...... 18 PREVACID SOLUTABS ...... 18 ranolazine ...... 9 selenium sulfide ...... 10 PREVPAC ...... 18 RAPAMUNE ...... 13 selexipag ...... 8 PREZCOBIX ...... 14 rasagiline mesylate ...... 18 SELSUN RX ...... 10 PREZISTA ...... 14 RAZADYNE ...... 6 SELZENTRY ...... 14 PRILOSEC ...... 18 RAZADYNE ER ...... 6 SEPTRA ...... 13 PRILOSEC OTC ...... 18 REBETOL ...... 15 SEPTRA DS ...... 13 PRIMAQUINE ...... 14 REBIF ...... 17 SERAX ...... 7 primaquine phosphate ...... 14 REBIF REBIDOSE ...... 17 SEREVENT DISKUS ...... 6 primidone ...... 18 REDERM ...... 10 SEROPHENE ...... 11 PRIMSOL ...... 13 REGLAN ...... 18 SEROQUEL ...... 7 PRINIVIL ...... 8 regorafenib ...... 16 SERPASIL ...... 8 PRINZIDE ...... 7 REGRANEX...... 11 sertraline hcl ...... 6 PRISTIQ ...... 6 RELAFEN ...... 15 sevelamer carbonate ...... 11 PROAIR HFA ...... 6 RELISTOR ...... 16 sevelamer hcl ...... 11 PROAIR RESPICLICK ...... 6 REMERON ...... 6 SFROWASA ...... 15 PROAMATINE ...... 9 RENAGEL ...... 11 short ragweed pollen extract ...... 6 probenecid ...... 13 RENVELA ...... 11 sildenafil citrate ...... 8, 11 procainamide hcl ...... 7 repaglinide...... 10 SILVADENE ...... 10 procarbazine hcl ...... 16 repaglinide/metformin hcl ...... 11 silver sulfadiazine ...... 10 PROCARDIA ...... 8 REPATHA ...... 8 SIMBRINZA ...... 12 PROCARDIA XL ...... 8 REPRONEX...... 11 simvastatin ...... 8 PROCHIEVE...... 11 REQUIP ...... 18 simvastatin (80mg only) ...... 8 prochlorperazine edisylate ...... 6 REQUIP XL...... 18 SINEMET 25-100 ...... 18 prochlorperazine maleate ...... 6 RESCRIPTOR ...... 14 SINEMET CR ...... 18 PROCRIT ...... 13 reserpine ...... 8 SINEQUAN ...... 7 PROCTOCORT ...... 15 RESTASIS ...... 12 SINGULAIR ...... 6 PROCTOCREAM-HC ...... 15 RESTORIL ...... 7 sirolimus ...... 13 PROCTOFOAM-HC ...... 15 RETROVIR ...... 15 sitagliptin phos/metformin hcl ...... 10 PROCTO-KIT ...... 15 REVATIO TABLET...... 8 sitagliptin phosphate ...... 10 PROCYSBI ...... 18 REVIA ...... 7 SIVEXTRO...... 14 PROFASI ...... 11 REVLIMID ...... 16 SKELAXIN ...... 18 progesterone, micronized ...... 11, 13 REYATAZ ...... 15 SLO-NIACIN ...... 9 PROGRAF ...... 13 RHEUMATREX ...... 15 sod chloride/nahco3/kcl/peg's ...... 16 PROLIXIN ...... 7 ribavirin ...... 14, 15 sodium chloride for inhalation ...... 17 PROLOPRIM ...... 13 RIFADIN ...... 14 sodium fluoride ...... 19 PROMACTA ...... 13 RIFAMATE ...... 14 sodium phenylbutyrate ...... 16 promethazine hcl ...... 6 rifampin ...... 14 sodium polystyrene sulfonate ...... 11 PROMETRIUM ...... 13 rifampin/isoniazid ...... 14 sofosbuvir ...... 15 PRONESTYL ...... 7 rifaximin ...... 14 SOFTCLIX ...... 11 propafenone hcl ...... 7 rilpivirine ...... 14 SOMA ...... 18 PROPINE ...... 12 rilpivirine/ emtricitabine/ tenofovir disoproxil SOMA COMPOUND ...... 18 propranolol hcl ...... 8 fumarate ...... 15 SOMA COMPOUND WITH CODEINE ...... 17 propranolol/hydrochlorothiazid ...... 8 riociguat ...... 8 somatropin ...... 12 propylthiouracil ...... 12 RIOMET ...... 11 SOMAVERT ...... 12 PROPYLTHIOURACIL ...... 12 RISPERDAL ...... 7 SONATA ...... 