2011-formulary by wuxiangyu

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									                                     2011 Formulary
                                          (List of Covered Drugs)




                   PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
                        ABOUT THE DRUGS WE COVER IN THIS PLAN.

             Note to existing members: This formulary has changed since last year. Please review this
                          document to make sure that it still contains the drugs you take.
     Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary,
         pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2011.
               Blue Cross of Idaho is a Medicare Advantage Organization with a Medicare contract.
                       This information is available in different formats, including large print.
                        For assistance or information, please call Customer Service toll free
                at 1-888-494-2583, our hours are 8:00 A.M. – 8:00 P.M. MST, seven days a week.
                                         TTY users call: 1-800-377-1363.




                       Medicare Advantage Plans | True Blue®HMO Secure Blue PPO Flexi Blue PFFS
                                                                            SM             SM




Last Updated: 04/19/2011                                                          Y0010_BCI_CS 11148 File and Use 10/3/2010
What is the Plan’s Formulary?                           we will immediately remove the drug from our
A formulary is a list of covered drugs selected by      formulary and provide notice to members who take
True Blue (HMO), Secure Blue (PPO), and Flexi           the drug. The enclosed formulary is current as of
Blue (PFFS) (The Plans) plans in consultation with      January 1, 2011. To get updated information about
a team of healthcare providers, which represents        the drugs covered by The Plans, please visit our
the prescription therapies believed to be a             website at www.bcidaho.com/ma_formulary or call
necessary part of a quality treatment program. The      Customer Services at 1-888-494-2583, seven days a
Plans will generally cover the drugs listed in our      week from 8:00 A.M. to 8:00 P.M. MT. TTY users
formulary as long as the drug is medically necessary,   should call toll free 1-800-377-1363.
the prescription is filled at The Plan’s network
                                                        In the event of a mid-year non-maintenance
pharmacies, and other plan rules are followed. For
                                                        formulary change is made, you will receive an
more information on how to fill your prescriptions,
                                                        Errata Notice by mail. Errata notices and changes
please review your Evidence of Coverage.
                                                        will be posted on The Plan’s website at
                                                        www.bcidaho.com/ma_formulary. Each Formulary
Can the Formulary Change?                               will also contact a “current as of date” along with
Generally, if you are taking a drug on our 2011         version dates to assist you in referencing the most
formulary that was covered at the beginning of the      up to date information.
year, we will not discontinue or reduce coverage
of the drug during the 2011 coverage year except
                                                        hoW do i use the Formulary?
when a new, less expensive generic drug becomes
                                                        There are two ways to find your drug within the
available or when new adverse information about
                                                        formulary:
the safety or effectiveness of a drug is released.
Other types of formulary changes, such as               medical condition
removing a drug from our formulary, will not affect       The formulary begins on page one. The drugs
members who are currently taking the drug. It             in this formulary are grouped into categories
will remain available at the same cost-sharing for        depending on the type of medical conditions
those members taking it for the remainder of the          that they are used to treat. For example, drugs
coverage year. We feel it is important that you have      used to treat a heart condition are listed under
continued access for the remainder of the coverage        the category “Cardiovascular Agents”. If you
year to the formulary drugs that were available           know what your drug is used for, look for the
when you chose our plan, except for cases in which        category name in the list that begins page one.
you can save additional money or we can ensure            Then look under the category name for your
your safety.                                              drug.

If we remove drugs from our formulary, add prior        alphabetical listing
authorization, quantity limits and/or step therapy        If you are not sure what category to look under,
restrictions on a drug or move a drug to a higher         you should look for your drug in the Index
cost-sharing tier, we must notify affected members        that begins on page 101. The Index provides
of the change at least 60 days before the change          an alphabetical list of all of the drugs included
becomes effective, or at the time the member              in this document. Both brand name drugs and
requests a refill of the drug, at which time the          generic drugs are listed in the Index. Look in
member will receive a 60-day supply of the drug.          the Index and find your drug. Next to your drug,
If the Food and Drug Administration deems a               you will see the page number where you can
drug on our formulary to be unsafe or the drug’s          find coverage information. Turn to the page
manufacturer removes the drug from the market,            listed in the Index and find the name of your
                                                          drug in the first column of the list.
What are generiC drugs?                                You can ask The Plans to make an exception
The Plan covers both brand name drugs and              to these restrictions or limits. See the section,
generic drugs. A generic drug is approved by the       “How do I request an exception to the The Plan’s
FDA as having the same active ingredient as the        formulary?” on this page for information about how
brand name drug. Generally, generic drugs cost less    to request an exception.
than brand name drugs.
                                                       What are over-the Counter (otC)
are there any restriCtions on my                       drugs?
Coverage?                                              OTC drugs are non-prescription drugs that are not
Some covered drugs may have additional                 normally covered by a Medicare Prescription Drug
requirements or limits on coverage. These              Plan.
requirements and limits may include:
                                                       What iF my drug is not on the
•	 Prior	Authorization:	The	Plans	require	you	[or	
   your physician] to get prior authorization for
                                                       Formulary?
                                                       If your drug is not included in this formulary, you
   certain drugs. This means that you will need to
                                                       should first contact Member Services and confirm
   get approval from The Plans before you fill your
                                                       that your drug is not covered. If you learn that The
   prescriptions. If you don’t get approval, The
                                                       Plans do not cover your drug, you have two options:
   Plans may not cover the drug.

•	 Quantity	Limits:	For	certain	drugs,	The	Plans	      •	 You	can	ask	Member	Services	for	a	list	of	similar	
   limits the amount of the drug that The Plans           drugs that are covered by The Plans. When you
   will cover. For example, The Plans provide 34          receive the list, show it to your doctor and ask
   tablets per prescription for Lipitor. This may be      him or her to prescribe a similar drug that is
   in addition to a standard one month or three           covered by The Plans.
   month supply.                                       •	 You	can	ask	The	Plans	to	make	an	exception	
•	 Step	Therapy:	In	some	cases,	The	Plans	require	        and cover your drug. See below for information
   you to first try certain drugs to treat your           about how to request an exception.
   medical condition before we will cover another
   drug for that condition. For example, if Drug A     hoW do i request an exCePtion to
   and Drug B both treat your medical condition,       the the Plans’ Formulary?
   The Plans may not cover Drug B unless you try       You can ask The Plans to make an exception
   Drug A first. If Drug A does not work for you,      to our coverage rules. There are several types of
   The Plans will then cover Drug B.                   exceptions that you can ask us to make.

You can find out if your drug has any additional       	•	 You	can	ask	us	to	cover	your	drug	even	if	it	is	
requirements or limits by looking in the formulary         not on our formulary.
that begins on page one. You can also get more
                                                       •	 You	can	ask	us	to	waive	coverage	restrictions	
information about the restrictions applied to
                                                          or limits on your drug. For example, for certain
specific covered drugs by visiting our website at
                                                          drugs, The Plans limit the amount of the drug
www.bcidaho.gov/ma_formulary.
                                                          that we will cover. If your drug has a quantity
                                                          limit, you can ask us to waive the limit and
                                                          cover more.

                                                       •	 You	can	ask	us	to	provide	a	higher	level	of	
   coverage for your drug. If your drug is contained    us before you can fill your prescription. You should
   in our non-preferred brand drug tier, Tier 3,        talk to your doctor to decide if you should switch
   you can ask us to cover it at the cost-sharing       to an appropriate drug that we cover or request
   amount that applies to drugs in the preferred        a formulary exception so that we will cover the
   brand tier, Tier 2 instead. This would lower         drug you take. While you talk to your doctor to
   the amount you must pay for your drug. Please        determine the right course of action for you, we
   note, if we grant your request to cover a drug       may cover your drug in certain cases during the first
   that is not on our formulary, you may not ask        90 days you are a member of our plan.
   us to provide a higher level of coverage for the
                                                        For each of your drugs that is not on our formulary
   drug. Also, you may not ask us to provide a
                                                        or if your ability to get your drugs is limited, we will
   higher level of coverage for drugs that are in the
                                                        cover a temporary 30-day supply (unless you have a
   Specialty Drug Tier, Tier 4.
                                                        prescription written for fewer days) when you go to
Generally, The Plans will only approve your request     a network pharmacy. After your first 30-day supply,
for an exception if the alternative drugs included      we will not pay for these drugs, even if you have
on the plan’s formulary, Preferred Brand, Tier 2, or    been a member of the plans less than 90 days.
additional utilization restrictions would not be as
                                                        If you are a resident of a long-term care facility,
effective in treating your condition and/or would
                                                        we will cover a temporary 31-day transition
cause you to have adverse medical effects.
                                                        supply (unless you have a prescription written for
You should contact us to ask us for an initial          fewer days). We will cover more than one refill of
coverage decision for a formulary, tiering or           these drugs for the first 90 days you are a member
utilization restriction exception. When you are         of our plans. If you need a drug that is not on
requesting a formulary, tiering or utilization          our formulary or if your ability to get your drugs
restriction exception you should submit a statement     is limited, but you are past the first 90 days of
from your physician supporting your request.            membership in our plans, we will cover a 31-day
Generally, we must make our decision within 72          emergency supply of that drug (unless you have
hours of getting your prescriber’s or prescribing       a prescription for fewer days) while you pursue a
physician’s supporting statement. You can request       formulary exception.
an expedited (fast) exception if you or your doctor
                                                        If you are taking non-formulary drugs or drugs
believe that your health could be seriously harmed
                                                        that are restrictive and experience a level of care
by waiting up to 72 hours for a decision. If your
                                                        change, such as when you have been discharged
request to expedite is granted, we must give you a
                                                        from a hospital, you may be able to get a temporary
decision no later than 24 hours after we get your
                                                        supply of the drug.
prescriber’s or prescribing physician’s supporting
statement.                                              During the time when you are getting a temporary
                                                        supply of a drug, you should talk with your doctor
What do i do beFore i Can talk                          to decide what to do when your temporary supply
to my doCtor about Changing my                          runs out. Perhaps there is a different drug covered
drugs or requesting an exCePtion?
                                                        by the plans that might work just as well for you.
As a new or continuing member in our plans you          Or you and your doctor can ask the plans to make
may be taking drugs that are not on our formulary.      an exception for you and cover the drug in the
Or, you may be taking a drug that is on our             way you would like it to be covered. The sections
formulary but your ability to get it is limited. For    following tell you more about these options.
example, you may need a prior authorization from
For more inFormation                                  the Plans’ Formulary
For more detailed information about your The          The formulary begining on the next page provides
Plan prescription drug coverage, please review your   coverage information about some of the drugs
Evidence of Coverage and other plan materials.        covered by The Plans. If you have trouble finding
                                                      your drug in the list, turn to the Index that begins
If you have questions about The Plans, please call
                                                      on page 101.
Customer Services at 1-888-494-2583, seven days
a week from 8:00 A.M. to 8:00 P.M. MST.               The first column of the chart lists the drug name.
TTY users should call 1-800-377-1363. Or visit        Brand name drugs are capitalized (e.g., LEXAPRO
www.bcidaho.com/medicare.                             and generic drugs are listed in lower-case italics
                                                      (e.g., DIGOZIN).
If you have general questions about Medicare
prescription drug coverage, please call Medicare at   The information in the Notes column tells you
1-800-MEDICARE (1-800-633-4227) 24 hours a            if The Plans have any special requirements for
day/7 days a week. TTY users should call              coverage of your drug.
1-877-486-2048.

Or, visit www.medicare.gov.
Formulary ID 11155 V.4

The symbol [INJ] next to a drug name indicates that the drug is available in injectable form.

The symbol [G] next to a drug name indicates that the drug may be available in a generic form.

The symbol [LA] next to a drug name indicates that the drug has been noted as being restricted
to certain pharmacies by the Food and Drug Administration. These drugs can only be obtained at
specialty designated pharmacies able to appropriately handle the drugs.

The symbol [PAR] in the Restrictions column indicates that prior authorization may apply.

The symbol [QLL] in the Restrictions column indicates that quantities dispensed may be limited.

The symbol [ST] in the Restrictions column indicates that step therapy may apply.



General Drug Table

                     Drug                                 Generic             Tier   Restrictions

ANESTHETICS
  LOCAL ANESTHETICS

     bupivacaine hcl injection [INJ]                                          1
     bupivacaine hcl-epinephrine [INJ]                                        1
     bupivacaine-dextrose [INJ]                                               1
     CARBOCAINE [INJ]                       mepivacaine                       3
     chloroprocaine hcl [INJ]                                                 1
     droperidol injection [INJ]                                               1
     lidocaine hcl 0.5% vial, -1%                                             1
     abboject, -1% ampul, -1% syringe, -
     1% vial, -1.5% ampul, -2%
     abboject, -2% ampul, -2% luer-jet, -
     2% syringe, -2% vial, -20% vial, -
     4% ampul [INJ]
     lidocaine hcl in 7.5% dextrose [INJ]                                     1
     lidocaine hcl-epinephrine [INJ]                                          1
     MARCAINE [INJ]                         bupivacaine                       3
     MARCAINE SPINAL [INJ]                  bupivacaine hcl/dextrose-h2o      3
     MARCAINE WITH EPINEPHRINE              bupivacaine hydrochloride/epi     3
     [INJ][G]
     MARCAINE-EPINEPHRINE [INJ]             bupivacaine hydrochloride/epi     3
     NAROPIN [INJ]                          ropivacaine                       3
Formulary ID 11155 V.4

                   Drug                                   Generic            Tier   Restrictions
     NESACAINE [INJ]                         chloroprocaine                  3
     NESACAINE-MPF [INJ]                     chloroprocaine                  3
     NOVOCAIN [INJ]                          procaine                        3
     POLOCAINE [INJ]                         mepivacaine                     3
     SENSORCAINE [INJ]                       bupivacaine                     3
     SENSORCAINE WITH DEXTROSE               bupivacaine hcl/dextrose-h2o    3
     [INJ]
     SENSORCAINE WITH EPINEPHRINE            bupivacaine hydrochloride/epi   3
     [INJ]
     SENSORCAINE-MPF [INJ][G]                bupivacaine                     3
     SENSORCAINE-MPF EPINEPHRINE             bupivacaine hydrochloride/epi   3
     [INJ]
     XYLOCAINE INJECTION [INJ][G]            lidocaine                       3
     XYLOCAINE IV [INJ]                      lidocaine                       3
     XYLOCAINE WITH EPINEPHRINE              lidocaine hydrochloride/epi     3
     [INJ]
     XYLOCAINE-MPF [INJ][G]                  lidocaine                       3
     XYLOCAINE-MPF WITH                      lidocaine hydrochloride/epi     3
     EPINEPHRINE [INJ][G]

  TOPICAL ANESTHETICS

     ANESTACON                               lidocaine                       3
     EMLA [G]                                lidocaine/prilocaine            3
     LIDAMANTLE                              lidocaine                       3
     lidocaine hcl cream, -dental/mucous                                     1
     membrn products, -gel, -lotion, -oint
     lidocaine hcl viscous                                                   1
     lidocaine-prilocaine                                                    1
     LIDODERM                                lidocaine                       2      [PAR]
     SYNERA                                  lidocaine/tetracaine            3
     XYLOCAINE DENTAL/MUCOUS                 lidocaine                       3
     MEMBRN PRODUCTS, -GEL [G]

ANTIINFECTIVES
  AMEBICIDES

     paromomycin sulfate                                                     1
Formulary ID 11155 V.4

                      Drug                               Generic       Tier   Restrictions
  AMINOGLYCOSIDES

     amikacin sulfate injection [INJ]                                  1
     gentamicin 100 mg/ns 100 ml, -60                                  1
     mg/ns 50 ml pb, -70 mg/ns 50 ml
     pb, -80 mg/ns 50 ml pb, -90 mg/ns
     100 ml pb, -gentamicin 100 mg/100
     ml, -gentamicin 60 mg/50 ml, -
     gentamicin 80 mg/50 ml [INJ]
     GENTAMICIN 60 MG/NS 100 ML PB,       gentamicin/sodium chloride   3
     -80 MG/NS 100 ML PB, -
     GENTAMICIN 100 MG/50 ML, -
     GENTAMICIN 60 MG/100 ML, -
     GENTAMICIN 80 MG/100 ML [INJ]
     gentamicin sulfate injection [INJ]                                1
     ISO GENTAMICIN 120 MG/100 ML, -      gentamicin/sodium chloride   2
     GENTAMICIN 40 MG/50 ML [INJ]
     kanamycin sulfate [INJ]                                           1
     NEO-FRADIN                           neomycin                     2
     neomycin sulfate tablet                                           1
     tobramycin sulfate in ns [INJ]                                    1
     tobramycin sulfate injection [INJ]                                1

  ANTHELMINTICS

     ALBENZA                              albendazole                  2
     BILTRICIDE                           praziquantel                 3
     mebendazole chew tab                                              1
     STROMECTOL                           ivermectin                   2

  ANTIINFECTIVES SPECIALIZED INDICATIONS

     DAPSONE                              dapsone                      2
     FLAGYL [G]                           metronidazole                3
     FLAGYL ER                            metronidazole                3
     metro iv [INJ]                                                    1
     metronidazole cap, -tablet                                        1
     metronidazole injection [INJ]                                     1
Formulary ID 11155 V.4

                    Drug                            Generic             Tier   Restrictions
  ANTIRETROVIRALS AND PROTEASE INH

     APTIVUS                           tipranavir/vitamin e tpgs        4
     ATRIPLA                           emtricitabine/tenofovir/efavir   4
     COMBIVIR                          lamivudine/zidovudine            4
     CRIXIVAN                          indinavir                        2
     didanosine                                                         1
     EMTRIVA                           emtricitabine                    2
     EPIVIR                            lamivudine                       2
     EPZICOM                           abacavir sulfate/lamivudine      4
     FUZEON [INJ]                      enfuvirtide                      4
     INTELENCE 100 MG TABLET, -200     etravirine                       4
     MG TABLET
     INVIRASE                          saquinavir mesylate              4
     ISENTRESS                         raltegravir potassium            4
     KALETRA 100-25 MG TABLET          ritonavir/lopinavir              2
     KALETRA 200-50 MG TABLET, -       ritonavir/lopinavir              4
     SOLUTION
     LEXIVA ORAL SUSP                  fosamprenavir calcium            2
     LEXIVA TABLET                     fosamprenavir calcium            4
     NORVIR CAP, -TABLET               ritonavir                        2
     NORVIR SOLUTION                   ritonavir                        4
     PREZISTA 150 MG TABLET, -75 MG    darunavir ethanolate             2
     TABLET
     PREZISTA 400 MG TABLET, -600 MG   darunavir ethanolate             4
     TABLET
     RESCRIPTOR                        delavirdine mesylate             2
     RETROVIR CAP, -SYRUP, -TABLET     zidovudine                       3
     [G]
     RETROVIR INJECTION [INJ]          zidovudine                       2
     REYATAZ                           atazanavir sulfate               4
     SELZENTRY                         maraviroc                        4
     stavudine                                                          1
     SUSTIVA                           efavirenz                        2
     TRIZIVIR                          zidovudine/lamivudine/abacavir   4
     TRUVADA                           emtricitabine/tenofovir          4
     VIDEX                             didanosine                       2
     VIDEX EC [G]                      didanosine                       3
     VIRACEPT                          nelfinavir mesylate              2
     VIRAMUNE                          nevirapine                       2
     VIREAD                            tenofovir disproxil fumarate     2
Formulary ID 11155 V.4

                      Drug                               Generic       Tier   Restrictions
     ZERIT [G]                             stavudine                   3
     ZIAGEN                                abacavir sulfate            2
     zidovudine                                                        1

  ANTITUBERCULOSIS DRUGS

     CAPASTAT SULFATE [INJ]                capreomycin                 4
     ethambutol hcl tablet                                             1
     isonarif                                                          1
     isoniazid injection [INJ]                                         1
     isoniazid syrup, -tablet                                          1
     MYAMBUTOL [G]                         ethambutol                  3
     MYCOBUTIN                             rifabutin                   2
     PASER                                 aminosalicylic acid         2
     PRIFTIN                               rifapentine                 2
     pyrazinamide                                                      1
     RIFADIN CAP                           rifampin                    3
     RIFADIN INJECTION [INJ]               rifampin                    4
     RIFAMATE                              rifampin/isoniazid          3
     rifampin cap                                                      1
     rifampin injection [INJ]                                          4
     RIFATER                               rifampin/inh/pyrazinamide   3
     SEROMYCIN                             cycloserine                 2
     STREPTOMYCIN SULFATE                  streptomycin                2
     INJECTION [INJ]
     TRECATOR                              ethionamide                 2

  CEPHALOSPORINS

     CEDAX                                 ceftibuten                  3
     cefaclor                                                          1
     cefaclor er                                                       1
     cefadroxil                                                        1
     cefazolin 1 gm add-van vial, -1 gm                                1
     vial, -1 gm-d5w bag, -10 gm vial, -
     20 gm bulk vial, -500 mg vial [INJ]
     cefdinir                                                          1
     CEFDITOREN PIVOXIL                    cefditoren pivoxil          3
     cefepime [INJ]                                                    1
     cefepime hcl [INJ]                                                1
Formulary ID 11155 V.4

                     Drug                                 Generic         Tier   Restrictions
     cefotaxime sodium [INJ]                                              1
     cefotetan [INJ]                                                      1
     cefoxitin [INJ]                                                      1
     cefoxitin sodium [INJ]                                               1
     cefpodoxime proxetil                                                 1
     cefprozil                                                            1
     ceftazidime [INJ]                                                    1
     CEFTIN [G]                             cefuroxime axetil             3
     ceftriaxone [INJ]                                                    1
     cefuroxime axetil                                                    1
     cefuroxime injection [INJ]                                           1
     cefuroxime sod 1.5 gm vial, -sod 7.5                                 1
     gm vial, -sod 750 mg vial [INJ]
     cefuroxime tablet                                                    1
     cephalexin                                                           1
     CLAFORAN [INJ][G]                      cefotaxime                    3
     FORTAZ 1 GM ADD-VANTAGE VIAL,          ceftazidime                   3
     -1 GM VIAL, -2 GM VIAL, -6 GM
     VIAL [INJ][G]
     FORTAZ 2 GM ADD-VANTAGE VIAL           ceftazidime                   4
     [INJ]
     FORTAZ 500 MG VIAL [INJ]               ceftazidime                   2
     FORTAZ IN ISO-OSMOTIC                  ceftazidime                   2
     DEXTROSE [INJ]
     KEFLEX [G]                             cephalexin                    3
     MAXIPIME 1 GM ADD-VANTAGE VL,          cefepime                      3
     -2 GM ADD-VANTAGE VL, -1 GRAM
     VIAL [INJ][G]
     MAXIPIME 2 GRAM VIAL [INJ]             cefepime                      4
     MEFOXIN [INJ][G]                       cefoxitin                     3
     OMNICEF                                cefdinir                      3
     ROCEPHIN [INJ][G]                      ceftriaxone                   3
     SPECTRACEF                             cefditoren pivoxil            3
     SUPRAX                                 cefixime                      2
     TAZICEF [INJ][G]                       ceftazidime                   3
     TEFLARO [INJ]                          ceftaroline fosamil acetate   3
     VANTIN                                 cefpodoxime                   3
     ZINACEF [INJ][G]                       cefuroxime                    3
     ZINACEF IN ISO-OSMOTIC WATER           cefuroxime                    3
     [INJ]
Formulary ID 11155 V.4

                  Drug                                     Generic       Tier   Restrictions
     ZINACEF ISO-OSMOTIC DEXTROSE          cefuroxime                    3
     [INJ]

  CHLORAMPHENICOLS

     chloramphenicol sod succinate [INJ]                                 1

  CLINDAMYCINS

     CLEOCIN   HCL [G]                     clindamycin hcl               3
     CLEOCIN   PALMITATE [G]               clindamycin palmitate         2
     CLEOCIN   PHOSPHATE [INJ][G]          clindamycin phosphate         3
     CLEOCIN   PHOSPHATE IN D5W [INJ]      clindamycin phosphate         3
     clindamycin hcl cap                                                 1
     clindamycin palmitate hcl                                           1
     clindamycin phosphate injection                                     1
     [INJ]

  ERYTHROMYCINS

     E.E.S. 200                            erythromycin ethylsuccinate   2
     E.E.S. 400 [G]                        erythromycin ethylsuccinate   3
     ERYPED 200                            erythromycin ethylsuccinate   2
     ERYPED 400                            erythromycin ethylsuccinate   2
     ERY-TAB                               erythromycin base             2
     ERYTHROCIN LACTOBIONATE [INJ]         erythromycin lactobionate     2
     erythrocin stearate                                                 1
     erythromycin e.c. cap, -tablet                                      1
     erythromycin ethylsuccinate tablet                                  1
     PCE                                   erythromycin base             3

  KETOLIDES

     KETEK                                 telithromycin                 3

  ORAL ANTIFUNGAL DRUGS

     ANCOBON                               flucytosine                   4
     clotrimazole loz                                                    1
Formulary ID 11155 V.4

                   Drug                                   Generic         Tier Restrictions
     DIFLUCAN 100 MG TABLET, -200          fluconazole                    3    [PAR]
     MG TABLET, -50 MG TABLET [G]
     DIFLUCAN 150 MG TABLET [G]            fluconazole                    3    [QLL, 2/7]
     DIFLUCAN SUSPENSION [G]               fluconazole                    3
     fluconazole 100 mg tablet, -200 mg                                   1    [PAR]
     tablet, -50 mg tablet
     fluconazole 150 mg tablet                                            1    [QLL, 2/7]
     fluconazole suspension                                               1
     GRIFULVIN V                           griseofulvin microsize         2
     griseofulvin oral susp                                               1
     GRIS-PEG                              griseofulvin ultramicrosize    2
     itraconazole cap                                                     1    [PAR]
     ketoconazole tablet                                                  1
     LAMISIL PKT                           terbinafine                    2
     LAMISIL TABLET [G]                    terbinafine                    3    [PAR]
     NOXAFIL                               posaconazole                   4
     nystatin 150,000,000 units pwd, -                                    1
     50,000,000 units pwd, -500,000 unit
     oral tab, -500,000,000 units pwd, -
     oral susp
     ORAVIG                                miconazole                     3
     SPORANOX CAP [G]                      itraconazole                   3    [PAR]
     SPORANOX SOLUTION                     itraconazole                   2
     terbinafine hcl                                                      1    [PAR]
     TERBINEX                              terbinafine/hydroxy chitosan   3    [PAR]
     VFEND                                 voriconazole                   4    [PAR]
     voriconazole                                                         1    [PAR]

  OTHER ANTIINFECTIVE DRUGS

     ALINIA                                nitazoxanide                   2
     AZACTAM 1 GM VIAL [INJ]               aztreonam                      2
     AZACTAM 2 GM VIAL [INJ][G]            aztreonam                      4
     AZACTAM-ISO-OSMOT 1 GM/50 ML          aztreonam/dextrose water       2
     [INJ]
     AZACTAM-ISO-OSMOT 2 GM/50 ML          aztreonam/dextrose water       4
     [INJ]
     aztreonam 1 gm vial [INJ]                                            1
     aztreonam 2 gm vial [INJ]                                            4
     baciim [INJ]                                                         1
     bacitracin injection [INJ]                                           1
Formulary ID 11155 V.4

                     Drug                              Generic          Tier Restrictions
     CAYSTON [LA]                          aztreonam lysine             4    [QLL, 84
                                                                             vials/28]
     colistimethate 150 mg vial [INJ]                                   4
     COLY-MYCIN M PARENTERAL               colistimethate, sodium       4
     [INJ][G]
     CUBICIN [INJ]                         daptomycin                   4    [PAR]
     DORIBAX 250 MG VIAL [INJ]             doripenem                    3
     DORIBAX 500 MG VIAL [INJ]             doripenem                    4
     INVANZ 1 GM ADD-VANTAGE VIAL          ertapenem sodium             3
     [INJ]
     INVANZ 1 GM VIAL [INJ]                ertapenem sodium             2
     LINCOCIN [INJ]                        lincomycin                   3
     lincoject [INJ]                                                    1
     MEPRON                                atovaquone                   4
     meropenem [INJ]                                                    1
     MERREM IV 1 GM VIAL [INJ]             meropenem                    4
     MERREM IV 500 MG VIAL [INJ][G]        meropenem                    2
     PENTAM 300 [INJ][G]                   pentamidine                  3
     pentamidine isethionate [INJ]                                      1
     POLYMYXIN B SULFATE EA                polymyxin b                  2
     polymyxin b sulfate injection [INJ]                                1
     PRIMAXIN 250 MG VIAL [INJ]            imipenem/cilastatin sodium   2
     PRIMAXIN 500 MG VIAL [INJ]            imipenem/cilastatin sodium   4
     PRIMAXIN I.M. [INJ]                   imipenem/cilastatin sodium   4
     SYNERCID [INJ]                        quinupristin/dalfopristin    4
     TYGACIL [INJ]                         tigecycline                  4
     VANCOCIN HCL                          vancomycin                   4
     vancomycin 1 gm add-van vial, -1                                   1    [PAR]
     gm vial, -10 gm vial, -1g/200 ml
     bag, -5 gm vial, -500 mg vial, -750
     mg vial [INJ]
     vancomycin 500 mg a/v vial [INJ]                                   1
     VANCOMYCIN-D5W [INJ]                  vancomycin                   3    [PAR]
     VIBATIV [INJ]                         telavancin                   4
     XIFAXAN 200 MG TABLET                 rifaximin                    2
     XIFAXAN 550 MG TABLET                 rifaximin                    4
     ZYVOX INJECTION [INJ]                 linezolid                    4
     ZYVOX ORAL SUSP, -TABLET              linezolid                    4    [PAR]
Formulary ID 11155 V.4

                     Drug                               Generic   Tier   Restrictions
  OTHER ANTIVIRAL DRUGS

     acyclovir cap, -oral susp, -tablet                           1
     acyclovir sodium [INJ]                                       1
     amantadine                                                   1
     BARACLUDE SOLUTION                   entecavir               2
     BARACLUDE TABLET                     entecavir               4
     COPEGUS [G]                          ribavirin               4
     CYTOVENE [INJ][G]                    ganciclovir             2
     DENAVIR                              penciclovir             2
     EPIVIR HBV                           lamivudine              2
     famciclovir 125 mg tablet                                    1      [QLL,
                                                                         21/10]
     famciclovir 250 mg tablet                                    1      [QLL,
                                                                         68/34]
     famciclovir 500 mg tablet                                    1      [QLL, 21/7]
     FAMVIR 125 MG TABLET [G]             famciclovir             3      [QLL,
                                                                         21/10]
     FAMVIR 250 MG TABLET [G]             famciclovir             3      [QLL,
                                                                         68/34]
     FAMVIR 500 MG TABLET [G]             famciclovir             3      [QLL, 21/7]
     FLUMADINE [G]                        rimantadine             3
     foscarnet sodium [INJ]                                       1
     ganciclovir                                                  4
     ganciclovir sodium [INJ]                                     1
     HEPSERA                              adefovir dipivoxil      4
     REBETOL SOLUTION, -CAP [G]           ribavirin               4
     RELENZA                              zanamivir               2      [QLL,
                                                                         60/180]
     ribapak                                                      4
     ribasphere 200 mg tablet                                     1
     ribasphere 400 mg tablet, -600 mg                            4
     tablet, -cap
     RIBATAB [G]                          ribavirin               4
     ribavirin 200 mg tablet                                      1
     ribavirin 400 mg tablet, -600 mg                             4
     tablet, -cap
     rimantadine hcl                                              1
     TAMIFLU 30 MG GELCAP                 oseltamivir phosphate   2      [QLL,
                                                                         84/180]
Formulary ID 11155 V.4

                  Drug                               Generic       Tier Restrictions
     TAMIFLU 45 MG GELCAP, -75 MG       oseltamivir phosphate      2    [QLL,
     GELCAP                                                             42/180]
     TAMIFLU SUSPENSION                 oseltamivir phosphate      2    [QLL,
                                                                        900/180]
     TYZEKA                             telbivudine                2
     valacyclovir                                                  1    [QLL,
                                                                        34/34]
     VALCYTE                            valganciclovir             4
     VALTREX [G]                        valacyclovir               3    [QLL,
                                                                        34/34]
     VIRAZOLE [INJ]                     ribavirin                  2
     VISTIDE [INJ]                      cidofovir                  4
     XERESE                             acyclovir/hydrocortisone   2
     ZOVIRAX CAP, -ORAL SUSP, -         acyclovir                  3
     TABLET [G]
     ZOVIRAX CREAM, -OINT               acyclovir                  2

  OTHER MACROLIDES

     azithromycin 100 mg/5 ml susp                                 1    [QLL,   30
                                                                        ml/5]
     azithromycin 200 mg/5 ml susp                                 1    [QLL,   90
                                                                        ml/5]
     azithromycin 250 mg tablet                                    1    [QLL,   8/7]
     azithromycin 500 mg tablet                                    1    [QLL,   4/4]
     azithromycin 600 mg tablet, -pkt                              1
     azithromycin injection [INJ]                                  1
     BIAXIN [G]                         clarithromycin             3
     BIAXIN XL [G]                      clarithromycin             3
     clarithromycin                                                1
     clarithromycin er                                             1
     ZITHROMAX 100 MG/5 ML SUSP [G]     azithromycin               3    [QLL, 30
                                                                        ml/5]
     ZITHROMAX 200 MG/5 ML SUSP [G]     azithromycin               3    [QLL, 90
                                                                        ml/5]
     ZITHROMAX 250 MG TABLET, -250      azithromycin               3    [QLL, 8/7]
     MG Z-PAK TABLET [G]
     ZITHROMAX 500 MG TABLET [G]        azithromycin               3    [QLL, 4/4]
     ZITHROMAX INJECTION [INJ][G]       azithromycin               3
     ZITHROMAX PKT, -600 MG TABLET      azithromycin               3
     [G]
Formulary ID 11155 V.4

                 Drug                                          Generic          Tier Restrictions
     ZITHROMAX TRI-PAK [G]                      azithromycin                    3    [QLL, 4/4]
     ZMAX ADULT-PEDIATRIC                       azithromycin                    3    [QLL, 60
                                                                                     ml/1]

  OTHER TOPICAL ANTIFUNGALS

     ciclopirox cream, -gel, -kit, -lotion, -                                   1
     oil,shampoo,cleanser
     ciclopirox soln, top                                                       1    [PAR]
     clotrimazole 1% cream, -1%                                                 1
     solution, -af 1% cream
     CNL 8                                      ciclopirox/nail lacquer remov   3    [PAR]
     econazole nitrate cream                                                    1
     ERTACZO                                    sertaconazole nitrate           3
     EXELDERM                                   sulconazole nitrate             3
     EXTINA                                     ketoconazole                    3
     KETOCON + PLUS                             ketoconazole/hydrocortisone     3
     ketoconazole cream, -                                                      1
     oil,shampoo,cleanser
     KURIC [G]                                  ketoconazole                    3
     LAMISIL SOLUTION                           terbinafine                     3
     LOPROX [G]                                 ciclopirox                      3
     MENTAX                                     butenafine                      3
     NAFTIN                                     naftifine                       3
     NIZORAL [G]                                ketoconazole                    3
     nyamyc                                                                     1
     nystatin 100,000 unit/gm powd, -                                           1
     cream, -oint
     nystop                                                                     1
     OXISTAT                                    oxiconazole                     3
     pedi-dri                                                                   1
     PENLAC [G]                                 ciclopirox                      3    [PAR]
     VUSION                                     miconazole nitrate/zinc oxide   3
     XOLEGEL                                    ketoconazole                    3

  PARENTERAL ANTIFUNGALS

     ABELCET [INJ]                              amphotericin b lipid complex    4
     AMBISOME [INJ]                             amphotericin b liposome         4
     AMPHOTEC 100 MG VIAL [INJ]                 ampho b c-s                     2
Formulary ID 11155 V.4

                     Drug                           Generic         Tier   Restrictions
     AMPHOTEC 50 MG VIAL [INJ]        ampho b c-s                   3
     amphotericin b injection [INJ]                                 1
     CANCIDAS [INJ]                   caspofungin acetate           4
     DIFLUCAN IN DEXTROSE [INJ]       fluconazole/dextrose-water    3
     DIFLUCAN IN SALINE [INJ][G]      fluconazole/sodium chloride   3
     ERAXIS (WATER DILUENT) [INJ]     anidulafungin                 3
     fluconazole in dextrose [INJ]                                  1
     fluconazole in saline [INJ]                                    1
     MYCAMINE [INJ]                   micafungin sodium             4
     VFEND IV [INJ]                   voriconazole                  4

  PENICILLINS

     amoclan                                                        1
     amox tr-potassium clavulanate                                  1
     amoxicillin                                                    1
     amoxicillin-clavulanate er                                     1
     AMOXIL [G]                       amoxicillin                   2
     ampicillin sodium [INJ]                                        1
     ampicillin trihydrate                                          1
     ampicillin-sulbactam [INJ]                                     1
     AUGMENTIN 125-31.25 SUSPEN       amoxicillin clavulanate       2
     AUGMENTIN 250-62.5 MG/5 ML, -    amoxicillin clavulanate       3
     TABLET [G]
     AUGMENTIN ES-600                 amoxicillin clavulanate       3
     AUGMENTIN XR [G]                 amoxicillin clavulanate       3
     BACTOCILL                        oxacillin                     3
     BICILLIN C-R [INJ]               pen g procaine/pen g benz     2
     BICILLIN L-A [INJ]               penicillin g benzathine       2
     dicloxacillin sodium                                           1
     MOXATAG                          amoxicillin                   3
     NAFCILL IN DEXTROSE [INJ]        nafcillin                     4
     nafcillin [INJ]                                                4
     nafcillin sodium [INJ]                                         4
     NALLPEN [INJ]                    nafcillin                     4
     NALLPEN IN DEXTROSE [INJ]        nafcillin                     4
     NALLPEN-ISO-OSMOTIC DEXTROSE     nafcillin                     4
     [INJ]
     oxacillin [INJ]                                                4
Formulary ID 11155 V.4

                      Drug                               Generic           Tier   Restrictions
     oxacillin 1 gm add-vantage vl, -10                                    4
     gm vial, -2 gm add-vantage vl, -2
     gm vial [INJ]
     oxacillin 1 gm vial [INJ]                                             1
     penicillin g potassium [INJ]                                          1
     PENICILLIN G POTASSIUM IN D5W        pen g pot/dextrose-water         2
     [INJ]
     penicillin g procaine [INJ]                                           1
     penicillin g sodium [INJ]                                             1
     PENICILLIN GK-ISO-OSM                pen g pot/dextrose-water         2
     DEXTROSE [INJ]
     penicillin v potassium                                                1
     PFIZERPEN [INJ][G]                   penicillin g potassium           3
     piperacillin [INJ]                                                    1
     piperacillin-tazobactam [INJ]                                         1
     PIPRACIL IN DEXTROSE [INJ]           piperacillin                     2
     TIMENTIN [INJ]                       ticarcillin/k clavulanate        2
     TOTACILLIN-N [INJ]                   ampicillin sodium                3
     UNASYN [INJ][G]                      ampicillin sodium/sulbactam na   3
     ZOSYN [INJ][G]                       piperacillin/tazobactam sodium   3

  PLASMODICIDES

     ARALEN PHOSPHATE [G]                 chloroquine phosphate            3
     chloroquine phosphate tablet                                          1
     COARTEM                              artemether/lumefantrine          2
     DARAPRIM                             pyrimethamine                    2
     HALFAN                               halofantrine                     2
     hydroxychloroquine sulfate tablet                                     1
     MALARONE                             atovaquone/proguanil hcl         2
     mefloquine hcl                                                        1
     PLAQUENIL [G]                        hydroxychloroquine               3
     PRIMAQUINE                           primaquine                       2
     QUALAQUIN                            quinine sulfate                  2

  QUINOLONES

     AVELOX                               moxifloxacin                     2
     AVELOX ABC PACK                      moxifloxacin                     2
     AVELOX IV [INJ]                      moxifloxacin                     2
Formulary ID 11155 V.4

                      Drug                                 Generic         Tier Restrictions
     CIPRO [G]                             ciprofloxacin                   3
     CIPRO I.V. [INJ][G]                   ciprofloxacin                   3
     CIPRO XR                              ciprofloxacin                   3
     ciprofloxacin [INJ]                                                   1
     ciprofloxacin er                                                      1
     ciprofloxacin hcl tablet                                              1
     ciprofloxacin-d5w [INJ]                                               1
     FACTIVE                               gemifloxacin                    3    [QLL, 7/7]
     LEVAQUIN INJECTION [INJ]              levofloxacin                    3
     LEVAQUIN SOLUTION, -TABLET            levofloxacin                    3
     NOROXIN                               norfloxacin                     3
     ofloxacin tablet                                                      1
     PROQUIN XR                            ciprofloxacin                   3

  SULFONAMIDES

     BACTRIM [G]                           sulfamethoxazole/trimethoprim   3
     BACTRIM DS [G]                        sulfamethoxazole/trimethoprim   3
     erythromycin-sulfisoxazole                                            1
     SEPTRA [G]                            sulfamethoxazole/trimethoprim   3
     SEPTRA DS [G]                         sulfamethoxazole/trimethoprim   3
     sulfadiazine tablet                                                   1
     sulfamethoxazole-trimethoprim                                         1
     injection [INJ]
     sulfamethoxazole-trimethoprim oral                                    1
     susp, -tablet
     sulfatrim                                                             1

  TETRACYCLINES

     ADOXA [G]                             doxycycline monohydrate         3
     ADOXA PAK [G]                         doxycycline monohydrate         3
     AVIDOXY                               doxycycline monohydrate         3
     demeclocycline hcl                                                    1
     DORYX                                 doxycycline hyclate             3
     doxycycline                                                           1
     doxycycline hyclate 100 mg tab, -                                     1
     cap, -e.c. cap, -e.c. tab
     doxycycline hyclate injection [INJ]                                   1
     doxycycline monohydrate                                               1
Formulary ID 11155 V.4

                  Drug                                     Generic         Tier   Restrictions
     DYNACIN [G]                             minocycline                   3
     MINOCIN COMBO PACKS, -CAP [G]           minocycline                   3
     MINOCIN INJECTION [INJ]                 minocycline                   3
     minocycline hcl cap, -tab sa, -tablet                                 1
     MONODOX [G]                             doxycycline monohydrate       3
     ORACEA                                  doxycycline monohydrate       3
     SOLODYN [G]                             minocycline                   3
     TERRAMYCIN [INJ]                        oxytetracycline               3
     TERRAMYCIN IM [INJ]                     oxytetracycline               3
     tetracycline hcl cap                                                  1
     VIBRAMYCIN 50 MG CAPSULE [INJ]          doxycycline hyclate           3
     VIBRAMYCIN SUSPENSION, -SYRUP,          doxycycline hyclate           3
     -100 MG CAPSULE [G]
     VIBRA-TABS                              doxycycline hyclate           3

  TOPICAL ANTIBACTERIAL DRUGS

     ALTABAX                                 retapamulin                   2
     BACTROBAN [G]                           mupirocin                     3
     BACTROBAN NASAL                         mupirocin calcium             2
     CENTANY                                 mupirocin                     3
     CENTANY AT                              mupirocin                     3
     CORTISPORIN CREAM, -OINT                neomycin/bacitracin/poly/hc   3
     gentamicin 0.1% ointment, -cream                                      1
     mupirocin oint                                                        1
     PHISOHEX                                hexachlorophene               3
     SILVADENE [G]                           silver sulfadiazine           3
     silver sulfadiazine                                                   1
     ssd                                                                   1
     ssd af                                                                1
     SULFAMYLON                              mafenide acetate              2
     thermazene                                                            1

  TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB.

     clotrimazole-betamethasone                                            1
     LOTRISONE [G]                           clotrimazole/betamethasone    3
     nystatin-triamcinolone                                                1
Formulary ID 11155 V.4

                     Drug                               Generic          Tier   Restrictions
  URINARY ANTIINFECTIVES

     FURADANTIN                          nitrofurantoin                  2
     HIPREX [G]                          methenamine hippurate           3
     MACROBID [G]                        nitrofurantoin/nitrofuran mac   3
     MACRODANTIN [G]                     nitrofurantoin macrocrystal     3
     methenamine hippurate                                               1
     methenamine mandelate e.c. tab, -                                   1
     tablet
     MONUROL                             fosfomycin tromethamine         2
     nitrofurantoin cap                                                  1
     nitrofurantoin mono-macro                                           1
     PRIMSOL                             trimethoprim                    2
     trimethoprim tablet                                                 1
     UROQID-ACID NO.2                    methenamine mandelate           3
     utac                                                                1
     visqid a-a                                                          1