7 PROSCAR ...... 18 RISPERDAL M-TAB ...... 7 sonidegib phosphate ...... 16 PROSED-DS ...... 13 risperidone ...... 7 sorafenib tosylate ...... 16 PROSOM ...... 7 risperidone ODT ...... 7 SORIATANE ...... 10 PROSTIGMIN ...... 6 RITALIN ...... 7 sotalol hcl ...... 8 PROTONIX ...... 18 RITALIN LA...... 7 SOTRET ...... 9 PROTOPIC ...... 10 RITALIN-SR ...... 7 SOVALDI ...... 15 PROVERA ...... 13 ritonavir ...... 15 SPIRIVA ...... 6 PROVIGIL ...... 7 rivaroxaban ...... 13 SPIRIVA RESPIMAT ...... 6 PROZAC ...... 6 rivastigmine ...... 6 spironolactone ...... 8 PROZAC WEEKLY ...... 6 rivastigmine tartrate ...... 6 SPORANOX ...... 14 PULMICORT FLEXHALER ...... 6 rizatriptan benzoate ...... 17 SPRYCEL ...... 16 PULMICORT RESPULES ...... 6 ROBAXIN ...... 18 STAGESIC-10 ...... 17 PULMOZYME ...... 17 ROBAXIN-750 ...... 18 STALEVO ...... 18 PURINETHOL ...... 16 ROCALTROL ...... 19 STARLIX ...... 10 PURIXAN ...... 16 roflumilast ...... 6 stavudine ...... 15 pyrazinamide ...... 14 ROMYCIN ...... 12 STELARA ...... 15 PYRAZINAMIDE ...... 14 ropinirole hcl ...... 18 STELAZINE ...... 7 PYRIDIUM ...... 18 rosuvastatin calcium ...... 8 STIOLTO RESPIMAT ...... 6 pyridostigmine bromide ...... 6 rotigotine ...... 18 STIVARGA...... 16 pyrimethamine ...... 14 ROWASA ...... 15 STRATTERA ...... 7 QNASL ...... 6 ROXANOL ...... 17 STRIBILD ...... 14 QNASL CHILDREN ...... 6 ROXICET ...... 17 STRIVERDI RESPIMAT ...... 6 QUALAQUIN...... 14 ROXICODONE ...... 17 SUBOXONE ...... 17 QUESTRAN ...... 8 ROXICODONE INTENSOL...... 17 SUBUTEX ...... 17

Portfolio High Formulary – July 2016 40 Portfolio High Formulary INDEX sucralfate ...... 18 thioridazine hcl ...... 7 TYBOST ...... 15 sulconazole nitrate ...... 10 thiothixene...... 7 TYKERB ...... 16 SULFAC ...... 12 THORAZINE ...... 7 TYLENOL-CODEINE ...... 17 sulfacetamide sodium ...... 9, 10, 12 thyroid, pork ...... 12 TYZEKA ...... 15 sulfadiazine ...... 13 TIAZAC ...... 8 ULORIC ...... 13 SULFADIAZINE ...... 13 ticagrelor ...... 13 ULTRACET ...... 17 sulfamethoxazole/trimethoprim ...... 13 TIKOSYN ...... 7 ULTRAM ...... 17 sulfanilamide ...... 19 timolol ...... 12 ULTRASE ...... 18 sulfasalazine ...... 15 timolol maleate ...... 8, 12 ULTRASE MT ...... 18 sulfisoxazole acetyl ...... 13 TIMOPTIC ...... 12 ULTRAVATE ...... 10 sulindac ...... 15 TIMOPTIC-XE ...... 12 UNIPHYL ...... 6 sumatriptan ...... 17 timothy grass pollen extract ...... 6 UNIRETIC ...... 8 sumatriptan succinate ...... 17 tiotropium br/olodaterol hcl ...... 6 UNIVASC ...... 8 sunitinib malate ...... 16 tiotropium bromide ...... 6 UPTRAVI ...... 8 SUPRAX ...... 13 tipranavir ...... 14 URECHOLINE ...... 16 SUSTIVA ...... 14 tipranavir/vitamin e tpgs ...... 14 URETRON D-S ...... 13 SUTENT ...... 16 TIVICAY ...... 15 uridine triacetate ...... 16, 17 SYEDA ...... 9 tizanidine hcl ...... 18 URIN D.S...... 13 SYMBYAX ...... 6 TOBI ...... 14 urofollitropin (fsh) ...... 11 SYMLIN ...... 10 TOBRADEX ...... 12 UROXATRAL ...... 18 SYMLINPEN 120 ...... 10 tobramycin for inhalation ...... 14 URSO ...... 16 SYMLINPEN 60 ...... 