  VAGINAL ANTIFUNGALS

     GYNAZOLE-1                          butoconazole                    3
     miconazole 3 200 mg vag supp                                        1      [QLL, 3/3]
     nystatin vaginal tablet                                             1
     TERAZOL 3 80 MG SUPPOSITORY         terconazole                     3      [QLL, 3/3]
     [G]
     TERAZOL 3 CREAM [G]                 terconazole                     3      [QLL, 20
                                                                                gm/3]
     TERAZOL 7 [G]                       terconazole                     3      [QLL, 45
                                                                                gm/7]
     terconazole 0.4% cream                                              1      [QLL, 45
                                                                                gm/7]
     terconazole 0.8% cream                                              1      [QLL, 20
                                                                                gm/3]
     terconazole 80 mg suppository                                       1      [QLL, 3/3]
     ZAZOLE 0.8% VAGINAL CREAM           terconazole                     3      [QLL, 20
                                                                                gm/3]
     ZAZOLE 80 MG VAGINAL SUPP [G]       terconazole                     3      [QLL, 3/3]
     ZAZOLE VAGINAL 0.4% CREAM [G]       terconazole                     3      [QLL, 45
                                                                                gm/7]
Formulary ID 11155 V.4

                     Drug                             Generic          Tier   Restrictions
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
  ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS

     AFINITOR                          everolimus                      4
     AGRYLIN [G]                       anagrelide                      3
     ALIMTA [INJ]                      pemetrexed disodium             4
     AMEVIVE [INJ][LA]                 alefacept                       4      [PAR]
     amifostine [INJ]                                                  4
     anagrelide hcl                                                    1
     anastrozole tablet                                                1
     ARAVA [G]                         leflunomide                     3      [QLL,
                                                                              34/34]
     ARIMIDEX [G]                      anastrozole                     2
     AROMASIN                          exemestane                      2
     AVASTIN [INJ]                     bevacizumab                     2
     AZASAN                            azathioprine                    2      [PAR]
     azathioprine sodium [INJ]                                         1      [PAR]
     azathioprine tablet                                               1      [PAR]
     bicalutamide tablet                                               1
     CAMPATH [INJ]                     alemtuzumab                     4
     CASODEX [G]                       bicalutamide                    3
     CEENU                             lomustine                       2
     CELLCEPT CAP [G]                  mycophenolate mofetil           3      [PAR]
     CELLCEPT INJECTION [INJ]          mycophenolate mofetil           2      [PAR]
     CELLCEPT TABLET, -ORAL SUSP [G]   mycophenolate mofetil           4      [PAR]
     CIMZIA [INJ]                      certolizumab pegol              4      [PAR]
     cyclophosphamide tablet                                           1      [PAR]
     cyclosporine cap, -solution                                       1      [PAR]
     cyclosporine injection [INJ]                                      1      [PAR]
     cyclosporine modified                                             1      [PAR]
     DACOGEN [INJ]                     decitabine                      4
     DEPO-PROVERA 400 MG/ML VIAL       medroxyprogesterone             2
     [INJ]
     DROXIA                            hydroxyurea                     2
     ELIGARD [INJ]                     leuprolide                      2      [PAR]
     ELITEK [INJ]                      rasburicase                     4
     EMCYT                             estramustine phosphate sodium   2
     ENBREL [INJ]                      etanercept                      4      [PAR]
     ETHYOL [INJ][G]                   amifostine                      4
     FARESTON                          toremifene                      2
Formulary ID 11155 V.4

                  Drug                                     Generic   Tier Restrictions
     FASLODEX [INJ]                         fulvestrant              4
     FEMARA                                 letrozole                2
     flutamide                                                       1
     gengraf                                                         1    [PAR]
     GLEEVEC                                imatinib mesylate        4
     HALAVEN [INJ]                          eribulin mesylate        4
     HEXALEN                                altretamine              4
     HUMIRA 20 MG/0.4 ML SYRINGE, -         adalimumab               4    [PAR][QLL,
     40 MG/0.8 ML SYRINGE [INJ]                                           5/35]
     HUMIRA 40 MG/0.8 ML PEN, -             adalimumab               4    [PAR][QLL,
     CROHN'S STARTER PACK, -                                              6/180]
     PSORIASIS STARTER PACK [INJ]
     HYDREA [G]                             hydroxyurea              3
     hydroxyurea cap                                                 1
     IMURAN [G]                             azathioprine             3    [PAR]
     IRESSA [LA]                            gefitinib                4
     leflunomide                                                     1    [QLL,
                                                                          34/34]
     leucovorin calcium injection [INJ]                              1
     leucovorin calcium tablet                                       1
     LEUKERAN                               chlorambucil             2
     LYSODREN                               mitotane                 4
     MATULANE                               procarbazine             4
     MEGACE [G]                             megestrol                3
     MEGACE ES                              megestrol                2
     megestrol acetate oral susp, -tablet                            1
     mercaptopurine tablet                                           1
     mesna [INJ]                                                     1
     MESNEX INJECTION [INJ][G]              mesna                    3
     MESNEX TABLET                          mesna                    4
     methotrexate injection [INJ]                                    1    [PAR]
     methotrexate tablet                                             1    [PAR]
     mitoxantrone hcl [INJ]                                          4    [PAR]
     MUSTARGEN [INJ]                        mechlorethamine          2
     mycophenolate mofetil cap                                       1    [PAR]
     mycophenolate mofetil tablet                                    4    [PAR]
     MYFORTIC                               mycophenolate sodium     2    [PAR]
     NEORAL [G]                             cyclosporine             3    [PAR]
     NEXAVAR [LA]                           sorafenib tosylate       4
     NILANDRON                              nilutamide               2
Formulary ID 11155 V.4

                 Drug                                     Generic    Tier Restrictions
     NOVANTRONE [INJ][G]                   mitoxantrone              4    [PAR]
     octreotide 1,000 mcg/ml vial, -acet                             4
     100 mcg/ml amp, -acet 100 mcg/ml
     vl, -acet 200 mcg/ml vl, -acet 500
     mcg/ml amp, -acet 500 mcg/ml vl
     [INJ]
     octreotide acet 50 mcg/ml amp, -                                1
     acet 50 mcg/ml vial [INJ]
     ORENCIA [INJ]                         abatacept/maltose         4    [PAR]
     ORTHOCLONE OKT-3 [INJ]                muronab-cd3               2    [PAR]
     PROGRAF 0.5 MG CAPSULE, -1 MG         tacrolimus                3    [PAR]
     CAPSULE [G]
     PROGRAF 5 MG CAPSULE [G]              tacrolimus                4    [PAR]
     PROGRAF INJECTION [INJ]               tacrolimus                2    [PAR]
     PURINETHOL [G]                        mercaptopurine            3
     RAPAMUNE                              sirolimus                 2    [PAR]
     REMICADE [INJ]                        infliximab                4    [PAR]
     REVLIMID [LA]                         lenalidomide              4
     RHEUMATREX                            methotrexate              3    [PAR]
     RITUXAN [INJ]                         rituximab                 4    [PAR]
     SANDIMMUNE CAP [G]                    cyclosporine              2    [PAR]
     SANDIMMUNE INJECTION [INJ][G]         cyclosporine              3    [PAR]
     SANDIMMUNE SOLUTION [G]               cyclosporine              3    [PAR]
     SANDOSTATIN [INJ][G]                  octreotide                4
     SANDOSTATIN LAR 10 MG KIT, -30        octreotide                4    [QLL, 1/28]
     MG KIT [INJ]
     SANDOSTATIN LAR 20 MG KIT [INJ]       octreotide                4    [QLL, 2/28]
     SIMPONI [INJ]                         golimumab                 4    [PAR]
     SIMULECT [INJ]                        basiliximab               2    [PAR]
     SOMATULINE DEPOT [INJ]                lanreotide acetate        4
     SPRYCEL                               dasatinib                 4
     STELARA [INJ]                         ustekinumab               4    [PAR]
     SUTENT                                sunitinib malate          4
     TABLOID                               thioguanine               2
     tacrolimus 0.5 mg capsule, -1 mg                                1    [PAR]
     capsule
     tacrolimus 5 mg capsule                                         4    [PAR]
     tamoxifen citrate tablet                                        1
     TARCEVA                               erlotinib hcl             4
     TARGRETIN                             bexarotene                4
     TASIGNA                               nilotinib hydrochloride   4
Formulary ID 11155 V.4

                    Drug                                  Generic   Tier   Restrictions
     THERACYS [INJ]                         bcg vaccine             2
     TRELSTAR 11.25 MG SYRINGE, -           triptorelin pamoate     2
     3.75 MG SYRINGE [INJ][LA]
     TRELSTAR 22.5 MG SYRINGE, -22.5        triptorelin pamoate     4
     MG VIAL [INJ][LA]
     TRELSTAR DEPOT [INJ][LA]               triptorelin pamoate     2
     TRELSTAR LA [INJ][LA]                  triptorelin pamoate     2
     tretinoin cap                                                  4
     TREXALL                                methotrexate sodium     2      [PAR]
     TYKERB                                 lapatinib ditosylate    4
     TYSABRI [INJ][LA]                      natalizumab             4      [PAR]
     VANTAS [INJ]                           histrelin ac            2
     VELCADE [INJ]                          bortezomib              4
     VIDAZA [INJ]                           azacitidine             4
     VOTRIENT                               pazopanib               4
     ZOLADEX [INJ]                          goserelin acetate       2
     ZOLINZA                                vorinostat              4
     ZORTRESS 0.25 MG TABLET                everolimus              2      [PAR]
     ZORTRESS 0.5 MG TABLET, -0.75          everolimus              4      [PAR]
     MG TABLET

AUTONOMIC AND CNS MEDICATIONS
  ANALGESICS

     acetaminophen-tramadol                                         1      [QLL,
                                                                           272/34]
     BUPRENEX [INJ]                         buprenorphine           3
     buprenorphine 0.3 mg/ml syrn [INJ]                             1
     buprenorphine 0.3 mg/ml vial [INJ]                             1
     butorphanol tartrate injection [INJ]                           1
     nalbuphine hcl [INJ]                                           1
     pentazocine-acetaminophen                                      1
     PRIALT [INJ]                           ziconotide acetate      2
     RYBIX ODT                              tramadol                3      [QLL,
                                                                           272/34][ST]
     RYZOLT                                 tramadol                3      [QLL,
                                                                           34/34][ST]
     sufenta [INJ]                                                  1
     sufentanil 50 mcg/ml ampul [INJ]                               1
     TALWIN 30 MG/ML AMPUL [INJ]            pentazocine             3
     TALWIN 30 MG/ML VIAL [INJ]             pentazocine             3
Formulary ID 11155 V.4

                     Drug                                 Generic   Tier Restrictions
     tramadol hcl tab sa                                            1    [QLL,
                                                                         34/34]
     tramadol hcl tablet                                            1    [QLL,
                                                                         272/34]
     tramadol hcl-acetaminophen                                     1    [QLL,
                                                                         272/34]
     ULTIVA [INJ]                           remifentanil            2
     ULTRACET [G]                           tramadol/apap           3    [QLL,
                                                                         272/34][ST]
     ULTRAM [G]                             tramadol                3    [QLL,
                                                                         272/34][ST]
     ULTRAM ER [G]                          tramadol                3    [QLL,
                                                                         34/34][ST]

  ANTIDEMENTIA DRUGS

     ARICEPT                                donepezil               2
     ARICEPT ODT                            donepezil               2
     COGNEX                                 tacrine                 3
     donepezil hcl                                                  1
     EXELON [G]                             rivastigmine tartrate   2
     galantamine hbr                                                1
     galantamine hydrobromide                                       1
     NAMENDA                                memantine hcl           2
     RAZADYNE [G]                           galantamine             3
     RAZADYNE ER [G]                        galantamine             3
     rivastigmine                                                   1

  ANTIMANIA DRUGS

     ESKALITH [INJ]                         lithium carbonate       3
     lithium                                                        1
     lithium carbonate cap, -tab sa, -                              1
     tablet
     LITHOBID [G]                           lithium carbonate       3

  ANTIPARKINSON ANTICHOLINERGIC DRUGS

     benztropine mesylate injection [INJ]                           1
     benztropine mesylate tablet                                    1
     COGENTIN [INJ][G]                      benztropine             3
Formulary ID 11155 V.4

                     Drug                                 Generic   Tier   Restrictions
     trihexyphenidyl hcl                                            1

  ANTIPSYCHOTIC DRUGS

     ABILIFY DISCMELT                      aripiprazole             2      [QLL,
                                                                           68/34]
     ABILIFY INJECTION [INJ]               aripiprazole             2
     ABILIFY SOLUTION                      aripiprazole             2
     ABILIFY TABLET                        aripiprazole             2      [QLL,
                                                                           34/34]
     chlorpromazine hcl injection [INJ]                             1
     chlorpromazine hcl tablet                                      1
     clozapine                                                      1
     CLOZARIL [G]                          clozapine                3
     FANAPT 1 MG TABLET, -10 MG            iloperidone              2      [QLL,
     TABLET, -12 MG TABLET, -2 MG                                          68/34]
     TABLET, -4 MG TABLET, -6 MG
     TABLET, -8 MG TABLET
     FANAPT TITRATION PACK                 iloperidone              2      [QLL, 1/34]
     FAZACLO                               clozapine                2
     fluphenazine decanoate [INJ]                                   1
     fluphenazine hcl elix, -solution, -                            1
     tablet
     fluphenazine hcl injection [INJ]                               1
     GEODON CAP                            ziprasidone              2      [QLL,
                                                                           68/34]
     GEODON INJECTION [INJ]                ziprasidone              2
     HALDOL [INJ]                          haloperidol              3
     HALDOL DECANOATE 100 [INJ]            haloperidol decanoate    3
     HALDOL DECANOATE 50 [INJ]             haloperidol decanoate    3
     haloperidol decanoate [INJ]                                    1
     haloperidol lactate injection [INJ]                            1
     haloperidol lactate solution                                   1
     haloperidol tablet                                             1
     INVEGA ER 1.5 MG TABLET, -ER 3        paliperidone             2      [QLL,
     MG TABLET, -ER 9 MG TABLET                                            34/34]
     INVEGA ER 6 MG TABLET                 paliperidone             2      [QLL,
                                                                           68/34]
     INVEGA SUSTENNA 117 MG PREF           paliperidone             4
     SY, -156 MG PREF SY, -234 MG
     PREF SY [INJ]
Formulary ID 11155 V.4

                   Drug                               Generic      Tier   Restrictions
     INVEGA SUSTENNA 39 MG PREF        paliperidone                2
     SYR, -78 MG PREF SYR [INJ]
     LATUDA                            lurasidone hcl              2      [QLL,
                                                                          34/34]
     loxapine                                                      1
     LOXITANE [G]                      loxapine succinate          3
     MOBAN                             molindone                   2
     NAVANE [G]                        thiothixene                 3
     ORAP                              pimozide                    2
     perphenazine                                                  1
     RISPERDAL CONSTA 12.5 MG SYR, -   risperidone                 2
     25 MG SYR [INJ]
     RISPERDAL CONSTA 37.5 MG SYR, -   risperidone                 4
     50 MG SYR [INJ]
     RISPERDAL M-TAB [G]               risperidone                 3      [QLL,
                                                                          68/34]
     RISPERDAL SOLUTION [G]            risperidone                 3      [QLL, 544
                                                                          ml/34]
     RISPERDAL TABLET [G]              risperidone                 3      [QLL,
                                                                          68/34]
     risperidone m-tab                                             1      [QLL,
                                                                          68/34]
     risperidone odt                                               1      [QLL,
                                                                          68/34]
     risperidone solution                                          1      [QLL, 544
                                                                          ml/34]
     risperidone tablet                                            1      [QLL,
                                                                          68/34]
     SAPHRIS                           asenapine                   2      [QLL,
                                                                          68/34]
     SEROQUEL 100 MG TABLET, -200      quetiapine fumarate         2      [QLL,
     MG TABLET, -25 MG TABLET, -50                                        102/34]
     MG TABLET
     SEROQUEL 300 MG TABLET, -400      quetiapine fumarate         2      [QLL,
     MG TABLET                                                            68/34]
     SEROQUEL XR 150 MG TABLET, -      quetiapine fumarate         2      [QLL,
     200 MG TABLET                                                        34/34]
     SEROQUEL XR 300 MG TABLET, -      quetiapine fumarate         2      [QLL,
     400 MG TABLET, -50 MG TABLET                                         68/34]
     SYMBYAX                           olanzapine/fluoxetine hcl   3
     thioridazine hcl                                              1
     thiothixene                                                   1
Formulary ID 11155 V.4

                      Drug                           Generic        Tier Restrictions
     trifluoperazine hcl                                            1
     ZYPREXA INJECTION [INJ]           olanzapine                   2
     ZYPREXA RELPREVV [INJ][LA]        olanzapine pamoate           4
     ZYPREXA TABLET                    olanzapine                   2    [QLL,
                                                                         34/34]
     ZYPREXA ZYDIS                     olanzapine                   2    [QLL,
                                                                         34/34]

  ANTIVERTIGO AND ANTIEMETIC DRUGS

     ALOXI [INJ]                       palonosetron hcl             4
     ANTIVERT [G]                      meclizine hcl                3
     ANZEMET INJECTION [INJ]           dolasetron mesylate          3
     ANZEMET TABLET                    dolasetron mesylate          3    [PAR][QLL,
                                                                         1/1]
     CESAMET                           nabilone                     4    [QLL, 30/5]
     COMPAZINE INJECTION [INJ]         prochlorperazine edisylate   3
     COMPAZINE SYRUP                   prochlorperazine edisylate   2
     compro                                                         1
     dimenhydrinate injection [INJ]                                 1
     dronabinol 10 mg capsule, -5 mg                                4    [PAR]
     capsule
     dronabinol 2.5 mg capsule                                      1    [PAR]
     EMEND 125 MG CAPSULE, -40 MG      aprepitant                   2    [PAR][QLL,
     CAPSULE                                                             1/1]
     EMEND 80 MG CAPSULE               aprepitant                   2    [PAR][QLL,
                                                                         2/2]
     EMEND INJECTION [INJ]             aprepitant                   2
     EMEND TRIFOLD PACK                aprepitant                   2    [PAR][QLL,
                                                                         3/3]
     granisetron hcl injection [INJ]                                1
     granisetron hcl tablet                                         1    [PAR][QLL,
                                                                         2/1]
     granisol                                                       1    [PAR][QLL,
                                                                         30 ml/3]
     KYTRIL INJECTION [INJ][G]         granisetron                  4
     KYTRIL TABLET [G]                 granisetron                  4    [PAR][QLL,
                                                                         2/1]
     MARINOL 10 MG CAPSULE, -5 MG      dronabinol                   4    [PAR]
     CAPSULE [G]
     MARINOL 2.5 MG CAPSULE [G]        dronabinol                   3    [PAR]
Formulary ID 11155 V.4

                    Drug                                Generic   Tier   Restrictions
     meclizine 12.5 mg tablet, -25 mg                             1
     tablet
     ondansetron hcl 24 mg tablet                                 1      [PAR][QLL,
                                                                         1/1]
     ondansetron hcl 4 mg tablet, -8 mg                           1      [PAR][QLL,
     tablet                                                              12/5]
     ondansetron hcl in dextrose [INJ]                            1
     ondansetron hcl injection [INJ]                              1
     ondansetron hcl solution                                     1      [PAR][QLL,
                                                                         150 ml/5]
     ondansetron odt                                              1      [PAR][QLL,
                                                                         12/5]
     phenadoz                                                     1
     prochlorperazine edisylate [INJ]                             1
     prochlorperazine maleate rectal, -                           1
     tablet
     promethazine hcl rectal                                      1
     promethegan                                                  1
     SANCUSO                              granisetron             4      [QLL, 1/7]
     TIGAN CAP [G]                        trimethobenzamide       3
     TIGAN INJECTION [INJ]                trimethobenzamide       3
     TRANSDERM-SCOP                       scopolamine             3
     trimethobenzamide hcl cap                                    1
     trimethobenzamide hcl injection                              1
     [INJ]
     ZOFRAN INJECTION [INJ][G]            ondansetron             3
     ZOFRAN ODT [G]                       ondansetron             3      [PAR][QLL,
                                                                         12/5]
     ZOFRAN SOLUTION [G]                  ondansetron             3      [PAR][QLL,
                                                                         150 ml/5]
     ZOFRAN TABLET [G]                    ondansetron             3      [PAR][QLL,
                                                                         12/5]
     ZUPLENZ                              ondansetron             3      [PAR][QLL,
                                                                         12/5]

  ANXIOLYTICS

     BUSPAR                               buspirone               3
     buspirone hcl tablet                                         1
     meprobamate                                                  1
Formulary ID 11155 V.4

                     Drug                                Generic         Tier   Restrictions
  CARBAMAZEPINES

     carbamazepine chew tab, -oral susp,                                 1
     -tablet
     carbamazepine xr                                                    1
     CARBATROL                             carbamazepine                 3
     epitol                                                              1
     EQUETRO                               carbamazepine                 3
     oxcarbazepine                                                       1
     TEGRETOL [G]                          carbamazepine                 3
     TEGRETOL XR 100 MG TABLET             carbamazepine                 2
     TEGRETOL XR 200 MG TABLET, -          carbamazepine                 3
     400 MG TABLET [G]
     TRILEPTAL [G]                         oxcarbazepine                 3

  CLASS II NARCOTICS

     ABSTRAL                               fentanyl citrate              4      [PAR][QLL,
                                                                                120/30]
     ACTIQ [G]                             fentanyl citrate              4      [PAR][QLL,
                                                                                120/30]
     ALFENTA [INJ]                         alfentanil                    3
     alfentanil hydrochloride [INJ]                                      1
     ASTRAMORPH-PF [INJ][G]                morphine                      3
     AVINZA                                morphine                      3      [QLL,
                                                                                60/30][ST]
     codeine phosphate injection [INJ]                                   1
     codeine sulfate                                                     1
     COMBUNOX                              oxycodone/ibuprofen           3
     DEMEROL [INJ]                         meperidine                    3
     DILAUDID INJECTION [INJ]              hydromorphone                 3
     DILAUDID TABLET [G]                   hydromorphone                 3
     DILAUDID-5                            hydromorphone                 3
     DILAUDID-HP [INJ][G]                  hydromorphone                 3
     diskets                                                             1
     DOLOPHINE HCL [G]                     methadone                     3
     DURAGESIC [G]                         fentanyl                      3
     DURAMORPH [INJ][G]                    morphine                      3
     EMBEDA                                morphine sulfate/naltrexone   3      [QLL,
                                                                                90/30][ST]
     endocet                                                             1
Formulary ID 11155 V.4

                      Drug                                 Generic     Tier Restrictions
     endodan                                                           1
     EXALGO                                  hydromorphone             3    [QLL,
                                                                            60/30][ST]
     fentanyl                                                          1
     fentanyl citrate injection [INJ]                                  1
     fentanyl citrate loz                                              4    [PAR][QLL,
                                                                            120/30]
     FENTORA                                 fentanyl citrate          4    [PAR][QLL,
                                                                            112/28]
     hydromorphone hcl injection [INJ]                                 1
     hydromorphone hcl rectal, -tablet                                 1
     INFUMORPH [INJ]                         morphine                  3
     KADIAN                                  morphine                  3    [QLL,
                                                                            90/30][ST]
     levorphanol tartrate tablet                                       1
     MAGNACET                                oxycodone/acetaminophen   3
     meperidine hcl injection [INJ]                                    1
     methadone hcl injection [INJ]                                     1
     methadone hcl solution, -tablet                                   1
     methadone intensol                                                1
     methadose                                                         1
     morphine sulfate in dextrose [INJ]                                1
     morphine sulfate injection [INJ]                                  1
     morphine sulfate rectal, -solution, -                             1
     tablet
     morphine sulfate tab sa                                           1    [QLL,
                                                                            120/30]
     MS CONTIN [G]                           morphine                  3    [QLL,
                                                                            120/30][ST]
     NUCYNTA                                 tapentadol hcl            3    [QLL,
                                                                            205/34]
     NUMORPHAN [INJ]                         oxymorphone               2
     ONSOLIS [LA]                            fentanyl citrate          4    [PAR][QLL,
                                                                            120/30]
     OPANA                                   oxymorphone               3
     OPANA ER                                oxymorphone               2    [QLL,
                                                                            90/30][ST]
     OPIUM                                   opium                     2
     ORAMORPH SR                             morphine                  3    [QLL,
                                                                            120/30][ST]
     oxycodone hcl                                                     1
Formulary ID 11155 V.4

                    Drug                          Generic              Tier Restrictions
     oxycodone hcl-acetaminophen                                       1
     oxycodone hcl-ibuprofen                                           1
     oxycodone-acetaminophen                                           1
     oxycodone-aspirin                                                 1
     OXYCONTIN [G]                  oxycodone                          2    [QLL,
                                                                            90/30][ST]
     oxymorphone hcl                                                   1
     PERCOCET [G]                   oxycodone/acetaminophen            3
     PERCODAN [G]                   oxycodone/aspirin                  3
     PRIMLEV                        oxycodone/acetaminophen            3
     ROXICET SOLUTION               oxycodone/acetaminophen            3
     roxicet tablet                                                    1
     ROXICODONE [G]                 oxycodone                          3
     ROXICODONE INTENSOL            oxycodone                          3
     sublimaze [INJ]                                                   1
     TYLOX                          oxycodone/acetaminophen            3
     XOLOX                          oxycodone/acetaminophen            3

  CLASS III NARCOTICS

     acetaminophen-codeine                                             1
     apap-caffeine-dihydrocodeine                                      1
     buprenorphine hcl tab, sl                                         1
     BUTRANS                        buprenorphine                      3
     CAPITAL W-CODEINE              codeine phosphate/apap             2
     COCET                          codeine phosphate/apap             3
     COCET PLUS                     codeine phosphate/apap             3
     co-gesic                                                          1
     HYCET                          hydrocodone bitartrate/apap        3
     hydrocodone bit-ibuprofen                                         1
     hydrocodone-acetaminophen                                         1
     hydrogesic                                                        1
     IBUDONE                        hydrocodone   bitartrate/ibuprof   3
     LORCET 10-650 [G]              hydrocodone   bitartrate/apap      3
     LORCET PLUS [G]                hydrocodone   bitartrate/apap      3
     LORTAB [G]                     hydrocodone   bitartrate/apap      3
     margesic h                                                        1
     MAXIDONE [G]                   hydrocodone bitartrate/apap        3
     NORCO [G]                      hydrocodone bitartrate/apap        3
     PANLOR DC                      dihydrocodeine/apap/caffeine       3
Formulary ID 11155 V.4

                   Drug                             Generic              Tier Restrictions
     PANLOR SS [G]                      dihydrocodeine/apap/caffeine     3
     POLYGESIC [INJ]                    hydrocodone bitartrate/apap      3
     reprexain                                                           1
     stagesic                                                            1
     SUBOXONE ORALLY DISSOLVING         buprenorphine/naloxone           3    [QLL,
     STRIPS                                                                   102/34]
     SUBOXONE TAB, SL                   buprenorphine/naloxone           2    [QLL,
                                                                              102/34]
     SUBUTEX [G]                        buprenorphine                    3
     SYNALGOS-DC                        dihydrocodeine/asa/caffeine      3
     trezix                                                              1
     TYLENOL-CODEINE NO.3 [G]           codeine phosphate/apap           3
     TYLENOL-CODEINE NO.4 [G]           codeine phosphate/apap           3
     VICODIN [G]                        hydrocodone bitartrate/apap      3
     VICODIN ES [G]                     hydrocodone bitartrate/apap      3
     VICODIN HP [G]                     hydrocodone bitartrate/apap      3
     VICOPROFEN [G]                     hydrocodone bitartrate/ibuprof   3
     XODOL 10-300                       hydrocodone bitartrate/apap      3
     XODOL 5-300                        hydrocodone bitartrate/apap      3
     XODOL 7.5-300                      hydrocodone bitartrate/apap      3
     zamicet                                                             1
     ZERLOR [G]                         dihydrocodeine/apap/caffeine     3
     ZOLVIT                             hydrocodone bitartrate/apap      3
     ZYDONE                             hydrocodone bitartrate/apap      3

  CNS STIMULANT DRUGS

     ADDERALL [G]                       amphetamine/dextroamphetamine 3
     ADDERALL XR                        amphetamine/dextroamphetamine 3
     amphetamine salt combo                                              1
     CAFCIT INJECTION [INJ]             caffeine citrated                3
     caffeine citrate injection [INJ]                                    1
     CONCERTA                           methylphenidate                  2
     DAYTRANA                           methylphenidate                  3
     DESOXYN [G]                        methamphetamine                  3
     DEXEDRINE [G]                      d-amphetamine                    3
     dexmethylphenidate hcl                                              1
     dextroamphetamine sulfate                                           1
     dextroamphetamine-amphetamine                                       1
     FOCALIN [G]                        dexmethylphenidate               3
Formulary ID 11155 V.4

                      Drug                               Generic            Tier   Restrictions
     FOCALIN XR                              dexmethylphenidate             3
     METADATE CD                             methylphenidate                2
     metadate er                                                            1
     methamphetamine hcl                                                    1
     METHYLIN 10 MG CHEWABLE                 methylphenidate                3
     TABLET, -2.5 MG CHEWABLE TAB, -
     5 MG CHEWABLE TABLET, -
     SOLUTION
     methylin 10 mg tablet, -20 mg                                          1
     tablet, -5 mg tablet
     methylin er                                                            1
     methylphenidate er                                                     1
     methylphenidate hcl solution, -tablet                                  1
     methylphenidate sr                                                     1
     NUVIGIL                                 armodafinil                    3      [PAR]
     PROCENTRA                               d-amphetamine                  3
     PROVIGIL                                modafinil                      2      [PAR]
     RITALIN [G]                             methylphenidate                3
     RITALIN LA                              methylphenidate                3
     RITALIN-SR [G]                          methylphenidate                3
     VYVANSE                                 lisdexamfetamine dimesylate    3

  DRUGS TO PREVENT AND TREAT HEADACHES

     AMERGE [G]                              naratriptan                    3      [QLL,
                                                                                   18/28]
     ascomp with codeine                                                    1
     AXERT 12.5 MG TABLET                    almotriptan                    3      [QLL,
                                                                                   24/28]
     AXERT 6.25 MG TABLET                    almotriptan                    3      [QLL,
                                                                                   18/28]
     butalb-caff-acetaminoph-codein                                         1
     butalbital compound-codeine                                            1
     butorphanol tartrate aerosol                                           1      [QLL, 5
                                                                                   ml/3]
     CAFERGOT [G]                            ergotamine tartrate/caffeine   3
     D.H.E.45 [INJ][G]                       dihydroergotamine              4
     dihydroergotamine mesylate                                             1
     injection [INJ]
     ERGOMAR                                 ergotamine                     3
     ergotamine-caffeine                                                    1
Formulary ID 11155 V.4

                  Drug                                     Generic           Tier Restrictions
     FIORICET WITH CODEINE [G]                codeine/apap/caffeine/butalb   3
     FIORINAL WITH CODEINE #3 [G]             codeine/asa/caffeine/butalb    3
     FROVA                                    frovatriptan                   2    [QLL,
                                                                                  27/28]
     IMITREX 20 MG NASAL SPRAY                sumatriptan                    3    [QLL, 18
                                                                                  nasal
                                                                                  sprayers/28]
     IMITREX 4 MG/0.5 ML SYRNG KIT, -         sumatriptan                    3    [QLL, 8/28]
     6 MG/0.5 ML SYRNG KIT [INJ]
     IMITREX 5 MG NASAL SPRAY                 sumatriptan                    3    [QLL, 36
                                                                                  nasal
                                                                                  sprayers/28]
     IMITREX 6 MG/0.5 ML VIAL, -4             sumatriptan                    3    [QLL, 8
     MG/0.5 ML KIT REFILL, -6 MG/0.5                                              vials/28]
     ML KIT REFILL [INJ][G]
     IMITREX TABLET [G]                       sumatriptan                    3    [QLL,
                                                                                  18/28]
     MAXALT                                   rizatriptan benzoate           2    [QLL,
                                                                                  27/28]
     MAXALT MLT                               rizatriptan benzoate           2    [QLL,
                                                                                  27/28]
     migergot                                                                1
     MIGRANAL                                 dihydroergotamine              2    [QLL, 16
                                                                                  mg/28]
     naratriptan hcl                                                         1    [QLL,
                                                                                  18/28]
     RELPAX                                   eletriptan                     3    [QLL,
                                                                                  18/28]
     SUMATRIPTAN 20 MG NASAL SPRAY            sumatriptan                    3    [QLL,
                                                                                  18/28]
     sumatriptan 4 mg/0.5 ml kit, -4                                         1    [QLL, 8/28]
     mg/0.5 ml refill, -4 mg/0.5 ml syrng,
     -6 mg/0.5 ml kit, -6 mg/0.5 ml refill,
     -6 mg/0.5 ml syrng [INJ]
     sumatriptan 4 mg/0.5 ml vial, -6                                        1    [QLL, 8
     mg/0.5 ml vial [INJ]                                                         ml/28]
     SUMATRIPTAN 5 MG NASAL SPRAY             sumatriptan                    3    [QLL,
                                                                                  36/28]
     sumatriptan succinate tablet                                            1    [QLL,
                                                                                  18/28]
     TREXIMET                                 sumatriptan suc/naproxen sod   3    [QLL,
                                                                                  18/28]
Formulary ID 11155 V.4

                  Drug                                 Generic   Tier Restrictions
     ZOMIG NASAL DROPS/SPRAYS           zolmitriptan             2    [QLL, 18
                                                                      nasal
                                                                      sprayers/28]
     ZOMIG TABLET                       zolmitriptan             3    [QLL,
                                                                      18/28]
     ZOMIG ZMT                          zolmitriptan             3    [QLL,
                                                                      18/28]

  HYDANTOINS

     CEREBYX [INJ]                      fosphenytoin             3
     DILANTIN 100 MG CAPSULE [G]        phenytoin sodium         3
     DILANTIN 30 MG CAPSULE, -CHEW      phenytoin                2
     TAB
     DILANTIN-125 [G]                   phenytoin sodium         3
     fosphenytoin sodium [INJ]                                   1
     PEGANONE                           ethotoin                 2
     PHENYTEK [G]                       phenytoin sodium         3
     phenytoin oral susp                                         1
     phenytoin sodium extended                                   1
     phenytoin sodium injection [INJ]                            1

  MAO INHIBITORS

     EMSAM                              selegiline               2
     MARPLAN                            isocarboxazid            2
     NARDIL                             phenelzine               2
     PARNATE                            tranylcypromine          3
     phenelzine sulfate tablet                                   1
     tranylcypromine sulfate                                     1

  OTHER ANTICONVULSANTS

     BANZEL 200 MG TABLET               rufinamide               2
     BANZEL 400 MG TABLET               rufinamide               4
     FELBATOL                           felbamate                2
     gabapentin cap, -tablet                                     1
     GABITRIL                           tiagabine                2
     KEPPRA INJECTION [INJ][G]          levetiracetam            2
     KEPPRA SOLUTION, -TABLET [G]       levetiracetam            3    [ST]
Formulary ID 11155 V.4

                   Drug                                  Generic   Tier   Restrictions
     KEPPRA XR                              levetiracetam          3      [ST]
     LAMICTAL [G]                           lamotrigine            3      [ST]
     LAMICTAL (BLUE)                        lamotrigine            3      [ST]
     LAMICTAL (GREEN) [G]                   lamotrigine            3      [ST]
     LAMICTAL (ORANGE) [G]                  lamotrigine            3      [ST]
     LAMICTAL ODT                           lamotrigine            3      [ST]
     LAMICTAL ODT (BLUE)                    lamotrigine            3      [ST]
     LAMICTAL ODT (GREEN)                   lamotrigine            3      [ST]
     LAMICTAL ODT (ORANGE)                  lamotrigine            3      [ST]
     LAMICTAL XR                            lamotrigine            3      [ST]
     LAMICTAL XR (BLUE)                     lamotrigine            3      [ST]
     LAMICTAL XR (GREEN)                    lamotrigine            3      [ST]
     LAMICTAL XR (ORANGE)                   lamotrigine            3      [ST]
     lamotrigine                                                   1
     levetiracetam injection [INJ]                                 1
     levetiracetam solution, -tablet                               1
     LYRICA                                 pregabalin             2      [ST]
     MYSOLINE [G]                           primidone              3
     NEURONTIN CAP, -TABLET [G]             gabapentin             3
     NEURONTIN SOLUTION                     gabapentin             2
     primidone                                                     1
     SABRIL [LA]                            vigabatrin             4
     TOPAMAX [G]                            topiramate             3      [PAR]
     topiragen                                                     1      [PAR]
     topiramate sprinkle, -tablet                                  1      [PAR]
     VIMPAT INJECTION [INJ]                 lacosamide             2
     VIMPAT SOLUTION, -TABLET               lacosamide             2
     ZONEGRAN [G]                           zonisamide             3      [PAR]
     zonisamide                                                    1      [PAR]

  OTHER ANTIDEPRESSANTS

     APLENZIN                               bupropion hbr          3      [QLL,
                                                                          34/34][ST]
     budeprion sr                                                  1      [QLL,
                                                                          68/34]
     budeprion xl                                                  1      [QLL,
                                                                          34/34]
     bupropion hcl sr 100 mg tablet, -200                          1      [QLL,
     mg tab                                                               68/34]
Formulary ID 11155 V.4

                     Drug                                 Generic      Tier Restrictions
     bupropion hcl tablet                                              1
     bupropion sr 150 mg tablet                                        1
     bupropion xl                                                      1    [QLL,
                                                                            34/34]
     chlordiazepoxide-amitriptyline                                    1
     CYMBALTA 20 MG CAPSULE, -60 MG         duloxetine                 2    [QLL,
     CAPSULE                                                                68/34][ST]
     CYMBALTA 30 MG CAPSULE                 duloxetine                 2    [QLL,
                                                                            34/34][ST]
     EFFEXOR                                venlafaxine                3    [QLL,
                                                                            102/34][ST]
     EFFEXOR XR 150 MG CAPSULE, -           venlafaxine                2    [QLL,
     37.5 MG CAPSULE [G]                                                    34/34][ST]
     EFFEXOR XR 75 MG CAPSULE [G]           venlafaxine                2    [QLL,
                                                                            102/34][ST]
     maprotiline hcl                                                   1
     mirtazapine                                                       1
     nefazodone hcl                                                    1
     OLEPTRO ER                             trazodone                  3
     perphenazine-amitriptyline                                        1
     PRISTIQ                                desvenlafaxine succinate   2    [QLL,
                                                                            34/34][ST]
     REMERON [G]                            mirtazapine                3
     SAVELLA 100 MG TABLET, -12.5 MG        milnacipran hcl            2    [QLL,
     TABLET, -25 MG TABLET, -50 MG                                          68/34][ST]
     TABLET
     SAVELLA TITRATION PACK                 milnacipran hcl            2    [QLL,
                                                                            1/34][ST]
     trazodone hcl tablet                                              1
     venlafaxine hcl                                                   1    [QLL,
                                                                            102/34]
     VENLAFAXINE HCL ER 150 MG TAB,         venlafaxine                3    [QLL,
     -225 MG TAB, -37.5 MG TAB, -75                                         34/34][ST]
     MG TAB (Upstate Pharma)
     venlafaxine hcl er 150 mg cap, -37.5                              1    [QLL,
     mg cap                                                                 34/34]
     venlafaxine hcl er 75 mg cap                                      1    [QLL,
                                                                            102/34]
     venlafaxine hcl er 150 mg tab, 225                                1    [QLL,
     mg tab, -37.5 mg tab, -75 mg tab,                                      34/34]
     (Schwarz Pharmac, Sun Pharma)
     WELLBUTRIN                             bupropion                  3
Formulary ID 11155 V.4

                 Drug                                   Generic         Tier Restrictions
     WELLBUTRIN SR [G]                     bupropion                    3    [QLL,
                                                                             68/34][ST]
     WELLBUTRIN XL [G]                     bupropion                    3    [QLL,
                                                                             34/34][ST]

  OTHER ANTIPARKINSON DRUGS

     APOKYN [INJ][LA]                      apomorphine hcl              4
     AZILECT                               rasagiline mesylate          2
     bromocriptine mesylate cap, -tablet                                1
     carbidopa-levodopa                                                 1
     COMTAN                                entacapone                   2
     ELDEPRYL                              selegiline                   3
     LODOSYN                               carbidopa                    2
     MIRAPEX [G]                           pramipexole                  3
     MIRAPEX ER                            pramipexole                  3
     PARCOPA [G]                           carbidopa/levodopa           3
     PARLODEL [G]                          bromocriptine mesylate       3
     pramipexole dihydrochloride                                        1
     REQUIP [G]                            ropinirole                   3
     REQUIP XL                             ropinirole                   2
     ropinirole hcl                                                     1
     selegiline hcl cap, -tablet                                        1
     SINEMET 10-100 [G]                    carbidopa/levodopa           3
     SINEMET 25-100 [G]                    carbidopa/levodopa           3
     SINEMET 25-250 [G]                    carbidopa/levodopa           3
     SINEMET CR [G]                        carbidopa/levodopa           3
     STALEVO 100                           carbidopa/levodopa/entacap   2
     STALEVO 125                           carbidopa/levodopa/entacap   2
     STALEVO 150                           carbidopa/levodopa/entacap   2
     STALEVO 200                           carbidopa/levodopa/entacap   2
     STALEVO 50                            carbidopa/levodopa/entacap   2
     STALEVO 75                            carbidopa/levodopa/entacap   2
     TASMAR                                tolcapone                    2
     ZELAPAR                               selegiline                   3

  OTHER CNS/AUTONOMIC DRUGS

     ANTABUSE                              disulfiram                   2
     atropine sulfate injection [INJ]                                   1
Formulary ID 11155 V.4

                         Drug                         Generic            Tier Restrictions
     CAMPRAL                              acamprosate calcium            3
     depade                                                              1
     ENLON [INJ]                          edrophonium                    2
     ENLON-PLUS [INJ]                     edrophonium/atropine sulfate   2
     flumazenil [INJ]                                                    1
     guanidine hcl                                                       1
     INTUNIV                              guanfacine                     3    [ST]
     KAPVAY                               clonidine                      3    [ST]
     MESTINON SYRUP, -TAB SA              pyridostigmine                 2
     MESTINON TABLET [G]                  pyridostigmine                 3
     MYTELASE                             ambenonium chloride            3
     naloxone hcl injection [INJ]                                        1
     naltrexone hcl tablet                                               1
     neostigmine methylsulfate [INJ]                                     1
     NUEDEXTA                             dextromethorphan/quinidine     2
     physostigmine salicylate injection                                  1
     [INJ]
     PROSTIGMIN                           neostigmine bromide            2
     pyridostigmine bromide                                              1
     REGONOL [INJ]                        pyridostigmine                 3
     REVIA [G]                            naltrexone                     3
     ROMAZICON [INJ]                      flumazenil                     3
     STRATTERA                            atomoxetine                    2    [ST]
     VIVITROL [INJ]                       naltrexone microspheres        4
     XENAZINE [LA]                        tetrabenazine                  4    [PAR]
     XYREM [LA]                           sodium oxybate                 4

  SECONDARY AMINES

     amoxapine                                                           1
     desipramine hcl tablet                                              1
     NORPRAMIN [G]                        desipramine                    3
     nortriptyline hcl cap, -solution                                    1
     PAMELOR [G]                          nortriptyline                  3
     protriptyline hcl                                                   1
     VIVACTIL [G]                         protriptyline                  3
Formulary ID 11155 V.4

                      Drug                             Generic   Tier   Restrictions
  SEDATIVE/HYPNOTIC DRUGS