10 tobramycin sulfate ...... 12 URSO FORTE ...... 16 SYMMETREL ...... 18 tobramycin sulfate/dexameth ...... 12 ursodiol ...... 16 SYNALAR ...... 10 tobramycin/lotepred etab ...... 12 ustekinumab ...... 15 SYNJARDY ...... 11 TOBREX ...... 12 VAGIFEM ...... 19 SYNTHROID...... 12 tofacitinib citrate ...... 16 valacyclovir hcl ...... 14 syringes & needles ...... 11 tofacitinib citrate XR ...... 16 VALCHLOR ...... 10 tacrolimus ...... 10 TOFRANIL ...... 7 VALISONE ...... 10 tacrolimus anhydrous ...... 13 tolazamide ...... 10 VALIUM ...... 7 tadalafil ...... 8, 11 tolbutamide ...... 11 valproate sodium ...... 18 TAFINLAR ...... 16 TOLECTIN 600 ...... 15 valproic acid ...... 18 TAGAMET ...... 18 TOLINASE ...... 10 valsartan ...... 8 TAGRISSO ...... 16 tolmetin sodium ...... 15 valsartan/hydrochlorothiazide ...... 8 TAKE ACTION ...... 9 tolterodine tartrate ...... 18 VALTREX ...... 14 TALADINE ...... 18 TOPAMAX ...... 18 VANCOCIN HCL ...... 14 TAMBOCOR ...... 7 TOPAMAX SPRINKLE ...... 18 vancomycin hcl ...... 14 TAMIFLU ...... 14 TOPICORT ...... 10 VANDAZOLE ...... 19 tamoxifen citrate ...... 16 TOPICORT LP ...... 10 VANOS ...... 10 tamsulosin hcl ...... 18 topiramate ...... 18 VANOXIDE-HC ...... 9 TAPAZOLE ...... 12 topotecan hcl ...... 16 VANSPAR ...... 7 tapentadol ...... 17 TOPROL XL...... 8 VANTIN ...... 13 tapentadol hcl ER ...... 17 TORADOL ...... 15 VASCEPA ...... 9 TARCEVA ...... 16 toremifene citrate ...... 16 VASERETIC ...... 7 TARGRETIN ...... 10, 16 torsemide ...... 8 VASOCIDIN ...... 12 TASIGNA ...... 16 TOUJEO ...... 11 VASOTEC ...... 8 tazarotene ...... 10 TOVIAZ ...... 18 V-CILLIN K...... 14 TAZORAC ...... 10 TRACLEER...... 8 VECTICAL ...... 19 tazorotene foam ...... 9 TRADJENTA ...... 10 vemurafenib ...... 16 TECFIDERA ...... 17 tramadol hcl ...... 17 VENCLEXTA ...... 16 tedizolid phosphate ...... 14 tramadol hcl/acetaminophen ...... 17 venetoclax ...... 16 teduglutide [rDNA origin] ...... 16 trametinib dimethyl sulfoxide ...... 16 venlafaxine hcl ...... 6 TEGRETOL ...... 18 TRANDATE ...... 8 VENTOLIN HFA ...... 6 TEGRETOL XR ...... 18 trandolapril ...... 8 VEPESID ...... 16 telbivudine ...... 15 TRANXENE T-TAB ...... 7 verapamil hcl ...... 8 telithromycin ...... 13 tranylcypromine sulfate ...... 6 verapamil hcl ER ...... 8 temazepam ...... 7 TRAVATAN...... 12 VERELAN ...... 8 TEMODAR ...... 16 TRAVATAN Z ...... 12 VERELAN PM ...... 8 TEMOVATE ...... 10 travoprost ...... 12 TEMOVATE EMOLLIENT ...... 10 travoprost (benzalkonium) ...... 12 VESANOID ...... 16 temozolomide ...... 16 trazodone hcl ...... 6 VESTURA ...... 9 TENEX ...... 8 TRENTAL ...... 13 VFEND ...... 14 tenofovir disoproxil fumarate ...... 15 tretinoin ...... 16 VIAGRA ...... 11 TENORETIC 100 ...... 8 TREXALL ...... 16 VIBRAMYCIN ...... 14 TENORETIC 50 ...... 8 triamcinolone acetonide ...... 6, 10, 17 VIBRAMYCIN ORAL SUSPENSION ...... 14 TENORMIN ...... 8 triamterene/hydrochlorothiazid ...... 8 VIBRAMYCIN SYRUP ...... 14 terazosin hcl ...... 8 TRIAZ ...... 9 VIBRA-TABS ...... 14 terbinafine hcl ...... 10, 14 triazolam ...... 7 VICODIN ...... 17 terbutaline sulfate ...... 6 TRIBENZOR ...... 8 VICODIN ES ...... 17 teriparatide ...... 11 TRICOR ...... 9 VICODIN HP ...... 17 testosterone ...... 13 TRIDERM ...... 10 VICON FORTE ...... 19 testosterone 1% ...... 13 TRIDESILON ...... 10 VICTOZA ...... 10 testosterone cypionate ...... 13 trifluoperazine hcl ...... 7 VIDEX ...... 15 testosterone gel 1.62% ...... 13 trifluridine ...... 12 VIDEX EC ...... 14 testosterone solution ...... 13 trifluridine/tipiracil hcl ...... 16 VIGAMOX ...... 12 TESTRED ...... 13 TRIGLIDE 160MG ...... 9 VIRACEPT ...... 15 tetrabenazine ...... 17 trihexyphenidyl hcl ...... 18 VIRAMUNE ...... 14 tetracycline hcl ...... 14 TRILAFON ...... 7 VIRAMUNE XR ...... 14 TEXACORT ...... 10 TRILEPTAL...... 18 VIRAZOLE ...... 14 thalidomide ...... 14 trimethoprim ...... 13 VIREAD ...... 15 THALITONE ...... 8 TRI-NORINYL ...... 9 VIROPTIC ...... 12 THALOMID ...... 14 TRIUMEQ ...... 14 VISKEN ...... 8 THEO-24 ...... 6 TRI-VI-FLOR W/IRON ...... 19 vismodegib...... 16 theophylline anhydrous ...... 6 TRIZIVIR ...... 14 VISTARIL ...... 6 THERMAZENE ...... 10 TRUSOPT ...... 12 VISTOGARD ...... 16 thioguanine ...... 16 TRUVADA ...... 14 VITEKTA ...... 15 THIOGUANINE ...... 16 TUSSIONEX ...... 9 VIVELLE-DOT ...... 13

Portfolio High Formulary – July 2016 41 Portfolio High Formulary INDEX

VOLTAREN ...... 12, 15 XYLOCAINE ...... 15 ZMAX ...... 13 VOLTAREN GEL ...... 10 XYZAL TABS ...... 6 ZMAX PEDIATRIC ...... 13 VOLTAREN-XR ...... 15 YASMIN 28 ...... 9 ZOCOR ...... 8 voriconazole ...... 14 YAZ ...... 9 ZOFRAN ...... 6 vorinostat ...... 16 YODOXIN ...... 14 ZOFRAN ODT ...... 6 VOSOL ...... 11 zaleplon ...... 7 ZOLINZA ...... 16 VOSOL HC ...... 11 ZANAFLEX ...... 18 zolmitriptan ...... 17 VOTRIENT ...... 16 ZANTAC ...... 18 ZOLOFT ...... 6 VYVANSE ...... 7 ZARAH ...... 9 zolpidem tartrate ...... 7 warfarin sodium ...... 13 ZARONTIN ...... 18 zolpidem tartrate ER ...... 7 WELCHOL ...... 8 ZAROXOLYN ...... 8 ZOMIG ...... 17 WELCHOL POWDER PACKETS ...... 8 ZEBETA ...... 8 ZOMIG ZMT ...... 17 WELLBUTRIN ...... 6 ZELBORAF ...... 16 ZONEGRAN ...... 18 WELLBUTRIN SR ...... 6 ZEMPLAR ...... 12 zonisamide ...... 18 WELLBUTRIN XL ...... 6 ZENATANE...... 9 ZORTRESS ...... 13 WESTCORT ...... 10 ZENPEP ...... 18 ZOVIRAX ...... 14 WESTHROID ...... 12 ZENZEDI ...... 7 ZOVIRAX CREAM ...... 10 XALATAN ...... 12 ZERIT ...... 15 ZOVIRAX OINTMENT ...... 10 XALKORI ...... 16 ZESTORETIC ...... 7 ZYDELIG ...... 16 XANAX ...... 7 ZESTRIL ...... 8 ZYKADIA ...... 16 XARELTO ...... 13 ZETIA ...... 9 ZYLET ...... 12 XELJANZ ...... 16 ZIAC ...... 8 ZYLOPRIM ...... 13 XELJANZ XR ...... 16 ZIAGEN ...... 14 ZYMAXID ...... 12 XELODA ...... 16 ZIANA ...... 9 ZYPREXA ...... 7 XENAZINE ...... 17 zidovudine ...... 15 ZYPREXA ZYDIS ...... 7 XIFAXAN 550MG ...... 14 ziprasidone hcl ...... 7 ZYRTEC (OTC) ...... 6 XODOL 10-300 ...... 17 ZIRGAN ...... 12 ZYRTEC-D (OTC) ...... 6 XTANDI ...... 16 ZITHROMAX ...... 13 ZYTIGA ...... 16 XURIDEN ...... 17 ZITHROMAX TRI-PAK ...... 13 ZYVOX ...... 14

Portfolio High Formulary – July 2016 42