     AMBIEN [G]                          zolpidem                3      [QLL,
                                                                        34/34][ST]
     AMBIEN CR                           zolpidem                2      [QLL,
                                                                        34/34][ST]
     EDLUAR                              zolpidem                3      [QLL,
                                                                        34/34][ST]
     LUNESTA                             eszopiclone             2      [QLL,
                                                                        34/34][ST]
     ROZEREM                             ramelteon               2      [QLL,
                                                                        34/34][ST]
     SILENOR                             doxepin                 3      [QLL,
                                                                        34/34][ST]
     SONATA 10 MG CAPSULE [G]            zaleplon                3      [QLL,
                                                                        68/34][ST]
     SONATA 5 MG CAPSULE [G]             zaleplon                3      [QLL,
                                                                        34/34][ST]
     zaleplon 10 mg capsule                                      1      [QLL,
                                                                        68/34]
     zaleplon 5 mg capsule                                       1      [QLL,
                                                                        34/34]
     zolpidem tartrate                                           1      [QLL,
                                                                        34/34]
     ZOLPIMIST                           zolpidem                3      [QLL,
                                                                        8/30][ST]

  SELECTIVE SEROTONIN REUPTAKE INHIBITORS

     CELEXA [G]                          citalopram              3      [QLL,
                                                                        34/34][ST]
     citalopram                                                  1
     citalopram hbr                                              1      [QLL,
                                                                        34/34]
     fluoxetine dr                                               1      [QLL, 5/34]
     fluoxetine hcl 10 mg capsule, -10                           1      [QLL,
     mg tablet                                                          34/34]
     fluoxetine hcl 20 mg capsule, -20                           1
     mg tablet, -solution
     fluoxetine hcl 40 mg capsule                                1      [QLL,
                                                                        68/34]
Formulary ID 11155 V.4

                   Drug                                  Generic   Tier Restrictions
     fluvoxamine maleate 100 mg tab                                1    [QLL,
                                                                        102/34]
     fluvoxamine maleate 25 mg tab                                 1    [QLL,
                                                                        34/34]
     fluvoxamine maleate 50 mg tab                                 1    [QLL,
                                                                        68/34]
     LEXAPRO SOLUTION                      escitalopram oxalate    2    [ST]
     LEXAPRO TABLET                        escitalopram oxalate    2    [QLL,
                                                                        34/34][ST]
     LUVOX CR                              fluvoxamine             3    [QLL,
                                                                        68/34][ST]
     paroxetine hcl 10 mg tablet, -40 mg                           1    [QLL,
     tablet                                                             34/34]
     paroxetine hcl 20 mg tablet, -30 mg                           1    [QLL,
     tablet, -tab sa                                                    68/34]
     paroxetine hcl oral susp                                      1
     PAXIL 10 MG TABLET, -40 MG            paroxetine              3    [QLL,
     TABLET [G]                                                         34/34][ST]
     PAXIL 20 MG TABLET, -30 MG            paroxetine              3    [QLL,
     TABLET [G]                                                         68/34][ST]
     PAXIL CR [G]                          paroxetine              3    [QLL,
                                                                        68/34][ST]
     PAXIL ORAL SUSP [G]                   paroxetine              3    [ST]
     PEXEVA 10 MG TABLET, -40 MG           paroxetine mesylate     3    [QLL,
     TABLET                                                             34/34][ST]
     PEXEVA 20 MG TABLET, -30 MG           paroxetine mesylate     3    [QLL,
     TABLET                                                             68/34][ST]
     PROZAC 10 MG PULVULE [G]              fluoxetine              3    [QLL,
                                                                        34/34][ST]
     PROZAC 20 MG PULVULE [G]              fluoxetine              3    [ST]
     PROZAC 40 MG PULVULE [G]              fluoxetine              3    [QLL,
                                                                        68/34][ST]
     PROZAC WEEKLY [G]                     fluoxetine              3    [QLL,
                                                                        5/34][ST]
     rapiflux 20 mg tablet                                         1
     SARAFEM 10 MG TABLET                  fluoxetine              3    [QLL,
                                                                        35/14][ST]
     SARAFEM 15 MG TABLET                  fluoxetine              3    [ST]
     SARAFEM 20 MG TABLET                  fluoxetine              3    [QLL,
                                                                        140/14][ST]
     selfemra 10 mg capsule                                        1    [QLL,
                                                                        35/14]
Formulary ID 11155 V.4

                   Drug                                    Generic   Tier Restrictions
     selfemra 20 mg capsule                                          1    [QLL,
                                                                          140/14]
     sertraline hcl 100 mg tablet, -50 mg                            1    [QLL,
     tablet                                                               68/34]
     sertraline hcl 25 mg tablet                                     1    [QLL,
                                                                          34/34]
     sertraline hcl solution                                         1
     ZOLOFT 100 MG TABLET, -50 MG           sertraline               3    [QLL,
     TABLET [G]                                                           68/34][ST]
     ZOLOFT 25 MG TABLET [G]                sertraline               3    [QLL,
                                                                          34/34][ST]
     ZOLOFT SOLUTION [G]                    sertraline               3    [ST]

  SMOKING CESSATION PRODUCTS

     buproban                                                        1
     CHANTIX                                varenicline tartrate     2
     NICOTROL                               nicotine inhaler         2
     NICOTROL NS                            nicotine ns              2
     ZYBAN [G]                              bupropion                3

  SUCCINIMIDES

     CELONTIN                               methsuximide             2
     ethosuximide                                                    1
     ZARONTIN [G]                           ethosuximide             3

  TERTIARY AMINES

     amitriptyline hcl tablet                                        1
     ANAFRANIL [G]                          clomipramine             3
     clomipramine hcl cap                                            1
     doxepin hcl cap, -solution                                      1
     imipramine hcl tablet                                           1
     imipramine pamoate                                              1
     SURMONTIL                              trimipramine             2
     TOFRANIL [G]                           imipramine hcl           3
     TOFRANIL-PM [G]                        imipramine pamoate       3
Formulary ID 11155 V.4

                     Drug                               Generic   Tier   Restrictions
  VALPROIC ACID AND DERIVATIVES

     DEPACON [INJ][G]                   valproate sodium          3
     DEPAKENE [G]                       valproic acid             3      [ST]
     DEPAKOTE [G]                       divalproex                3      [ST]
     DEPAKOTE ER [G]                    divalproex                3      [ST]
     DEPAKOTE SPRINKLE [G]              divalproex                3      [ST]
     divalproex sodium                                            1
     divalproex sodium er                                         1
     STAVZOR                            valproic acid             3      [ST]
     valproate sodium injection [INJ]                             1
     valproic acid cap, -syrup                                    1

CARDIOVASCULAR MEDICATIONS
  AMIODARONES

     amiodarone hcl injection [INJ]                               1
     amiodarone hcl tablet                                        1
     CORDARONE [G]                      amiodarone                3
     PACERONE 100 MG TABLET, -400       amiodarone                3
     MG TABLET [G]
     pacerone 200 mg tablet                                       1

  ANGIOTENSIN CONVERTING ENZYME INHIBITORS

     ACCUPRIL [G]                       quinapril                 3      [ST]
     ACEON [G]                          perindopril erbumine      3      [ST]
     ALTACE [G]                         ramipril                  3      [ST]
     benazepril hcl                                               1
     captopril tablet                                             1
     enalapril maleate tablet                                     1
     enalaprilat [INJ]                                            1
     fosinopril sodium                                            1
     lisinopril tablet                                            1
     LOTENSIN [G]                       benazepril                3      [ST]
     MAVIK [G]                          trandolapril              3      [ST]
     moexipril hcl                                                1
     MONOPRIL                           fosinopril                3      [ST]
     perindopril erbumine                                         1
     PRINIVIL [G]                       lisinopril                3      [ST]
Formulary ID 11155 V.4

                     Drug                                  Generic   Tier Restrictions
     quinapril hcl                                                   1
     ramipril                                                        1
     trandolapril                                                    1
     UNIVASC [G]                           moexipril                 3    [ST]
     VASOTEC [G]                           enalapril                 3    [ST]
     ZESTRIL [G]                           lisinopril                3    [ST]

  ANGIOTENSIN II RECEPTOR ANTAGONISTS

     ATACAND                               candesartan cilexetil     3    [ST]
     AVAPRO                                irbesartan                3    [ST]
     BENICAR                               olmesartan medoxomil      2    [ST]
     COZAAR [G]                            losartan                  3    [ST]
     DIOVAN                                valsartan                 2    [ST]
     losartan potassium                                              1
     MICARDIS                              telmisartan               3    [ST]
     TEVETEN                               eprosartan mesylate       3    [ST]

  ANTIDYSRHYTHMIC DRUGS

     flecainide acetate                                              1
     mexiletine hcl cap                                              1
     procainamide hcl injection [INJ]                                1
     PRONESTYL                             procainamide              3
     propafenone hcl                                                 1
     quinidine gluconate injection [INJ]                             1
     quinidine gluconate tab sa                                      1
     quinidine sulfate tab sa, -tablet                               1
     RYTHMOL [G]                           propafenone               3
     RYTHMOL SR                            propafenone               2
     TAMBOCOR [G]                          flecainide                3

  BETA-ADRENERGIC ANTAGONIST DRUGS

     acebutolol hcl cap                                              1
     atenolol tablet                                                 1
     betaxolol hcl tablet                                            1
     bisoprolol fumarate                                             1
     BYSTOLIC                              nebivolol hcl             2
     carvedilol                                                      1
Formulary ID 11155 V.4

                   Drug                                   Generic   Tier   Restrictions
     COREG [G]                              carvedilol              3
     COREG CR                               carvedilol              2
     CORGARD [G]                            nadolol                 3
     INDERAL LA [G]                         propranolol             3
     INNOPRAN XL                            propranolol             3
     KERLONE [G]                            betaxolol               3
     labetalol hcl injection [INJ]                                  1
     labetalol hcl tablet                                           1
     LEVATOL                                penbutolol              3
     LOPRESSOR INJECTION [INJ][G]           metoprolol tartrate     3
     LOPRESSOR TABLET [G]                   metoprolol tartrate     3
     metoprolol succinate                                           1
     metoprolol tartrate injection [INJ]                            1
     metoprolol tartrate tablet                                     1
     nadolol tablet                                                 1
     pindolol                                                       1
     propranolol hcl cap sa, -solution, -                           1
     tablet
     propranolol hcl injection [INJ]                                1
     SECTRAL [G]                            acebutolol              3
     TENORMIN [G]                           atenolol                3
     timolol maleate tablet                                         1
     TOPROL XL [G]                          metoprolol succinate    3
     TRANDATE [G]                           labetalol               3
     ZEBETA [G]                             bisoprolol              3

  CALCIUM ANTAGONISTS

     ADALAT CC [G]                          nifedipine              3      [ST]
     afeditab cr                                                    1
     amlodipine besylate                                            1
     CALAN [G]                              verapamil               3      [ST]
     CALAN SR [G]                           verapamil               3      [ST]
     CARDIZEM [G]                           diltiazem               3
     CARDIZEM CD [G]                        diltiazem               3
     CARDIZEM LA                            diltiazem               3
     cartia xt                                                      1
     COVERA-HS                              verapamil               3      [ST]
     DILACOR XR [G]                         diltiazem               3
     dilt-cd                                                        1
Formulary ID 11155 V.4

                      Drug                                  Generic   Tier   Restrictions
     diltia xt                                                        1
     diltiazem 24hr er                                                1
     diltiazem er                                                     1
     diltiazem hcl injection [INJ]                                    1
     diltiazem hcl tablet                                             1
     dilt-xr                                                          1
     diltzac er                                                       1
     DYNACIRC CR                              isradipine              3      [ST]
     felodipine er                                                    1
     ISOPTIN SR [G]                           verapamil               3      [ST]
     isradipine                                                       1
     nicardipine hcl cap                                              1
     nicardipine hcl injection [INJ]                                  1
     nifediac cc                                                      1
     nifedical xl                                                     1
     nifedipine cap                                                   1
     nifedipine er                                                    1
     nimodipine                                                       4
     NIMOTOP [INJ]                            nimodipine              3
     nisoldipine                                                      1
     NORVASC [G]                              amlodipine              3      [ST]
     PROCARDIA [G]                            nifedipine              3      [ST]
     PROCARDIA XL [G]                         nifedipine              3      [ST]
     SULAR                                    nisoldipine             3      [ST]
     taztia xt                                                        1
     TIAZAC [G]                               diltiazem               3
     verapamil er                                                     1
     verapamil er pm                                                  1
     verapamil hcl cap sa, -tab sa, -tablet                           1
     verapamil hcl injection [INJ]                                    1
     VERELAN [G]                              verapamil               3      [ST]
     VERELAN PM [G]                           verapamil               3      [ST]

  CARDIAC GLYCOSIDES

     digoxin injection [INJ]                                          1
     digoxin solution, -tablet                                        1
     LANOXIN INJECTION [INJ][G]               digoxin                 3
     LANOXIN PEDIATRIC [INJ]                  digoxin                 2
     LANOXIN TABLET [G]                       digoxin                 3
Formulary ID 11155 V.4

                     Drug                             Generic   Tier   Restrictions
     milrinone in 5% dextrose [INJ]                             1
     milrinone lactate [INJ]                                    1

  CENTRALLY ACTING ANTIHYPERTENSIVES

     CATAPRES [G]                       clonidine               3
     CATAPRES-TTS 1 [G]                 clonidine               3      [QLL,   5/35]
     CATAPRES-TTS 2 [G]                 clonidine               3      [QLL,   5/35]
     CATAPRES-TTS 3 [G]                 clonidine               3      [QLL,   5/35]
     clonidine                                                  1      [QLL,   5/35]
     clonidine hcl injection [INJ]                              1
     clonidine hcl tablet                                       1
     DURACLON [INJ]                     clonidine               3
     guanabenz acetate                                          1
     guanfacine hcl                                             1
     methyldopa                                                 1
     methyldopate hcl [INJ]                                     1
     TENEX [G]                          guanfacine              3

  DRUGS FOR PHEOCHROMOCYTOMA

     DEMSER                             metyrosine              2
     DIBENZYLINE                        phenoxybenzamine        2
     PHENTOLAMINE MESYLATE              phentolamine            2
     INJECTION [INJ]

  ENDOTHELIN RECPTR ANTAGONIST

     LETAIRIS [LA]                      ambrisentan             4      [PAR]
     TRACLEER [LA]                      bosentan                4      [PAR]

  HMG-COA REDUCTASE INHIBITORS

     ADVICOR 1,000 MG-20 MG TABLET, lovastatin/niacin           2      [QLL,
     -1,000 MG-40 MG TABLET, -750 MG-                                  68/34]
     20 MG TABLET
     ADVICOR 500 MG-20 MG TABLET      lovastatin/niacin         2      [QLL,
                                                                       34/34]
     ALTOPREV                           lovastatin              3      [QLL,
                                                                       34/34][ST]
Formulary ID 11155 V.4

                     Drug                           Generic      Tier Restrictions
     CADUET                            amlodipine/atorvast cal   3    [QLL,
                                                                      34/34][ST]
     CRESTOR 10 MG TABLET, -20 MG      rosuvastatin calcium      2    [QLL,
     TABLET, -40 MG TABLET                                            34/34]
     CRESTOR 5 MG TABLET               rosuvastatin calcium      2    [QLL,
                                                                      34/34][ST]
     LESCOL 20 MG CAPSULE              fluvastatin               3    [QLL,
                                                                      34/34][ST]
     LESCOL 40 MG CAPSULE              fluvastatin               3    [QLL,
                                                                      68/34][ST]
     LESCOL XL                         fluvastatin               3    [QLL,
                                                                      34/34][ST]
     LIPITOR                           atorvastatin calcium      3    [QLL,
                                                                      34/34][ST]
     LIVALO                            pitavastatin calcium      3    [QLL,
                                                                      34/34][ST]
     lovastatin 10 mg tablet                                     1    [QLL,
                                                                      34/34]
     lovastatin 20 mg tablet, -40 mg                             1    [QLL,
     tablet                                                           68/34]
     MEVACOR [G]                       lovastatin                3    [QLL,
                                                                      68/34][ST]
     PRAVACHOL [G]                     pravastatin               3    [QLL,
                                                                      34/34][ST]
     pravastatin sodium                                          1    [QLL,
                                                                      34/34]
     SIMCOR 1,000-20 MG TABLET, -      niacin/simvastatin        2    [QLL,
     750-20 MG TABLET                                                 68/34]
     SIMCOR 1,000-40 MG TABLET, -      niacin/simvastatin        2    [QLL,
     500-20 MG TABLET, -500-40 MG                                     34/34]
     TABLET
     simvastatin tablet                                          1    [QLL,
                                                                      34/34]
     VYTORIN 10-10 MG TABLET           ezetimibe/simvastatin     2    [QLL,
                                                                      34/34][ST]
     VYTORIN 10-20 MG TABLET, -10-40   ezetimibe/simvastatin     2    [QLL,
     MG TABLET, -10-80 MG TABLET                                      34/34]
     ZOCOR [G]                         simvastatin               3    [QLL,
                                                                      34/34][ST]
Formulary ID 11155 V.4

                      Drug                        Generic       Tier   Restrictions
  HYPOLIPOPROTEINEMICS

     ANTARA                         fenofibrate                 3      [ST]
     cholestyramine                                             1
     cholestyramine light                                       1
     COLESTID [G]                   colestipol                  3
     colestipol hcl                                             1
     fenofibrate                                                1
     FENOFIBRIC ACID                fenofibric acid             3      [ST]
     FENOGLIDE                      fenofibrate                 3      [ST]
     FIBRICOR                       fenofibric acid             3      [ST]
     gemfibrozil tablet                                         1
     LIPOFEN                        fenofibrate                 3      [ST]
     LOFIBRA [G]                    fenofibrate                 3      [ST]
     LOPID [G]                      gemfibrozil                 3
     LOVAZA                         omega-3 acid ethyl esters   2
     NIACOR                         niacin                      3
     NIASPAN                        niacin                      2
     prevalite                                                  1
     QUESTRAN [G]                   cholestyramine/sucrose      3
     QUESTRAN LIGHT [G]             cholestyramine/aspartame    3
     TRICOR                         fenofibrate                 2      [ST]
     TRIGLIDE                       fenofibrate                 3      [ST]
     TRILIPIX                       fenofibric acid             2      [ST]
     WELCHOL                        colesevelam                 2      [ST]
     ZETIA                          ezetimibe                   2      [ST]

  LOOP DIURETICS

     bumetanide injection [INJ]                                 1
     bumetanide tablet                                          1
     DEMADEX [G]                    torsemide                   3
     EDECRIN                        ethacrynic acid             3
     furosemide injection [INJ]                                 1
     furosemide solution, -tablet                               1
     LASIX [G]                      furosemide                  3
     SODIUM EDECRIN [INJ]           ethacrynate sodium          3
     torsemide injection [INJ]                                  1
     torsemide tablet                                           1
Formulary ID 11155 V.4

                     Drug                            Generic   Tier   Restrictions
  NITRATES

     DILATRATE-SR                    isosorbide dinitrate      2
     IMDUR [G]                       isosorbide mononitrate    3
     ISMO [G]                        isosorbide mononitrate    3
     ISOCHRON [G]                    isosorbide dinitrate      3
     isoditrate                                                1
     ISORDIL                         isosorbide dinitrate      3
     ISORDIL TITRADOSE [G]           isosorbide dinitrate      3
     isosorbide dinitrate                                      1
     isosorbide mononitrate                                    1
     MINITRAN [G]                    nitroglycerin             3
     MONOKET [G]                     isosorbide mononitrate    3
     nitro-bid                                                 1
     NITRO-DUR [G]                   nitroglycerin             3
     nitroglycerin in d5w [INJ]                                1
     nitroglycerin injection [INJ]                             1
     nitroglycerin patch                                       1
     nitroglycerin tab, sl                                     1
     NITROLINGUAL                    nitroglycerin             2
     NITROMIST                       nitroglycerin             3
     NITROSTAT                       nitroglycerin             2

  OTHER ANTIARRHYTHMICS

     BETAPACE [G]                    sotalol                   3
     BETAPACE AF [G]                 sotalol                   3
     CORVERT [INJ]                   ibutilide fumarate        3
     ibutilide fumarate [INJ]                                  1
     lidocaine hcl 10% vial [INJ]                              1
     MULTAQ                          dronedarone               3
     sorine                                                    1
     sotalol                                                   1
     sotalol af                                                1
     SOTALOL HCL [INJ]               sotalol                   3
     TIKOSYN                         dofetilide                2

  OTHER ANTIHYPERTENSIVES

     ACCURETIC [G]                   quinapril/hctz            3      [ST]
Formulary ID 11155 V.4

                    Drug                                Generic        Tier   Restrictions
     amlodipine besylate-benazepril                                    1
     AMTURNIDE                        aliskiren/amlodipine/hctz        3      [ST]
     ATACAND HCT                      candesartan cilexetil/hctz       3      [ST]
     atenolol-chlorthalidone                                           1
     AVALIDE                          irbesartan/hctz                  3      [ST]
     AZOR                             amlodipine bes/olmesartan med    2      [ST]
     benazepril-hydrochlorothiazide                                    1
     BENICAR HCT                      olmesartan medoxomil/hctz        2      [ST]
     bisoprolol-hydrochlorothiazide                                    1
     captopril-hydrochlorothiazide                                     1
     CLORPRES                         clonidine hcl/chlorthalidone     2
     CORLOPAM [INJ]                   fenoldopam mesylate              3
     CORZIDE [G]                      bendroflumethiazide/nadolol      3
     DIOVAN HCT                       hctz/valsartan                   2      [ST]
     enalapril-hydrochlorothiazide                                     1
     EXFORGE                          amlodipine/valsartan             2      [ST]
     EXFORGE HCT                      amlodipine/valsartan/hctz        2      [ST]
     fosinopril-hydrochlorothiazide                                    1
     HYZAAR [G]                       losartan /hctz                   3      [ST]
     lisinopril-hydrochlorothiazide                                    1
     LOPRESSOR HCT [G]                hctz/metoprolol                  3
     losartan-hydrochlorothiazide                                      1
     LOTENSIN HCT [G]                 benazepril/hctz                  3      [ST]
     LOTREL [G]                       benazepril/amlodipine besylate   3      [ST]
     methyldopa-hydrochlorothiazide                                    1
     metoprolol-hydrochlorothiazide                                    1
     MICARDIS HCT                     telmisartan/hctz                 3      [ST]
     moexipril-hydrochlorothiazide                                     1
     nadolol-bendroflumethiazide                                       1
     PRINZIDE [G]                     lisinopril/hctz                  3      [ST]
     propranolol-hydrochlorothiazid                                    1
     quinapril-hydrochlorothiazide                                     1
     reserpine                                                         1
     TARKA [G]                        trandolapril/verapamil           3      [ST]
     TEKAMLO                          aliskiren/amlodipine             2      [ST]
     TEKTURNA                         aliskiren hemifumarate           2      [ST]
     TEKTURNA HCT                     aliskiren/hydrochlorothiazid     2      [ST]
     TENORETIC 100 [G]                chlorthalidone/atenolol          3
     TENORETIC 50 [G]                 chlorthalidone/atenolol          3
     TEVETEN HCT                      eprosartan mesylate/hctz         3      [ST]
Formulary ID 11155 V.4

                      Drug                                Generic        Tier   Restrictions
     trandolapril-verapamil                                              1
     TRIBENZOR                           olmesartan med/amlodipine/hct   2      [ST]
     TWYNSTA                             telmisartan/amlodipine          3      [ST]
     UNIRETIC [G]                        moexipril/hctz                  3      [ST]
     VALTURNA                            aliskiren/valsartan             3      [ST]
     VASERETIC [G]                       enalapril maleate/hctz          3      [ST]
     ZESTORETIC [G]                      lisinopril/hctz                 3      [ST]
     ZIAC [G]                            hctz/bisoprolol fumarate        3

  OTHER CARDIOVASCULAR DRUGS

     alprostadil injection [INJ]                                         1
     dobutamine hcl [INJ]                                                1
     dobutamine hcl in dextrose [INJ]                                    1
     dopamine hcl [INJ]                                                  1
     dopamine hcl in 5% dextrose [INJ]                                   1
     isoproterenol hcl [INJ]                                             1
     ISUPREL [INJ]                       isoproterenol hcl               3
     midodrine hcl                                                       1
     norepinephrine bitartrate [INJ]                                     1
     pentopak                                                            1
     pentoxifylline tab sa                                               1
     PROAMATINE [G]                      midodrine                       3
     PROSTIN VR PEDIATRIC [INJ]          alprostadil                     3
     RANEXA                              ranolazine                      2
     TRENTAL [G]                         pentoxifylline                  3

  OTHER VASODILATING DRUGS

     ADCIRCA                             adcirca (tadalafil)             4      [PAR][QLL,
                                                                                68/34]
     BIDIL                               isosorb dinit/hydralazine hcl   3
     epoprostenol sodium [INJ]                                           1
     FLOLAN [INJ]                        epoprostenol na                 3
     NATRECOR [INJ]                      nesiritide                      3
     REMODULIN [INJ][LA]                 treprostinil sodium             4
     REVATIO INJECTION [INJ]             revatio (sildenafil citrate)    4
     REVATIO TABLET                      revatio (sildenafil citrate)    4      [PAR][QLL,
                                                                                102/34]
     veletri [INJ]                                                       1
Formulary ID 11155 V.4

                     Drug                            Generic      Tier   Restrictions

  POTASSIUM SPARING DIURETICS

     ALDACTAZIDE [G]                    spironolactone/hctz       3
     ALDACTONE [G]                      spironolactone            3
     amiloride hcl tablet                                         1
     amiloride-hydrochlorothiazide                                1
     DYAZIDE [G]                        hctz/triamterene          3
     DYRENIUM                           triamterene               3
     eplerenone                                                   1
     INSPRA [G]                         eplerenone                3
     MAXZIDE [G]                        hctz/triamterene          3
     MAXZIDE-25 MG [G]                  hctz/triamterene          3
     MIDAMOR                            amiloride hydrochloride   3
     spironolactone tablet                                        1
     spironolactone-hctz                                          1
     triamterene-hctz                                             1

  THIAZIDE AND RELATED DRUGS

     chlorothiazide                                               1
     chlorothiazide sodium [INJ]                                  4
     chlorthalidone                                               1
     DIURIL                             chlorothiazide            3
     DIURIL SODIUM [INJ][G]             chlorothiazide sodium     3
     hydrochlorothiazide cap, -tablet                             1
     indapamide                                                   1
     methyclothiazide tablet                                      1
     metolazone                                                   1
     MICROZIDE [G]                      hydrochlorothiazide       3
     NATURETIN-5                        bendroflumethiazide       3
     THALITONE                          chlorthalidone            3
     ZAROXOLYN [G]                      metolazone                3

  VASODILATOR ANTIHYPERTENSIVES

     CARDURA 1 MG TABLET, -2 MG         doxazosin                 3      [QLL,
     TABLET, -4 MG TABLET [G]                                            34/34]
     CARDURA 8 MG TABLET [G]            doxazosin                 3      [QLL,
                                                                         68/34]
Formulary ID 11155 V.4

                       Drug                            Generic             Tier Restrictions
     CARDURA XL                           doxazosin                        3    [QLL,
                                                                                34/34]
     doxazosin mesylate 1 mg tab, -2 mg                                    1    [QLL,
     tab, -4 mg tab                                                             34/34]
     doxazosin mesylate 8 mg tab                                           1    [QLL,
                                                                                68/34]
     hydralazine hcl injection [INJ]                                       1
     hydralazine hcl tablet                                                1
     MINIPRESS [G]                        prazosin                         3
     minoxidil tablet                                                      1
     prazosin hcl                                                          1
     terazosin 1 mg capsule, -2 mg                                         1    [QLL,
     capsule, -5 mg capsule                                                     34/34]
     terazosin 10 mg capsule                                               1    [QLL,
                                                                                68/34]

DERMATOLOGICAL MEDICATIONS
  ANTIACNE DRUGS

     ACANYA                               clindamycin phos/benz per        3
     ACZONE                               dapsone                          3
     adapalene                                                             1    [PAR]
     AKNE-MYCIN                           erythromycin base                3
     ATRALIN                              tretinoin                        3    [PAR]
     AVAR                                 sulfacetamide/sulfur             3
     AVAR LS                              sulfacetamide/sulfur             3
     AVAR-E                               sulfacetamide/sulfur             3
     AVAR-E GREEN                         sulfacetamide/sulfur             3
     AVAR-E LS CREAM                      sulfacetamide/sulfur             3
     AVITA [G]                            tretinoin                        3    [PAR]
     AZELEX                               azelaic acid                     3
     BENZACLIN                            clindamycin/benz per/hyalur na   3
     BENZAMYCIN                           erythromycin base/benz per       3
     BENZAMYCINPAK                        erythromycin base/benz per       3
     bp 10-1                                                               1
     CLARIFOAM EF                         sulfacetamide/sulfur             3
     CLENIA CREAM                         sulfacetamide/sulfur             3
     clenia emulsion                                                       1
     CLEOCIN T [G]                        clindamycin phosphate            3
     clinda-derm                                                           1
Formulary ID 11155 V.4

                  Drug                                    Generic             Tier   Restrictions
     CLINDAGEL                               clindamycin phosphate            3
     CLINDAMAX [INJ]                         clindamycin phosphate            3
     clindamycin phosphate foam (non-                                         1
     contraceptive), -gel, -lotion, -soln,
     top, -swabs, applicators
     clindamycin-benzoyl peroxide                                             1
     CLINDAREACH                             clindamycin phosphate            3
     DIFFERIN [G]                            adapalene                        3      [PAR]
     DUAC CS                                 clindamycin/benzoyl prx/skn #5   3
     EMGEL [INJ]                             erythromycin base                3
     EPIDUO                                  adapalene/benzoyl peroxide       3      [PAR]
     ery                                                                      1
     erythromycin gel, -soln, top, -swabs,                                    1
     applicators
     erythromycin-benzoyl peroxide                                            1
     EVOCLIN [G]                             clindamycin phosphate            3
     FINACEA                                 azelaic acid                     2
     METROCREAM [G]                          metronidazole                    3
     METROGEL                                metronidazole                    2
     METROLOTION [G]                         metronidazole                    3
     metronidazole cream, -gel, -lotion                                       1
     NORITATE                                metronidazole                    3
     PLEXION                                 sulfacetamide/sulfur             3
     prascion                                                                 1
     prascion fc                                                              1
     prascion ts                                                              1
     RETIN-A [G]                             tretinoin                        3      [PAR]
     RETIN-A MICRO                           tretinoin                        3      [PAR]
     RETIN-A MICRO PUMP                      tretinoin                        3      [PAR]
     rosaderm emulsion                                                        1
     ROSANIL                                 sulfacetamide/sulfur             3
     sodium sulfacetamide-sulfur foam                                         1
     (non-contraceptive), -
     oil,shampoo,cleanser, -pad,
     medicated pad, -sulfacetamide-
     sulfur lotn, -sulf-sulfur wash, -
     suspensions, (not oral)
     sulfatol c                                                               1
     SUMAXIN                                 sulfacetamide/sulfur             3
     SUMAXIN TS                              sulfacetamide/sulfur             3
     topisulf                                                                 1
Formulary ID 11155 V.4

                     Drug                             Generic            Tier Restrictions
     tretinoin 0.025% cream, -0.05%                                      1    [PAR]
     cream, -0.1% cream, -gel
     TRETIN-X                            tretinoin/emol cmb9/skin cln1   3    [PAR]
     VELTIN                              clindamycin/tretinoin           3    [PAR]
     vitazol                                                             1
     ZENCIA                              sulfacetamide/sulfur            3
     ZIANA                               clindamycin/tretinoin           3    [PAR]

  ANTIPRURITIC DRUGS

     hydroxyzine hcl injection [INJ]                                     1
     hydroxyzine hcl syrup, -tablet                                      1    [PAR]
     hydroxyzine pamoate cap                                             1    [PAR]
     VISTARIL [G]                        hydroxyzine pamoate             3    [PAR]

  ANTIPSORIASIS AND ANTIECZEMA DRUGS

     calcipotriene                                                       1
     CALCITRENE                          calcipotriene                   3
     CLOBETA + PLUS                      clobetasol propiona/coal tar    3    [ST]
     DOVONEX CREAM                       calcipotriene                   2
     DOVONEX SOLUTION                    calcipotriene                   3
     DRITHOCREME HP                      anthralin                       2
     DRITHO-SCALP                        anthralin                       3
     KLARON [G]                          sulfacetamide sodium            3
     seb-prev cream, -gel                                                1
     selenium sulfide 2.25% shampoo, -                                   1
     2.5% lotion, -sulf 2.5% shampoo
     selenos                                                             1
     SELSEB                              selenium sulfide                3
     SORIATANE                           acitretin                       4
     SORIATANE CK                        acitretin/emollient comb        4
     sulfacetamide sodium lotion                                         1
     TACLONEX                            betamet diprop/calcipotriene    3
     TACLONEX SCALP                      betamet diprop/calcipotriene    3
     TAZORAC                             tazarotene                      2    [PAR]
     TERSI FOAM                          selenium sulfide                3
     VECTICAL                            calcitriol                      3
     ZITHRANOL-RR                        anthralin                       3
Formulary ID 11155 V.4

                    Drug                        Generic        Tier   Restrictions
  KERATOLYTIC DRUGS

     CONDYLOX GEL                 podofilox                    2
     CONDYLOX SOLN, TOP [G]       podofilox                    3
     podofilox                                                 1

  ORAL DERMATOLOGICAL DRUGS

     8-MOP                        methoxsalen                  4
     amnesteem                                                 1
     claravis                                                  1
     OXSORALEN-ULTRA              methoxsalen                  4
     sotret                                                    1

  SCABICIDES

     acticin                                                   1
     EURAX                        crotamiton                   2
     LINDANE                      benzene hexachloride gamma   2
     malathion                                                 1
     OVIDE [G]                    malathion                    3
     permethrin cream                                          1
     ULESFIA                      benzyl alcohol               3

  TOPICAL ANTI-INFLAMMATORY DRUGS

     FLECTOR                      diclofenac epolamine         2      [QLL,
                                                                      60/34][ST]
     PENNSAID                     diclofenac sodium            3      [ST]
     VOLTAREN GEL                 diclofenac sodium            2      [ST]

  TOPICAL CORTICOSTEROID DRUGS

     ACLOVATE [G]                 alclometasone                3      [ST]
     ALA-CORT [G]                 hydrocortisone               3      [ST]
     ALA-SCALP HP                 hydrocortisone               3      [ST]
     alclometasone dipropionate                                1
     amcinonide                                                1
     ANAMANTLE HC CREAM           hc acetate/lidocaine hcl     3
     ANAMANTLE HC FORTE           hc acetate/lidocaine hcl     3
Formulary ID 11155 V.4

                   Drug                                   Generic           Tier Restrictions
     APEXICON [INJ]                         diflorasone                     3    [ST]
     APEXICON E                             diflorasone                     3    [ST]
     betamethasone dipropionate cream,                                      1
     -gel, -lotion, -oint
     betamethasone valerate cream, -                                        1
     lotion, -oint
     betanate                                                               1
     beta-val                                                               1
     CAPEX SHAMPOO                          fluocinolone acetonide          3
     CARMOL HC                              hydrocortisone acetate/urea     3    [ST]
     clobetasol emollient                                                   1
     clobetasol propionate cream, -foam                                     1
     (non-contraceptive), -gel, -oint, -
     soln, top
     CLOBEX                                 clobetasol propionate           3    [ST]
     CLODERM                                clocortolone pivalate           3    [ST]
     CORDRAN LOTION, -OINT                  flurandrenolide                 3    [ST]
     CORDRAN SP                             flurandrenolide                 3    [ST]
     CORDRAN TAPE, MED. TAPE                flurandrenolide                 3    [QLL, 900
                                                                                 square
                                                                                 cm/34][ST]
     cormax                                                                 1
     CUTIVATE [G]                           fluticasone propionate          3    [ST]
     del-beta                                                               1
     DERMA-SMOOTHE-FS                       fluocinolone acetonide          3    [ST]
     DERMATOP [G]                           prednicarbate                   3    [ST]
     DESONATE                               desonide                        3    [ST]
     desonide cream, -lotion, -oint                                         1
     DESONIL + PLUS                         desonide/emollient combo no.3   3    [ST]
     DESOWEN [G]                            desonide/emollient combo #30    3    [ST]
     desoximetasone cream, -gel, -oint                                      1
     diflorasone diacetate                                                  1
     DIPROLENE [G]                          betameth/propylene glycol       3    [ST]
     DIPROLENE AF [G]                       betameth/propylene glycol       3    [ST]
     DIPROSONE                              betamethasone dipropionate      3    [ST]
     ELOCON [G]                             mometasone                      3    [ST]
     FIRST-HYDROCORTISONE                   hydrocortisone                  3
     fluocinolone acetonide cream, -oint,                                   1
     -soln, top
     fluocinonide cream, -gel, -oint, -                                     1
     soln, top
Formulary ID 11155 V.4

                     Drug                               Generic           Tier Restrictions
     fluocinonide emollient                                               1
     fluocinonide-e                                                       1
     fluticasone propionate cream, -oint                                  1
     halobetasol propionate                                               1
     HALOG                                 halcinonide                    3    [ST]
     HALONATE                              halobetasol prop/amonium lac   3    [ST]
     halonate pac                                                         1
     hydrocortisone 1% absorbase, -1%                                     1
     cream, -1% lotion, -1% oint, -1%
     ointment, -2.5% cream, -2.5%
     lotion, -2.5% ointment, -aloe 1%
     cream, -plus 1% cream
     hydrocortisone butyrate                                              1
     hydrocortisone valerate                                              1
     KENALOG                               triamcinolone acetonide        3    [ST]
     LIDAMANTLE HC                         hc acetate/lidocaine hcl       3
     lidocaine-hydrocortisone cream, -                                    1
     lotion
     LOCOID [G]                            hydrocortisone butyrate        3    [ST]
     LOCOID LIPOCREAM                      hydrocortisone butyrate        3    [ST]
     LOKARA [G]                            desonide                       3    [ST]
     LUXIQ                                 betamethasone valerate         3    [ST]
     mometasone furoate                                                   1
     MOMEXIN                               mometasone furoat/ammonium l   3    [ST]
     OLUX                                  clobetasol propionate          3    [ST]
     OLUX-E                                clobetasol propionate          3    [ST]
     OLUX-OLUX-E                           clobetasol propionate          3    [ST]
     PANDEL                                hydrocortisone buteprate       3    [ST]
     PEDIADERM HC                          hydrocortisone/emol no.45      3    [ST]
     PERANEX HC PAD, MEDICATED PAD         hc acetate/lidocaine hcl       3
     prednicarbate                                                        1
     SCALACORT                             hydrocortisone                 3    [ST]
     TEMOVATE [G]                          clobetasol propionate          3    [ST]
     TEMOVATE EMOLLIENT                    clobetasol propionate          3    [ST]
     TEXACORT                              hydrocortisone                 3    [ST]
     TOPICORT [G]                          desoximetasone                 3    [ST]
     TOPICORT LP [G]                       desoximetasone                 3    [ST]
     triamcinolone acetonide cream, -                                     1
     lotion, -oint
     triderm                                                              1
     U-CORT                                hydrocortisone acetate/urea    3    [ST]
Formulary ID 11155 V.4

                  Drug                             Generic            Tier   Restrictions
     ULTRAVATE [G]                    halobetasol propionate          3      [ST]
     ULTRAVATE PAC                    halobetasol prop/amonium lac    3
     VANOS                            fluocinonide                    3      [ST]
     VERDESO                          desonide                        3      [ST]
     WESTCORT [G]                     hydrocortisone valerate         3      [ST]

  TOPICAL DERMATOLOGICAL DRUGS

     ALDARA [G]                       imiquimod                       3
     ammonium lactate 12% cream, -                                    1
     12% lotion
     CARAC                            fluorouracil                    3
     DRYSOL                           aluminum chloride hexahydrate   3
     EFUDEX [G]                       fluorouracil                    3
     ELIDEL                           pimecrolimus                    2      [ST]
     FLUOROPLEX                       fluorouracil                    2
     fluorouracil cream, -soln, top                                   1
     GORDO-UREA                       urea                            3
     HYDRO 35                         urea                            3
     HYDRO 40                         urea                            3
     hypercare                                                        1
     imiquimod cream                                                  1
     KERAFOAM                         urea                            3
     LAC-HYDRIN [G]                   lactate, ammonium               3
     LACLOTION [G]                    lactate, ammonium               3
     LEVULAN                          aminolevulinic acid hcl         3
     METVIXIA                         methyl aminolevulinate hcl      3
     OXSORALEN                        methoxsalen                     2
     PANRETIN                         alitretinoin                    4
     PROTOPIC                         tacrolimus                      2      [ST]
     PRUDOXIN                         doxepin                         2
     REGRANEX                         becaplermin                     2      [PAR][QLL,
                                                                             30 gm/34]
     remeven                                                          1
     re-u40                                                           1
     SANTYL                           collagenase                     2
     SOLARAZE                         diclofenac sodium               2      [PAR]
     u40                                                              1
     UMECTA                           urea                            3
     UMECTA PD                        urea                            3
Formulary ID 11155 V.4

                     Drug                                 Generic           Tier   Restrictions
     URAMAXIN                               urea                            3
     URAMAXIN GT                            urea                            3
     urea 35% lotion, -40% cream, -40%                                      1
     lotion, -45% cream, -50% cream, -
     50% nail stick, -50% nailstik, -foam
     (non-contraceptive), -gel, -oint, -
     pad, medicated pad
     urea 40                                                                1
     VEREGEN                                sinecatechins                   3
     XERAC AC                               aluminum chloride hexahydrate   3
     x-viate                                                                1
     ZONALON                                doxepin                         2
     ZYCLARA                                imiquimod                       2

DIAGNOSTIC AND MISCELLANEOUS MEDICATIONS
  DIAGNOSTIC PRODUCTS

     CHEMET                                 succimer                        2
     EXJADE [LA]                            deferasirox                     4

  MISCELLANEOUS DRUGS

     ADAGEN [INJ][LA]                       pegademase bovine               4
     AMICAR [G]                             aminocaproic acid               3
     aminocaproic acid injection [INJ]                                      1
     aminocaproic acid syrup, -tablet                                       1
     AMMONUL [INJ]                          sodium benzoate/na ph-acetate   3
     AMPYRA [LA]                            dalfampridine                   4      [PAR]
     ANTIZOL [INJ][G]                       fomepizole                      3
     BUPHENYL                               sodium phenylbutyrate           4
     COPAXONE [INJ]                         glatiramer acetate              4      [PAR][QLL,
                                                                                   30 ml/30]
     CYKLOKAPRON [INJ]                      tranexamic acid                 2
     ergoloid mesylates tablet                                              1
     fomepizole [INJ]                                                       1
     GILENYA                                fingolimod hydrochloride        4      [PAR]
     HESPAN [INJ]                           hetastarch/na chlor 0.9%        3
     hetastarch in ns [INJ]                                                 1
     HEXTEND LACTATED ELECTROLYTE           hetastarch/e-lytes,lactate      3
     [INJ]
Formulary ID 11155 V.4

                    Drug                                  Generic             Tier   Restrictions
     LYSTEDA                                 tranexamic acid                  3
     ORFADIN [LA]                            nitisinone                       4
     PANHEMATIN [INJ]                        hemin                            3
     PROTOPAM CHLORIDE [INJ]                 pralidoxime chloride             2
     SOTRADECOL [INJ]                        sodium tetradecyl sulfate        3
     THALOMID                                thalidomide                      4
     VOLUVEN [INJ]                           hetastarch/na chlor 0.9%         3
     XIAFLEX [INJ][LA]                       collagenase clostridium hist.    4

EAR-NOSE-THROAT MEDICATIONS
  DRUGS AFFECTING THE EAR

     acetasol hc                                                              1
     acetic acid otic drops                                                   1
     acetic acid-aluminum                                                     1
     acetic acid-hydrocortisone                                               1
     antipyrine-benzocaine                                                    1
     aurodex                                                                  1
     auroguard                                                                1
     BENZOTIC                                antipyrine/benzocaine            3
     borofair                                                                 1
     chloroxylenol-pramoxine hcl                                              1
     CIPRO HC                                ciprofloxacin/hc                 3
     CIPRODEX                                ciprofloxacin/dexameth           2
     COLY-MYCIN S                            neomycin sulfate/colist sul/hc   3
     CORTISPORIN OTIC DROPS [G]              neomycin sulfate/polymyxin/hc    3
     CORTISPORIN-TC                          neomycin/colist sul/hc/thonz     3
     cortomycin otic drops, -suspensions,                                     1
     (not oral)
     DERMOTIC                                fluocinolone acetonide           2
     DOMEBORO OTIC DROPS [INJ]               acetic acid/aluminum acetate     3
     neomycin-polymyxin-hc otic drops, -                                      1
     solution, -suspensions, (not oral)
     ofloxacin otic drops                                                     1
     otic edge                                                                1
     oticin hc ear solution, -suspensions,                                    1
     (not oral)
     otocidin                                                                 1
     otomycet-hc                                                              1
     pr otic solution                                                         1
Formulary ID 11155 V.4

                     Drug                               Generic           Tier   Restrictions
     PRAMOTIC                               pramoxine hcl/chloroxylenol   3
     treagan otic                                                         1
     VOSOL [G]                              acetic acid                   3
     VOSOL HC [INJ]                         acetic acid/hydrocortisone    3

  DRUGS AFFECTING THE NOSE

     ASTELIN [G]                            azelastine hcl                3      [QLL, 60
                                                                                 ml/34]
     ASTEPRO                                azelastine hcl                2      [QLL, 60
                                                                                 ml/34]
     ATROVENT 0.03% SPRAY [G]               ipratropium                   3      [QLL, 60
                                                                                 ml/34]
     ATROVENT 0.06% SPRAY [G]               ipratropium                   3      [QLL, 30
                                                                                 ml/34]
     azelastine hcl nasal drops/sprays                                    1      [QLL, 60
                                                                                 ml/34]
     BECONASE AQ                            beclomethasone                3      [QLL, 50
                                                                                 gm/34]
     FLONASE [G]                            fluticasone propionate        3      [QLL, 32
                                                                                 gm/34]
     flunisolide 0.025% spray                                             1      [QLL, 75
                                                                                 ml/34]
     flunisolide 29 mcg-0.025% spr                                        1      [QLL,
                                                                                 75/34]
     fluticasone propionate nasal inhaled                                 1      [QLL, 32
     steroids                                                                    gm/34]
     ipratropium 0.03% spray                                              1      [QLL, 60
                                                                                 ml/34]
     ipratropium 0.06% spray                                              1      [QLL, 30
                                                                                 ml/34]
     NASACORT AQ                            triamcinolone acetonide       2      [QLL, 33
                                                                                 gm/34]
     NASONEX                                mometasone                    3      [QLL, 51
                                                                                 gm/34]
     OMNARIS                                ciclesonide                   3      [QLL, 25
                                                                                 gm/34]
     PATANASE                               olopatadine hcl               3      [QLL, 61
                                                                                 gm/34]
     RHINOCORT AQUA                         budesonide                    3      [QLL, 26
                                                                                 gm/34]
     TYZINE                                 tetrahydrozoline              2
Formulary ID 11155 V.4

                     Drug                           Generic          Tier Restrictions
     VERAMYST                         fluticasone furoate            2    [QLL, 20
                                                                          gm/34]

  DRUGS AFFECTING THE THROAT AND MOUTH

     APHTHASOL                        amlexanox                      3
     ARESTIN                          minocycline                    3
     chlorhexidine gluconate                                         1
     dental/mucous membrn products
     DEBACTEROL                       sulfuric acid/sulf phenol      3
     doxycycline hyclate 20 mg tab                                   1
     EVOXAC                           cevimeline                     3
     FIRST-MOUTHWASH BLM              mag hydrox/alh/smc/dpha/lido   2
     ORALONE                          triamcinolone acetonide        3
     ORASEP                           b-caine/tan ac/menth/cpyrd     3
     oraxyl                                                          1
     periogard                                                       1
     PERIOSTAT [G]                    doxycycline hyclate            3
     pilocarpine hcl tablet                                          1
     SALAGEN [G]                      pilocarpine hcl                3
     triamcinolone acetonide paste                                   1

ENDOCRINE MEDICATIONS
  ANTITHYROID DRUGS

     methimazole tablet                                              1
     propylthiouracil                                                1
     TAPAZOLE [G]                     methimazole                    3

  GLUCOCORTICOID DRUGS

     A-HYDROCORT [INJ]                hydrocortisone sod succinate   3
     a-methapred [INJ]                                               1
     ARISTOSPAN [INJ]                 triamcinolone hexacetonide     2
     ASMALPRED PLUS                   prednisolone sod phosphate     3
     baycadron                                                       1
     betamethasone acetate-sod phos                                  1
     [INJ]
     CELESTONE INJECTION [INJ]        betamethasone/betamethasone    2
     CELESTONE SYRUP                  betamethasone                  2
Formulary ID 11155 V.4

                        Drug                             Generic           Tier   Restrictions
     CORTEF [G]                             hydrocortisone                 3
     cortisone tablet                                                      1
     DEPO-MEDROL [INJ][G]                   methylprednisolone acetate     3
     dexamethasone elix, -tablet                                           1
     dexamethasone intensol                                                1
     dexamethasone sodium phosphate                                        1
     injection [INJ]
     DEXPAK [G]                             dexamethasone                  3
     hydrocortisone tablet                                                 1
     KENALOG-10 [INJ]                       triamcinolone acetonide        3
     KENALOG-40 [INJ]                       triamcinolone acetonide        3
     MEDROL [G]                             methylprednisolone             3
     methylprednisolone acetate injection                                  1
     [INJ]
     methylprednisolone sod succ [INJ]                                     1
     methylprednisolone tab(in                                             1
     convenience package), -tablet
     MILLIPRED                              prednisolone                   3
     MILLIPRED DP                           prednisolone                   3
     ORAPRED [G]                            prednisolone sod phosphate     3
     ORAPRED ODT                            prednisolone sod phosphate     3
     PEDIAPRED [G]                          prednisolone sod phosphate     3
     prednisolone sodium phosphate                                         1
     solution
     prednisolone syrup                                                    1
     prednisone intensol                                                   1
     prednisone solution, -tab(in                                          1
     convenience package), -tablet
     PRELONE [G]                            prednisolone                   3
     SOLU-CORTEF [INJ]                      hydrocortisone sod succinate   3
     SOLU-CORTEF (PF) [INJ]                 hydrocortisone sod succinate   3
     SOLU-MEDROL (PF) [INJ]                 methylprednisolone sod succ    3
     SOLU-MEDROL 1 GM VIAL, -2,000          methylprednisolone sod succ    3
     MG VIAL, -40 MG VIAL, -125 MG
     VIAL, -500 MG VIAL [INJ][G]
     triamcinolone acetonide injection                                     1
     [INJ]
     veripred 20                                                           1
     zema-pak                                                              1
Formulary ID 11155 V.4

                    Drug                             Generic         Tier   Restrictions
  GLUCOSE ELEVATING DRUGS

     GLUCAGEN [INJ]                    glucagon, human recombinant   2
     GLUCAGON EMERGENCY KIT [INJ]      glucagon, human recombinant   2
     PROGLYCEM                         diazoxide                     2

  HYPOGLYCEMIC DRUGS

     BYETTA 10 MCG DOSE PEN INJ        exenatide                     2      [PAR][QLL,
     [INJ]                                                                  5 ml/34]
     BYETTA 5 MCG DOSE PEN INJ [INJ]   exenatide                     2      [PAR][QLL,
                                                                            2 ml/34]
     SYMLIN [INJ]                      pramlintide acetate           2      [PAR][QLL,
                                                                            35 ml/34]
     SYMLINPEN 120 [INJ]               pramlintide acetate           2      [PAR][QLL,
                                                                            22 ml/34]
     SYMLINPEN 60 [INJ]                pramlintide acetate           2      [PAR][QLL,
                                                                            12 pens/34]
     VICTOZA 2-PAK [INJ]               liraglutide                   2      [PAR][QLL,
                                                                            3/30]
     VICTOZA 3-PAK [INJ]               liraglutide                   2      [PAR][QLL,
                                                                            3 pens/30]

  INSULIN

     APIDRA [INJ]                                                    3
     APIDRA SOLOSTAR [INJ]                                           3
     HUMALOG [INJ]                                                   2
     HUMALOG MIX 50-50 [INJ]                                         2
     HUMALOG MIX 75-25 [INJ]                                         2
     HUMULIN 50-50 [INJ]                                             2
     HUMULIN 70-30 [INJ]                                             2
     HUMULIN N [INJ]                                                 2
     HUMULIN R [INJ]                                                 2
     LANTUS [INJ]                                                    2
     LANTUS SOLOSTAR [INJ]                                           2
     LEVEMIR [INJ]                                                   2
     NOVOLIN 70-30 100 UNIT/ML VIAL                                  2
     [INJ]
     NOVOLIN 70-30 INNOLET [INJ]                                     2
Formulary ID 11155 V.4

                   Drug                            Generic             Tier   Restrictions
     NOVOLIN N 100 UNIT/ML INNOLET,                                    2
     -100 UNITS/ML VIAL [INJ]
     NOVOLIN R 100 UNIT/ML INNOLET,                                    3
     -RELION 100 UNITS/ML [INJ]
     NOVOLIN R 100 UNITS/ML VIAL                                       2
     [INJ]
     NOVOLOG [INJ]                                                     2
     NOVOLOG MIX 70-30 [INJ]                                           2
     RELION NOVOLIN 70-30 VIAL, -                                      3
     RELION VIAL [INJ]
     RELION NOVOLIN N 100 UNITS/ML,                                    3
     -RELION 100 UNITS/ML [INJ]

  MINERALOCORTICOID DRUGS

     fludrocortisone acetate tablet                                    1

  ORAL HYPOGLYCEMICS AND COMBOS

     acarbose                                                          1
     ACTOPLUS MET                     pioglitazone hcl/metformin hc    2      [QLL,
                                                                              102/34][ST]
     ACTOPLUS MET XR 15-1,000 MG TB   pioglitazone hcl/metformin hc    2      [QLL,
                                                                              68/34][ST]
     ACTOPLUS MET XR 30-1,000 MG TB   pioglitazone hcl/metformin hc    2      [QLL,
                                                                              34/34][ST]
     ACTOS                            pioglitazone hcl                 2      [QLL,
                                                                              34/34][ST]
     AMARYL [G]                       glimepiride                      3
     AVANDAMET                        rosiglitazone/metformin hcl      2      [QLL,
                                                                              68/34][ST]
     AVANDARYL                        rosiglitazone maleate/glimepir   2      [QLL,
                                                                              34/34][ST]
     AVANDIA 2 MG TABLET, -4 MG       rosiglitazone maleate            2      [QLL,
     TABLET                                                                   68/34][ST]
     AVANDIA 8 MG TABLET              rosiglitazone maleate            2      [QLL,
                                                                              34/34][ST]
     CYCLOSET                         bromocriptine mesylate           3
     DIABETA                          glyburide                        3
     DUETACT                          pioglitazone/glimepiride         2      [QLL,
                                                                              34/34][ST]
Formulary ID 11155 V.4

                    Drug                             Generic            Tier   Restrictions
     FORTAMET                          metformin                        3      [ST]
     glimepiride                                                        1
     glipizide er                                                       1
     glipizide tablet                                                   1
     glipizide xl                                                       1
     glipizide-metformin                                                1
     GLUCOPHAGE [G]                    metformin                        3      [ST]
     GLUCOPHAGE XR [G]                 metformin                        3      [ST]
     GLUCOTROL [G]                     glipizide                        3
     GLUCOTROL XL [G]                  glipizide                        3
     GLUCOVANCE [G]                    glyburide/metformin hcl          3
     GLUMETZA                          metformin                        3      [ST]
     glyburide                                                          1
     glyburide micronized                                               1
     glyburide-metformin hcl                                            1
     glycron                                                            1
     GLYNASE [G]                       glyburide                        3
     GLYSET                            miglitol                         3
     JANUMET                           sitagliptin phos/metformin hcl   2      [QLL,
                                                                               68/34]
     JANUVIA                           sitagliptin phosphate            2      [QLL,
                                                                               34/34]
     KOMBIGLYZE XR 2.5-1,000 MG TAB    saxagliptin hcl/metformin hcl    2      [QLL,
                                                                               68/34]
     KOMBIGLYZE XR 5-1,000 MG TAB, -   saxagliptin hcl/metformin hcl    2      [QLL,
     5-500 MG TABLET                                                           34/34]
     METAGLIP [G]                      glipizide/metformin hcl          3
     metformin hcl                                                      1
     metformin hcl er                                                   1
     nateglinide                                                        1
     ONGLYZA                           saxagliptin hydrochloride        2      [QLL,
                                                                               34/34]
     PRANDIMET                         repaglinide/metformin hcl        3      [QLL,
                                                                               170/34]
     PRANDIN                           repaglinide                      2
     PRECOSE [G]                       acarbose                         3
     RIOMET                            metformin                        2      [ST]
     STARLIX [G]                       nateglinide                      3
     tolazamide                                                         1
     tolbutamide                                                        1
Formulary ID 11155 V.4

                     Drug                                 Generic           Tier   Restrictions
  OTHER ENDOCRINE DRUGS

     ACTHAR H.P. [INJ]                      corticotropin                   4
     ACTHREL [INJ]                          corticorelin ovine triflutate   3
     ACTONEL 150 MG TABLET                  risedronate                     2      [QLL,
                                                                                   1/34][ST]
     ACTONEL 30 MG TABLET, -5 MG            risedronate                     2      [QLL,
     TABLET                                                                        34/34][ST]
     ACTONEL 35 MG TABLET                   risedronate                     2      [QLL,
                                                                                   5/35][ST]
     ACTONEL WITH CALCIUM                   risedron sod/calcium carbona    2      [QLL,
                                                                                   35/35][ST]
     ALDURAZYME [INJ][LA]                   laronidase                      4
     alendronate sodium 10 mg tab, -40                                      1      [QLL,
     mg tab, -5 mg tablet                                                          34/34]
     alendronate sodium 35 mg tab, -70                                      1      [QLL, 5/35]
     mg tab
     AREDIA 30 MG VIAL [INJ][G]             pamidronate disodium            3      [PAR]
     AREDIA 90 MG VIAL [INJ][G]             pamidronate disodium            4      [PAR]
     ATELVIA                                risedronate                     2      [QLL,
                                                                                   5/35][ST]
     BONIVA INJECTION [INJ]                 ibandronate                     3      [PAR]
     BONIVA TABLET                          ibandronate                     2      [QLL,
                                                                                   1/34][ST]
     cabergoline                                                            1      [QLL,
                                                                                   20/34]
     calcitonin-salmon                                                      1
     CEREDASE [INJ][LA]                     alglucerase                     4
     CEREZYME [INJ][LA]                     imiglucerase                    4
     DDAVP 4 MCG/ML AMPUL [INJ][G]          desmopressin acetate            4
     DDAVP 4 MCG/ML VIAL [INJ][G]           desmopressin acetate            3
     DDAVP SOLUTION, -NASAL                 desmopressin acetate            3
     DROPS/SPRAYS, -TABLET [G]
     desmopressin acetate injection [INJ]                                   1
     desmopressin acetate nasal                                             1
     drops/sprays, -solution, -tablet
     DIDRONEL [G]                           etidronate                      3
     ELAPRASE [INJ][LA]                     idursulfase                     4
     etidronate disodium                                                    1
     EVISTA                                 raloxifene                      2
     FABRAZYME [INJ][LA]                    agalsidase                      4
Formulary ID 11155 V.4

                    Drug                                   Generic        Tier Restrictions
     FORTEO [INJ]                           teriparatide                  2    [PAR][QLL,
                                                                               1/28]
     fortical                                                             1
     FOSAMAX 10 MG TABLET, -40 MG           alendronate                   3    [QLL,
     TABLET, -5 MG TABLET [G]                                                  34/34][ST]
     FOSAMAX 35 MG TABLET, -70 MG           alendronate                   3    [QLL,
     TABLET [G]                                                                5/35][ST]
     FOSAMAX PLUS D                         alendronate/vitamin d3        3    [QLL,
                                                                               5/35][ST]
     FOSAMAX SOLUTION                       alendronate                   3    [QLL, 375
                                                                               ml/35][ST]
     KUVAN [LA]                             sapropterin dihydrochloride   4
     LUMIZYME [INJ][LA]                     alglucosidase alfa            4
     MIACALCIN INJECTION [INJ]              calcitonin                    2    [PAR]
     MIACALCIN NASAL DROPS/SPRAYS           calcitonin                    3
     [G]
     MYOZYME [INJ][LA]                      alglucosidase alfa            4
     NAGLAZYME [INJ][LA]                    galsulfase                    4
     pamidronate disodium [INJ]                                           1    [PAR]
     PROLIA [INJ]                           denosumab                     3    [PAR]
     RECLAST [INJ]                          zoledronic acid               2    [PAR]
     SAMSCA                                 tolvaptan                     4    [PAR][QLL,
                                                                               68/34]
     SENSIPAR                               cinacalcet hcl                2
     SKELID                                 tiludronate                   3
     SOMAVERT [INJ][LA]                     pegvisomant                   4
     STIMATE                                desmopressin acetate          3
     VPRIV [INJ]                            velaglucerase alfa            4
     XGEVA [INJ]                            denosumab                     4
     ZAVESCA [LA]                           miglustat                     4
     ZOMETA [INJ]                           zoledronic acid               4

  THYROID SUPPLEMENTS

     ARMOUR THYROID                         thyroid                       2
     CYTOMEL [G]                            liothyronine                  3
     levothroid                                                           1
     levothyroxine sodium injection [INJ]                                 1
     levothyroxine sodium tablet                                          1
     levoxyl                                                              1
     liothyronine sodium injection [INJ]                                  1
Formulary ID 11155 V.4

                     Drug                                Generic             Tier   Restrictions
     liothyronine sodium tablet                                              1
     SYNTHROID [G]                          levothyroxine                    3
     THYROLAR-1                             liotrix                          2
     THYROLAR-1/2                           liotrix                          2
     THYROLAR-1/4                           liotrix                          2
     THYROLAR-2                             liotrix                          2
     THYROLAR-3                             liotrix                          2
     TIROSINT                               levothyroxine                    3
     TRIOSTAT [INJ]                         liothyronine                     3
     unithroid                                                               1

GASTROINTESTINAL MEDICATIONS
  ANTIDIARRHEAL DRUGS

     diphenoxylate-atropine                                                  1
     LOMOTIL [G]                            diphenoxylate/atropine sulfate   3
     lonox                                                                   1
     loperamide cap                                                          1
     MOTOFEN                                difenoxin/atropine sulfate       3
     paregoric                                                               1

  ANTISPASMODICS/DRUGS AFFECT GI MOTILITY

     BENTYL CAP, -SYRUP, -TABLET [G]        dicyclomine                      3
     BENTYL INJECTION [INJ]                 dicyclomine                      3
     CANTIL                                 mepenzolate                      3
     CUVPOSA                                glycopyrrolate                   3
     dicyclomine hcl cap, -syrup, -tablet                                    1
     dicyclomine hcl injection [INJ]                                         1
     glycopyrrolate injection [INJ]                                          1
     glycopyrrolate tablet                                                   1
     methscopolamine bromide                                                 1
     metoclopramide hcl injection [INJ]                                      1
     metoclopramide hcl syrup, -tablet                                       1
     METOZOLV ODT                           metoclopramide                   3
     PAMINE [G]                             methscopolamine                  3
     PAMINE FORTE [G]                       methscopolamine                  3
     propantheline bromide                                                   1
     REGLAN INJECTION [INJ][G]              metoclopramide                   3
     REGLAN TABLET [G]                      metoclopramide                   3
Formulary ID 11155 V.4

                   Drug                                Generic        Tier   Restrictions
     ROBINUL FORTE [G]                   glycopyrrolate               3
     ROBINUL INJECTION [INJ][G]          glycopyrrolate               3
     ROBINUL TABLET [G]                  glycopyrrolate               3
     SAL-TROPINE                         atropine sulfate             3
     SCOPACE                             scopolamine                  3
     SCOPOLAMINE HYDROBROMIDE            scopolamine                  3
     INJECTION [INJ]

  ANTIULCER DRUGS

     AXID [G]                            nizatidine                   3
     cimetidine 200 mg tablet, -300 mg                                1
     tablet, -400 mg tablet, -800 mg
     tablet, -solution
     cimetidine injection [INJ]                                       1
     famotidine 20 mg tablet, -40 mg                                  1
     tablet, -oral susp
     famotidine injection [INJ]                                       1
     nizatidine                                                       1
     PEPCID INJECTION [INJ]              famotidine                   3
     PEPCID ORAL SUSP, -TABLET [G]       famotidine                   3
     ranitidine 150 mg tablet, -300 mg                                1
     tablet, -cap, -syrup
     ranitidine hcl injection [INJ]                                   1
     ZANTAC 25                           ranitidine                   3
     ZANTAC INJECTION [INJ][G]           ranitidine                   3
     ZANTAC SYRUP, -TABLET [G]           ranitidine                   3

  IRRITABLE BOWEL DRUGS

     AMITIZA                             lubiprostone                 2
     LOTRONEX                            alosetron                    4

  LAXATIVES AND CATHARTICS

     OSMOPREP                            sodium phosphate/na biphos   2
     polyethylene glycol 3350, -pkt, -                                1
     powd
     VISICOL                             sodium phosphate/na biphos   2
Formulary ID 11155 V.4

                     Drug                            Generic          Tier   Restrictions
  OTHER ANTIULCER DRUGS

     CARAFATE ORAL SUSP                sucralfate                     2
     CARAFATE TABLET [G]               sucralfate                     3
     CYTOTEC [G]                       misoprostol                    3
     misoprostol                                                      1
     sucralfate oral susp, -tablet                                    1

  OTHER GI DRUGS

     ACTIGALL [G]                      ursodiol                       3
     ANUSOL-HC [G]                     hydrocortisone                 3
     APRISO                            mesalamine                     2
     ASACOL                            mesalamine                     2
     ASACOL HD                         mesalamine                     2
     AZULFIDINE [G]                    sulfasalazine                  3
     balsalazide disodium                                             1
     CANASA                            mesalamine                     2
     CHENODAL [LA]                     chenodiol                      4
     COLAZAL [G]                       balsalazide disodium           3
     COLOCORT [G]                      hydrocortisone                 3
     COLYTE WITH FLAVOR PACKETS        electrolyte solution/peg's     3
     COLYTE WITH FLAVOR PACKS          electrolyte solution/peg's     3
     CORTENEMA [G]                     hydrocortisone                 3
     CORTIFOAM                         hydrocortisone acetate         2
     CREON                             amylase/lipase/protease        2
     DIPENTUM                          olsalazine                     3
     ENTOCORT EC                       budesonide                     2
     gavilyte-c                                                       1
     gavilyte-g                                                       1
     gavilyte-n                                                       1
     GOLYTELY [G]                      electrolyte solution/peg's     3
     HALFLYTELY-BISACODYL              electrolyte solution/peg's     3
     HELIDAC                           tetracyc hcl/bis ss/metronid   3
     hydrocortisone rectal                                            1
     LIALDA                            mesalamine                     3
     mesalamine                                                       1
     MOVIPREP                       electrolyte solution/peg's        2
     NULYTELY WITH FLAVOR PACKS [G] electrolyte solution/peg's        3
     OCL                            electrolyte solution/peg's        2
Formulary ID 11155 V.4

                  Drug                            Generic            Tier Restrictions
     PANCREAZE                       amylase/lipase/protease         3
     PANCRELIPASE 5,000              amylase/lipase/protease         3
     peg 3350-electrolyte                                            1
     peg-3350 and electrolytes                                       1
     peg-3350 with flavor packs                                      1
     PENTASA                         mesalamine                      2
     PREVPAC                         lansoprazole/amox tr/clarith    3    [QLL,
                                                                          14/14]
     PROCTOCORT [G]                  hydrocortisone                  3
     PROCTOCREAM-HC [G]              hydrocortisone                  3
     procto-pak                                                      1
     proctosol-hc                                                    1
     proctozone-hc                                                   1
     PYLERA                          bismuth/metronid/tetracyclin    2
     RELISTOR [INJ]                  methylnaltrexone bromide        2
     ROWASA [G]                      mesalamine                      3
     SFROWASA [INJ]                  mesalamine                      3
     sulfasalazine dr                                                1
     sulfasalazine tablet                                            1
     sulfazine                                                       1
     sulfazine ec                                                    1
     SUPREP                          sodium,potassium,&mag sulfate   3
     trilyte with flavor packets                                     1
     URSO [G]                        ursodiol                        3
     URSO FORTE [G]                  ursodiol                        3
     ursodiol cap, -tablet                                           1
     ZENPEP                          amylase/lipase/protease         3

  PROTON PUMP INHIBITORS

     ACIPHEX                         rabeprazole sodium              3    [ST]
     DEXILANT DR 30 MG CAPSULE       dexlansoprazole                 3    [QLL,
                                                                          34/34][ST]
     DEXILANT DR 60 MG CAPSULE       dexlansoprazole                 3    [ST]
     KAPIDEX DR 30 MG CAPSULE        dexlansoprazole                 3    [QLL,
                                                                          34/34][ST]
     KAPIDEX DR 60 MG CAPSULE        dexlansoprazole                 3    [ST]
     lansoprazole dr 15 mg capsule                                   1    [QLL,
                                                                          34/34]
     lansoprazole dr 30 mg capsule                                   1
Formulary ID 11155 V.4

                    Drug                               Generic         Tier Restrictions
     lansoprazole odt 15 mg tablet                                     1    [QLL,
                                                                            34/34][ST]
     lansoprazole odt 30 mg tablet                                     1    [ST]
     NEXIUM DR 10 MG PACKET, -DR 20     esomeprazole mag trihyd        2    [QLL,
     MG CAPSULE, -DR 20 MG PACKET                                           34/34][ST]
     NEXIUM DR 40 MG CAPSULE, -DR       esomeprazole mag trihyd        2    [ST]
     40 MG PACKET
     NEXIUM I.V. [INJ]                  esomeprazole mag trihyd        2
     omeprazole dr 10 mg capsule                                       1    [QLL,
                                                                            34/34]
     omeprazole dr 20 mg capsule, -dr                                  1
     40 mg capsule
     omeprazole-bicarb 20-1,100 cap                                    1    [QLL,
                                                                            34/34][ST]
     omeprazole-bicarb 40-1,100 cap                                    1    [ST]
     pantoprazole sod dr 20 mg tab                                     1    [QLL,
                                                                            34/34]
     pantoprazole sod dr 40 mg tab                                     1
     PREVACID 30 MG SOLUTAB, -DR 30     lansoprazole                   3    [ST]
     MG CAPSULE
     PREVACID DR 15 MG CAPSULE, -15     lansoprazole                   3    [QLL,
     MG SOLUTAB [G]                                                         34/34][ST]
     PRILOSEC DR 10 MG CAPSULE, -DR     omeprazole                     3    [QLL,
     20 MG CAPSULE [G]                                                      34/34][ST]
     PRILOSEC DR 10 MG SUSPENSION       omeprazole magnesium-legend    3    [ST]
     PRILOSEC DR 2.5 MG SUSPENSION      omeprazole magnesium-legend    3    [QLL,
                                                                            68/34][ST]
     PRILOSEC DR 40 MG CAPSULE [G]      omeprazole                     3    [ST]
     PROTONIX DR 20 MG TABLET [G]       pantoprazole                   3    [QLL,
                                                                            34/34][ST]
     PROTONIX DR 40 MG TABLET, -PKT     pantoprazole                   3    [ST]
     [G]
     PROTONIX IV [INJ]                  pantoprazole                   3
     ZEGERID 20 MG CAPSULE [G]          omeprazole/sodium bicarbonat   3    [QLL,
                                                                            34/34][ST]
     ZEGERID 20 MG PACKET               omeprazole/sodium bicarbonat   3    [QLL,
                                                                            34/34][ST]
     ZEGERID 40 MG CAPSULE [G]          omeprazole/sodium bicarbonat   3    [ST]
     ZEGERID 40 MG PACKET               omeprazole/sodium bicarbonat   3    [ST]
Formulary ID 11155 V.4

                   Drug                             Generic           Tier   Restrictions
IMMUNOLOGICALS AND VACCINES
  GROWTH HORMONES AND RELATED DRUGS

     EGRIFTA [INJ]                     tesamorelin acetate            4
     GENOTROPIN 12 MG CARTRIDGE, -     somatropin                     4      [PAR]
     5 MG CARTRIDGE [INJ]
     GENOTROPIN MINIQUICK 0.2 MG, -    somatropin                     3      [PAR]
     MINIQUICK 0.4 MG, -MINIQUICK
     0.6 MG, -MINIQUICK 0.8 MG, -
     MINIQUICK 1 MG, -MINIQUICK 1.2
     MG, -MINIQUICK 1.4 MG, -
     MINIQUICK 1.6 MG, -MINIQUICK
     1.8 MG, -MINIQUICK 2 MG [INJ]
     HUMATROPE [INJ]                   somatropin                     4      [PAR]
     NORDITROPIN [INJ]                 somatropin                     4      [PAR]
     NORDITROPIN FLEXPRO [INJ]         somatropin                     4      [PAR]
     NORDITROPIN NORDIFLEX [INJ]       somatropin                     4      [PAR]
     NUTROPIN [INJ]                    somatropin                     4      [PAR]
     NUTROPIN AQ [INJ]                 somatropin                     4      [PAR]
     NUTROPIN AQ NUSPIN [INJ]          somatropin                     4      [PAR]
     OMNITROPE [INJ]                   somatropin                     4      [PAR]
     SAIZEN [INJ]                      somatropin                     4      [PAR]
     SEROSTIM [INJ][LA]                somatropin                     4      [PAR]
     TEV-TROPIN [INJ]                  somatropin                     4      [PAR]
     ZORBTIVE [INJ][LA]                somatropin                     4      [PAR]

  IMMUNOLOGICALS AND VACCINES

     ACTHIB [INJ]                      haemophilus b-tet toxoid       2
     ADACEL [INJ]                      diphther,pertuss,tetanus vac   2
     ARANESP 100 MCG/0.5 ML            darbepoetin alfa               4      [PAR]
     SYRINGE, -100 MCG/ML VIAL, -150
     MCG/0.3 ML SYRINGE, -150
     MCG/0.75 ML VIAL, -200 MCG/0.4
     ML SYRINGE, -200 MCG/ML VIAL, -
     300 MCG/0.6 ML SYRINGE, -300
     MCG/ML VIAL, -500 MCG/1 ML
     SYRINGE, -60 MCG/0.3 ML
     SYRINGE, -60 MCG/ML VIAL [INJ]
Formulary ID 11155 V.4

                   Drug                             Generic             Tier Restrictions
     ARANESP 25 MCG/0.42 ML SYRING,    darbepoetin alfa                 2    [PAR]
     -25 MCG/ML VIAL, -40 MCG/0.4 ML
     SYRINGE, -40 MCG/ML VIAL [INJ]
     ATGAM [INJ]                       lymphocyte immune globulin       4    [PAR]
     ATTENUVAX VACCINE WITH            measles vaccine,atten            2
     DILUENT [INJ]
     BCG VACCINE (TICE STRAIN) [INJ]   bcg vaccine                      2
     BOOSTRIX [INJ]                    diphther,pertuss,tetanus vac     2
     CARIMUNE NF NANOFILTERED [INJ]    immune globulin - iv             4    [PAR]
     CERVARIX [INJ]                    human papillomav vacc bival/pf   2
     COMVAX [INJ]                      hepatitis b/haemophilus b vacc   2
     CYTOGAM [INJ]                     cytomegalovirus immune glob      4
     DAPTACEL [INJ]                    diphther,pertuss,tetanus vac     2
     DECAVAC [INJ]                     tetanus,diphtheria toxoid        2
     DIPHTHERIA-TETANUS TOXOID         tetanus,diphtheria toxoid        2
     [INJ]
     ENGERIX-B [INJ]                   hepatitis b virus vaccine        2
     EPOGEN 10,000 UNITS/ML VIAL, -    epoetin alfa                     4    [PAR]
     20,000 UNITS/2 ML VIAL, -20,000
     UNITS/ML VIAL, -40,000 UNITS/ML
     VIAL [INJ]
     EPOGEN 2,000 UNITS/ML VIAL, -     epoetin alfa                     3    [PAR]
     3,000 UNITS/ML VIAL, -4,000
     UNITS/ML VIAL [INJ]
     GAMASTAN S-D [INJ]                immune globulin - im             2
     GAMMAGARD LIQUID [INJ]            immune globulin - iv             4    [PAR]
     GAMMAGARD S-D [INJ]               immune globulin - iv             4    [PAR]
     GAMMAPLEX [INJ]                   immune globulin - iv             4    [PAR]
     GAMUNEX [INJ]                     immune globulin - iv             4    [PAR]
     GAMUNEX-C [INJ]                   immune globulin - iv/sq          4    [PAR]
     GARDASIL [INJ]                    human papillomavirus vacc        2
     HAVRIX [INJ]                      hepatatis a virus vaccine        2
     HEPAGAM B [INJ]                   hep.b immune glob/maltose        3
     HIBERIX [INJ]                     haemophilus b-tet toxoid         3
     HIZENTRA 1 GRAM/5 ML VIAL [INJ]   immune globulin- sq              2    [PAR]
     HIZENTRA 2 GRAM/10 ML VIAL, -4    immune globulin- sq              4    [PAR]
     GRAM/20 ML VIAL [INJ]
     HYPERHEP B S-D [INJ]              hepatitis b immune globulin      2
     HYPERRAB S-D [INJ]                rabies immune globulin           3
     HYPERRHO S-D [INJ]                rho(d) immune globulin           2
     HYPERTET S-D [INJ]                tetanus immune globulin          3
Formulary ID 11155 V.4

                    Drug                             Generic            Tier   Restrictions
     IMOGAM RABIES-HT [INJ]            rabies immune globulin           2
     IMOVAX RABIES VACCINE [INJ]       rabies vaccine,human diploid     2
     INFANRIX [INJ]                    diphther,pertuss,tetanus vac     2
     INFANRIX PF [INJ]                 diphther,pertuss,tetanus vac     2
     IPOL [INJ]                        poliomyelitis vac,killed         2
     IXIARO [INJ]                      japanese encephalitis vaccine    2
     JE-VAX [INJ]                      japanese encephalitis vaccine    2
     KEPIVANCE [INJ][LA]               palifermin                       4
     KINRIX [INJ]                      diph,pertus(acel),tet,polio      3
     MENACTRA [INJ]                    meningococcal vac a,c,y,w-135    2
     MENOMUNE-A-C-Y-W-135 [INJ]        meningococcal vac a,c,y,w-135    2
     MENVEO A-C-Y-W-135-DIP            mening vac a,c,y,w-135 dip       3
     MERUVAX II VACCINE W-DILUENT      rubella vaccine                  2
     [INJ]
     MICRHOGAM [INJ]                   rho(d) immune globulin           3
     MICRHOGAM PLUS [INJ]              rho(d) immune globulin           3
     M-M-R II VACCINE [INJ]            measles,mumps&rubella vaccine    2
     MOZOBIL [INJ]                     plerixafor                       4
     MUMPSVAX VACCINE W-DILUENT        mumps vaccine,live               2
     [INJ]
     OCTAGAM [INJ]                     immune globulin - iv             4      [PAR]
     PEDIARIX [INJ]                    hep b vaccine/dp (a) t-polio     2
     PEDVAXHIB [INJ]                   haemophilus b vaccine            2
     PENTACEL [INJ]                    dp (a) t-polio/hib conj-tet/pf   3
     PRIVIGEN [INJ]                    immune globulin - iv             4      [PAR]
     PROCRIT 10,000 UNITS/ML VIAL, -   epoetin alfa                     2      [PAR]
     2,000 UNITS/ML VIAL, -3,000
     UNITS/ML VIAL, -4,000 UNITS/ML
     VIAL [INJ]
     PROCRIT 20,000 UNITS/ML VIAL, -   epoetin alfa                     4      [PAR]
     40,000 UNITS/ML VIAL [INJ]
     PROQUAD [INJ]                     measles,mumps,rub,varicella      2
     RABAVERT [INJ]                    rabies vac,pf chick-emb cell     2
     RECOMBIVAX HB [INJ]               hepatitis b virus vaccine        2
     RHOGAM                            rho(d) immune globulin           3
     RHOGAM PLUS [INJ]                 rho(d) immune globulin           3
     RHOPHYLAC [INJ]                   rho(d) immune globulin           3
     ROTARIX                           rotavirus vac, live att, 89-12   3
     ROTATEQ                           rotavirus vac, live pentav       2
     SYNAGIS [INJ][LA]                 palivizumab                      4
Formulary ID 11155 V.4

                     Drug                           Generic           Tier   Restrictions
     TETANUS DIPHTHERIA TOXOIDS        tetanus,diphtheria toxoid      2
     [INJ]
     tetanus toxoid adsorbed [INJ]                                    1
     TETANUS-DIPHTERIA-DECAVAC         tetanus,diphtheria toxoid      2
     [INJ]
     THYMOGLOBULIN [INJ]               lymphocyte immune globulin     4      [PAR]
     TRIHIBIT [INJ]                    dp (a) ped/hib conj-tet        2
     TRIPEDIA [INJ]                    diphther,pertuss,tetanus vac   2
     TWINRIX [INJ]                     hep b vir recomb/hep a vir     2
     TYPHIM VI [INJ]                   typhoid vaccine                2
     VAQTA [INJ]                       hepatatis a virus vaccine      2
     VARIVAX VACCINE [INJ]             varicella virus vaccine live   2
     VIVAGLOBIN [INJ]                  immune globulin- sq            4      [PAR]
     WINRHO SDF [INJ]                  rho(d) immune globulin         3
     YF-VAX [INJ]                      yellow fever vaccine           2
     ZOSTAVAX [INJ]                    varicella vacc/pf              2

  INSULIN LIKE GROWTH FACTORS-1

     INCRELEX [INJ][LA]                mecasermin                     4      [PAR]

  INTERFERONS

     ACTIMMUNE [INJ][LA]               interferon gamma-1b,recomb.    4
     AVONEX [INJ]                      interferon beta-1a             4      [PAR][QLL,
                                                                             4 kits/28]
     AVONEX ADMINISTRATION PACK        interferon beta-1a             4      [PAR][QLL,
     [INJ]                                                                   4 kits/28]
     BETASERON [INJ]                   interferon beta-1b             4      [PAR][QLL,
                                                                             15/30]
     EXTAVIA [INJ]                     interferon beta-1b             4      [PAR][QLL,
                                                                             15 trays/30]
     INFERGEN [INJ]                    interferon alfacon-1           4
     INTRON A 10 MILLION UNIT PEN, -   interferon alfa-2b , recomb.   4
     10 MILLION UNIT/ML, -18 MILLION
     UNITS VIAL, -5 MILLION UNIT/ML
     PEN, -50 MILLION UNITS VIAL, -6
     MILLION UNIT/ML VL [INJ]
     INTRON A 10 MILLION UNITS VIAL,   interferon alfa-2b , recomb.   2
     -3 MILLION UNIT/ML PEN [INJ]
Formulary ID 11155 V.4

                  Drug                               Generic         Tier Restrictions
     PEGASYS 180 MCG/0.5 ML CONV.PK     peginterferon alfa-2a        4    [PAR][QLL,
     [INJ]                                                                4
                                                                          syringes/28]
     PEGASYS 180 MCG/ML VIAL [INJ]      peginterferon alfa-2a        4    [PAR][QLL,
                                                                          4 vials/28]
     PEGINTRON 120 MCG KIT, -150        peginterferon alfa-2b        4    [PAR][QLL,
     MCG KIT, -80 MCG KIT [INJ]                                           5/34]
     PEGINTRON 50 MCG KIT [INJ]         peginterferon alfa-2b        4    [PAR][QLL,
                                                                          5 kits/34]
     PEGINTRON REDIPEN [INJ]            peginterferon alfa-2b        4    [PAR][QLL,
                                                                          5 pens/34]
     REBIF 22 MCG/0.5 ML SYRINGE, -44   interferon beta-1a/albumin   4    [PAR][QLL,
     MCG/0.5 ML SYRINGE [INJ]                                             8
                                                                          syringes/35]
     REBIF TITRATION PACK [INJ]         interferon beta-1a/albumin   4    [PAR][QLL,
                                                                          12
                                                                          syringes/28]

  INTERLEUKIN RECPTR ANTAGONIST

     ACTEMRA 200 MG/10 ML VIAL, -400    tocilizumab                  4    [PAR]
     MG/20 ML VIAL [INJ]
     ACTEMRA 80 MG/4 ML VIAL [INJ]      tocilizumab                  2    [PAR]
     ARCALYST [INJ][LA]                 rilonacept                   4    [PAR]
     ILARIS [INJ]                       canakinumab                  2
     KINERET [INJ]                      anakinra                     4    [PAR]

  INTERLEUKINS

     NEUMEGA [INJ]                      oprelvekin                   4    [QLL, 21
                                                                          vials/21]
     PROLEUKIN [INJ]                    aldesleukin                  4

  MYELOID STIMULANTS

     LEUKINE [INJ]                      sargramostim                 4
     NEULASTA [INJ]                     pegfilgrastim                4    [PAR][QLL,
                                                                          2/30]
     NEUPOGEN [INJ]                     filgrastim                   4    [PAR]
Formulary ID 11155 V.4

                   Drug                            Generic            Tier   Restrictions
  THROMBOPOIETIC AGENTS

     PROMACTA [LA]                     eltrombopag olamine            4

MEDICAL (MISCELLANEOUS) SUPPLIES
  DIABETIC SUPPLIES

     1ST TIER UNIFINE PENTIPS                                         2
     AIMSCO ULTRA THIN II                                             2
     ALCOHOL PREP PADS                                                2
     ALCOHOL PREP SWABS                                               2
     ALCOHOL SWABS                                                    2
     ALCOHOL WIPES                                                    2
     AUTO INJECTOR                                                    2
     AUTOJECT 2                                                       2
     AUTOPEN                                                          2
     CLICKFINE                                                        2
     CURAD GAUZE PADS                  misc supp (dress,tape,gauze)   2
     CURITY ALCOHOL PREPS                                             2
     CURITY GAUZE SPONGES              misc supp (dress,tape,gauze)   2
     EASY COMFORT INSULIN SYRINGE                                     2
     EASY TOUCH INSULIN NEEDLES -                                     2
     DISPOSABLE, -INSULIN SYRINGES -
     DISPOSABLE
     EXEL INSULIN SYRINGE                                             2
     FREESTYLE PRECISION                                              2
     GLUCOPRO INSULIN SYRINGES -                                      2
     DISPOSABLE
     HUMAPEN LUXURA HD                                                2
     HUMAPEN MEMOIR                                                   2
     IN CONTROL PEN NEEDLE                                            2
     INJECT-EASE                                                      2
     INSULIN PEN NEEDLE                                               2
     INSULIN SYRINGE                                                  2
     INSUMED                                                          2
     INSUPEN                                                          2
     INTEGRA SYRINGE INSULIN                                          2
     SYRINGES - DISPOSABLE
     LISCO SPONGES                     misc supp (dress,tape,gauze)   2
     LITE TOUCH INSULIN PEN NEEDLES                                   2
Formulary ID 11155 V.4

                   Drug                 Generic   Tier   Restrictions
     LITE TOUCH INSULIN SYRINGES -                2
     DISPOSABLE
     LUER-LOK SYRINGE INSULIN                     2
     SYRINGES - DISPOSABLE
     MAGELLAN INSULIN SYRINGE                     2
     MEDI-JECTOR NEEDLE-FREE SYR A                2
     MEDI-JECTOR NEEDLE-FREE SYR B                2
     MEDI-JECTOR NEEDLE-FREE SYR C                2
     MEDI-JECTOR VISION                           2
     MONOJECT 0.5 ML SYRN 28GX1/2                 2
     MONOJECT INSULIN SAFETY SYRNG                2
     MONOJECT INSULIN SYRINGE                     2
     NEEDLE FREE SYRINGE KIT A                    2
     NEEDLE FREE SYRINGE KIT B                    2
     NEEDLE FREE SYRINGE KIT C                    2
     NOVOFINE 32                                  2
     NOVOFINE AUTOCOVER                           2
     NOVOPEN 3                                    2
     NOVOPEN JR                                   2
     NOVOTWIST                                    2
     ORSINI INSULIN SYRINGE                       2
     PEN 12MM 29G NEEDLES, -                      2
     31GX3/16, -31GX5/16, -6MM 31G, -
     8MM 31G NEEDLES, -AURORA 6MM
     31G, -AURORA S 12MM 29G, -
     AURORA S 8MM 31G, -BD 29GX1/2,
     -BD 29GX3/16, -BD 29GX5/16, -BD
     MINI 31GX3/16, -BD NANO
     32GX5/32, -BD ORIG 29GX1/2, -BD
     SHORT 31GX5/16, -HLT PN NE
     PEN NEEDLES                                  2
     PRECISION INSULIN SYRINGES -                 2
     DISPOSABLE
     PRODIGY INSULIN SYRINGE                      2
     PRODIGY PEN NEEDLE                           2
     SAFESNAP INSULIN SYRINGE                     2
     SAFETYGLIDE INSULIN SYRINGE                  2
     SAFETYGLIDE SYRINGE INSULIN                  2
     SYRINGES - DISPOSABLE
     SINGLE USE SWAB                              2
     SURE COMFORT                                 2
Formulary ID 11155 V.4

                   Drug                           Generic           Tier   Restrictions
     SURE COMFORT ALCOHOL                                           2
     SURE-FINE PEN NEEDLES                                          2
     SURE-JECT INSULIN SYRINGE                                      2
     SURE-PREP ALCOHOL PREP PADS                                    2
     TERUMO INSULIN SYRINGE                                         2
     TERUMO SURGUARD                                                2
     THINPRO INSULIN SYRINGE                                        2
     TOPCARE CLICKFINE                                              2
     TOPCARE ULTRA COMFORT                                          2
     ULTICARE INSULIN NEEDLES -                                     2
     DISPOSABLE, -INSULIN SYRINGES -
     DISPOSABLE
     ULTIGUARD 30GX0.5 ML SYRINGE, -                                2
     30GX1 ML SYRINGE, -INSULIN
     SYRINGES - DISPOSABLE
     ULTILET ALCOHOL SWAB                                           2
     ULTILET INSULIN SYRINGE                                        2
     ULTILET PEN NEEDLE                                             2
     ULTRA COMFORT                                                  2
     ULTRACOMFORT INSULIN NEEDLES                                   2
     - DISPOSABLE, -INSULIN SYRINGES
     - DISPOSABLE
     UNIFINE PENTIPS                                                2
     VANISHPOINT INSULIN SYRINGES -                                 2
     DISPOSABLE
     VERSALON ALL PURPOSE SPONGE     misc supp (dress,tape,gauze)   2
     WEBCOL                                                         2

MUSCULOSKELETAL MEDICATIONS
  CNS MUSCLE RELAXANTS

     AMRIX                             cyclobenzaprine              3      [PAR]
     carisoprodol compound                                          1      [PAR]
     carisoprodol compound-codeine                                  1      [PAR]
     carisoprodol tablet                                            1      [PAR]
     chlorzoxazone                                                  1      [PAR]
     cyclobenzaprine hcl tablet                                     1      [PAR]
     FEXMID                            cyclobenzaprine              3      [PAR]
     FLEXERIL [G]                      cyclobenzaprine              3      [PAR]
     metaxalone                                                     1      [PAR]
     methocarbamol tablet                                           1      [PAR]
Formulary ID 11155 V.4

                   Drug                                    Generic   Tier   Restrictions
     NORFLEX [INJ][G]                       orphenadrine             3
     orphenadrine citrate injection [INJ]                            1
     orphenadrine citrate tab sa                                     1      [PAR]
     orphenadrine compound                                           1      [PAR]
     orphenadrine compound forte                                     1      [PAR]
     PARAFON FORTE DSC [G]                  chlorzoxazone            3      [PAR]
     RILUTEK                                riluzole                 4
     ROBAXIN INJECTION [INJ]                methocarbamol            3
     ROBAXIN TABLET [G]                     methocarbamol            3      [PAR]
     ROBAXIN-750 [G]                        methocarbamol            3      [PAR]
     SKELAXIN [G]                           metaxalone               3      [PAR]
     SOMA [G]                               carisoprodol             3      [PAR]

  DIRECT MUSCLE RELAXANTS

     ANECTINE [INJ]                         succinylcholine          3
     baclofen tablet                                                 1
     DANTRIUM CAP [G]                       dantrolene               3
     DANTRIUM INJECTION [INJ]               dantrolene               3
     dantrolene sodium                                               1
     DYSPORT [INJ]                          abobotulinumtoxina       3
     revonto [INJ]                                                   1
     tizanidine hcl                                                  1
     XEOMIN [INJ]                           incobotulinumtoxina      3
     ZANAFLEX [G]                           tizanidine               3

  DRUGS TO PREVENT AND TREAT GOUT

     allopurinol sodium [INJ]                                        1
     allopurinol tablet                                              1
     ALOPRIM [INJ][G]                       allopurinol              3
     COLCRYS                                colchicine               2
     KRYSTEXXA [INJ]                        pegloticase              4
     probenecid                                                      1
     probenecid-colchicine                                           1
     ULORIC                                 febuxostat               2      [ST]
     ZYLOPRIM [G]                           allopurinol              3
Formulary ID 11155 V.4

                     Drug                               Generic             Tier   Restrictions
  NON-STEROIDAL ANTIINFLAMMATORY AGENTS

     ANAPROX [G]                           naproxen sodium                  3      [ST]
     ANAPROX DS [G]                        naproxen sodium                  3      [ST]
     ANSAID                                flurbiprofen                     3      [ST]
     ARTHROTEC 50                          diclofenac sodium/misoprostol    3      [ST]
     ARTHROTEC 75                          diclofenac sodium/misoprostol    3      [ST]
     CATAFLAM [G]                          diclofenac potassium             3      [ST]
     CELEBREX                              celecoxib                        2      [ST]
     CLINORIL [G]                          sulindac                         3      [ST]
     DAYPRO [G]                            oxaprozin                        3      [ST]
     diclofenac potassium                                                   1
     diclofenac sodium e.c. tab, -tab sa                                    1
     EC-NAPROSYN [G]                       naproxen                         3      [ST]
     etodolac                                                               1
     FELDENE [G]                           piroxicam                        3      [ST]
     fenoprofen calcium                                                     1
     flurbiprofen tablet                                                    1
     ibuprofen 100 mg/5 ml sus, -100                                        1
     mg/5 ml susp, -400 mg tablet, -600
     mg tablet, -800 mg tablet
     INDOCIN I.V. [INJ]                    indomethacin sodium trihydrate   3
     INDOCIN ORAL SUSP                     indomethacin                     3      [ST]
     INDOCIN RECTAL                        indomethacin                     3
     indomethacin cap, -cap sa                                              1
     indomethacin injection [INJ]                                           4
     ketoprofen cap, -cap sa                                                1
     ketorolac tromethamine injection                                       1
     [INJ]
     ketorolac tromethamine tablet                                          1      [QLL, 20/5]
     meclofenamate sodium cap                                               1
     mefenamic acid cap                                                     1
     meloxicam 15 mg tablet, -oral susp                                     1
     meloxicam 7.5 mg tablet                                                1      [QLL,
                                                                                   34/34]
     MOBIC 15 MG TABLET, -ORAL SUSP        meloxicam                        3      [ST]
     [G]
     MOBIC 7.5 MG TABLET [G]               meloxicam                        3      [QLL,
                                                                                   34/34][ST]
     nabumetone                                                             1
     NALFON                                fenoprofen                       3      [ST]
Formulary ID 11155 V.4

                  Drug                                    Generic         Tier Restrictions
     NAPRELAN                                 naproxen sodium             3    [ST]
     NAPRELAN CR DOSE CARD                    naproxen                    3    [ST]
     NAPROSYN [G]                             naproxen                    3    [ST]
     naproxen e.c. tab, -oral susp, -tablet                               1
     naproxen sodium 275 mg tab, -550                                     1
     mg tab
     NEOPROFEN [INJ]                          ibuprofen lysine            3
     oxaprozin                                                            1
     piroxicam cap                                                        1
     PONSTEL                                  mefenamic acid              3    [ST]
     sulindac tablet                                                      1
     tolmetin sodium                                                      1
     TORADOL [INJ]                            ketorolac                   3
     VIMOVO                                   naproxen/esomeprazole mag   3    [ST]
     VOLTAREN E.C. TAB                        diclofenac sodium           3    [ST]
     VOLTAREN-XR [G]                          diclofenac sodium           3    [ST]
     ZIPSOR                                   diclofenac potassium        3    [ST]

  OTHER DRUGS FOR ARTHRITIS

     CUPRIMINE                                penicillamine               2
     DEPEN                                    penicillamine               3
     gold sodium thiomalate [INJ]                                         1
     myochrysine [INJ]                                                    1
     RIDAURA                                  auranofin                   2
     SYPRINE                                  trientine                   2

  SALICYLATES AND RELATED DRUGS

     aspirin ec 975 mg tablet                                             1
     choline mag trisalicylate                                            1
     diflunisal                                                           1
     EASPRIN                                  aspirin                     3
     salsalate tablet                                                     1
     ZORPRIN                                  aspirin                     3

NUTRITION,BLOOD MODIFIERS,ELECTROLYTES
  ANTIPLATELET DRUGS

     AGGRASTAT [INJ]                          tirofib hc m-hyd/na chlor   3
Formulary ID 11155 V.4

                       Drug                        Generic   Tier   Restrictions
     AGGRENOX                        aspirin/dipyridamole    2
     cilostazol                                              1
     dipyridamole tablet                                     1
     EFFIENT                         prasugrel               2
     INTEGRILIN [INJ]                eptifibatide            3
     PERSANTINE [G]                  dipyridamole            3
     PLAVIX                          clopidogrel             2
     PLETAL [G]                      cilostazol              3
     REOPRO [INJ]                    abciximab               3
     ticlopidine hcl                                         1

  BLOOD DETOXICANTS

     constulose                                              1
     enulose                                                 1
     FOSRENOL                        lanthanum carbonate     3
     generlac                                                1
     KRISTALOSE                      lactulose               3
     lactulose                                               1
     RENAGEL                         sevelamer               3
     RENVELA                         sevelamer carbonate     2

  ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.

     ALBUMIN (HUMAN) [INJ]           albumin human           3
     ALBUMINAR-25 [INJ]              albumin human           3
     ALBUMINAR-5 [INJ]               albumin human           3
     alburx (human) 25% vial [INJ]                           1
     ALBURX (HUMAN) 5% VIAL [INJ]    albumin human           3
     alcohol in dextrose [INJ]                               1
     AMINOSYN [INJ]                  amino acids             2
     AMINOSYN II [INJ]               amino acids             2
     AMINOSYN II 3.5% M-DEXTROSE     amino acids             2
     5% [INJ]
     AMINOSYN II 3.5%-DEXTROSE 25%   amino acids             2
     [INJ]
     AMINOSYN II 3.5%-DEXTROSE 5%    amino acids             2
     [INJ]
     AMINOSYN II 4.25% M-DEXT 10%    amino acids             2
     [INJ]
Formulary ID 11155 V.4

                     Drug                                Generic            Tier   Restrictions
     AMINOSYN II 4.25%-DEXTROSE            amino acids                      2
     25% [INJ]
     AMINOSYN II 5% IN 25%                 amino acids                      2
     DEXTROSE [INJ]
     AMINOSYN II IN DEXTROSE [INJ]         amino acids                      2
     AMINOSYN II WITH LYTES-CA-DW          amino acids                      2
     [INJ]
     AMINOSYN M [INJ]                      amino acids                      2
     AMINOSYN WITH ELECTROLYTES            amino acids                      2
     [INJ]
     AMINOSYN-HBC [INJ]                    amino acids                      2
     AMINOSYN-HF [INJ]                     amino acids                      2
     AMINOSYN-PF [INJ]                     amino acids                      2
     AMINOSYN-RF [INJ]                     amino acids                      2
     AMMONIUM CHLORIDE INJECTION           ammonium chloride                2
     [INJ]
     BUMINATE [INJ]                        albumin human                    3
     calcium chloride injection [INJ]                                       1
     CLINIMIX [INJ]                        amino acids                      2
     CLINIMIX E [INJ]                      amino acids                      2
     CLINISOL [INJ]                        amino acids                      2
     CYSTAGON [LA]                         cysteamine                       2
     d5w/kcl 10 meq/l iv solution, -30                                      1
     meq/l iv solution [INJ]
     dextrose 10%-1/4ns [INJ]                                               1
     dextrose 10%-1/4ns-kcl [INJ]                                           1
     dextrose 2.5%-lr 1/2 str sol [INJ]                                     1
     dextrose 5%-1/2ns-kcl [INJ]                                            1
     dextrose 5%-1/3ns-kcl [INJ]                                            1
     dextrose 5%-1/4ns-kcl [INJ]                                            1
     dextrose 5%-electrolyte #48 [INJ]                                      1
     dextrose 5%-electrolyte #75 [INJ]                                      1
     dextrose 5%-ns-kcl [INJ]                                               1
     dextrose in ringers injection [INJ]                                    1
     dextrose in water [INJ]                                                1
     dextrose with sodium chloride [INJ]                                    1
     FLEXBUMIN [INJ]                       albumin human                    3
     FREAMINE HBC [INJ]                    amino acids                      3
     FREAMINE III [INJ]                    amino acids                      2
     FREAMINE III WITH ELECTROLYTES        aa 3%/electrolyte-tpn/glycerin   3
     [INJ]
Formulary ID 11155 V.4

                        Drug                           Generic            Tier   Restrictions
     HEPATAMINE [INJ]                    amino acids                      2
     HEPATASOL [INJ]                     amino acids                      2
     HYPERLYTE CR [INJ]                  electrolyte solutions            3
     IONOSOL B WITH DEXTROSE 5%          electrolyte solutions            2
     [INJ]
     IONOSOL MB-DEXTROSE 5% [INJ]        electrolyte solutions            2
     IONOSOL T-DEXTROSE 5% [INJ]         electrolyte solutions            2
     ISOLYTE H WITH DEXTROSE [INJ]       dextrose/electrolytes            2
     ISOLYTE M WITH DEXTROSE [INJ]       dextrose/electrolytes            2
     ISOLYTE P WITH DEXTROSE [INJ]       dextrose/electrolytes            2
     ISOLYTE S [INJ]                     electrolyte solutions            2
     ISOLYTE S WITH DEXTROSE [INJ]       dextrose/electrolytes            2
     lactated ringers injection [INJ]                                     1
     magnesium sulfate injection [INJ]                                    1
     MAGNESIUM SULFATE-D5W [INJ]         magnesium sulfate/d5w            2
     mannitol injection [INJ]                                             1
     NEPHRAMINE [INJ]                    amino acids                      2
     NEUT [INJ]                          sodium bicarbonate               2
     NORMOSOL-M AND DEXTROSE             dextrose/electrolytes            2
     [INJ]
     NORMOSOL-R [INJ]                    electrolyte solutions            2
     NORMOSOL-R AND DEXTROSE [INJ]       electrolyte solutions            2
     NORMOSOL-R PH 7.4 [INJ]             electrolyte solutions            2
     NOVAMINE [INJ]                      amino acids                      2
     nutrilyte [INJ]                                                      1
     nutrilyte ii [INJ]                                                   1
     OSMITROL [INJ]                      mannitol                         3
     PLASBUMIN-25 [INJ]                  albumin human                    3
     PLASMA-LYTE 148 [INJ]               electrolyte solutions            2
     PLASMA-LYTE 148 IN DEXTROSE         electrolyte solutions            2
     [INJ]
     PLASMA-LYTE 56 [INJ]                electrolyte solutions            2
     PLASMA-LYTE 56 IN DEXTROSE          d5w/electrolyte-56 solution      2
     [INJ]
     PLASMA-LYTE A PH 7.4 [INJ]          electrolyte solutions            2
     PLASMA-LYTE R [INJ]                 electrolyte solutions            2
     potassium chl-normal saline [INJ]                                    1
     potassium chloride-nacl [INJ]                                        1
     PREMASOL [INJ]                      amino acids                      2
     PROCALAMINE [INJ]                   aa 3%/electrolyte-tpn/glycerin   2
Formulary ID 11155 V.4

                      Drug                                Generic         Tier   Restrictions
     PROSOL [INJ]                           amino acids                   3
     RENAMIN [INJ]                          amino acids                   2
     RESECTISOL                             mannitol                      3
     R-GENE 10 [INJ]                        arginine                      2
     ringers injection [INJ]                                              1
     sodium acetate injection [INJ]                                       1
     sodium bicarbonate injection [INJ]                                   1
     sodium chloride 0.45% irrig, -0.9%                                   1
     irrig., -sterile saline 0.9% irr
     sodium chloride 0.45% soln, -0.45%                                   1
     soln-excel con, -0.9% soln, -0.9%
     soln., -0.9% soln-excel cont, -0.9%
     solution, -3% iv soln, -4 meq/ml vl,
     -5% iv soln, -cl 2.5 meq/ml vial
     [INJ]
     sodium lactate [INJ]                                                 1
     sodium phosphate injection [INJ]                                     1
     TPN ELECTROLYTES [INJ][G]              electrolyte solutions         3
     TPN ELECTROLYTES II [INJ]              electrolyte solutions         2
     TRAVASOL [INJ]                         amino acids                   2
     TRAVASOL WITH ELECTROLYTES             amino acids                   2
     [INJ]
     TROPHAMINE [INJ]                       amino acids                   2

  FLUORIDE PRODUCTS

     CAVIRINSE                              sodium fluoride               3
     CONTROL RX                             sodium fluoride               3
     denta 5000 plus                                                      1
     dentagel                                                             1
     epiflur                                                              1
     FLUORABON                              sodium fluoride               3
     fluor-a-day chew tab                                                 1
     FLUOR-A-DAY ORAL DROPS                 sodium fluoride               3
     fluoridex daily defense                                              1
     FLUORIDEX SENSITIVITY RELIEF           sodium fluoride/pot nitrate   3
     fluoritab chew tab                                                   1
     FLURA-DROPS                            sodium fluoride               3
     GEL-KAM                                stannous fluoride             3
     lozi-flur                                                            1
     ludent fluoride                                                      1
Formulary ID 11155 V.4

                    Drug                                Generic          Tier   Restrictions
     neutragard advanced                                                 1
     perio med                                                           1
     PHOS-FLUR                             sodium fluoride               3
     PREVIDENT                             sodium fluoride               3
     PREVIDENT 5000                        sodium fluoride               3
     PREVIDENT 5000 PLUS                   sodium fluoride               3
     PREVIDENT 5000 SENSITIVE              sodium fluoride/pot nitrate   3
     renaf                                                               1
     sf                                                                  1
     sf 5000 plus                                                        1
     sodium fluoride chew tab, -                                         1
     dental/mucous membrn products, -
     oral drops, -tablet
     stannous fluoride dental/mucous                                     1
     membrn products

  HEPARIN ANTAGONISTS

     PROTAMINE SULFATE [INJ]               protamine                     3

  INJECTABLE ANTICOAGULANTS

     ARIXTRA 10 MG SYRINGE, -5 MG          fondaparinux sodium           4
     SYRINGE, -7.5 MG SYRINGE [INJ]
     ARIXTRA 2.5 MG SYRINGE [INJ]          fondaparinux sodium           2
     enoxaparin 100 mg/ml syr, -30                                       1
     mg/0.3 ml syr, -40 mg/0.4 ml syr, -
     60 mg/0.6 ml syr, -80 mg/0.8 ml syr
     [INJ]
     enoxaparin 120 mg/0.8 ml syr, -150                                  4
     mg/ml syr [INJ]
     FRAGMIN 10,000 UNITS SYRINGE, -       dalteparin (porcine)          4
     12,500 UNITS SYRINGE, -15,000
     UNITS SYRINGE, -18,000 UNITS
     SYRINGE, -25,000 UNITS/ML VIAL, -
     7,500 UNITS SYRINGE [INJ]
     FRAGMIN 2,500 UNITS SYRINGE, -        dalteparin (porcine)          3
     5,000 UNITS SYRINGE [INJ]
     heparin sodium in 0.45% nacl [INJ]                                  1      [PAR]
     heparin sodium in 0.9% nacl [INJ]                                   1      [PAR]
Formulary ID 11155 V.4

                    Drug                            Generic             Tier Restrictions
     heparin sodium in 5% dextrose                                      1    [PAR]
     [INJ]
     heparin sodium injection [INJ]                                     1    [PAR]
     heparin sodium-ns [INJ]                                            1    [PAR]
     INNOHEP [INJ]                   tinzaparin sodium, porcine         3
     LOVENOX 100 MG PREFILLED SYR, - enoxaparin                         4
     120 MG PREFILLED SYR, -150 MG
     PREFILLED SYR, -300 MG VIAL, -
     300 MG/3 ML VIAL, -60 MG
     PREFILLED SYRN, -80 MG
     PREFILLED SYRN [INJ]
     LOVENOX 30 MG PREFILLED SYRN,   enoxaparin                         2
     -40 MG PREFILLED SYRN [INJ]

  ORAL ANTICOAGULANTS, VITAMIN K

     ARGATROBAN [INJ]                  argatroban                       3
     COUMADIN INJECTION [INJ]          warfarin sodium                  3
     COUMADIN TABLET [G]               warfarin sodium                  3
     jantoven                                                           1
     PRADAXA                           dabigatran etexilate mesylate    2    [PAR]
     warfarin sodium                                                    1

  OTHER DRUGS AFFECTING COAGULATION

     ATRYN [INJ]                       antithrombin iii, human recomb   3
     REFLUDAN [INJ]                    lepirudin,recombinant            2    [PAR]
     THROMBATE III [INJ]               antithrombin iii,human           3

  POTASSIUM REMOVING RESINS

     kalexate                                                           1
     KAYEXALATE [G]                    sodium polystyrene sulfonate     3
     kionex oral susp                                                   1
     KIONEX PWD [G]                    sodium polystyrene sulfonate     3
     marlexate                                                          1
     sodium polystyrene sulfonate                                       1
     sps                                                                1
Formulary ID 11155 V.4

                     Drug                                  Generic        Tier   Restrictions
  POTASSIUM SUPPLEMENTS

     cytra-2                                                              1
     dextrose 5%-lr iv solution [INJ]                                     1
     EFFER-K 10 MEQ TABLET EFF, -20          potassium bicarb/ca          3
     MEQ TABLET EFF
     effer-k 25 meq tablet eff                                            1
     epiklor                                                              1
     k effervescent                                                       1
     KAOCHLOR                                potassium chloride           3
     kaon-cl 10                                                           1
     kcl 20 meq in d5w solution, -20                                      1
     meq/l iv solution, -40 meq in d5w
     solution, -40 meq/l iv solution [INJ]
     kcl 20 meq in d5w-lact ringer, -40                                   1
     meq in d5w-lact ringer [INJ]
     kcl 40 meq in d5w-lact ringer [INJ]                                  1
     klor-con 10                                                          1
     klor-con 20 meq packet                                               1
     KLOR-CON 25 MEQ PACKET                  potassium chloride           3
     klor-con 8                                                           1
     klor-con m10                                                         1
     klor-con m15                                                         1
     klor-con m20                                                         1
     klor-con-ef                                                          1
     K-PHOS NEUTRAL                          phosphorus                   3
     K-TAB                                   potassium chloride           3
     MICRO-K [INJ]                           potassium chloride           3
     ORACIT                                  sodium citrate/citric acid   3
     phospha 250 neutral                                                  1
     potassium acetate injection [INJ]                                    1
     potassium bicarbonate unique tablet                                  1
     formulation
     potassium chloride cap sa, -solution,                                1
     -tab sa, -unique tablet formulation
     potassium chloride injection [INJ]                                   1
     sodium citrate & citric acid                                         1
     vis-phos n                                                           1
Formulary ID 11155 V.4

                      Drug                             Generic   Tier   Restrictions
  THERAPEUTIC VITAMINS AND MINERALS

     CALCIJEX [INJ][G]                 calcitriol                3      [PAR]
     calcitriol cap, -solution                                   1
     calcitriol injection [INJ]                                  1      [PAR]
     calcium acetate                                             1
     CARNITOR INJECTION [INJ][G]       levocarnitine             3      [PAR]
     CARNITOR SF                       levocarnitine             3      [PAR]
     CARNITOR SOLUTION, -TABLET [G]    levocarnitine             3      [PAR]
     eliphos                                                     1
     HECTOROL CAP                      doxercalciferol           3
     HECTOROL INJECTION [INJ]          doxercalciferol           3      [PAR]
     levocarnitine injection [INJ]                               1      [PAR]
     levocarnitine solution, -tablet                             1      [PAR]
     PHOSLO [G]                        calcium acetate           3
     ROCALTROL [G]                     calcitriol                3
     ZEMPLAR CAP                       paricalcitol              2
     ZEMPLAR INJECTION [INJ]           paricalcitol              2      [PAR]

  VITAMINS AND MINERALS AND RELATED PRODUCTS

     INTRALIPID 10% IV FAT EMUL, -     fat emulsions             3
     20% IV FAT EMUL [INJ][G]
     INTRALIPID 30% IV FAT EMUL        fat emulsions             2
     [INJ][G]
     LIPOSYN II [INJ]                  fat emulsions             2
     liposyn iii [INJ]                                           1

OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS
  ABORTIFACIENTS

     CERVIDIL                          dinoprostone              3
     HEMABATE [INJ]                    carboprost tromethamine   2
     PROSTIN E2 VAGINAL                dinoprostone              2
     SUPPOSITORY

  ANDROGEN DRUGS

     ANADROL-50                        oxymetholone              4      [PAR]
     ANDRODERM                         testosterone              3      [PAR]
Formulary ID 11155 V.4

                    Drug                             Generic             Tier   Restrictions
     ANDROGEL                           testosterone                     2      [PAR]
     ANDROID                            methyltestosterone               3
     ANDROXY                            fluoxymesterone                  2
     danazol cap                                                         1
     DELATESTRYL [INJ][G]               testosterone enanthate           3
     DEPO-TESTOSTERONE [INJ][G]         testosterone cypionate           3
     FIRST-TESTOSTERONE                 testosterone propionate          3
     FIRST-TESTOSTERONE MC              testosterone propionate          3
     FORTESTA                           testosterone                     3      [PAR]
     METHITEST                          methyltestosterone               2
     OXANDRIN 10 MG TABLET [G]          oxandrolone                      4      [PAR]
     OXANDRIN 2.5 MG TABLET [G]         oxandrolone                      3      [PAR]
     oxandrolone                                                         1      [PAR]
     STRIANT                            testosterone                     3      [PAR]
     TESTIM                             testosterone                     2      [PAR]
     TESTOPEL [INJ]                     testosterone                     2
     testosterone cypionate injection                                    1
     [INJ]
     testosterone enanthate [INJ]                                        1
     TESTRED                            methyltestosterone               3

  CONTRACEPTIVES

     apri                                                                1
     aranelle                                                            1
     aviane                                                              1
     azurette                                                            1
     balziva                                                             1
     BEYAZ                              drospir/eth estra/levomefol ca   3
     BREVICON [G]                       norethindrone-ethin estradiol    3
     caziant                                                             1
     cesia                                                               1
     cryselle                                                            1
     cyclafem                                                            1
     CYCLESSA [G]                       desogestrel-ethinyl estradiol    3
     DEMULEN 1-50-21                    ethynodiol diace-eth estradiol   3
     DESOGEN [G]                        desogestrel-ethinyl estradiol    3
     ELLA                               ulipristal acetate               3
     enpresse                                                            1
     ESTROSTEP FE [G]                   noreth a-et estra/fe fumarate    3
Formulary ID 11155 V.4

                      Drug                  Generic             Tier   Restrictions
     FEMCON FE                 noreth-ethinyl estradiol/iron    3
     gianvi                                                     1
     gildess fe                                                 1
     introvale                                                  1
     jolessa                                                    1
     junel                                                      1
     junel fe                                                   1
     kariva                                                     1
     kelnor 1-35                                                1
     leena                                                      1
     lessina                                                    1
     LEVLEN 28                 levonorgestrel-ethin estradiol   3
     levora-28                                                  1
     LO LOESTRIN FE            noreth a-et estra/fe fumarate    3
     LOESTRIN [G]              norethindrone a-e estradiol      3
     LOESTRIN 24 FE            noreth a-et estra/fe fumarate    3
     LOESTRIN FE [G]           noreth a-et estra/fe fumarate    3
     LO-OVRAL-28 [G]           norgestrel-ethinyl estradiol     3
     LOSEASONIQUE              l-norgest-eth estr/ethin estr    3
     low-ogestrel                                               1
     lutera                                                     1
     LYBREL                    levonorgestrel-ethin estradiol   3
     microgestin                                                1
     microgestin fe                                             1
     MIRCETTE                  desog-et estra/ethin estra       3
     MODICON [G]               norethindrone-ethin estradiol    3
     mononessa                                                  1
     NATAZIA                   estradiol valerate/dienogest     3
     necon                                                      1
     next choice                                                1
     NORDETTE-28 [G]           levonorgestrel-ethin estradiol   3
     norgestrel-ethiny estra                                    1
     NORINYL 1+35 [G]          norethindrone-ethin estradiol    3
     NORINYL 1+50              norethindrone-mestranol          3
     nortrel                                                    1
     NUVARING                  etonogestrel/ethin estradiol     3
     ocella                                                     1
     ogestrel                                                   1
     ORTHO EVRA                ethinyl estradiol/norelgest      3
     ORTHO TRI-CYCLEN          norgestimate-ethinyl estradiol   3
Formulary ID 11155 V.4

                  Drug                   Generic             Tier   Restrictions
     ORTHO TRI-CYCLEN LO    norgestimate-ethinyl estradiol   3
     ORTHO-CEPT [G]         desogestrel-ethinyl estradiol    3
     ORTHO-CYCLEN [G]       norgestimate-ethinyl estradiol   3
     ORTHO-NOVUM [G]        norethindrone-ethin estradiol    3
     OVCON-35 [G]           norethindrone-ethin estradiol    3
     OVCON-50               norethindrone-ethin estradiol    3
     PLAN B [G]             levonorgestrel                   3
     PLAN B ONE-STEP        levonorgestrel                   3
     portia                                                  1
     previfem                                                1
     quasense                                                1
     reclipsen                                               1
     SAFYRAL                drospir/eth estra/levomefol ca   3
     SEASONALE [G]          levonorgestrel-ethin estradiol   3
     SEASONIQUE             l-norgest-eth estr/ethin estr    3
     solia                                                   1
     sprintec                                                1
     sronyx                                                  1
     tilia fe                                                1
     tri-legest fe                                           1
     trinessa                                                1
     TRI-NORINYL [G]        norethindrone-ethin estradiol    3
     tri-previfem                                            1
     tri-sprintec                                            1
     trivora-28                                              1
     velivet                                                 1
     YASMIN 28 [G]          eth estradiol/drospirenone       3
     YAZ [G]                eth estradiol/drospirenone       3
     zarah                                                   1
     zenchent                                                1
     zovia 1-35e                                             1
     zovia 1-50e                                             1

  ESTROGEN DRUGS

     ALORA                  estradiol                        3      [QLL,
                                                                    10/35]
     CENESTIN               estrogen,conjug,synthetic a      3
     CLIMARA [G]            estradiol                        3      [QLL, 5/35]
     DELESTROGEN [INJ][G]   estradiol valerate               3
Formulary ID 11155 V.4

                 Drug                                   Generic         Tier Restrictions
     DEPO-ESTRADIOL [INJ]                 estradiol cypionate           3
     DIVIGEL                              estradiol                     3    [QLL,
                                                                             34/34]
     ELESTRIN                             estradiol                     3    [QLL, 144
                                                                             gm/34]
     ENJUVIA                              estrogen,conjug,synthetic b   2
     ESTRACE TABLET [G]                   estradiol                     3
     ESTRACE VAGINAL PRODUCTS             estradiol                     2
     ESTRADERM                            estradiol                     2    [QLL,
                                                                             10/35]
     estradiol adh. patch                                               1    [QLL, 5/35]
     estradiol tablet                                                   1
     estradiol valerate injection [INJ]                                 1
     ESTRASORB                            estradiol                     3    [QLL,
                                                                             118/34]
     ESTRING                              estradiol                     2
     estropipate                                                        1
     EVAMIST                              estradiol                     3    [QLL, 16
                                                                             ml/34]
     FEMRING                              estradiol                     3
     FEMTRACE                             estradiol                     3
     GYNODIOL                             estradiol                     3
     MENEST                               estrogens,esterified          3
     MENOSTAR                             estradiol                     3    [QLL, 5/35]
     OGEN [G]                             estropipate                   3
     ORTHO-EST                            estropipate                   3
     PREMARIN INJECTION [INJ]             estrogens,conjugated          2
     PREMARIN TABLET, -VAGINAL            estrogens,conjugated          2
     PRODUCTS
     VAGIFEM                              estradiol                     2
     VIVELLE-DOT                          estradiol                     2    [QLL,
                                                                             10/35]

  ESTROGEN/PROGESTIN COMBINATIONS

     ACTIVELLA [G]                        estradiol/noreth ac           3
     ANGELIQ                              estradiol/drospirenone        3
     CLIMARA PRO                          estradiol/levonorgestrel      2    [QLL, 5/35]
     COMBIPATCH                           estradiol/noreth ac           2
     estradiol-norethindrone acetat                                     1
     FEMHRT                               norethindrone a-e estradiol   3
Formulary ID 11155 V.4

                     Drug                          Generic             Tier   Restrictions
     mimvey                                                            1
     PREFEST                          estradiol/norgestimate           3
     PREMPHASE                        estrogen/medroxyprogesterone     2
     PREMPRO                          estrogen/medroxyprogesterone     2

  OB/GYN TOPICAL ANTIINFECTIVES

     ACID JELLY                       acetic ac/ricinoleic/oxyquinol   3
     AVC                              sulfanilamide                    3
     CLEOCIN [G]                      clindamycin phosphate            3
     clindamycin phosphate vaginal                                     1
     products
     CLINDESSE                        clindamycin phosphate            3
     fem ph                                                            1
     METROGEL-VAGINAL [G]             metronidazole                    3
     metronidazole vaginal products                                    1
     RELAGARD                         acetic acid/oxyquin so4          3
     vandazole                                                         1

  OXYTOCICS

     METHERGINE INJECTION [INJ]       methylergonovine                 2
     METHERGINE TABLET                methylergonovine                 2
     oxytocin injection [INJ]                                          1
     PITOCIN [INJ]                    oxytocin                         3

  PRENATAL VITAMINS

     CITRANATAL DHA                   prenatal vit( = or > 1mg fa)     3
     CITRANATAL RX                    prenatal vit( = or > 1mg fa)     3
     co-natal fa                                                       1
     CONCEPT DHA                      prenatal vit( = or > 1mg fa)     3
     CONCEPT OB                       prenatal vit( = or > 1mg fa)     3
     docosavit                                                         1
     dualvit ob                                                        1
     edge ob                                                           1
     fe c plus tablet                                                  1
     folbecal                                                          1
     folcal dha softgel                                                1
     foltabs                                                           1
Formulary ID 11155 V.4

                 Drug                              Generic            Tier   Restrictions
     GESTICARE                       prenatal vit( = or > 1mg fa)     3
     GESTICARE DHA                   prenatal vit( = or > 1mg fa)     3
     ICAR-C PLUS                     iron,carbonyl/vit c/vit b12/fa   3
     inatal advance                                                   1
     inatal gt                                                        1
     inatal ultra                                                     1
     LACTOCAL-F                      prenatal vit( = or > 1mg fa)     3
     maternity                                                        1
     multi-nate 30                                                    1
     multi-nate dha extra prenatal                                    1
     NATACHEW                        prenatal vitamins (< 1mg fa)     3
     NATAFORT                        prenatal vitamins (< 1mg fa)     3
     NATELLE C                       prenatal vit( = or > 1mg fa)     3
     NATELLE ONE                     prenatal vit( = or > 1mg fa)     3
     NATELLE PLUS                    prenatal vit( = or > 1mg fa)     3
     NATELLE-EZ                      prenatal vit( = or > 1mg fa)     3
     NEEVO                           prenatal vit( = or > 1mg fa)     3
     NEXA SELECT                     prenatal vit( = or > 1mg fa)     3
     ob + dha                                                         1
     ob 90 + dha                                                      1
     ob-natal one                                                     1
     OBSTETRIX EC                    prenatal vit( = or > 1mg fa)     3
     OBTREX                          prenatal vit( = or > 1mg fa)     3
     O-CAL FA                        prenatal vit( = or > 1mg fa)     3
     O-CAL PRENATAL                  prenatal vit( = or > 1mg fa)     3
     POLY IRON PN FORTE              prenatal vitamins (< 1mg fa)     3
     PREFERA OB                      prenatal vit( = or > 1mg fa)     3
     PREFERA-OB                      prenatal vit( = or > 1mg fa)     3
     PREFERA-OB ONE                  prenatal vit( = or > 1mg fa)     3
     PREFERA-OB PLUS DHA             prenatal vit( = or > 1mg fa)     3
     prenacare                                                        1
     prenafirst                                                       1
     prenaplus                                                        1
     prenatabs fa                                                     1
     prenatabs obn                                                    1
     prenatabs rx                                                     1
     prenatal 19                                                      1
     prenatal ad                                                      1
     prenatal low iron tablet                                         1
     prenatal multivitamin w-iron                                     1
Formulary ID 11155 V.4

                       Drug                  Generic             Tier   Restrictions
     prenatal plus                                               1
     prenatal-u                                                  1
     PRENATE DHA                prenatal vit( = or > 1mg fa)     3
     PRENATE ELITE              prenatal vit( = or > 1mg fa)     3
     PRENATE ESSENTIAL          prenatal vit( = or > 1mg fa)     3
     PRENEXA                    prenatal vit( = or > 1mg fa)     3
     PRENEXA PREMIER            prenatal vitamins (< 1mg fa)     3
     PREQUE 10                  prenatal vitamins (< 1mg fa)     3
     pruet dha                                                   1
     pruet dha ec                                                1
     re-nata 29                                                  1
     re-nata 29 ob                                               1
     SELECT-OB                  prenatal vit( = or > 1mg fa)     3
     SELECT-OB + DHA            prenatal vit( = or > 1mg fa)     3
     se-natal one                                                1
     setonet                                                     1
     setonet-ec                                                  1
     TANDEM DHA                 prenatal vit( = or   > 1mg fa)   3
     TANDEM OB                  prenatal vit( = or   > 1mg fa)   3
     TRICARE                    prenatal vit( = or   > 1mg fa)   3
     TRICARE PRENATAL DHA ONE   prenatal vit( = or   > 1mg fa)   3
     trinate                                                     1
     vinacal                                                     1
     vinate az                                                   1
     vinate az extra                                             1
     vinate c                                                    1
     vinate calcium                                              1
     vinate care                                                 1
     vinate gt                                                   1
     vinate ic                                                   1
     vinate ii                                                   1
     vinate one                                                  1
     vinate pn care                                              1
     vinate ultra                                                1
     vinate-m                                                    1
     vitafol-ob                                                  1
     VITAFOL-OB+DHA             prenatal vit( = or > 1mg fa)     3
     vitafol-pn                                                  1
     vitaphil                                                    1
     vitaphil + dha                                              1
Formulary ID 11155 V.4

                     Drug                                  Generic    Tier   Restrictions
     vol-nate                                                         1

  PROGESTIN DRUGS

     AYGESTIN [G]                           norethindrone acetate     3
     camila                                                           1
     CRINONE                                progesterone              3
     DEPO-PROVERA 150 MG/ML SYRN            medroxyprogesterone       3      [QLL, 1/90]
     [INJ][G]
     DEPO-PROVERA 150 MG/ML VIAL            medroxyprogesterone       3      [QLL, 1
     [INJ][G]                                                                ml/90]
     DEPO-SUBQ PROVERA 104 [INJ]            medroxyprogesterone       3      [QLL, 1
                                                                             syringe/90]
     errin                                                            1
     FIRST-PROGESTERONE         VGS   100   progesterone              2
     FIRST-PROGESTERONE         VGS   200   progesterone              2
     FIRST-PROGESTERONE         VGS   25    progesterone              2
     FIRST-PROGESTERONE         VGS   400   progesterone              2
     FIRST-PROGESTERONE         VGS   50    progesterone              2
     heather                                                          1
     jolivette                                                        1
     MAKENA [INJ]                           hydroxyprogest caproate   4
     medroxyprogesterone acetate                                      1      [QLL, 1
     injection [INJ]                                                         ml/90]
     medroxyprogesterone acetate tablet                               1
     MICRONOR [G]                           norethindrone             3
     nora-be                                                          1
     norethindrone                                                    1
     norethindrone acetate tablet                                     1
     NOR-Q-D [G]                            norethindrone             3
     PROCHIEVE                              progesterone              3
     progesterone in oil [INJ]                                        1
     progesterone injection [INJ]                                     1
     PROMETRIUM                             progesterone              2
     PROVERA [G]                            medroxyprogesterone       3

  SPECIALIZED OB/GYN DRUGS

     leuprolide acetate [INJ]                                         1
Formulary ID 11155 V.4

                   Drug                                 Generic         Tier Restrictions
     LUPRON DEPOT 11.25 MG 3MO KIT,      leuprolide                     2    [PAR]
     -22.5 MG 3MO KIT, -3.75 MG KIT, -
     4 MONTH KIT [INJ]
     LUPRON DEPOT 7.5 MG KIT [INJ]       leuprolide                     4    [PAR]
     LUPRON DEPOT-PED [INJ]              leuprolide                     4    [PAR]
     PREPIDIL                            dinoprostone                   3
     SUPPRELIN LA [INJ]                  histrelin ac                   4
     SYNAREL                             nafarelin                      4

OPHTHALMIC MEDICATIONS
  ANTIGLAUCOMA DRUGS

     acetazolamide cap sa, -tablet                                      1
     acetazolamide sodium [INJ]                                         1
     ALPHAGAN P 0.1% DROPS               brimonidine tartrate           2
     ALPHAGAN P 0.15% EYE DROPS [G]      brimonidine tartrate           3
     apraclonidine hcl                                                  1
     AZOPT                               brinzolamide                   3
     BETAGAN [G]                         levobunolol                    3    [ST]
     betaxolol hcl ophth drops                                          1
     BETIMOL                             timolol                        3    [ST]
     BETOPTIC S                          betaxolol                      3    [ST]
     brimonidine tartrate                                               1
     carteolol hcl                                                      1
     COMBIGAN                            brimonidine tartrate/timolol   2    [ST]
     COSOPT [G]                          dorzolamide/timolol            3    [ST]
     DIAMOX SEQUELS [G]                  acetazolamide                  3
     dorzolamide hcl                                                    1
     dorzolamide-timolol                                                1
     IOPIDINE [G]                        apraclonidine                  3
     ISOPTO CARBACHOL                    carbachol                      3
     ISOPTO CARPINE                      pilocarpine hcl                3
     ISTALOL                             timolol                        3    [ST]
     levobunolol hcl                                                    1
     LUMIGAN                             bimatoprost                    3
     methazolamide                                                      1
     metipranolol                                                       1
     MIOSTAT [INJ]                       carbachol                      3
     NEPTAZANE [G]                       methazolamide                  3
     OPTIPRANOLOL [G]                    metipranolol                   3    [ST]
Formulary ID 11155 V.4

                 Drug                                Generic             Tier Restrictions
     PHOSPHOLINE IODIDE                  echothiophate iodide            2
     pilocarpine hcl ophth drops                                         1
     PILOPINE HS                         pilocarpine hcl                 2
     PROPINE                             dipivefrin                      3
     timolol maleate ophth drops                                         1
     TIMOPTIC                            timolol                         3    [ST]
     TIMOPTIC OCUDOSE                    timolol                         3    [ST]
     TIMOPTIC-XE [G]                     timolol                         3    [ST]
     TRAVATAN                            travoprost                      2
     TRAVATAN Z                          travoprost                      2
     TRUSOPT [G]                         dorzolamide                     3
     XALATAN                             latanoprost                     2

  OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS

     BLEPHAMIDE                          sulfacetamide/prednisolone ac   3
     BLEPHAMIDE S.O.P.                   sulfacetamide/prednisolone ac   3
     cortomycin oint                                                     1
     dexasporin                                                          1
     MAXITROL [G]                        neomycin/polymyxin/dexameth     3
     neomycin-bacitracin-poly-hc                                         1
     neomycin-polymyxin-dexameth                                         1
     neomycin-polymyxin-hc ophth drops                                   1
     poly-dex                                                            1
     POLY-PRED                           neomycin/polymyxin/prednisol    2
     PRED-G                              gentamicin/prednisolone         2
     sulfacetamide-prednisolone                                          1
     TOBRADEX [G]                        tobramycin sulfate/dexameth     3
     TOBRADEX ST                         tobramycin sulfate/dexameth     3
     tobramycin-dexamethasone                                            1
     ZYLET                               tobramycin/lotepred etab        2

  OPHTHALMIC CORTICOSTEROID DRUGS

     ALREX                               loteprednol etabonate           2
     dexamethasone sodium phosphate                                      1
     ophth drops
     DUREZOL                             difluprednate                   3
     FLAREX                              fluorometholone                 3
     fluorometholone                                                     1
Formulary ID 11155 V.4

                  Drug                               Generic      Tier   Restrictions
     FML [G]                            fluorometholone           3
     FML FORTE                          fluorometholone           3
     FML S.O.P.                         fluorometholone           2
     LOTEMAX                            loteprednol etabonate     2
     MAXIDEX                            dexamethasone             3
     OMNIPRED [G]                       prednisolone acetate      3
     PRED FORTE [G]                     prednisolone acetate      3
     PRED MILD                          prednisolone acetate      2
     prednisol                                                    1
     prednisolone acetate ophth drops                             1
     prednisolone sodium phosphate                                1
     ophth drops
     RETISERT                           fluocinolone acetonide    3
     TRIESENCE [INJ]                    triamcinolone acetonide   3
     VEXOL                              rimexolone                3

  OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS

     ak-poly-bac                                                  1
     aktob                                                        1
     AZASITE                            azithromycin              2
     bacitracin 500 unit/gm ointmnt                               1
     bacitracin-polymyxin eye oint                                1
     BESIVANCE                          besifloxacin              3
     BLEPH-10 [G]                       sulfacetamide sodium      3
     CILOXAN [G]                        ciprofloxacin             3
     ciprofloxacin hcl ophth drops                                1
     erythromycin oint                                            1
     GARAMYCIN [G]                      gentamicin                3
     gentak                                                       1
     gentamicin 3 mg/gm eye oint, -                               1
     ophth drops
     gentasol                                                     1
     ILOTYCIN [G]                       erythromycin base         3
     IQUIX                              levofloxacin              3
     levofloxacin ophth drops                                     1
     MOXEZA                             moxifloxacin              3
     neocidin                                                     1
     neomycin-bacitracin-polymyxin                                1
     neomycin-polymyxin-gramicidin                                1
Formulary ID 11155 V.4

                 Drug                               Generic             Tier   Restrictions
     NEOSPORIN OPHTH DROPS [G]          neomycin/gramicidin/polymyxin   3
     OCUFLOX [G]                        ofloxacin                       3
     ofloxacin ophth drops                                              1
     polycin-b                                                          1
     polymyxin b sul-trimethoprim                                       1
     POLYTRIM [G]                       polymyxin b sulfate/tmp         3
     QUIXIN                             levofloxacin                    3
     romycin                                                            1
     sulfac                                                             1
     sulfacetamide sodium ophth drops                                   1
     sulfamide                                                          1
     TERRAMYCIN WITH POLYMYXIN          oxytetracycline hcl/polymyxin   3
     tobramycin sulfate ophth drops                                     1
     tobrasol                                                           1
     TOBREX [G]                         tobramycin                      3
     VIGAMOX                            moxifloxacin                    2
     ZYMAR                              gatifloxacin                    2
     ZYMAXID                            gatifloxacin                    2

  OPHTHALMIC TOPICAL ANTIVIRAL DRUGS

     trifluridine                                                       1
     VIROPTIC [G]                       trifluridine                    3

  OTHER OPHTHALMIC DRUGS

     ACULAR [G]                         ketorolac                       3
     ACULAR LS [G]                      ketorolac                       3
     ACUVAIL                            ketorolac                       3
     ak-con                                                             1
     ak-dilate                                                          1
     akorn balanced salt                                                1
     ak-pentolate                                                       1
     AKTEN                              lidocaine                       3
     ALAMAST                            pemirolast potassium            3
     ALCAINE [G]                        proparacaine                    3
     ALOCRIL                            nedocromil                      3
     ALOMIDE                            lodoxamide                      3
     altafrin                                                           1
     atropine care                                                      1
Formulary ID 11155 V.4

                     Drug                                Generic          Tier Restrictions
     atropine sulfate oint, -ophth drops                                  1
     azelastine hcl ophth drops                                           1
     BEPREVE                               bepotastine besilate           3
     BETADINE SOLUTION                     povidone-iodine                3
     BOTOX [INJ]                           botulinum toxin a              2    [PAR]
     BROMDAY                               bromfenac                      3
     BSS [INJ]                             sodium/calcium/mag/potassium   3
     BSS PLUS                              sodium/calcium/mag/potassium   3
     cromolyn sodium ophth drops                                          1
     CYCLOGYL 0.5% EYE DROPS, -2%          cyclopentolate                 3
     EYE DROPS
     CYCLOGYL 1% EYE DROPS [INJ]           cyclopentolate                 3
     cyclopentolate hcl                                                   1
     cylate                                                               1
     diclofenac sodium ophth drops                                        1
     ELESTAT                               epinastine hcl                 3
     EMADINE                               emedastine difumarate          3
     flurbiprofen sodium                                                  1
     homatropaire                                                         1
     homatropine                                                          1
     ISOPTO ATROPINE                       atropine sulfate               3
     ISOPTO HOMATROPINE                    homatropine hbr                3
     ISOPTO HYOSCINE                       scopolamine                    3
     ketorolac tromethamine ophth drops                                   1
     LACRISERT                             hydroxypropylmethylcellulose   3
     LASTACAFT                             alcaftadine                    3
     LUCENTIS [INJ]                        ranibizumab                    3
     MYDFRIN                               phenylephrine hcl              3
     mydral                                                               1
     MYDRIACYL [G]                         tropicamide                    3
     naphazoline hcl ophth drops                                          1
     NATACYN                               natamycin                      2
     neofrin                                                              1
     NEVANAC                               nepafenac                      2
     OCUFEN [G]                            flurbiprofen                   3
     OPTIVAR [G]                           azelastine hcl                 3
     parcaine                                                             1
     PATADAY                               olopatadine hcl                2
     PATANOL                               olopatadine hcl                2
     phenylephrine hcl ophth drops                                        1
Formulary ID 11155 V.4

                    Drug                             Generic   Tier Restrictions
     proparacaine hcl                                          1
     RESTASIS                         cyclosporine             2    [QLL, 60
                                                                    vials/30]
     tropicacyl                                                1
     tropicamide                                               1
     VISUDYNE [INJ]                   verteporfin              2
     VITRASERT                        ganciclovir              3
     VOLTAREN OPHTH DROPS [G]         diclofenac sodium        3
     XIBROM                           bromfenac                3
     ZIRGAN                           ganciclovir              3

RESPIRATORY MEDICATIONS
  ANTIHISTAMINE/DECONGESTANT COMBINATIONS

     ALLEGRA-D 12 HOUR [G]            pse/fexofenadine         3    [QLL,
                                                                    68/34][ST]
     ALLEGRA-D 24 HOUR                pse/fexofenadine         3    [QLL,
                                                                    34/34][ST]
     CLARINEX-D 12 HOUR               pse/desloratadine        3    [QLL,
                                                                    68/34][ST]
     CLARINEX-D 24 HOUR               pse/desloratadine        3    [QLL,
                                                                    34/34][ST]
     fexofenadine-pse er 180-240 tb                            1    [QLL,
                                                                    34/34]
     fexofenadine-pse er 60-120 tab                            1    [QLL,
                                                                    68/34]
     promethazine vc                                           1    [PAR]
     SEMPREX-D                        pse/acrivas              3

  ANTIHISTAMINES

     ALLEGRA 180 MG TABLET [G]        fexofenadine             3    [QLL,
                                                                    34/34][ST]
     ALLEGRA 60 MG TABLET [G]         fexofenadine             3    [QLL,
                                                                    68/34][ST]
     ALLEGRA ODT                      fexofenadine             3    [QLL,
                                                                    68/34][ST]
     ALLEGRA ORAL SUSP                fexofenadine             3    [ST]
     carbinoxamine maleate                                     1
Formulary ID 11155 V.4

                      Drug                                Generic          Tier   Restrictions
     cetirizine hcl 1 mg/1 ml soln, -1                                     1
     mg/ml soln, -1 mg/ml syrup, -5
     mg/5 ml syrup
     CLARINEX SYRUP                          desloratadine                 3      [ST]
     CLARINEX TABLET                         desloratadine                 3      [QLL,
                                                                                  34/34][ST]
     clemastine fum 2.68 mg tab, -syrup                                    1
     cyproheptadine hcl syrup, -tablet                                     1      [PAR]
     dexchlorpheniramine maleate                                           1      [PAR]
     diphenhydramine 12.5 mg/5 ml, -50                                     1      [PAR]
     mg capsule
     diphenhydramine hcl injection [INJ]                                   1
     DYTAN                                   diphenhydramine tannate       3      [PAR]
     fexofenadine hcl 180 mg tablet                                        1      [QLL,
                                                                                  34/34]
     fexofenadine hcl 30 mg tablet, -60                                    1      [QLL,
     mg tablet                                                                    68/34]
     levocetirizine dihydrochloride                                        1      [QLL,
                                                                                  34/34]
     palgic                                                                1
     PHENERGAN [INJ][G]                      promethazine                  3
     promethazine hcl injection [INJ]                                      1
     promethazine hcl syrup, -tablet                                       1      [PAR]
     tripohist                                                             1
     triprolidine hcl syrup                                                1
     XYZAL SOLUTION                          levocetirizine dihydrochlor   2      [ST]
     XYZAL TABLET                            levocetirizine dihydrochlor   2      [QLL,
                                                                                  34/34][ST]

  BETA-2 ADRENERGIC DRUGS

     albuterol sulfate nebs, -syrup, -tab                                  1
     sa, -tablet
     FORADIL                                 formoterol fumarate           2      [QLL,
                                                                                  120/34]
     MAXAIR AUTOHALER                        pirbuterol                    3      [QLL,
                                                                                  28/34]
     metaproterenol sulfate syrup, -tablet                                 1
     PROAIR HFA                              albuterol                     2      [QLL, 26
                                                                                  gm/34]
Formulary ID 11155 V.4

                  Drug                                    Generic   Tier Restrictions
     PROVENTIL HFA                         albuterol                3    [QLL, 20
                                                                         gm/34]
     SEREVENT DISKUS                       salmeterol               2    [QLL, 120
                                                                         doses/34]
     terbutaline sulfate injection [INJ]                            1
     terbutaline sulfate tablet                                     1
     VENTOLIN HFA                          albuterol                2    [QLL, 54
                                                                         gm/34]
     VOSPIRE ER [G]                        albuterol                3
     XOPENEX HFA                           levalbuterol             3    [QLL, 45
                                                                         gm/34]

  LEUKOTRIENE MODIFIERS

     ACCOLATE                              zafirlukast              3
     SINGULAIR                             montelukast sodium       2
     zafirlukast                                                    1
     ZYFLO                                 zileuton                 3
     ZYFLO CR                              zileuton                 2

  METHYL XANTHINE DRUGS

     aminophylline injection [INJ]                                  1
     aminophylline tablet                                           1
     CAFCIT SOLUTION [INJ]                 caffeine citrated        3
     caffeine citrate solution                                      1
     dylix                                                          1
     ELIXOPHYLLIN                          theophylline             3
     LUFYLLIN                              dyphylline               3
     THEO-24                               theophylline             3
     theochron                                                      1
     theophylline                                                   1
     theophylline anhydrous tab sa                                  1
     UNIPHYL                               theophylline             3

  OTHER DRUGS FOR ASTHMA

     ADRENACLICK [INJ]                     epinephrine hcl          3    [QLL, 4/2]
     ADRENALIN CHLORIDE INJECTION          epinephrine hcl          3
     [INJ]
Formulary ID 11155 V.4

                  Drug                                 Generic           Tier Restrictions
     ADRENALIN CHLORIDE NEBS             epinephrine hcl                 3
     ADVAIR DISKUS                       salmeterol/fluticasone          2    [QLL, 120
                                                                              doses/34]
     ADVAIR HFA                          salmeterol/fluticasone          2    [QLL, 24
                                                                              gm/34]
     AEROBID                             flunisolide                     3    [QLL,
                                                                              21/34]
     AEROBID-M                           flunisolide                     3    [QLL, 21
                                                                              gm/34]
     ALVESCO 160 MCG INHALER             ciclesonide                     3    [QLL, 18
                                                                              gm/34]
     ALVESCO 80 MCG INHALER              ciclesonide                     3    [QLL, 12
                                                                              gm/34]
     ASMANEX TWISTHALER 110 MCG          mometasone                      2    [QLL, 60
     #30, -TWISTHALER 110 MCG #7, -                                           doses/30]
     TWISTHALER 220 MCG #30
     ASMANEX TWISTHALER 220 MCG          mometasone                      2    [QLL, 14
     #14                                                                      doses/14]
     ASMANEX TWISTHALER 220 MCG          mometasone                      2    [QLL, 120
     #60                                                                      doses/30]
     ASMANEX TWISTHALR 220 MCG           mometasone                      2    [QLL, 240
     #120                                                                     doses/30]
     ATROVENT HFA                        ipratropium                     2    [QLL, 26
                                                                              gm/34]
     COMBIVENT                           albuterol sulfate/ipratropium   2    [QLL, 44
                                                                              gm/34]
     cromolyn sodium nebs                                                1
     DULERA                              mometasone/formoterol           3    [QLL, 26
                                                                              gm/34]
     epinephrine 0.1 mg/ml syringe, -1                                   1
     mg/ml ampul, -1 mg/ml vial [INJ]
     EPINEPHRINE 0.15 MG AUTO-           epinephrine hcl                 3    [QLL, 4/2]
     INJCT, -0.3 MG AUTO-INJECT [INJ]
     EPINEPHRINE 0.3 MG/0.3 ML SYR       epinephrine hcl                 2
     [INJ]
     EPIPEN [INJ]                        epinephrine hcl                 2    [QLL, 4
                                                                              pens/2]
     EPIPEN JR [INJ]                     epinephrine hcl                 2    [QLL, 4
                                                                              pens/2]
     FLOVENT 100 MCG DISKUS, -50         fluticasone propionate          2    [QLL, 120
     MCG DISKUS                                                               doses/34]
Formulary ID 11155 V.4

                  Drug                             Generic              Tier Restrictions
     FLOVENT 250 MCG DISKUS          fluticasone propionate             2    [QLL, 300
                                                                             doses/34]
     FLOVENT HFA 110 MCG INHALER     fluticasone propionate             2    [QLL, 12
                                                                             gm/34]
     FLOVENT HFA 220 MCG INHALER     fluticasone propionate             2    [QLL, 36
                                                                             gm/34]
     FLOVENT HFA 44 MCG INHALER      fluticasone propionate             2    [QLL, 21
                                                                             gm/34]
     GASTROCROM                      cromolyn                           2
     ipratropium bromide nebs                                           1
     PULMICORT 180 MCG FLEXHALER     budesonide                         3    [QLL, 3
                                                                             inhalers/34]
     PULMICORT 90 MCG FLEXHALER      budesonide                         3    [QLL, 2
                                                                             inhalers/34]
     QVAR                            beclomethasone                     2    [QLL, 22
                                                                             gm/34]
     SPIRIVA                         tiotropium bromide                 2    [QLL, 60
                                                                             capsules/34]
     SYMBICORT                       budesonide/formoterol fum          2    [QLL, 20
                                                                             gm/34]
     TWINJECT [INJ]                  epinephrine hcl                    3    [QLL, 4
                                                                             pens/2]
     XOLAIR [INJ][LA]                omalizumab                         4    [PAR][QLL,
                                                                             6/28]

  OTHER RESPIRATORY DRUGS

     ARALAST [INJ][LA]               alpha-1-proteinase     inhibitor   4    [PAR]
     ARALAST NP [INJ][LA]            alpha-1-proteinase     inhibitor   4    [PAR]
     GLASSIA [INJ][LA]               alpha-1-proteinase     inhibitor   4    [PAR]
     PROLASTIN [INJ][LA]             alpha-1-proteinase     inhibitor   4    [PAR]
     PROLASTIN C [INJ][LA]           alpha-1-proteinase     inhibitor   4    [PAR]
     ZEMAIRA [INJ][LA]               alpha-1-proteinase     inhibitor   4    [PAR]

UROLOGICAL MEDICATIONS
  ANTICHOLINERGIC ANTISPASMODICS

     DETROL                          tolterodine tartrate               3    [ST]
     DETROL LA                       tolterodine tartrate               3    [ST]
     DITROPAN XL 10 MG TABLET, -15   oxybutynin                         3    [ST]
     MG TABLET [G]
Formulary ID 11155 V.4

                  Drug                                     Generic         Tier Restrictions
     DITROPAN XL 5 MG TABLET [G]             oxybutynin                    3    [QLL,
                                                                                34/34][ST]
     ENABLEX                                 darifenacin hydrobromide      2    [ST]
     flavoxate hcl                                                         1
     GELNIQUE                                oxybutynin                    3    [QLL,
                                                                                34/34][ST]
     oxybutynin chloride syrup, -tablet                                    1
     oxybutynin cl er 10 mg tablet, -cl er                                 1
     15 mg tablet
     oxybutynin cl er 5 mg tablet                                          1    [QLL,
                                                                                34/34]
     OXYTROL                                 oxybutynin                    3    [QLL,
                                                                                10/35][ST]
     SANCTURA [G]                            trospium chloride             2    [ST]
     SANCTURA XR                             trospium chloride             2    [ST]
     TOVIAZ                                  fesoterodine fumarate         3    [ST]
     trospium chloride                                                     1
     VESICARE                                solifenacin succinate         3    [ST]

  CHOLINERGIC STIMULANTS

     bethanechol chloride tablet                                           1
     URECHOLINE [G]                          bethanechol                   3

  OTHER GENITOURINARY PRODUCTS

     acetic acid 0.25% irrig soln                                          1
     AVODART                                 dutasteride                   2
     CYSTADANE                               betaine hcl                   2
     cytra-3                                                               1
     cytra-k                                                               1
     ELMIRON                                 pentosan polysulfate sodium   2
     finasteride                                                           1
     FLOMAX [G]                              tamsulosin                    3
     glycine solution                                                      1
     JALYN                                   dutasteride/tamsulosin hcl    2
     K-PHOS M.F.                             pot acid phos/sod acid phos   2
     K-PHOS NO.2                             pot acid phos/sod acid phos   2
     K-PHOS ORIGINAL                         potassium acid phosphate      2
     neomycin-polymyxin b [INJ]                                            1
Formulary ID 11155 V.4

                 Drug                            Generic          Tier   Restrictions
     NEOSPORIN G.U. IRRIGANT [INJ]   neomycin sulfate/polymyxin   3
     potassium citrate tab sa                                     1
     potassium citrate-citric acid                                1
     PROSCAR [G]                     finasteride                  3
     RAPAFLO                         silodosin                    3
     RENACIDIN                       gluconic acid/citric acid    2
     RIMSO-50                        dimethyl sulfoxide           3
     tamsulosin hcl                                               1
     tricitrates                                                  1
     UROXATRAL                       alfuzosin hcl                2
Formulary ID 11155 V.4

Index:

1ST TIER UNIFINE PENTIPS, 80             acitretin, 55
8-MOP, 55                                acitretin/emollient comb, 55
aa 3%/electrolyte-tpn/glycerin, 88, 89   ACLOVATE, 56
abacavir sulfate, 5                      ACTEMRA 200 MG/10 ML VIAL, -400 MG/20
abacavir sulfate/lamivudine, 4             ML VIAL, 79
abatacept/maltose, 20                    ACTEMRA 80 MG/4 ML VIAL, 79
abciximab, 86                            ACTHAR H.P., 68
ABELCET, 12                              ACTHIB, 75
ABILIFY DISCMELT, 23                     ACTHREL, 68
ABILIFY INJECTION, 23                    acticin, 56
ABILIFY SOLUTION, 23                     ACTIGALL, 72
ABILIFY TABLET, 23                       ACTIMMUNE, 78
abobotulinumtoxina, 83                   ACTIQ, 27
ABORTIFACIENTS, 94                       ACTIVELLA, 98
ABSTRAL, 27                              ACTONEL 150 MG TABLET, 68
acamprosate calcium, 37                  ACTONEL 30 MG TABLET, -5 MG TABLET, 68
ACANYA, 53                               ACTONEL 35 MG TABLET, 68
acarbose, 66, 67                         ACTONEL WITH CALCIUM, 68
ACCOLATE, 110                            ACTOPLUS MET, 66
ACCUPRIL, 42                             ACTOPLUS MET XR 15-1,000 MG TB, 66
ACCURETIC, 49                            ACTOPLUS MET XR 30-1,000 MG TB, 66
acebutolol, 44                           ACTOS, 66
acebutolol hcl cap, 43                   ACULAR, 106
ACEON, 42                                ACULAR LS, 106
acetaminophen-codeine, 29                ACUVAIL, 106
acetaminophen-tramadol, 21               acyclovir, 11
acetasol hc, 61                          acyclovir cap, -oral susp, -tablet, 10
acetazolamide, 103                       acyclovir sodium, 10
acetazolamide cap sa, -tablet, 102       acyclovir/hydrocortisone, 11
acetazolamide sodium, 102                ACZONE, 53
acetic ac/ricinoleic/oxyquinol, 98       ADACEL, 75
acetic acid, 62                          ADAGEN, 60
acetic acid 0.25% irrig soln, 113        ADALAT CC, 44
acetic acid otic drops, 61               adalimumab, 19
acetic acid/aluminum acetate, 61         adapalene, 53
acetic acid/hydrocortisone, 62           adapalene/benzoyl peroxide, 53
acetic acid/oxyquin so4, 98              ADCIRCA, 51
acetic acid-aluminum, 61                 adcirca (tadalafil), 51
acetic acid-hydrocortisone, 61           ADDERALL, 31
ACID JELLY, 98                           ADDERALL XR, 31
ACIPHEX, 73                              adefovir dipivoxil, 10
Formulary ID 11155 V.4

ADOXA, 15                               albuterol sulfate nebs, -syrup, -tab sa, -
ADOXA PAK, 15                              tablet, 109
ADRENACLICK, 110                        albuterol sulfate/ipratropium, 111
ADRENALIN CHLORIDE INJECTION, 110       alcaftadine, 107
ADRENALIN CHLORIDE NEBS, 110            ALCAINE, 106
ADVAIR DISKUS, 110                      alclometasone, 56
ADVAIR HFA, 110                         alclometasone dipropionate, 56
ADVICOR 1,000 MG-20 MG TABLET, -1,000   alcohol in dextrose, 87
  MG-40 MG TABLET, -750 MG-20 MG        ALCOHOL PREP PADS, 80
  TABLET, 46                            ALCOHOL PREP SWABS, 80
ADVICOR 500 MG-20 MG TABLET, 46         ALCOHOL SWABS, 80
AEROBID, 110                            ALCOHOL WIPES, 80
AEROBID-M, 110                          ALDACTAZIDE, 51
afeditab cr, 44                         ALDACTONE, 51
AFINITOR, 18                            ALDARA, 59
agalsidase, 69                          aldesleukin, 80
AGGRASTAT, 86                           ALDURAZYME, 68
AGGRENOX, 86                            alefacept, 18
AGRYLIN, 18                             alemtuzumab, 18
A-HYDROCORT, 63                         alendronate, 69
AIMSCO ULTRA THIN II, 80                alendronate sodium 10 mg tab, -40 mg tab, -
ak-con, 106                                5 mg tablet, 68
ak-dilate, 106                          alendronate sodium 35 mg tab, -70 mg tab,
AKNE-MYCIN, 53                             68
akorn balanced salt, 106                alendronate/vitamin d3, 69
ak-pentolate, 106                       ALFENTA, 27
ak-poly-bac, 105                        alfentanil, 27
AKTEN, 106                              alfentanil hydrochloride, 27
aktob, 105                              alfuzosin hcl, 113
ALA-CORT, 56                            alglucerase, 68
ALAMAST, 106                            alglucosidase alfa, 69
ALA-SCALP HP, 56                        ALIMTA, 18
albendazole, 3                          ALINIA, 8
ALBENZA, 3                              aliskiren hemifumarate, 50
ALBUMIN (HUMAN), 86                     aliskiren/amlodipine, 50
albumin human, 86, 87, 88, 89           aliskiren/amlodipine/hctz, 49
ALBUMINAR-25, 87                        aliskiren/hydrochlorothiazid, 50
ALBUMINAR-5, 87                         aliskiren/valsartan, 50
alburx (human) 25% vial, 87             alitretinoin, 59
ALBURX (HUMAN) 5% VIAL, 87              ALLEGRA 180 MG TABLET, 108
albuterol, 109                          ALLEGRA 60 MG TABLET, 108
                                        ALLEGRA ODT, 108
Formulary ID 11155 V.4

ALLEGRA ORAL SUSP, 108                  amiloride hcl tablet, 51
ALLEGRA-D 12 HOUR, 108                  amiloride hydrochloride, 51
ALLEGRA-D 24 HOUR, 108                  amiloride-hydrochlorothiazide, 51
allopurinol, 84                         amino acids, 87, 88, 89
allopurinol sodium, 84                  aminocaproic acid, 60
allopurinol tablet, 84                  aminocaproic acid injection, 60
almotriptan, 32                         aminocaproic acid syrup, -tablet, 60
ALOCRIL, 106                            AMINOGLYCOSIDES, 3
ALOMIDE, 106                            aminolevulinic acid hcl, 59
ALOPRIM, 84                             aminophylline injection, 110
ALORA, 97                               aminophylline tablet, 110
alosetron, 71                           aminosalicylic acid, 5
ALOXI, 25                               AMINOSYN, 87
alpha-1-proteinase inhibitor, 112       AMINOSYN II, 87
ALPHAGAN P 0.1% DROPS, 102              AMINOSYN II 3.5% M-DEXTROSE 5%, 87
ALPHAGAN P 0.15% EYE DROPS, 102         AMINOSYN II 3.5%-DEXTROSE 25%, 87
alprostadil, 51                         AMINOSYN II 3.5%-DEXTROSE 5%, 87
alprostadil injection, 50               AMINOSYN II 4.25% M-DEXT 10%, 87
ALREX, 104                              AMINOSYN II 4.25%-DEXTROSE 25%, 87
ALTABAX, 16                             AMINOSYN II 5% IN 25% DEXTROSE, 87
ALTACE, 42                              AMINOSYN II IN DEXTROSE, 87
altafrin, 106                           AMINOSYN II WITH LYTES-CA-DW, 87
ALTOPREV, 46                            AMINOSYN M, 87
altretamine, 19                         AMINOSYN WITH ELECTROLYTES, 87
aluminum chloride hexahydrate, 59, 60   AMINOSYN-HBC, 87
ALVESCO 160 MCG INHALER, 110            AMINOSYN-HF, 87
ALVESCO 80 MCG INHALER, 111             AMINOSYN-PF, 87
amantadine, 10                          AMINOSYN-RF, 87
AMARYL, 66                              amiodarone, 41
ambenonium chloride, 37                 amiodarone hcl injection, 41
AMBIEN, 38                              amiodarone hcl tablet, 41
AMBIEN CR, 38                           AMIODARONES, 41
AMBISOME, 13                            AMITIZA, 71
ambrisentan, 46                         amitriptyline hcl tablet, 41
amcinonide, 56                          amlexanox, 63
AMEBICIDES, 2                           amlodipine, 45
AMERGE, 32                              amlodipine bes/olmesartan med, 49
a-methapred, 63                         amlodipine besylate, 44
AMEVIVE, 18                             amlodipine besylate-benazepril, 49
AMICAR, 60                              amlodipine/atorvast cal, 46
amifostine, 18                          amlodipine/valsartan, 50
amikacin sulfate injection, 3           amlodipine/valsartan/hctz, 50
Formulary ID 11155 V.4

ammonium chloride, 87                      ANDRODERM, 94
AMMONIUM CHLORIDE INJECTION, 87            ANDROGEL, 94
ammonium lactate 12% cream, -12% lotion,   ANDROGEN DRUGS, 94
  59                                       ANDROID, 94
AMMONUL, 60                                ANDROXY, 94
amnesteem, 55                              ANECTINE, 83
amoclan, 13                                ANESTACON, 2
amox tr-potassium clavulanate, 13          ANESTHETICS, 1
amoxapine, 38                              ANGELIQ, 98
amoxicillin, 13                            ANGIOTENSIN CONVERTING ENZYME
amoxicillin clavulanate, 13                  INHIBITORS, 42
amoxicillin-clavulanate er, 13             ANGIOTENSIN II RECEPTOR ANTAGONISTS,
AMOXIL, 13                                   42
amphetamine salt combo, 31                 anidulafungin, 13
amphetamine/dextroamphetamine, 31          ANSAID, 84
ampho b c-s, 13                            ANTABUSE, 37
AMPHOTEC 100 MG VIAL, 13                   ANTARA, 47
AMPHOTEC 50 MG VIAL, 13                    ANTHELMINTICS, 3
amphotericin b injection, 13               anthralin, 55
amphotericin b lipid complex, 12           ANTIACNE DRUGS, 53
amphotericin b liposome, 13                ANTICHOLINERGIC ANTISPASMODICS, 112
ampicillin sodium, 13, 14                  ANTIDEMENTIA DRUGS, 22
ampicillin sodium/sulbactam na, 14         ANTIDIARRHEAL DRUGS, 70
ampicillin trihydrate, 13                  ANTIDYSRHYTHMIC DRUGS, 43
ampicillin-sulbactam, 13                   ANTIGLAUCOMA DRUGS, 102
AMPYRA, 60                                 ANTIHISTAMINE/DECONGESTANT
AMRIX, 83                                    COMBINATIONS, 108
AMTURNIDE, 49                              ANTIHISTAMINES, 108
amylase/lipase/protease, 72, 73            ANTIINFECTIVES, 2
ANADROL-50, 94                             ANTIINFECTIVES SPECIALIZED
ANAFRANIL, 41                                INDICATIONS, 3
anagrelide, 18                             ANTIMANIA DRUGS, 22
anagrelide hcl, 18                         ANTINEOPLASTIC/IMMUNOSUPPRESSANT
anakinra, 79                                 DRUGS, 18
ANALGESICS, 21                             ANTIPARKINSON ANTICHOLINERGIC
ANAMANTLE HC CREAM, 56                       DRUGS, 23
ANAMANTLE HC FORTE, 56                     ANTIPLATELET DRUGS, 86
ANAPROX, 84                                ANTIPRURITIC DRUGS, 54
ANAPROX DS, 84                             ANTIPSORIASIS AND ANTIECZEMA DRUGS,
anastrozole, 18                              55
anastrozole tablet, 18                     ANTIPSYCHOTIC DRUGS, 23
ANCOBON, 7                                 antipyrine/benzocaine, 61
Formulary ID 11155 V.4

antipyrine-benzocaine, 61                  ARANESP 25 MCG/0.42 ML SYRING, -25
ANTIRETROVIRALS AND PROTEASE INH, 4           MCG/ML VIAL, -40 MCG/0.4 ML SYRINGE,
ANTISPASMODICS/DRUGS AFFECT GI                -40 MCG/ML VIAL, 76
  MOTILITY, 70                             ARAVA, 18
antithrombin iii, human recomb, 92         ARCALYST, 79
antithrombin iii,human, 92                 AREDIA 30 MG VIAL, 68
ANTITHYROID DRUGS, 63                      AREDIA 90 MG VIAL, 68
ANTITUBERCULOSIS DRUGS, 5                  ARESTIN, 63
ANTIULCER DRUGS, 71                        argatroban, 91
ANTIVERT, 25                               ARGATROBAN, 91
ANTIVERTIGO AND ANTIEMETIC DRUGS, 25       arginine, 89
ANTIZOL, 60                                ARICEPT, 22
ANUSOL-HC, 72                              ARICEPT ODT, 22
ANXIOLYTICS, 27                            ARIMIDEX, 18
ANZEMET INJECTION, 25                      aripiprazole, 23
ANZEMET TABLET, 25                         ARISTOSPAN, 63
apap-caffeine-dihydrocodeine, 29           ARIXTRA 10 MG SYRINGE, -5 MG SYRINGE, -
APEXICON, 56                                  7.5 MG SYRINGE, 91
APEXICON E, 56                             ARIXTRA 2.5 MG SYRINGE, 91
APHTHASOL, 63                              armodafinil, 31
APIDRA, 65                                 ARMOUR THYROID, 69
APIDRA SOLOSTAR, 65                        AROMASIN, 18
APLENZIN, 35                               artemether/lumefantrine, 14
APOKYN, 36                                 ARTHROTEC 50, 84
apomorphine hcl, 36                        ARTHROTEC 75, 84
apraclonidine, 103                         ASACOL, 72
apraclonidine hcl, 102                     ASACOL HD, 72
aprepitant, 25                             ascomp with codeine, 32
apri, 95                                   asenapine, 24
APRISO, 72                                 ASMALPRED PLUS, 63
APTIVUS, 4                                 ASMANEX TWISTHALER 110 MCG #30, -
ARALAST, 112                                  TWISTHALER 110 MCG #7, -TWISTHALER
ARALAST NP, 112                               220 MCG #30, 111
ARALEN PHOSPHATE, 14                       ASMANEX TWISTHALER 220 MCG #14, 111
aranelle, 95                               ASMANEX TWISTHALER 220 MCG #60, 111
ARANESP 100 MCG/0.5 ML SYRINGE, -100       ASMANEX TWISTHALR 220 MCG #120, 111
  MCG/ML VIAL, -150 MCG/0.3 ML SYRINGE,    aspirin, 86
  -150 MCG/0.75 ML VIAL, -200 MCG/0.4 ML   aspirin ec 975 mg tablet, 86
  SYRINGE, -200 MCG/ML VIAL, -300          aspirin/dipyridamole, 86
  MCG/0.6 ML SYRINGE, -300 MCG/ML VIAL,    ASTELIN, 62
  -500 MCG/1 ML SYRINGE, -60 MCG/0.3 ML    ASTEPRO, 62
  SYRINGE, -60 MCG/ML VIAL, 76             ASTRAMORPH-PF, 27
Formulary ID 11155 V.4

ATACAND, 42                                AVAR LS, 53
ATACAND HCT, 49                            AVAR-E, 53
atazanavir sulfate, 4                      AVAR-E GREEN, 53
ATELVIA, 68                                AVAR-E LS CREAM, 53
atenolol, 44                               AVASTIN, 18
atenolol tablet, 43                        AVC, 98
atenolol-chlorthalidone, 49                AVELOX, 14
ATGAM, 76                                  AVELOX ABC PACK, 14
atomoxetine, 38                            AVELOX IV, 15
atorvastatin calcium, 46                   aviane, 95
atovaquone, 9                              AVIDOXY, 15
atovaquone/proguanil hcl, 14               AVINZA, 27
ATRALIN, 53                                AVITA, 53
ATRIPLA, 4                                 AVODART, 113
atropine care, 106                         AVONEX, 78
atropine sulfate, 71, 107                  AVONEX ADMINISTRATION PACK, 78
atropine sulfate injection, 37             AXERT 12.5 MG TABLET, 32
atropine sulfate oint, -ophth drops, 106   AXERT 6.25 MG TABLET, 32
ATROVENT 0.03% SPRAY, 62                   AXID, 71
ATROVENT 0.06% SPRAY, 62                   AYGESTIN, 101
ATROVENT HFA, 111                          azacitidine, 21
ATRYN, 92                                  AZACTAM 1 GM VIAL, 8
ATTENUVAX VACCINE WITH DILUENT, 76         AZACTAM 2 GM VIAL, 8
AUGMENTIN 125-31.25 SUSPEN, 13             AZACTAM-ISO-OSMOT 1 GM/50 ML, 8
AUGMENTIN 250-62.5 MG/5 ML, -TABLET,       AZACTAM-ISO-OSMOT 2 GM/50 ML, 8
  13                                       AZASAN, 18
AUGMENTIN ES-600, 13                       AZASITE, 105
AUGMENTIN XR, 13                           azathioprine, 18, 19
auranofin, 85                              azathioprine sodium, 18
aurodex, 61                                azathioprine tablet, 18
auroguard, 61                              azelaic acid, 53, 54
AUTO INJECTOR, 80                          azelastine hcl, 62, 107
AUTOJECT 2, 80                             azelastine hcl nasal drops/sprays, 62
AUTONOMIC AND CNS MEDICATIONS, 21          azelastine hcl ophth drops, 106
AUTOPEN, 80                                AZELEX, 53
AVALIDE, 49                                AZILECT, 36
AVANDAMET, 66                              azithromycin, 11, 12, 105
AVANDARYL, 66                              azithromycin 100 mg/5 ml susp, 11
AVANDIA 2 MG TABLET, -4 MG TABLET, 66      azithromycin 200 mg/5 ml susp, 11
AVANDIA 8 MG TABLET, 66                    azithromycin 250 mg tablet, 11
AVAPRO, 42                                 azithromycin 500 mg tablet, 11
AVAR, 53                                   azithromycin 600 mg tablet, -pkt, 11
Formulary ID 11155 V.4

azithromycin injection, 11            BENICAR HCT, 49
AZOPT, 103                            BENTYL CAP, -SYRUP, -TABLET, 70
AZOR, 49                              BENTYL INJECTION, 70
aztreonam, 8                          BENZACLIN, 53
aztreonam 1 gm vial, 8                BENZAMYCIN, 53
aztreonam 2 gm vial, 8                BENZAMYCINPAK, 53
aztreonam lysine, 9                   benzene hexachloride gamma, 56
aztreonam/dextrose water, 8           BENZOTIC, 61
AZULFIDINE, 72                        benztropine, 23
azurette, 95                          benztropine mesylate injection, 23
baciim, 9                             benztropine mesylate tablet, 23
bacitracin 500 unit/gm ointmnt, 105   benzyl alcohol, 56
bacitracin injection, 9               bepotastine besilate, 106
bacitracin-polymyxin eye oint, 105    BEPREVE, 106
baclofen tablet, 83                   besifloxacin, 105
BACTOCILL, 13                         BESIVANCE, 105
BACTRIM, 15                           BETA-2 ADRENERGIC DRUGS, 109
BACTRIM DS, 15                        BETA-ADRENERGIC ANTAGONIST DRUGS,
BACTROBAN, 16                           43
BACTROBAN NASAL, 16                   BETADINE SOLUTION, 106
balsalazide disodium, 72              BETAGAN, 103
balziva, 95                           betaine hcl, 113
BANZEL 200 MG TABLET, 34              betamet diprop/calcipotriene, 55
BANZEL 400 MG TABLET, 34              betameth/propylene glycol, 57
BARACLUDE SOLUTION, 10                betamethasone, 63
BARACLUDE TABLET, 10                  betamethasone acetate-sod phos, 63
basiliximab, 20                       betamethasone dipropionate, 57
baycadron, 63                         betamethasone dipropionate cream, -gel, -
b-caine/tan ac/menth/cpyrd, 63          lotion, -oint, 56
bcg vaccine, 21, 76                   betamethasone valerate, 58
BCG VACCINE (TICE STRAIN), 76         betamethasone valerate cream, -lotion, -oint,
becaplermin, 59                         56
beclomethasone, 62, 112               betamethasone/betamethasone, 63
BECONASE AQ, 62                       betanate, 56
benazepril, 42                        BETAPACE, 49
benazepril hcl, 42                    BETAPACE AF, 49
benazepril/amlodipine besylate, 50    BETASERON, 78
benazepril/hctz, 50                   beta-val, 56
benazepril-hydrochlorothiazide, 49    betaxolol, 43, 103
bendroflumethiazide, 52               betaxolol hcl ophth drops, 103
bendroflumethiazide/nadolol, 49       betaxolol hcl tablet, 43
BENICAR, 42                           bethanechol, 113
Formulary ID 11155 V.4

bethanechol chloride tablet, 113          budeprion sr, 35
BETIMOL, 103                              budeprion xl, 35
BETOPTIC S, 103                           budesonide, 62, 72, 111, 112
bevacizumab, 18                           budesonide/formoterol fum, 112
bexarotene, 21                            bumetanide injection, 48
BEYAZ, 95                                 bumetanide tablet, 48
BIAXIN, 11                                BUMINATE, 87
BIAXIN XL, 11                             BUPHENYL, 60
bicalutamide, 18                          bupivacaine, 1, 2
bicalutamide tablet, 18                   bupivacaine hcl injection, 1
BICILLIN C-R, 13                          bupivacaine hcl/dextrose-h2o, 1, 2
BICILLIN L-A, 13                          bupivacaine hcl-epinephrine, 1
BIDIL, 51                                 bupivacaine hydrochloride/epi, 1, 2
BILTRICIDE, 3                             bupivacaine-dextrose, 1
bimatoprost, 103                          BUPRENEX, 21
bismuth/metronid/tetracyclin, 73          buprenorphine, 21, 29, 30
bisoprolol, 44                            buprenorphine 0.3 mg/ml syrn, 21
bisoprolol fumarate, 43                   buprenorphine 0.3 mg/ml vial, 21
bisoprolol-hydrochlorothiazide, 49        buprenorphine hcl tab, sl, 29
BLEPH-10, 105                             buprenorphine/naloxone, 30
BLEPHAMIDE, 103                           buproban, 40
BLEPHAMIDE S.O.P., 104                    bupropion, 36, 40
BLOOD DETOXICANTS, 86                     bupropion hbr, 35
BONIVA INJECTION, 68                      bupropion hcl sr 100 mg tablet, -200 mg tab,
BONIVA TABLET, 68                           35
BOOSTRIX, 76                              bupropion hcl tablet, 35
borofair, 61                              bupropion sr 150 mg tablet, 35
bortezomib, 21                            bupropion xl, 35
bosentan, 46                              BUSPAR, 27
BOTOX, 106                                buspirone, 27
botulinum toxin a, 106                    buspirone hcl tablet, 27
bp 10-1, 53                               butalb-caff-acetaminoph-codein, 32
BREVICON, 95                              butalbital compound-codeine, 32
brimonidine tartrate, 102, 103            butenafine, 12
brimonidine tartrate/timolol, 103         butoconazole, 17
brinzolamide, 103                         butorphanol tartrate aerosol, 32
BROMDAY, 106                              butorphanol tartrate injection, 21
bromfenac, 106, 107                       BUTRANS, 29
bromocriptine mesylate, 36, 66            BYETTA 10 MCG DOSE PEN INJ, 65
bromocriptine mesylate cap, -tablet, 36   BYETTA 5 MCG DOSE PEN INJ, 65
BSS, 106                                  BYSTOLIC, 43
BSS PLUS, 106                             cabergoline, 68
Formulary ID 11155 V.4

CADUET, 46                                     carbamazepine xr, 27
CAFCIT INJECTION, 31                           CARBAMAZEPINES, 27
CAFCIT SOLUTION, 110                           CARBATROL, 27
CAFERGOT, 32                                   carbidopa, 36
caffeine citrate injection, 31                 carbidopa/levodopa, 36, 37
caffeine citrate solution, 110                 carbidopa/levodopa/entacap, 37
caffeine citrated, 31, 110                     carbidopa-levodopa, 36
CALAN, 44                                      carbinoxamine maleate, 108
CALAN SR, 44                                   CARBOCAINE, 1
CALCIJEX, 93                                   carboprost tromethamine, 94
calcipotriene, 55                              CARDIAC GLYCOSIDES, 45
calcitonin, 69                                 CARDIOVASCULAR MEDICATIONS, 41
calcitonin-salmon, 68                          CARDIZEM, 44
CALCITRENE, 55                                 CARDIZEM CD, 44
calcitriol, 55, 93                             CARDIZEM LA, 44
calcitriol cap, -solution, 93                  CARDURA 1 MG TABLET, -2 MG TABLET, -4
calcitriol injection, 93                         MG TABLET, 52
calcium acetate, 93                            CARDURA 8 MG TABLET, 52
CALCIUM ANTAGONISTS, 44                        CARDURA XL, 52
calcium chloride injection, 87                 CARIMUNE NF NANOFILTERED, 76
camila, 101                                    carisoprodol, 83
CAMPATH, 18                                    carisoprodol compound, 83
CAMPRAL, 37                                    carisoprodol compound-codeine, 83
canakinumab, 79                                carisoprodol tablet, 83
CANASA, 72                                     CARMOL HC, 56
CANCIDAS, 13                                   CARNITOR INJECTION, 93
candesartan cilexetil, 42                      CARNITOR SF, 93
candesartan cilexetil/hctz, 49                 CARNITOR SOLUTION, -TABLET, 93
CANTIL, 70                                     carteolol hcl, 103
CAPASTAT SULFATE, 5                            cartia xt, 44
CAPEX SHAMPOO, 56                              carvedilol, 43
CAPITAL W-CODEINE, 29                          CASODEX, 18
capreomycin, 5                                 caspofungin acetate, 13
captopril tablet, 42                           CATAFLAM, 84
captopril-hydrochlorothiazide, 49              CATAPRES, 45
CARAC, 59                                      CATAPRES-TTS 1, 45
CARAFATE ORAL SUSP, 72                         CATAPRES-TTS 2, 45
CARAFATE TABLET, 72                            CATAPRES-TTS 3, 45
carbachol, 103                                 CAVIRINSE, 90
carbamazepine, 27                              CAYSTON, 9
carbamazepine chew tab, -oral susp, -tablet,   caziant, 95
  27                                           CEDAX, 5
Formulary ID 11155 V.4

CEENU, 18                                       CENTANY, 16
cefaclor, 5                                     CENTANY AT, 16
cefaclor er, 5                                  CENTRALLY ACTING ANTIHYPERTENSIVES,
cefadroxil, 5                                     45
cefazolin 1 gm add-van vial, -1 gm vial, -1     cephalexin, 6
  gm-d5w bag, -10 gm vial, -20 gm bulk vial,    CEPHALOSPORINS, 5
  -500 mg vial, 5                               CEREBYX, 33
cefdinir, 5, 6                                  CEREDASE, 68
cefditoren pivoxil, 5, 6                        CEREZYME, 68
CEFDITOREN PIVOXIL, 5                           certolizumab pegol, 18
cefepime, 5, 6                                  CERVARIX, 76
cefepime hcl, 6                                 CERVIDIL, 94
cefixime, 6                                     CESAMET, 25
cefotaxime, 6                                   cesia, 95
cefotaxime sodium, 6                            cetirizine hcl 1 mg/1 ml soln, -1 mg/ml soln,
cefotetan, 6                                      -1 mg/ml syrup, -5 mg/5 ml syrup, 108
cefoxitin, 6                                    cevimeline, 63
cefoxitin sodium, 6                             CHANTIX, 40
cefpodoxime, 6                                  CHEMET, 60
cefpodoxime proxetil, 6                         CHENODAL, 72
cefprozil, 6                                    chenodiol, 72
ceftaroline fosamil acetate, 6                  chlorambucil, 19
ceftazidime, 6                                  chloramphenicol sod succinate, 7
ceftibuten, 5                                   CHLORAMPHENICOLS, 7
CEFTIN, 6                                       chlordiazepoxide-amitriptyline, 35
ceftriaxone, 6                                  chlorhexidine gluconate dental/mucous
cefuroxime, 6, 7                                  membrn products, 63
cefuroxime axetil, 6                            chloroprocaine, 2
cefuroxime injection, 6                         chloroprocaine hcl, 1
cefuroxime sod 1.5 gm vial, -sod 7.5 gm vial,   chloroquine phosphate, 14
  -sod 750 mg vial, 6                           chloroquine phosphate tablet, 14
cefuroxime tablet, 6                            chlorothiazide, 52
CELEBREX, 84                                    chlorothiazide sodium, 52
celecoxib, 84                                   chloroxylenol-pramoxine hcl, 61
CELESTONE INJECTION, 63                         chlorpromazine hcl injection, 23
CELESTONE SYRUP, 63                             chlorpromazine hcl tablet, 23
CELEXA, 39                                      chlorthalidone, 52
CELLCEPT CAP, 18                                chlorthalidone/atenolol, 50
CELLCEPT INJECTION, 18                          chlorzoxazone, 83
CELLCEPT TABLET, -ORAL SUSP, 18                 cholestyramine, 47
CELONTIN, 41                                    cholestyramine light, 47
CENESTIN, 97                                    cholestyramine/aspartame, 48
Formulary ID 11155 V.4

cholestyramine/sucrose, 48                     clarithromycin er, 11
choline mag trisalicylate, 86                  CLASS II NARCOTICS, 27
CHOLINERGIC STIMULANTS, 113                    CLASS III NARCOTICS, 29
ciclesonide, 62, 110, 111                      clemastine fum 2.68 mg tab, -syrup, 108
ciclopirox, 12                                 CLENIA CREAM, 53
ciclopirox cream, -gel, -kit, -lotion, -       clenia emulsion, 53
   oil,shampoo,cleanser, 12                    CLEOCIN, 98
ciclopirox soln, top, 12                       CLEOCIN HCL, 7
ciclopirox/nail lacquer remov, 12              CLEOCIN PALMITATE, 7
cidofovir, 11                                  CLEOCIN PHOSPHATE, 7
cilostazol, 86                                 CLEOCIN PHOSPHATE IN D5W, 7
CILOXAN, 105                                   CLEOCIN T, 53
cimetidine 200 mg tablet, -300 mg tablet, -    CLICKFINE, 80
   400 mg tablet, -800 mg tablet, -solution,   CLIMARA, 97
   71                                          CLIMARA PRO, 98
cimetidine injection, 71                       clinda-derm, 53
CIMZIA, 18                                     CLINDAGEL, 53
cinacalcet hcl, 69                             CLINDAMAX, 53
CIPRO, 15                                      clindamycin hcl, 7
CIPRO HC, 61                                   clindamycin hcl cap, 7
CIPRO I.V., 15                                 clindamycin palmitate, 7
CIPRO XR, 15                                   clindamycin palmitate hcl, 7
CIPRODEX, 61                                   clindamycin phos/benz per, 53
ciprofloxacin, 15, 105                         clindamycin phosphate, 7, 53, 54, 98
ciprofloxacin er, 15                           clindamycin phosphate foam (non-
ciprofloxacin hcl ophth drops, 105                contraceptive), -gel, -lotion, -soln, top, -
ciprofloxacin hcl tablet, 15                      swabs, applicators, 53
ciprofloxacin/dexameth, 61                     clindamycin phosphate injection, 7
ciprofloxacin/hc, 61                           clindamycin phosphate vaginal products, 98
ciprofloxacin-d5w, 15                          clindamycin/benz per/hyalur na, 53
citalopram, 39                                 clindamycin/benzoyl prx/skn #5, 53
citalopram hbr, 39                             clindamycin/tretinoin, 54
CITRANATAL DHA, 99                             clindamycin-benzoyl peroxide, 53
CITRANATAL RX, 99                              CLINDAMYCINS, 7
CLAFORAN, 6                                    CLINDAREACH, 53
claravis, 56                                   CLINDESSE, 98
CLARIFOAM EF, 53                               CLINIMIX, 87
CLARINEX SYRUP, 108                            CLINIMIX E, 87
CLARINEX TABLET, 108                           CLINISOL, 87
CLARINEX-D 12 HOUR, 108                        CLINORIL, 84
CLARINEX-D 24 HOUR, 108                        CLOBETA + PLUS, 55
clarithromycin, 11                             clobetasol emollient, 57
Formulary ID 11155 V.4

clobetasol propiona/coal tar, 55                 colestipol hcl, 47
clobetasol propionate, 57, 58                    colistimethate 150 mg vial, 9
clobetasol propionate cream, -foam (non-         colistimethate, sodium, 9
   contraceptive), -gel, -oint, -soln, top, 57   collagenase, 59
CLOBEX, 57                                       collagenase clostridium hist., 61
clocortolone pivalate, 57                        COLOCORT, 72
CLODERM, 57                                      COLY-MYCIN M PARENTERAL, 9
clomipramine, 41                                 COLY-MYCIN S, 61
clomipramine hcl cap, 41                         COLYTE WITH FLAVOR PACKETS, 72
clonidine, 37, 45                                COLYTE WITH FLAVOR PACKS, 72
clonidine hcl injection, 45                      COMBIGAN, 103
clonidine hcl tablet, 45                         COMBIPATCH, 98
clonidine hcl/chlorthalidone, 49                 COMBIVENT, 111
clopidogrel, 86                                  COMBIVIR, 4
CLORPRES, 49                                     COMBUNOX, 27
clotrimazole 1% cream, -1% solution, -af 1%      COMPAZINE INJECTION, 25
   cream, 12                                     COMPAZINE SYRUP, 25
clotrimazole loz, 8                              compro, 25
clotrimazole/betamethasone, 16                   COMTAN, 36
clotrimazole-betamethasone, 16                   COMVAX, 76
clozapine, 23                                    co-natal fa, 99
CLOZARIL, 23                                     CONCEPT DHA, 99
CNL 8, 12                                        CONCEPT OB, 99
CNS MUSCLE RELAXANTS, 83                         CONCERTA, 31
CNS STIMULANT DRUGS, 31                          CONDYLOX GEL, 55
COARTEM, 14                                      CONDYLOX SOLN, TOP, 55
COCET, 29                                        constulose, 86
COCET PLUS, 30                                   CONTRACEPTIVES, 95
codeine phosphate injection, 27                  CONTROL RX, 90
codeine phosphate/apap, 29, 30                   COPAXONE, 60
codeine sulfate, 27                              COPEGUS, 10
codeine/apap/caffeine/butalb, 32                 CORDARONE, 41
codeine/asa/caffeine/butalb, 32                  CORDRAN LOTION, -OINT, 57
COGENTIN, 23                                     CORDRAN SP, 57
co-gesic, 30                                     CORDRAN TAPE, MED. TAPE, 57
COGNEX, 22                                       COREG, 43
COLAZAL, 72                                      COREG CR, 43
colchicine, 84                                   CORGARD, 43
COLCRYS, 84                                      CORLOPAM, 49
colesevelam, 48                                  cormax, 57
COLESTID, 47                                     CORTEF, 64
colestipol, 47                                   CORTENEMA, 72
Formulary ID 11155 V.4

corticorelin ovine triflutate, 68           cyclopentolate, 106
corticotropin, 68                           cyclopentolate hcl, 106
CORTIFOAM, 72                               cyclophosphamide tablet, 18
cortisone tablet, 64                        cycloserine, 5
CORTISPORIN CREAM, -OINT, 16                CYCLOSET, 66
CORTISPORIN OTIC DROPS, 61                  cyclosporine, 19, 20, 107
CORTISPORIN-TC, 61                          cyclosporine cap, -solution, 18
cortomycin oint, 104                        cyclosporine injection, 18
cortomycin otic drops, -suspensions, (not   cyclosporine modified, 18
  oral), 61                                 CYKLOKAPRON, 60
CORVERT, 49                                 cylate, 106
CORZIDE, 49                                 CYMBALTA 20 MG CAPSULE, -60 MG
COSOPT, 103                                   CAPSULE, 35
COUMADIN INJECTION, 91                      CYMBALTA 30 MG CAPSULE, 35
COUMADIN TABLET, 91                         cyproheptadine hcl syrup, -tablet, 108
COVERA-HS, 44                               CYSTADANE, 113
COZAAR, 42                                  CYSTAGON, 87
CREON, 72                                   cysteamine, 87
CRESTOR 10 MG TABLET, -20 MG TABLET, -      CYTOGAM, 76
  40 MG TABLET, 46                          cytomegalovirus immune glob, 76
CRESTOR 5 MG TABLET, 46                     CYTOMEL, 69
CRINONE, 101                                CYTOTEC, 72
CRIXIVAN, 4                                 CYTOVENE, 10
cromolyn, 111                               cytra-2, 92
cromolyn sodium nebs, 111                   cytra-3, 113
cromolyn sodium ophth drops, 106            cytra-k, 113
crotamiton, 56                              D.H.E.45, 32
cryselle, 95                                d5w/electrolyte-56 solution, 89
CUBICIN, 9                                  d5w/kcl 10 meq/l iv solution, -30 meq/l iv
CUPRIMINE, 85                                 solution, 87
CURAD GAUZE PADS, 80                        dabigatran etexilate mesylate, 91
CURITY ALCOHOL PREPS, 80                    DACOGEN, 18
CURITY GAUZE SPONGES, 80                    dalfampridine, 60
CUTIVATE, 57                                dalteparin (porcine), 91
CUVPOSA, 70                                 d-amphetamine, 31
cyclafem, 95                                danazol cap, 94
CYCLESSA, 95                                DANTRIUM CAP, 83
cyclobenzaprine, 83                         DANTRIUM INJECTION, 83
cyclobenzaprine hcl tablet, 83              dantrolene, 83
CYCLOGYL 0.5% EYE DROPS, -2% EYE            dantrolene sodium, 83
  DROPS, 106                                dapsone, 3, 53
CYCLOGYL 1% EYE DROPS, 106                  DAPSONE, 3
Formulary ID 11155 V.4

DAPTACEL, 76                           DEPO-SUBQ PROVERA 104, 101
daptomycin, 9                          DEPO-TESTOSTERONE, 94
DARAPRIM, 14                           DERMA-SMOOTHE-FS, 57
darbepoetin alfa, 76                   DERMATOLOGICAL MEDICATIONS, 53
darifenacin hydrobromide, 112          DERMATOP, 57
darunavir ethanolate, 4                DERMOTIC, 61
dasatinib, 20                          desipramine, 38
DAYPRO, 84                             desipramine hcl tablet, 38
DAYTRANA, 31                           desloratadine, 108
DDAVP 4 MCG/ML AMPUL, 68               desmopressin acetate, 68, 69
DDAVP 4 MCG/ML VIAL, 68                desmopressin acetate injection, 68
DDAVP SOLUTION, -NASAL DROPS/SPRAYS,   desmopressin acetate nasal drops/sprays, -
  -TABLET, 68                            solution, -tablet, 68
DEBACTEROL, 63                         DESOGEN, 95
DECAVAC, 76                            desogestrel-ethinyl estradiol, 95, 96
decitabine, 18                         desog-et estra/ethin estra, 96
deferasirox, 60                        DESONATE, 57
DELATESTRYL, 94                        desonide, 57, 58
delavirdine mesylate, 4                desonide cream, -lotion, -oint, 57
del-beta, 57                           desonide/emollient combo #30, 57
DELESTROGEN, 97                        desonide/emollient combo no.3, 57
DEMADEX, 48                            DESONIL + PLUS, 57
demeclocycline hcl, 15                 DESOWEN, 57
DEMEROL, 28                            desoximetasone, 58
DEMSER, 46                             desoximetasone cream, -gel, -oint, 57
DEMULEN 1-50-21, 95                    DESOXYN, 31
DENAVIR, 10                            desvenlafaxine succinate, 36
denosumab, 69                          DETROL, 112
denta 5000 plus, 90                    DETROL LA, 112
dentagel, 90                           dexamethasone, 64, 104
DEPACON, 41                            dexamethasone elix, -tablet, 64
depade, 37                             dexamethasone intensol, 64
DEPAKENE, 41                           dexamethasone sodium phosphate injection,
DEPAKOTE, 41                             64
DEPAKOTE ER, 41                        dexamethasone sodium phosphate ophth
DEPAKOTE SPRINKLE, 41                    drops, 104
DEPEN, 85                              dexasporin, 104
DEPO-ESTRADIOL, 97                     dexchlorpheniramine maleate, 108
DEPO-MEDROL, 64                        DEXEDRINE, 31
DEPO-PROVERA 150 MG/ML SYRN, 101       DEXILANT DR 30 MG CAPSULE, 73
DEPO-PROVERA 150 MG/ML VIAL, 101       DEXILANT DR 60 MG CAPSULE, 73
DEPO-PROVERA 400 MG/ML VIAL, 18        dexlansoprazole, 73, 74
Formulary ID 11155 V.4

dexmethylphenidate, 31                     diflorasone, 56
dexmethylphenidate hcl, 31                 diflorasone diacetate, 57
DEXPAK, 64                                 DIFLUCAN 100 MG TABLET, -200 MG
dextroamphetamine sulfate, 31                 TABLET, -50 MG TABLET, 8
dextroamphetamine-amphetamine, 31          DIFLUCAN 150 MG TABLET, 8
dextromethorphan/quinidine, 37             DIFLUCAN IN DEXTROSE, 13
dextrose 10%-1/4ns, 87                     DIFLUCAN IN SALINE, 13
dextrose 10%-1/4ns-kcl, 87                 DIFLUCAN SUSPENSION, 8
dextrose 2.5%-lr 1/2 str sol, 88           diflunisal, 86
dextrose 5%-1/2ns-kcl, 88                  difluprednate, 104
dextrose 5%-1/3ns-kcl, 88                  digoxin, 45
dextrose 5%-1/4ns-kcl, 88                  digoxin injection, 45
dextrose 5%-electrolyte #48, 88            digoxin solution, -tablet, 45
dextrose 5%-electrolyte #75, 88            dihydrocodeine/apap/caffeine, 30
dextrose 5%-lr iv solution, 92             dihydrocodeine/asa/caffeine, 30
dextrose 5%-ns-kcl, 88                     dihydroergotamine, 32, 33
dextrose in ringers injection, 88          dihydroergotamine mesylate injection, 32
dextrose in water, 88                      DILACOR XR, 44
dextrose with sodium chloride, 88          DILANTIN 100 MG CAPSULE, 33
dextrose/electrolytes, 88                  DILANTIN 30 MG CAPSULE, -CHEW TAB, 33
DIABETA, 66                                DILANTIN-125, 33
DIABETIC SUPPLIES, 80                      DILATRATE-SR, 48
DIAGNOSTIC AND MISCELLANEOUS               DILAUDID INJECTION, 28
   MEDICATIONS, 60                         DILAUDID TABLET, 28
DIAGNOSTIC PRODUCTS, 60                    DILAUDID-5, 28
DIAMOX SEQUELS, 103                        DILAUDID-HP, 28
diazoxide, 65                              dilt-cd, 44
DIBENZYLINE, 46                            diltia xt, 44
diclofenac epolamine, 56                   diltiazem, 44, 45
diclofenac potassium, 84, 85               diltiazem 24hr er, 44
diclofenac sodium, 56, 59, 85, 107         diltiazem er, 44
diclofenac sodium e.c. tab, -tab sa, 84    diltiazem hcl injection, 44
diclofenac sodium ophth drops, 107         diltiazem hcl tablet, 44
diclofenac sodium/misoprostol, 84          dilt-xr, 44
dicloxacillin sodium, 13                   diltzac er, 44
dicyclomine, 70                            dimenhydrinate injection, 25
dicyclomine hcl cap, -syrup, -tablet, 70   dimethyl sulfoxide, 113
dicyclomine hcl injection, 70              dinoprostone, 94, 102
didanosine, 4                              DIOVAN, 42
DIDRONEL, 68                               DIOVAN HCT, 49
difenoxin/atropine sulfate, 70             DIPENTUM, 72
DIFFERIN, 53                               diph,pertus(acel),tet,polio, 77
Formulary ID 11155 V.4

diphenhydramine 12.5 mg/5 ml, -50 mg           dorzolamide hcl, 103
  capsule, 108                                 dorzolamide/timolol, 103
diphenhydramine hcl injection, 108             dorzolamide-timolol, 103
diphenhydramine tannate, 108                   DOVONEX CREAM, 55
diphenoxylate/atropine sulfate, 70             DOVONEX SOLUTION, 55
diphenoxylate-atropine, 70                     doxazosin, 52
diphther,pertuss,tetanus vac, 75, 76, 77, 78   doxazosin mesylate 1 mg tab, -2 mg tab, -4
DIPHTHERIA-TETANUS TOXOID, 76                    mg tab, 52
dipivefrin, 103                                doxazosin mesylate 8 mg tab, 52
DIPROLENE, 57                                  doxepin, 38, 59, 60
DIPROLENE AF, 57                               doxepin hcl cap, -solution, 41
DIPROSONE, 57                                  doxercalciferol, 93
dipyridamole, 86                               doxycycline, 15
dipyridamole tablet, 86                        doxycycline hyclate, 15, 16, 63
DIRECT MUSCLE RELAXANTS, 83                    doxycycline hyclate 100 mg tab, -cap, -e.c.
diskets, 28                                      cap, -e.c. tab, 15
disulfiram, 37                                 doxycycline hyclate 20 mg tab, 63
DITROPAN XL 10 MG TABLET, -15 MG               doxycycline hyclate injection, 15
  TABLET, 112                                  doxycycline monohydrate, 15, 16
DITROPAN XL 5 MG TABLET, 112                   dp (a) ped/hib conj-tet, 78
DIURIL, 52                                     dp (a) t-polio/hib conj-tet/pf, 77
DIURIL SODIUM, 52                              DRITHOCREME HP, 55
divalproex, 41                                 DRITHO-SCALP, 55
divalproex sodium, 41                          dronabinol, 26
divalproex sodium er, 41                       dronabinol 10 mg capsule, -5 mg capsule, 25
DIVIGEL, 97                                    dronabinol 2.5 mg capsule, 25
dobutamine hcl, 50                             dronedarone, 49
dobutamine hcl in dextrose, 50                 droperidol injection, 1
docosavit, 99                                  drospir/eth estra/levomefol ca, 95, 96
dofetilide, 49                                 DROXIA, 18
dolasetron mesylate, 25                        DRUGS AFFECTING THE EAR, 61
DOLOPHINE HCL, 28                              DRUGS AFFECTING THE NOSE, 62
DOMEBORO OTIC DROPS, 61                        DRUGS AFFECTING THE THROAT AND
donepezil, 22                                    MOUTH, 63
donepezil hcl, 22                              DRUGS FOR PHEOCHROMOCYTOMA, 46
dopamine hcl, 51                               DRUGS TO PREVENT AND TREAT GOUT, 84
dopamine hcl in 5% dextrose, 51                DRUGS TO PREVENT AND TREAT
DORIBAX 250 MG VIAL, 9                           HEADACHES, 32
DORIBAX 500 MG VIAL, 9                         DRYSOL, 59
doripenem, 9                                   DUAC CS, 53
DORYX, 15                                      dualvit ob, 99
dorzolamide, 103                               DUETACT, 66
Formulary ID 11155 V.4

DULERA, 111                           EGRIFTA, 75
duloxetine, 35                        ELAPRASE, 68
DURACLON, 45                          ELDEPRYL, 36
DURAGESIC, 28                         electrolyte solution/peg's, 72, 73
DURAMORPH, 28                         electrolyte solutions, 88, 89
DUREZOL, 104                          ELECTROLYTES, IRRIGATING SOLUTIONS,
dutasteride, 113                         ETC., 86
dutasteride/tamsulosin hcl, 113       ELESTAT, 107
DYAZIDE, 51                           ELESTRIN, 97
dylix, 110                            eletriptan, 33
DYNACIN, 16                           ELIDEL, 59
DYNACIRC CR, 44                       ELIGARD, 18
dyphylline, 110                       eliphos, 93
DYRENIUM, 51                          ELITEK, 18
DYSPORT, 83                           ELIXOPHYLLIN, 110
DYTAN, 108                            ELLA, 95
E.E.S. 200, 7                         ELMIRON, 113
E.E.S. 400, 7                         ELOCON, 57
EAR-NOSE-THROAT MEDICATIONS, 61       eltrombopag olamine, 80
EASPRIN, 86                           EMADINE, 107
EASY COMFORT INSULIN SYRINGE, 80      EMBEDA, 28
EASY TOUCH INSULIN NEEDLES -          EMCYT, 18
  DISPOSABLE, -INSULIN SYRINGES -     emedastine difumarate, 107
  DISPOSABLE, 80                      EMEND 125 MG CAPSULE, -40 MG CAPSULE,
echothiophate iodide, 103                25
EC-NAPROSYN, 84                       EMEND 80 MG CAPSULE, 25
econazole nitrate cream, 12           EMEND INJECTION, 25
EDECRIN, 48                           EMEND TRIFOLD PACK, 25
edge ob, 99                           EMGEL, 53
EDLUAR, 38                            EMLA, 2
edrophonium, 37                       EMSAM, 34
edrophonium/atropine sulfate, 37      emtricitabine, 4
efavirenz, 4                          emtricitabine/tenofovir, 4
EFFER-K 10 MEQ TABLET EFF, -20 MEQ    emtricitabine/tenofovir/efavir, 4
  TABLET EFF, 92                      EMTRIVA, 4
effer-k 25 meq tablet eff, 92         ENABLEX, 112
EFFEXOR, 35                           enalapril, 42
EFFEXOR XR 150 MG CAPSULE, -37.5 MG   enalapril maleate tablet, 42
  CAPSULE, 35                         enalapril maleate/hctz, 50
EFFEXOR XR 75 MG CAPSULE, 35          enalaprilat, 42
EFFIENT, 86                           enalapril-hydrochlorothiazide, 49
EFUDEX, 59                            ENBREL, 18
Formulary ID 11155 V.4

endocet, 28                                    EPOGEN 2,000 UNITS/ML VIAL, -3,000
ENDOCRINE MEDICATIONS, 63                        UNITS/ML VIAL, -4,000 UNITS/ML VIAL,
endodan, 28                                      76
ENDOTHELIN RECPTR ANTAGONIST, 46               epoprostenol na, 51
enfuvirtide, 4                                 epoprostenol sodium, 51
ENGERIX-B, 76                                  eprosartan mesylate, 42
ENJUVIA, 97                                    eprosartan mesylate/hctz, 50
ENLON, 37                                      eptifibatide, 86
ENLON-PLUS, 37                                 EPZICOM, 4
enoxaparin, 91                                 EQUETRO, 27
enoxaparin 100 mg/ml syr, -30 mg/0.3 ml        ERAXIS (WATER DILUENT), 13
  syr, -40 mg/0.4 ml syr, -60 mg/0.6 ml syr,   ergoloid mesylates tablet, 60
  -80 mg/0.8 ml syr, 91                        ERGOMAR, 32
enoxaparin 120 mg/0.8 ml syr, -150 mg/ml       ergotamine, 32
  syr, 91                                      ergotamine tartrate/caffeine, 32
enpresse, 95                                   ergotamine-caffeine, 32
entacapone, 36                                 eribulin mesylate, 19
entecavir, 10                                  erlotinib hcl, 20
ENTOCORT EC, 72                                errin, 101
enulose, 86                                    ERTACZO, 12
EPIDUO, 53                                     ertapenem sodium, 9
epiflur, 90                                    ery, 53
epiklor, 92                                    ERYPED 200, 7
epinastine hcl, 107                            ERYPED 400, 7
epinephrine 0.1 mg/ml syringe, -1 mg/ml        ERY-TAB, 7
  ampul, -1 mg/ml vial, 111                    ERYTHROCIN LACTOBIONATE, 7
EPINEPHRINE 0.15 MG AUTO-INJCT, -0.3 MG        erythrocin stearate, 7
  AUTO-INJECT, 111                             erythromycin base, 7, 53, 105
EPINEPHRINE 0.3 MG/0.3 ML SYR, 111             erythromycin base/benz per, 53
epinephrine hcl, 110, 111, 112                 erythromycin e.c. cap, -tablet, 7
EPIPEN, 111                                    erythromycin ethylsuccinate, 7
EPIPEN JR, 111                                 erythromycin ethylsuccinate tablet, 7
epitol, 27                                     erythromycin gel, -soln, top, -swabs,
EPIVIR, 4                                        applicators, 54
EPIVIR HBV, 10                                 erythromycin lactobionate, 7
eplerenone, 51                                 erythromycin oint, 105
epoetin alfa, 76, 77                           erythromycin-benzoyl peroxide, 54
EPOGEN 10,000 UNITS/ML VIAL, -20,000           ERYTHROMYCINS, 7
  UNITS/2 ML VIAL, -20,000 UNITS/ML            erythromycin-sulfisoxazole, 15
  VIAL, -40,000 UNITS/ML VIAL, 76              escitalopram oxalate, 39
                                               ESKALITH, 22
                                               esomeprazole mag trihyd, 74
Formulary ID 11155 V.4

ESTRACE TABLET, 97                    etodolac, 84
ESTRACE VAGINAL PRODUCTS, 97          etonogestrel/ethin estradiol, 96
ESTRADERM, 97                         etravirine, 4
estradiol, 97, 98                     EURAX, 56
estradiol adh. patch, 97              EVAMIST, 97
estradiol cypionate, 97               everolimus, 18, 21
estradiol tablet, 97                  EVISTA, 68
estradiol valerate, 97                EVOCLIN, 54
estradiol valerate injection, 97      EVOXAC, 63
estradiol valerate/dienogest, 96      EXALGO, 28
estradiol/drospirenone, 98            EXEL INSULIN SYRINGE, 80
estradiol/levonorgestrel, 98          EXELDERM, 12
estradiol/noreth ac, 98               EXELON, 22
estradiol/norgestimate, 98            exemestane, 18
estradiol-norethindrone acetat, 98    exenatide, 65
estramustine phosphate sodium, 18     EXFORGE, 50
ESTRASORB, 97                         EXFORGE HCT, 50
ESTRING, 97                           EXJADE, 60
ESTROGEN DRUGS, 97                    EXTAVIA, 79
estrogen,conjug,synthetic a, 97       EXTINA, 12
estrogen,conjug,synthetic b, 97       ezetimibe, 48
estrogen/medroxyprogesterone, 98      ezetimibe/simvastatin, 47
ESTROGEN/PROGESTIN COMBINATIONS, 98   FABRAZYME, 69
estrogens,conjugated, 98              FACTIVE, 15
estrogens,esterified, 98              famciclovir, 10
estropipate, 97, 98                   famciclovir 125 mg tablet, 10
ESTROSTEP FE, 95                      famciclovir 250 mg tablet, 10
eszopiclone, 38                       famciclovir 500 mg tablet, 10
etanercept, 18                        famotidine, 71
eth estradiol/drospirenone, 97        famotidine 20 mg tablet, -40 mg tablet, -oral
ethacrynate sodium, 48                  susp, 71
ethacrynic acid, 48                   famotidine injection, 71
ethambutol, 5                         FAMVIR 125 MG TABLET, 10
ethambutol hcl tablet, 5              FAMVIR 250 MG TABLET, 10
ethinyl estradiol/norelgest, 96       FAMVIR 500 MG TABLET, 10
ethionamide, 5                        FANAPT 1 MG TABLET, -10 MG TABLET, -12
ethosuximide, 41                        MG TABLET, -2 MG TABLET, -4 MG
ethotoin, 33                            TABLET, -6 MG TABLET, -8 MG TABLET, 23
ethynodiol diace-eth estradiol, 95    FANAPT TITRATION PACK, 23
ETHYOL, 18                            FARESTON, 19
etidronate, 68                        FASLODEX, 19
etidronate disodium, 68               fat emulsions, 93, 94
Formulary ID 11155 V.4

FAZACLO, 23                                     FIRST-PROGESTERONE VGS 100, 101
fe c plus tablet, 99                            FIRST-PROGESTERONE VGS 200, 101
febuxostat, 84                                  FIRST-PROGESTERONE VGS 25, 102
felbamate, 34                                   FIRST-PROGESTERONE VGS 400, 102
FELBATOL, 34                                    FIRST-PROGESTERONE VGS 50, 102
FELDENE, 84                                     FIRST-TESTOSTERONE, 94
felodipine er, 44                               FIRST-TESTOSTERONE MC, 94
fem ph, 98                                      FLAGYL, 3
FEMARA, 19                                      FLAGYL ER, 3
FEMCON FE, 95                                   FLAREX, 104
FEMHRT, 98                                      flavoxate hcl, 112
FEMRING, 98                                     flecainide, 43
FEMTRACE, 98                                    flecainide acetate, 43
fenofibrate, 47, 48                             FLECTOR, 56
fenofibric acid, 47, 48                         FLEXBUMIN, 88
FENOFIBRIC ACID, 47                             FLEXERIL, 83
FENOGLIDE, 47                                   FLOLAN, 51
fenoldopam mesylate, 49                         FLOMAX, 113
fenoprofen, 85                                  FLONASE, 62
fenoprofen calcium, 84                          FLOVENT 100 MCG DISKUS, -50 MCG
fentanyl, 28                                       DISKUS, 111
fentanyl citrate, 27, 28, 29                    FLOVENT 250 MCG DISKUS, 111
fentanyl citrate injection, 28                  FLOVENT HFA 110 MCG INHALER, 111
fentanyl citrate loz, 28                        FLOVENT HFA 220 MCG INHALER, 111
FENTORA, 28                                     FLOVENT HFA 44 MCG INHALER, 111
fesoterodine fumarate, 113                      fluconazole, 8
FEXMID, 83                                      fluconazole 100 mg tablet, -200 mg tablet, -
fexofenadine, 108                                  50 mg tablet, 8
fexofenadine hcl 180 mg tablet, 109             fluconazole 150 mg tablet, 8
fexofenadine hcl 30 mg tablet, -60 mg tablet,   fluconazole in dextrose, 13
   109                                          fluconazole in saline, 13
fexofenadine-pse er 180-240 tb, 108             fluconazole suspension, 8
fexofenadine-pse er 60-120 tab, 108             fluconazole/dextrose-water, 13
FIBRICOR, 47                                    fluconazole/sodium chloride, 13
filgrastim, 80                                  flucytosine, 7
FINACEA, 54                                     fludrocortisone acetate tablet, 66
finasteride, 113                                FLUMADINE, 10
fingolimod hydrochloride, 60                    flumazenil, 37, 38
FIORICET WITH CODEINE, 32                       flunisolide, 110
FIORINAL WITH CODEINE #3, 32                    flunisolide 0.025% spray, 62
FIRST-HYDROCORTISONE, 57                        flunisolide 29 mcg-0.025% spr, 62
FIRST-MOUTHWASH BLM, 63                         fluocinolone acetonide, 56, 57, 61, 104
Formulary ID 11155 V.4

fluocinolone acetonide cream, -oint, -soln,       fluvoxamine maleate 25 mg tab, 39
   top, 57                                        fluvoxamine maleate 50 mg tab, 39
fluocinonide, 58                                  FML, 104
fluocinonide cream, -gel, -oint, -soln, top, 57   FML FORTE, 104
fluocinonide emollient, 57                        FML S.O.P., 104
fluocinonide-e, 57                                FOCALIN, 31
FLUORABON, 90                                     FOCALIN XR, 31
fluor-a-day chew tab, 90                          folbecal, 99
FLUOR-A-DAY ORAL DROPS, 90                        folcal dha softgel, 99
FLUORIDE PRODUCTS, 90                             foltabs, 99
fluoridex daily defense, 90                       fomepizole, 60
FLUORIDEX SENSITIVITY RELIEF, 90                  fondaparinux sodium, 91
fluoritab chew tab, 90                            FORADIL, 109
fluorometholone, 104                              formoterol fumarate, 109
FLUOROPLEX, 59                                    FORTAMET, 67
fluorouracil, 59                                  FORTAZ 1 GM ADD-VANTAGE VIAL, -1 GM
fluorouracil cream, -soln, top, 59                   VIAL, -2 GM VIAL, -6 GM VIAL, 6
fluoxetine, 40                                    FORTAZ 2 GM ADD-VANTAGE VIAL, 6
fluoxetine dr, 39                                 FORTAZ 500 MG VIAL, 6
fluoxetine hcl 10 mg capsule, -10 mg tablet,      FORTAZ IN ISO-OSMOTIC DEXTROSE, 6
   39                                             FORTEO, 69
fluoxetine hcl 20 mg capsule, -20 mg tablet,      FORTESTA, 94
   -solution, 39                                  fortical, 69
fluoxetine hcl 40 mg capsule, 39                  FOSAMAX 10 MG TABLET, -40 MG TABLET, -
fluoxymesterone, 94                                  5 MG TABLET, 69
fluphenazine decanoate, 23                        FOSAMAX 35 MG TABLET, -70 MG TABLET,
fluphenazine hcl elix, -solution, -tablet, 23        69
fluphenazine hcl injection, 23                    FOSAMAX PLUS D, 69
FLURA-DROPS, 90                                   FOSAMAX SOLUTION, 69
flurandrenolide, 57                               fosamprenavir calcium, 4
flurbiprofen, 84, 107                             foscarnet sodium, 10
flurbiprofen sodium, 107                          fosfomycin tromethamine, 17
flurbiprofen tablet, 84                           fosinopril, 42
flutamide, 19                                     fosinopril sodium, 42
fluticasone furoate, 63                           fosinopril-hydrochlorothiazide, 50
fluticasone propionate, 57, 62, 111               fosphenytoin, 33
fluticasone propionate cream, -oint, 57           fosphenytoin sodium, 33
fluticasone propionate nasal inhaled steroids,    FOSRENOL, 86
   62                                             FRAGMIN 10,000 UNITS SYRINGE, -12,500
fluvastatin, 46                                      UNITS SYRINGE, -15,000 UNITS SYRINGE,
fluvoxamine, 39                                      -18,000 UNITS SYRINGE, -25,000
fluvoxamine maleate 100 mg tab, 39
Formulary ID 11155 V.4

   UNITS/ML VIAL, -7,500 UNITS SYRINGE,   gemfibrozil, 47
   91                                     gemfibrozil tablet, 47
FRAGMIN 2,500 UNITS SYRINGE, -5,000       gemifloxacin, 15
   UNITS SYRINGE, 91                      generlac, 86
FREAMINE HBC, 88                          gengraf, 19
FREAMINE III, 88                          GENOTROPIN 12 MG CARTRIDGE, -5 MG
FREAMINE III WITH ELECTROLYTES, 88           CARTRIDGE, 75
FREESTYLE PRECISION, 80                   GENOTROPIN MINIQUICK 0.2 MG, -
FROVA, 32                                    MINIQUICK 0.4 MG, -MINIQUICK 0.6 MG, -
frovatriptan, 32                             MINIQUICK 0.8 MG, -MINIQUICK 1 MG, -
fulvestrant, 19                              MINIQUICK 1.2 MG, -MINIQUICK 1.4 MG, -
FURADANTIN, 17                               MINIQUICK 1.6 MG, -MINIQUICK 1.8 MG, -
furosemide, 48                               MINIQUICK 2 MG, 75
furosemide injection, 48                  gentak, 105
furosemide solution, -tablet, 48          gentamicin, 105
FUZEON, 4                                 gentamicin 0.1% ointment, -cream, 16
gabapentin, 34                            gentamicin 100 mg/ns 100 ml, -60 mg/ns 50
gabapentin cap, -tablet, 34                  ml pb, -70 mg/ns 50 ml pb, -80 mg/ns 50
GABITRIL, 34                                 ml pb, -90 mg/ns 100 ml pb, -gentamicin
galantamine, 22                              100 mg/100 ml, -gentamicin 60 mg/50 ml,
galantamine hbr, 22                          -gentamicin 80 mg/50 ml, 3
galantamine hydrobromide, 22              gentamicin 3 mg/gm eye oint, -ophth drops,
galsulfase, 69                               105
GAMASTAN S-D, 76                          GENTAMICIN 60 MG/NS 100 ML PB, -80
GAMMAGARD LIQUID, 76                         MG/NS 100 ML PB, -GENTAMICIN 100
GAMMAGARD S-D, 76                            MG/50 ML, -GENTAMICIN 60 MG/100 ML, -
GAMMAPLEX, 76                                GENTAMICIN 80 MG/100 ML, 3
GAMUNEX, 76                               gentamicin sulfate injection, 3
GAMUNEX-C, 76                             gentamicin/prednisolone, 104
ganciclovir, 10, 107                      gentamicin/sodium chloride, 3
ganciclovir sodium, 10                    gentasol, 105
GARAMYCIN, 105                            GEODON CAP, 23
GARDASIL, 76                              GEODON INJECTION, 23
GASTROCROM, 111                           GESTICARE, 99
GASTROINTESTINAL MEDICATIONS, 70          GESTICARE DHA, 99
gatifloxacin, 106                         gianvi, 95
gavilyte-c, 72                            gildess fe, 95
gavilyte-g, 72                            GILENYA, 60
gavilyte-n, 72                            GLASSIA, 112
gefitinib, 19                             glatiramer acetate, 60
GEL-KAM, 90                               GLEEVEC, 19
GELNIQUE, 112                             glimepiride, 66, 67
Formulary ID 11155 V.4

glipizide, 67                     griseofulvin oral susp, 8
glipizide er, 67                  griseofulvin ultramicrosize, 8
glipizide tablet, 67              GRIS-PEG, 8
glipizide xl, 67                  GROWTH HORMONES AND RELATED
glipizide/metformin hcl, 67         DRUGS, 75
glipizide-metformin, 67           guanabenz acetate, 45
GLUCAGEN, 65                      guanfacine, 37, 46
GLUCAGON EMERGENCY KIT, 65        guanfacine hcl, 45
glucagon, human recombinant, 65   guanidine hcl, 37
GLUCOCORTICOID DRUGS, 63          GYNAZOLE-1, 17
gluconic acid/citric acid, 113    GYNODIOL, 98
GLUCOPHAGE, 67                    haemophilus b vaccine, 77
GLUCOPHAGE XR, 67                 haemophilus b-tet toxoid, 75, 77
GLUCOPRO INSULIN SYRINGES -       HALAVEN, 19
   DISPOSABLE, 80                 halcinonide, 57
GLUCOSE ELEVATING DRUGS, 65       HALDOL, 23
GLUCOTROL, 67                     HALDOL DECANOATE 100, 23
GLUCOTROL XL, 67                  HALDOL DECANOATE 50, 23
GLUCOVANCE, 67                    HALFAN, 14
GLUMETZA, 67                      HALFLYTELY-BISACODYL, 72
glyburide, 66, 67                 halobetasol prop/amonium lac, 57, 58
glyburide micronized, 67          halobetasol propionate, 57, 58
glyburide/metformin hcl, 67       halofantrine, 14
glyburide-metformin hcl, 67       HALOG, 57
glycine solution, 113             HALONATE, 57
glycopyrrolate, 70, 71            halonate pac, 57
glycopyrrolate injection, 70      haloperidol, 23
glycopyrrolate tablet, 70         haloperidol decanoate, 23
glycron, 67                       haloperidol lactate injection, 23
GLYNASE, 67                       haloperidol lactate solution, 23
GLYSET, 67                        haloperidol tablet, 23
gold sodium thiomalate, 85        HAVRIX, 76
golimumab, 20                     hc acetate/lidocaine hcl, 56, 58
GOLYTELY, 72                      hctz/bisoprolol fumarate, 50
GORDO-UREA, 59                    hctz/metoprolol, 50
goserelin acetate, 21             hctz/triamterene, 51
granisetron, 26                   hctz/valsartan, 49
granisetron hcl injection, 25     heather, 102
granisetron hcl tablet, 26        HECTOROL CAP, 93
granisol, 26                      HECTOROL INJECTION, 93
GRIFULVIN V, 8                    HELIDAC, 72
griseofulvin microsize, 8         HEMABATE, 94
Formulary ID 11155 V.4

hemin, 61                                HUMATROPE, 75
hep b vaccine/dp (a) t-polio, 77         HUMIRA 20 MG/0.4 ML SYRINGE, -40 MG/0.8
hep b vir recomb/hep a vir, 78             ML SYRINGE, 19
hep.b immune glob/maltose, 77            HUMIRA 40 MG/0.8 ML PEN, -CROHN'S
HEPAGAM B, 77                              STARTER PACK, -PSORIASIS STARTER
HEPARIN ANTAGONISTS, 90                    PACK, 19
heparin sodium in 0.45% nacl, 91         HUMULIN 50-50, 65
heparin sodium in 0.9% nacl, 91          HUMULIN 70-30, 65
heparin sodium in 5% dextrose, 91        HUMULIN N, 65
heparin sodium injection, 91             HUMULIN R, 65
heparin sodium-ns, 91                    HYCET, 30
HEPATAMINE, 88                           HYDANTOINS, 33
HEPATASOL, 88                            hydralazine hcl injection, 52
hepatatis a virus vaccine, 76, 78        hydralazine hcl tablet, 52
hepatitis b immune globulin, 77          HYDREA, 19
hepatitis b virus vaccine, 76, 78        HYDRO 35, 59
hepatitis b/haemophilus b vacc, 76       HYDRO 40, 59
HEPSERA, 10                              hydrochlorothiazide, 52
HESPAN, 60                               hydrochlorothiazide cap, -tablet, 52
hetastarch in ns, 60                     hydrocodone bitartrate/apap, 30
hetastarch/e-lytes,lactate, 60           hydrocodone bitartrate/ibuprof, 30
hetastarch/na chlor 0.9%, 60, 61         hydrocodone bit-ibuprofen, 30
hexachlorophene, 16                      hydrocodone-acetaminophen, 30
HEXALEN, 19                              hydrocortisone, 56, 57, 58, 64, 72, 73
HEXTEND LACTATED ELECTROLYTE, 60         hydrocortisone 1% absorbase, -1% cream, -
HIBERIX, 77                                1% lotion, -1% oint, -1% ointment, -2.5%
HIPREX, 17                                 cream, -2.5% lotion, -2.5% ointment, -
histrelin ac, 21, 102                      aloe 1% cream, -plus 1% cream, 58
HIZENTRA 1 GRAM/5 ML VIAL, 77            hydrocortisone acetate, 72
HIZENTRA 2 GRAM/10 ML VIAL, -4 GRAM/20   hydrocortisone acetate/urea, 56, 58
  ML VIAL, 77                            hydrocortisone buteprate, 58
HMG-COA REDUCTASE INHIBITORS, 46         hydrocortisone butyrate, 58
homatropaire, 107                        hydrocortisone rectal, 72
homatropine, 107                         hydrocortisone sod succinate, 63, 64
homatropine hbr, 107                     hydrocortisone tablet, 64
HUMALOG, 65                              hydrocortisone valerate, 58
HUMALOG MIX 50-50, 65                    hydrocortisone/emol no.45, 58
HUMALOG MIX 75-25, 65                    hydrogesic, 30
human papillomav vacc bival/pf, 76       hydromorphone, 28
human papillomavirus vacc, 76            hydromorphone hcl injection, 28
HUMAPEN LUXURA HD, 80                    hydromorphone hcl rectal, -tablet, 28
HUMAPEN MEMOIR, 80                       hydroxychloroquine, 14
Formulary ID 11155 V.4

hydroxychloroquine sulfate tablet, 14           IMITREX 5 MG NASAL SPRAY, 32
hydroxyprogest caproate, 102                    IMITREX 6 MG/0.5 ML VIAL, -4 MG/0.5 ML
hydroxypropylmethylcellulose, 107                  KIT REFILL, -6 MG/0.5 ML KIT REFILL, 32
hydroxyurea, 18, 19                             IMITREX TABLET, 32
hydroxyurea cap, 19                             immune globulin - im, 76
hydroxyzine hcl injection, 54                   immune globulin - iv, 76, 77
hydroxyzine hcl syrup, -tablet, 55              immune globulin - iv/sq, 76
hydroxyzine pamoate, 55                         immune globulin- sq, 77, 78
hydroxyzine pamoate cap, 55                     IMMUNOLOGICALS AND VACCINES, 75
hypercare, 59                                   IMOGAM RABIES-HT, 77
HYPERHEP B S-D, 77                              IMOVAX RABIES VACCINE, 77
HYPERLYTE CR, 88                                IMURAN, 19
HYPERRAB S-D, 77                                IN CONTROL PEN NEEDLE, 80
HYPERRHO S-D, 77                                inatal advance, 99
HYPERTET S-D, 77                                inatal gt, 99
HYPOGLYCEMIC DRUGS, 65                          inatal ultra, 99
HYPOLIPOPROTEINEMICS, 47                        incobotulinumtoxina, 83
HYZAAR, 50                                      INCRELEX, 78
ibandronate, 68                                 indapamide, 52
IBUDONE, 30                                     INDERAL LA, 43
ibuprofen 100 mg/5 ml sus, -100 mg/5 ml         indinavir, 4
   susp, -400 mg tablet, -600 mg tablet, -800   INDOCIN I.V., 84
   mg tablet, 84                                INDOCIN ORAL SUSP, 84
ibuprofen lysine, 85                            INDOCIN RECTAL, 84
ibutilide fumarate, 49                          indomethacin, 84
ICAR-C PLUS, 99                                 indomethacin cap, -cap sa, 84
idursulfase, 68                                 indomethacin injection, 84
ILARIS, 79                                      indomethacin sodium trihydrate, 84
iloperidone, 23                                 INFANRIX, 77
ILOTYCIN, 105                                   INFANRIX PF, 77
imatinib mesylate, 19                           INFERGEN, 79
IMDUR, 48                                       infliximab, 20
imiglucerase, 68                                INFUMORPH, 28
imipenem/cilastatin sodium, 9                   INJECTABLE ANTICOAGULANTS, 91
imipramine hcl, 41                              INJECT-EASE, 81
imipramine hcl tablet, 41                       INNOHEP, 91
imipramine pamoate, 41                          INNOPRAN XL, 43
imiquimod, 59, 60                               INSPRA, 51
imiquimod cream, 59                             INSULIN, 65
IMITREX 20 MG NASAL SPRAY, 32                   INSULIN LIKE GROWTH FACTORS-1, 78
IMITREX 4 MG/0.5 ML SYRNG KIT, -6 MG/0.5        INSULIN PEN NEEDLE, 81
   ML SYRNG KIT, 32                             INSULIN SYRINGE, 81
Formulary ID 11155 V.4

INSUMED, 81                               IPOL, 77
INSUPEN, 81                               ipratropium, 62, 111
INTEGRA SYRINGE INSULIN SYRINGES -        ipratropium 0.03% spray, 62
   DISPOSABLE, 81                         ipratropium 0.06% spray, 62
INTEGRILIN, 86                            ipratropium bromide nebs, 111
INTELENCE 100 MG TABLET, -200 MG          IQUIX, 105
   TABLET, 4                              irbesartan, 42
interferon alfa-2b , recomb., 79          irbesartan/hctz, 49
interferon alfacon-1, 79                  IRESSA, 19
interferon beta-1a, 78                    iron,carbonyl/vit c/vit b12/fa, 99
interferon beta-1a/albumin, 79            IRRITABLE BOWEL DRUGS, 71
interferon beta-1b, 78, 79                ISENTRESS, 4
interferon gamma-1b,recomb., 78           ISMO, 48
INTERFERONS, 78                           ISO GENTAMICIN 120 MG/100 ML, -
INTERLEUKIN RECPTR ANTAGONIST, 79            GENTAMICIN 40 MG/50 ML, 3
INTERLEUKINS, 79                          isocarboxazid, 34
INTRALIPID 10% IV FAT EMUL, -20% IV FAT   ISOCHRON, 48
   EMUL, 93                               isoditrate, 48
INTRALIPID 30% IV FAT EMUL, 94            ISOLYTE H WITH DEXTROSE, 88
INTRON A 10 MILLION UNIT PEN, -10         ISOLYTE M WITH DEXTROSE, 88
   MILLION UNIT/ML, -18 MILLION UNITS     ISOLYTE P WITH DEXTROSE, 88
   VIAL, -5 MILLION UNIT/ML PEN, -50      ISOLYTE S, 88
   MILLION UNITS VIAL, -6 MILLION         ISOLYTE S WITH DEXTROSE, 88
   UNIT/ML VL, 79                         isonarif, 5
INTRON A 10 MILLION UNITS VIAL, -3        isoniazid injection, 5
   MILLION UNIT/ML PEN, 79                isoniazid syrup, -tablet, 5
introvale, 95                             isoproterenol hcl, 51
INTUNIV, 37                               ISOPTIN SR, 44
INVANZ 1 GM ADD-VANTAGE VIAL, 9           ISOPTO ATROPINE, 107
INVANZ 1 GM VIAL, 9                       ISOPTO CARBACHOL, 103
INVEGA ER 1.5 MG TABLET, -ER 3 MG         ISOPTO CARPINE, 103
   TABLET, -ER 9 MG TABLET, 24            ISOPTO HOMATROPINE, 107
INVEGA ER 6 MG TABLET, 24                 ISOPTO HYOSCINE, 107
INVEGA SUSTENNA 117 MG PREF SY, -156      ISORDIL, 48
   MG PREF SY, -234 MG PREF SY, 24        ISORDIL TITRADOSE, 48
INVEGA SUSTENNA 39 MG PREF SYR, -78       isosorb dinit/hydralazine hcl, 51
   MG PREF SYR, 24                        isosorbide dinitrate, 48
INVIRASE, 4                               isosorbide mononitrate, 48
IONOSOL B WITH DEXTROSE 5%, 88            isradipine, 44
IONOSOL MB-DEXTROSE 5%, 88                ISTALOL, 103
IONOSOL T-DEXTROSE 5%, 88                 ISUPREL, 51
IOPIDINE, 103                             itraconazole, 8
Formulary ID 11155 V.4

itraconazole cap, 8                         KERATOLYTIC DRUGS, 55
ivermectin, 3                               KERLONE, 43
IXIARO, 77                                  KETEK, 7
JALYN, 113                                  KETOCON + PLUS, 12
jantoven, 91                                ketoconazole, 12
JANUMET, 67                                 ketoconazole cream, -oil,shampoo,cleanser,
JANUVIA, 67                                    12
japanese encephalitis vaccine, 77           ketoconazole tablet, 8
JE-VAX, 77                                  ketoconazole/hydrocortisone, 12
jolessa, 95                                 KETOLIDES, 7
jolivette, 102                              ketoprofen cap, -cap sa, 84
junel, 95                                   ketorolac, 85, 106
junel fe, 95                                ketorolac tromethamine injection, 85
k effervescent, 92                          ketorolac tromethamine ophth drops, 107
KADIAN, 28                                  ketorolac tromethamine tablet, 85
KALETRA 100-25 MG TABLET, 4                 KINERET, 79
KALETRA 200-50 MG TABLET, -SOLUTION, 4      KINRIX, 77
kalexate, 92                                kionex oral susp, 92
kanamycin sulfate, 3                        KIONEX PWD, 92
KAOCHLOR, 92                                KLARON, 55
kaon-cl 10, 92                              klor-con 10, 92
KAPIDEX DR 30 MG CAPSULE, 74                klor-con 20 meq packet, 92
KAPIDEX DR 60 MG CAPSULE, 74                KLOR-CON 25 MEQ PACKET, 92
KAPVAY, 37                                  klor-con 8, 92
kariva, 95                                  klor-con m10, 92
KAYEXALATE, 92                              klor-con m15, 93
kcl 20 meq in d5w solution, -20 meq/l iv    klor-con m20, 93
   solution, -40 meq in d5w solution, -40   klor-con-ef, 93
   meq/l iv solution, 92                    KOMBIGLYZE XR 2.5-1,000 MG TAB, 67
kcl 20 meq in d5w-lact ringer, -40 meq in   KOMBIGLYZE XR 5-1,000 MG TAB, -5-500
   d5w-lact ringer, 92                         MG TABLET, 67
kcl 40 meq in d5w-lact ringer, 92           K-PHOS M.F., 113
KEFLEX, 6                                   K-PHOS NEUTRAL, 93
kelnor 1-35, 95                             K-PHOS NO.2, 113
KENALOG, 58                                 K-PHOS ORIGINAL, 113
KENALOG-10, 64                              KRISTALOSE, 86
KENALOG-40, 64                              KRYSTEXXA, 84
KEPIVANCE, 77                               K-TAB, 93
KEPPRA INJECTION, 34                        KURIC, 12
KEPPRA SOLUTION, -TABLET, 34                KUVAN, 69
KEPPRA XR, 34                               KYTRIL INJECTION, 26
KERAFOAM, 59                                KYTRIL TABLET, 26
Formulary ID 11155 V.4

labetalol, 44                       lapatinib ditosylate, 21
labetalol hcl injection, 43         laronidase, 68
labetalol hcl tablet, 43            LASIX, 48
LAC-HYDRIN, 59                      LASTACAFT, 107
LACLOTION, 59                       latanoprost, 103
lacosamide, 35                      LATUDA, 24
LACRISERT, 107                      LAXATIVES AND CATHARTICS, 71
lactate, ammonium, 59               leena, 95
lactated ringers injection, 88      leflunomide, 18, 19
LACTOCAL-F, 99                      lenalidomide, 20
lactulose, 86                       lepirudin,recombinant, 92
LAMICTAL, 34                        LESCOL 20 MG CAPSULE, 46
LAMICTAL (BLUE), 34                 LESCOL 40 MG CAPSULE, 46
LAMICTAL (GREEN), 34                LESCOL XL, 46
LAMICTAL (ORANGE), 34               lessina, 95
LAMICTAL ODT, 34                    LETAIRIS, 46
LAMICTAL ODT (BLUE), 34             letrozole, 19
LAMICTAL ODT (GREEN), 34            leucovorin calcium injection, 19
LAMICTAL ODT (ORANGE), 34           leucovorin calcium tablet, 19
LAMICTAL XR, 34                     LEUKERAN, 19
LAMICTAL XR (BLUE), 34              LEUKINE, 80
LAMICTAL XR (GREEN), 34             LEUKOTRIENE MODIFIERS, 110
LAMICTAL XR (ORANGE), 34            leuprolide, 18, 102
LAMISIL PKT, 8                      leuprolide acetate, 102
LAMISIL SOLUTION, 12                levalbuterol, 109
LAMISIL TABLET, 8                   LEVAQUIN INJECTION, 15
lamivudine, 4, 10                   LEVAQUIN SOLUTION, -TABLET, 15
lamivudine/zidovudine, 4            LEVATOL, 43
lamotrigine, 34                     LEVEMIR, 65
LANOXIN INJECTION, 45               levetiracetam, 34
LANOXIN PEDIATRIC, 45               levetiracetam injection, 34
LANOXIN TABLET, 45                  levetiracetam solution, -tablet, 34
lanreotide acetate, 20              LEVLEN 28, 95
lansoprazole, 74                    levobunolol, 103
lansoprazole dr 15 mg capsule, 74   levobunolol hcl, 103
lansoprazole dr 30 mg capsule, 74   levocarnitine, 93
lansoprazole odt 15 mg tablet, 74   levocarnitine injection, 93
lansoprazole odt 30 mg tablet, 74   levocarnitine solution, -tablet, 93
lansoprazole/amox tr/clarith, 73    levocetirizine dihydrochlor, 109
lanthanum carbonate, 86             levocetirizine dihydrochloride, 109
LANTUS, 65                          levofloxacin, 15, 105
LANTUS SOLOSTAR, 65                 levofloxacin ophth drops, 105
Formulary ID 11155 V.4

levonorgestrel, 96                               liothyronine sodium tablet, 70
levonorgestrel-ethin estradiol, 95, 96           liotrix, 70
levora-28, 95                                    LIPITOR, 46
levorphanol tartrate tablet, 28                  LIPOFEN, 47
levothroid, 69                                   LIPOSYN II, 94
levothyroxine, 70                                liposyn iii, 94
levothyroxine sodium injection, 69               liraglutide, 65
levothyroxine sodium tablet, 69                  LISCO SPONGES, 81
levoxyl, 70                                      lisdexamfetamine dimesylate, 31
LEVULAN, 59                                      lisinopril, 42
LEXAPRO SOLUTION, 39                             lisinopril tablet, 42
LEXAPRO TABLET, 39                               lisinopril/hctz, 50
LEXIVA ORAL SUSP, 4                              lisinopril-hydrochlorothiazide, 50
LEXIVA TABLET, 4                                 LITE TOUCH INSULIN PEN NEEDLES, 81
LIALDA, 73                                       LITE TOUCH INSULIN SYRINGES -
LIDAMANTLE, 2                                       DISPOSABLE, 81
LIDAMANTLE HC, 58                                lithium, 22
lidocaine, 2, 106                                lithium carbonate, 22
lidocaine hcl 0.5% vial, -1% abboject, -1%       lithium carbonate cap, -tab sa, -tablet, 22
   ampul, -1% syringe, -1% vial, -1.5%           LITHOBID, 22
   ampul, -2% abboject, -2% ampul, -2%           LIVALO, 46
   luer-jet, -2% syringe, -2% vial, -20% vial,   l-norgest-eth estr/ethin estr, 95, 96
   -4% ampul, 1                                  LO LOESTRIN FE, 95
lidocaine hcl 10% vial, 49                       LOCAL ANESTHETICS, 1
lidocaine hcl cream, -dental/mucous membrn       LOCOID, 58
   products, -gel, -lotion, -oint, 2             LOCOID LIPOCREAM, 58
lidocaine hcl in 7.5% dextrose, 1                LODOSYN, 36
lidocaine hcl viscous, 2                         lodoxamide, 106
lidocaine hcl-epinephrine, 1                     LOESTRIN, 95
lidocaine hydrochloride/epi, 2                   LOESTRIN 24 FE, 95
lidocaine/prilocaine, 2                          LOESTRIN FE, 95
lidocaine/tetracaine, 2                          LOFIBRA, 47
lidocaine-hydrocortisone cream, -lotion, 58      LOKARA, 58
lidocaine-prilocaine, 2                          LOMOTIL, 70
LIDODERM, 2                                      lomustine, 18
LINCOCIN, 9                                      lonox, 70
lincoject, 9                                     LOOP DIURETICS, 48
lincomycin, 9                                    LO-OVRAL-28, 95
LINDANE, 56                                      loperamide cap, 70
linezolid, 9                                     LOPID, 47
liothyronine, 69, 70                             LOPRESSOR HCT, 50
liothyronine sodium injection, 70                LOPRESSOR INJECTION, 43
Formulary ID 11155 V.4

LOPRESSOR TABLET, 43                         LUNESTA, 38
LOPROX, 12                                   LUPRON DEPOT 11.25 MG 3MO KIT, -22.5
LORCET 10-650, 30                               MG 3MO KIT, -3.75 MG KIT, -4 MONTH
LORCET PLUS, 30                                 KIT, 102
LORTAB, 30                                   LUPRON DEPOT 7.5 MG KIT, 102
losartan, 42                                 LUPRON DEPOT-PED, 102
losartan /hctz, 50                           lurasidone hcl, 24
losartan potassium, 42                       lutera, 96
losartan-hydrochlorothiazide, 50             LUVOX CR, 39
LOSEASONIQUE, 95                             LUXIQ, 58
LOTEMAX, 104                                 LYBREL, 96
LOTENSIN, 42                                 lymphocyte immune globulin, 76, 78
LOTENSIN HCT, 50                             LYRICA, 34
loteprednol etabonate, 104                   LYSODREN, 19
LOTREL, 50                                   LYSTEDA, 60
LOTRISONE, 16                                MACROBID, 17
LOTRONEX, 71                                 MACRODANTIN, 17
lovastatin, 46, 47                           mafenide acetate, 16
lovastatin 10 mg tablet, 47                  mag hydrox/alh/smc/dpha/lido, 63
lovastatin 20 mg tablet, -40 mg tablet, 47   MAGELLAN INSULIN SYRINGE, 81
lovastatin/niacin, 46                        MAGNACET, 28
LOVAZA, 47                                   magnesium sulfate injection, 88
LOVENOX 100 MG PREFILLED SYR, -120 MG        magnesium sulfate/d5w, 88
   PREFILLED SYR, -150 MG PREFILLED SYR,     MAGNESIUM SULFATE-D5W, 88
   -300 MG VIAL, -300 MG/3 ML VIAL, -60      MAKENA, 102
   MG PREFILLED SYRN, -80 MG PREFILLED       MALARONE, 14
   SYRN, 91                                  malathion, 56
LOVENOX 30 MG PREFILLED SYRN, -40 MG         mannitol, 89
   PREFILLED SYRN, 91                        mannitol injection, 88
low-ogestrel, 95                             MAO INHIBITORS, 34
loxapine, 24                                 maprotiline hcl, 35
loxapine succinate, 24                       maraviroc, 4
LOXITANE, 24                                 MARCAINE, 1
lozi-flur, 90                                MARCAINE SPINAL, 1
lubiprostone, 71                             MARCAINE WITH EPINEPHRINE, 1
LUCENTIS, 107                                MARCAINE-EPINEPHRINE, 1
ludent fluoride, 90                          margesic h, 30
LUER-LOK SYRINGE INSULIN SYRINGES -          MARINOL 10 MG CAPSULE, -5 MG CAPSULE,
   DISPOSABLE, 81                               26
LUFYLLIN, 110                                MARINOL 2.5 MG CAPSULE, 26
LUMIGAN, 103                                 marlexate, 92
LUMIZYME, 69                                 MARPLAN, 34
Formulary ID 11155 V.4

maternity, 99                                 meloxicam 7.5 mg tablet, 85
MATULANE, 19                                  memantine hcl, 22
MAVIK, 42                                     MENACTRA, 77
MAXAIR AUTOHALER, 109                         MENEST, 98
MAXALT, 32                                    mening vac a,c,y,w-135 dip, 77
MAXALT MLT, 32                                meningococcal vac a,c,y,w-135, 77
MAXIDEX, 104                                  MENOMUNE-A-C-Y-W-135, 77
MAXIDONE, 30                                  MENOSTAR, 98
MAXIPIME 1 GM ADD-VANTAGE VL, -2 GM           MENTAX, 12
 ADD-VANTAGE VL, -1 GRAM VIAL, 6              MENVEO A-C-Y-W-135-DIP, 77
MAXIPIME 2 GRAM VIAL, 6                       mepenzolate, 70
MAXITROL, 104                                 meperidine, 28
MAXZIDE, 51                                   meperidine hcl injection, 28
MAXZIDE-25 MG, 51                             mepivacaine, 1, 2
measles vaccine,atten, 76                     meprobamate, 27
measles,mumps&rubella vaccine, 77             MEPRON, 9
measles,mumps,rub,varicella, 78               mercaptopurine, 20
mebendazole chew tab, 3                       mercaptopurine tablet, 19
mecasermin, 78                                meropenem, 9
mechlorethamine, 19                           MERREM IV 1 GM VIAL, 9
meclizine 12.5 mg tablet, -25 mg tablet, 26   MERREM IV 500 MG VIAL, 9
meclizine hcl, 25                             MERUVAX II VACCINE W-DILUENT, 77
meclofenamate sodium cap, 85                  mesalamine, 72, 73
MEDICAL (MISCELLANEOUS) SUPPLIES, 80          mesna, 19
MEDI-JECTOR NEEDLE-FREE SYR A, 81             MESNEX INJECTION, 19
MEDI-JECTOR NEEDLE-FREE SYR B, 81             MESNEX TABLET, 19
MEDI-JECTOR NEEDLE-FREE SYR C, 81             MESTINON SYRUP, -TAB SA, 37
MEDI-JECTOR VISION, 81                        MESTINON TABLET, 37
MEDROL, 64                                    METADATE CD, 31
medroxyprogesterone, 18, 101, 102             metadate er, 31
medroxyprogesterone acetate injection, 102    METAGLIP, 67
medroxyprogesterone acetate tablet, 102       metaproterenol sulfate syrup, -tablet, 109
mefenamic acid, 85                            metaxalone, 83
mefenamic acid cap, 85                        metformin, 67
mefloquine hcl, 14                            metformin hcl, 67
MEFOXIN, 6                                    metformin hcl er, 67
MEGACE, 19                                    methadone, 28
MEGACE ES, 19                                 methadone hcl injection, 28
megestrol, 19                                 methadone hcl solution, -tablet, 28
megestrol acetate oral susp, -tablet, 19      methadone intensol, 28
meloxicam, 85                                 methadose, 28
meloxicam 15 mg tablet, -oral susp, 85        methamphetamine, 31
Formulary ID 11155 V.4

methamphetamine hcl, 31                       methylprednisolone tab(in convenience
methazolamide, 103                              package), -tablet, 64
methenamine hippurate, 17                     methyltestosterone, 94
methenamine mandelate, 17                     metipranolol, 103
methenamine mandelate e.c. tab, -tablet, 17   metoclopramide, 70, 71
METHERGINE INJECTION, 99                      metoclopramide hcl injection, 70
METHERGINE TABLET, 99                         metoclopramide hcl syrup, -tablet, 70
methimazole, 63                               metolazone, 52
methimazole tablet, 63                        metoprolol succinate, 43, 44
METHITEST, 94                                 metoprolol tartrate, 43
methocarbamol, 83                             metoprolol tartrate injection, 43
methocarbamol tablet, 83                      metoprolol tartrate tablet, 43
methotrexate, 20                              metoprolol-hydrochlorothiazide, 50
methotrexate injection, 19                    METOZOLV ODT, 70
methotrexate sodium, 21                       metro iv, 3
methotrexate tablet, 19                       METROCREAM, 54
methoxsalen, 55, 56, 59                       METROGEL, 54
methscopolamine, 70                           METROGEL-VAGINAL, 98
methscopolamine bromide, 70                   METROLOTION, 54
methsuximide, 41                              metronidazole, 3, 54, 98
methyclothiazide tablet, 52                   metronidazole cap, -tablet, 3
methyl aminolevulinate hcl, 59                metronidazole cream, -gel, -lotion, 54
METHYL XANTHINE DRUGS, 110                    metronidazole injection, 3
methyldopa, 46                                metronidazole vaginal products, 98
methyldopa-hydrochlorothiazide, 50            METVIXIA, 59
methyldopate hcl, 46                          metyrosine, 46
methylergonovine, 99                          MEVACOR, 47
METHYLIN 10 MG CHEWABLE TABLET, -2.5          mexiletine hcl cap, 43
 MG CHEWABLE TAB, -5 MG CHEWABLE              MIACALCIN INJECTION, 69
 TABLET, -SOLUTION, 31                        MIACALCIN NASAL DROPS/SPRAYS, 69
methylin 10 mg tablet, -20 mg tablet, -5 mg   micafungin sodium, 13
 tablet, 31                                   MICARDIS, 42
methylin er, 31                               MICARDIS HCT, 50
methylnaltrexone bromide, 73                  miconazole, 8
methylphenidate, 31                           miconazole 3 200 mg vag supp, 17
methylphenidate er, 31                        miconazole nitrate/zinc oxide, 12
methylphenidate hcl solution, -tablet, 31     MICRHOGAM, 77
methylphenidate sr, 31                        MICRHOGAM PLUS, 77
methylprednisolone, 64                        microgestin, 96
methylprednisolone acetate, 64                microgestin fe, 96
methylprednisolone acetate injection, 64      MICRO-K, 93
methylprednisolone sod succ, 64               MICRONOR, 102
Formulary ID 11155 V.4

MICROZIDE, 52                               moexipril-hydrochlorothiazide, 50
MIDAMOR, 51                                 molindone, 24
midodrine, 51                               mometasone, 57, 62, 111
midodrine hcl, 51                           mometasone furoat/ammonium l, 58
migergot, 32                                mometasone furoate, 58
miglitol, 67                                mometasone/formoterol, 111
miglustat, 69                               MOMEXIN, 58
MIGRANAL, 33                                MONODOX, 16
MILLIPRED, 64                               MONOJECT 0.5 ML SYRN 28GX1/2, 81
MILLIPRED DP, 64                            MONOJECT INSULIN SAFETY SYRNG, 81
milnacipran hcl, 36                         MONOJECT INSULIN SYRINGE, 81
milrinone in 5% dextrose, 45                MONOKET, 48
milrinone lactate, 45                       mononessa, 96
mimvey, 98                                  MONOPRIL, 42
MINERALOCORTICOID DRUGS, 66                 montelukast sodium, 110
MINIPRESS, 52                               MONUROL, 17
MINITRAN, 48                                morphine, 27, 28, 29
MINOCIN COMBO PACKS, -CAP, 16               morphine sulfate in dextrose, 28
MINOCIN INJECTION, 16                       morphine sulfate injection, 28
minocycline, 16, 63                         morphine sulfate rectal, -solution, -tablet, 28
minocycline hcl cap, -tab sa, -tablet, 16   morphine sulfate tab sa, 28
minoxidil tablet, 52                        morphine sulfate/naltrexone, 28
MIOSTAT, 103                                MOTOFEN, 70
MIRAPEX, 36                                 MOVIPREP, 73
MIRAPEX ER, 36                              MOXATAG, 13
MIRCETTE, 96                                MOXEZA, 105
mirtazapine, 35, 36                         moxifloxacin, 14, 15, 105, 106
misc supp (dress,tape,gauze), 80, 81, 82    MOZOBIL, 77
MISCELLANEOUS DRUGS, 60                     MS CONTIN, 29
misoprostol, 72                             MULTAQ, 49
mitotane, 19                                multi-nate 30, 99
mitoxantrone, 20                            multi-nate dha extra prenatal, 99
mitoxantrone hcl, 19                        mumps vaccine,live, 77
M-M-R II VACCINE, 77                        MUMPSVAX VACCINE W-DILUENT, 77
MOBAN, 24                                   mupirocin, 16
MOBIC 15 MG TABLET, -ORAL SUSP, 85          mupirocin calcium, 16
MOBIC 7.5 MG TABLET, 85                     mupirocin oint, 16
modafinil, 31                               muronab-cd3, 20
MODICON, 96                                 MUSCULOSKELETAL MEDICATIONS, 83
moexipril, 42                               MUSTARGEN, 19
moexipril hcl, 42                           MYAMBUTOL, 5
moexipril/hctz, 50                          MYCAMINE, 13
Formulary ID 11155 V.4

MYCOBUTIN, 5                                 naproxen sodium, 84, 85
mycophenolate mofetil, 18                    naproxen sodium 275 mg tab, -550 mg tab,
mycophenolate mofetil cap, 19                  85
mycophenolate mofetil tablet, 19             naproxen/esomeprazole mag, 85
mycophenolate sodium, 19                     naratriptan, 32
MYDFRIN, 107                                 naratriptan hcl, 33
mydral, 107                                  NARDIL, 34
MYDRIACYL, 107                               NAROPIN, 1
MYELOID STIMULANTS, 80                       NASACORT AQ, 62
MYFORTIC, 19                                 NASONEX, 62
myochrysine, 85                              NATACHEW, 99
MYOZYME, 69                                  NATACYN, 107
MYSOLINE, 34                                 NATAFORT, 99
MYTELASE, 37                                 natalizumab, 21
nabilone, 25                                 natamycin, 107
nabumetone, 85                               NATAZIA, 96
nadolol, 43                                  nateglinide, 67
nadolol tablet, 43                           NATELLE C, 99
nadolol-bendroflumethiazide, 50              NATELLE ONE, 99
nafarelin, 102                               NATELLE PLUS, 99
NAFCILL IN DEXTROSE, 13                      NATELLE-EZ, 99
nafcillin, 13                                NATRECOR, 51
nafcillin sodium, 13                         NATURETIN-5, 52
naftifine, 12                                NAVANE, 24
NAFTIN, 12                                   nebivolol hcl, 43
NAGLAZYME, 69                                necon, 96
nalbuphine hcl, 21                           nedocromil, 106
NALFON, 85                                   NEEDLE FREE SYRINGE KIT A, 81
NALLPEN, 13                                  NEEDLE FREE SYRINGE KIT B, 81
NALLPEN IN DEXTROSE, 13                      NEEDLE FREE SYRINGE KIT C, 81
NALLPEN-ISO-OSMOTIC DEXTROSE, 13             NEEVO, 99
naloxone hcl injection, 37                   nefazodone hcl, 35
naltrexone, 38                               nelfinavir mesylate, 4
naltrexone hcl tablet, 37                    neocidin, 105
naltrexone microspheres, 38                  NEO-FRADIN, 3
NAMENDA, 22                                  neofrin, 107
naphazoline hcl ophth drops, 107             neomycin, 3
NAPRELAN, 85                                 neomycin sulfate tablet, 3
NAPRELAN CR DOSE CARD, 85                    neomycin sulfate/colist sul/hc, 61
NAPROSYN, 85                                 neomycin sulfate/polymyxin, 113
naproxen, 84, 85                             neomycin sulfate/polymyxin/hc, 61
naproxen e.c. tab, -oral susp, -tablet, 85   neomycin/bacitracin/poly/hc, 16
Formulary ID 11155 V.4

neomycin/colist sul/hc/thonz, 61               niacin/simvastatin, 47
neomycin/gramicidin/polymyxin, 105             NIACOR, 47
neomycin/polymyxin/dexameth, 104               NIASPAN, 48
neomycin/polymyxin/prednisol, 104              nicardipine hcl cap, 44
neomycin-bacitracin-poly-hc, 104               nicardipine hcl injection, 44
neomycin-bacitracin-polymyxin, 105             nicotine inhaler, 40
neomycin-polymyxin b, 113                      nicotine ns, 40
neomycin-polymyxin-dexameth, 104               NICOTROL, 40
neomycin-polymyxin-gramicidin, 105             NICOTROL NS, 40
neomycin-polymyxin-hc ophth drops, 104         nifediac cc, 44
neomycin-polymyxin-hc otic drops, -solution,   nifedical xl, 44
  -suspensions, (not oral), 61                 nifedipine, 44, 45
NEOPROFEN, 85                                  nifedipine cap, 44
NEORAL, 19                                     nifedipine er, 45
NEOSPORIN G.U. IRRIGANT, 113                   NILANDRON, 20
NEOSPORIN OPHTH DROPS, 105                     nilotinib hydrochloride, 21
neostigmine bromide, 37                        nilutamide, 20
neostigmine methylsulfate, 37                  nimodipine, 45
nepafenac, 107                                 NIMOTOP, 45
NEPHRAMINE, 88                                 nisoldipine, 45
NEPTAZANE, 103                                 nitazoxanide, 8
NESACAINE, 2                                   nitisinone, 60
NESACAINE-MPF, 2                               NITRATES, 48
nesiritide, 51                                 nitro-bid, 48
NEULASTA, 80                                   NITRO-DUR, 48
NEUMEGA, 79                                    nitrofurantoin, 17
NEUPOGEN, 80                                   nitrofurantoin cap, 17
NEURONTIN CAP, -TABLET, 34                     nitrofurantoin macrocrystal, 17
NEURONTIN SOLUTION, 34                         nitrofurantoin mono-macro, 17
NEUT, 88                                       nitrofurantoin/nitrofuran mac, 17
neutragard advanced, 90                        nitroglycerin, 48, 49
NEVANAC, 107                                   nitroglycerin in d5w, 48
nevirapine, 4                                  nitroglycerin injection, 49
NEXA SELECT, 100                               nitroglycerin patch, 49
NEXAVAR, 19                                    nitroglycerin tab, sl, 49
NEXIUM DR 10 MG PACKET, -DR 20 MG              NITROLINGUAL, 49
  CAPSULE, -DR 20 MG PACKET, 74                NITROMIST, 49
NEXIUM DR 40 MG CAPSULE, -DR 40 MG             NITROSTAT, 49
  PACKET, 74                                   nizatidine, 71
NEXIUM I.V., 74                                NIZORAL, 12
next choice, 96                                NON-STEROIDAL ANTIINFLAMMATORY
niacin, 47, 48                                    AGENTS, 84
Formulary ID 11155 V.4

nora-be, 102                                NOVOLIN 70-30 INNOLET, 65
NORCO, 30                                   NOVOLIN N 100 UNIT/ML INNOLET, -100
NORDETTE-28, 96                               UNITS/ML VIAL, 66
NORDITROPIN, 75                             NOVOLIN R 100 UNIT/ML INNOLET, -RELION
NORDITROPIN FLEXPRO, 75                       100 UNITS/ML, 66
NORDITROPIN NORDIFLEX, 75                   NOVOLIN R 100 UNITS/ML VIAL, 66
norepinephrine bitartrate, 51               NOVOLOG, 66
noreth a-et estra/fe fumarate, 95           NOVOLOG MIX 70-30, 66
noreth-ethinyl estradiol/iron, 95           NOVOPEN 3, 81
norethindrone, 102                          NOVOPEN JR, 81
norethindrone acetate, 101                  NOVOTWIST, 81
norethindrone acetate tablet, 102           NOXAFIL, 8
norethindrone a-e estradiol, 95, 98         NUCYNTA, 29
norethindrone-ethin estradiol, 95, 96, 97   NUEDEXTA, 37
norethindrone-mestranol, 96                 NULYTELY WITH FLAVOR PACKS, 73
NORFLEX, 83                                 NUMORPHAN, 29
norfloxacin, 15                             nutrilyte, 88
norgestimate-ethinyl estradiol, 96          nutrilyte ii, 89
norgestrel-ethiny estra, 96                 NUTRITION,BLOOD
norgestrel-ethinyl estradiol, 95              MODIFIERS,ELECTROLYTES, 86
NORINYL 1+35, 96                            NUTROPIN, 75
NORINYL 1+50, 96                            NUTROPIN AQ, 75
NORITATE, 54                                NUTROPIN AQ NUSPIN, 75
NORMOSOL-M AND DEXTROSE, 88                 NUVARING, 96
NORMOSOL-R, 88                              NUVIGIL, 31
NORMOSOL-R AND DEXTROSE, 88                 nyamyc, 12
NORMOSOL-R PH 7.4, 88                       nystatin 100,000 unit/gm powd, -cream, -
NOROXIN, 15                                   oint, 12
NORPRAMIN, 38                               nystatin 150,000,000 units pwd, -50,000,000
NOR-Q-D, 102                                  units pwd, -500,000 unit oral tab, -
nortrel, 96                                   500,000,000 units pwd, -oral susp, 8
nortriptyline, 38                           nystatin vaginal tablet, 17
nortriptyline hcl cap, -solution, 38        nystatin-triamcinolone, 16
NORVASC, 45                                 nystop, 12
NORVIR CAP, -TABLET, 4                      ob + dha, 100
NORVIR SOLUTION, 4                          ob 90 + dha, 100
NOVAMINE, 88                                OB/GYN TOPICAL ANTIINFECTIVES, 98
NOVANTRONE, 20                              ob-natal one, 100
NOVOCAIN, 2                                 OBSTETRICAL AND GYNECOLOGICAL
NOVOFINE 32, 81                               MEDICATIONS, 94
NOVOFINE AUTOCOVER, 81                      OBSTETRIX EC, 100
NOVOLIN 70-30 100 UNIT/ML VIAL, 65          OBTREX, 100
Formulary ID 11155 V.4

O-CAL FA, 100                               OMNARIS, 62
O-CAL PRENATAL, 100                         OMNICEF, 6
ocella, 96                                  OMNIPRED, 104
OCL, 73                                     OMNITROPE, 75
OCTAGAM, 77                                 ondansetron, 26, 27
octreotide, 20                              ondansetron hcl 24 mg tablet, 26
octreotide 1,000 mcg/ml vial, -acet 100     ondansetron hcl 4 mg tablet, -8 mg tablet,
   mcg/ml amp, -acet 100 mcg/ml vl, -acet     26
   200 mcg/ml vl, -acet 500 mcg/ml amp, -   ondansetron hcl in dextrose, 26
   acet 500 mcg/ml vl, 20                   ondansetron hcl injection, 26
octreotide acet 50 mcg/ml amp, -acet 50     ondansetron hcl solution, 26
   mcg/ml vial, 20                          ondansetron odt, 26
OCUFEN, 107                                 ONGLYZA, 67
OCUFLOX, 105                                ONSOLIS, 29
ofloxacin, 105                              OPANA, 29
ofloxacin ophth drops, 105                  OPANA ER, 29
ofloxacin otic drops, 61                    OPHTHALMIC
ofloxacin tablet, 15                          ANTIINFECTIVE/CORTICOSTEROIDS, 103
OGEN, 98                                    OPHTHALMIC CORTICOSTEROID DRUGS,
ogestrel, 96                                  104
olanzapine, 25                              OPHTHALMIC MEDICATIONS, 102
olanzapine pamoate, 25                      OPHTHALMIC TOPICAL ANTIBACTERIAL
olanzapine/fluoxetine hcl, 25                 DRUGS, 105
OLEPTRO ER, 35                              OPHTHALMIC TOPICAL ANTIVIRAL DRUGS,
olmesartan med/amlodipine/hct, 50             106
olmesartan medoxomil, 42                    opium, 29
olmesartan medoxomil/hctz, 49               OPIUM, 29
olopatadine hcl, 62, 107                    oprelvekin, 79
olsalazine, 72                              OPTIPRANOLOL, 103
OLUX, 58                                    OPTIVAR, 107
OLUX-E, 58                                  ORACEA, 16
OLUX-OLUX-E, 58                             ORACIT, 93
omalizumab, 112                             ORAL ANTICOAGULANTS, VITAMIN K, 91
omega-3 acid ethyl esters, 47               ORAL ANTIFUNGAL DRUGS, 7
omeprazole, 74                              ORAL DERMATOLOGICAL DRUGS, 55
omeprazole dr 10 mg capsule, 74             ORAL HYPOGLYCEMICS AND COMBOS, 66
omeprazole dr 20 mg capsule, -dr 40 mg      ORALONE, 63
   capsule, 74                              ORAMORPH SR, 29
omeprazole magnesium-legend, 74             ORAP, 24
omeprazole/sodium bicarbonat, 74, 75        ORAPRED, 64
omeprazole-bicarb 20-1,100 cap, 74          ORAPRED ODT, 64
omeprazole-bicarb 40-1,100 cap, 74          ORASEP, 63
Formulary ID 11155 V.4

ORAVIG, 8                            OTHER VASODILATING DRUGS, 51
oraxyl, 63                           otic edge, 61
ORENCIA, 20                          oticin hc ear solution, -suspensions, (not
ORFADIN, 60                             oral), 61
orphenadrine, 83                     otocidin, 61
orphenadrine citrate injection, 83   otomycet-hc, 61
orphenadrine citrate tab sa, 83      OVCON-35, 96
orphenadrine compound, 83            OVCON-50, 96
orphenadrine compound forte, 83      OVIDE, 56
ORSINI INSULIN SYRINGE, 81           oxacillin, 13, 14
ORTHO EVRA, 96                       oxacillin 1 gm add-vantage vl, -10 gm vial, -2
ORTHO TRI-CYCLEN, 96                    gm add-vantage vl, -2 gm vial, 14
ORTHO TRI-CYCLEN LO, 96              oxacillin 1 gm vial, 14
ORTHO-CEPT, 96                       OXANDRIN 10 MG TABLET, 94
ORTHOCLONE OKT-3, 20                 OXANDRIN 2.5 MG TABLET, 94
ORTHO-CYCLEN, 96                     oxandrolone, 94
ORTHO-EST, 98                        oxaprozin, 84, 85
ORTHO-NOVUM, 96                      oxcarbazepine, 27
oseltamivir phosphate, 11            oxiconazole, 12
OSMITROL, 89                         OXISTAT, 12
OSMOPREP, 71                         OXSORALEN, 59
OTHER ANTIARRHYTHMICS, 49            OXSORALEN-ULTRA, 56
OTHER ANTICONVULSANTS, 34            oxybutynin, 112, 113
OTHER ANTIDEPRESSANTS, 35            oxybutynin chloride syrup, -tablet, 112
OTHER ANTIHYPERTENSIVES, 49          oxybutynin cl er 10 mg tablet, -cl er 15 mg
OTHER ANTIINFECTIVE DRUGS, 8            tablet, 112
OTHER ANTIPARKINSON DRUGS, 36        oxybutynin cl er 5 mg tablet, 112
OTHER ANTIULCER DRUGS, 72            oxycodone, 29
OTHER ANTIVIRAL DRUGS, 10            oxycodone hcl, 29
OTHER CARDIOVASCULAR DRUGS, 50       oxycodone hcl-acetaminophen, 29
OTHER CNS/AUTONOMIC DRUGS, 37        oxycodone hcl-ibuprofen, 29
OTHER DRUGS AFFECTING COAGULATION,   oxycodone/acetaminophen, 28, 29
  92                                 oxycodone/aspirin, 29
OTHER DRUGS FOR ARTHRITIS, 85        oxycodone/ibuprofen, 27
OTHER DRUGS FOR ASTHMA, 110          oxycodone-acetaminophen, 29
OTHER ENDOCRINE DRUGS, 68            oxycodone-aspirin, 29
OTHER GENITOURINARY PRODUCTS, 113    OXYCONTIN, 29
OTHER GI DRUGS, 72                   oxymetholone, 94
OTHER MACROLIDES, 11                 oxymorphone, 29
OTHER OPHTHALMIC DRUGS, 106          oxymorphone hcl, 29
OTHER RESPIRATORY DRUGS, 112         oxytetracycline, 16
OTHER TOPICAL ANTIFUNGALS, 12        oxytetracycline hcl/polymyxin, 105
Formulary ID 11155 V.4

OXYTOCICS, 99                                   PASER, 5
oxytocin, 99                                    PATADAY, 107
oxytocin injection, 99                          PATANASE, 62
OXYTROL, 113                                    PATANOL, 107
PACERONE 100 MG TABLET, -400 MG                 PAXIL 10 MG TABLET, -40 MG TABLET, 39
  TABLET, 41                                    PAXIL 20 MG TABLET, -30 MG TABLET, 39
pacerone 200 mg tablet, 42                      PAXIL CR, 39
palgic, 109                                     PAXIL ORAL SUSP, 40
palifermin, 77                                  pazopanib, 21
paliperidone, 24                                PCE, 7
palivizumab, 78                                 PEDIADERM HC, 58
palonosetron hcl, 25                            PEDIAPRED, 64
PAMELOR, 38                                     PEDIARIX, 77
pamidronate disodium, 68, 69                    pedi-dri, 12
PAMINE, 70                                      PEDVAXHIB, 77
PAMINE FORTE, 70                                peg 3350-electrolyte, 73
PANCREAZE, 73                                   peg-3350 and electrolytes, 73
PANCRELIPASE 5,000, 73                          peg-3350 with flavor packs, 73
PANDEL, 58                                      pegademase bovine, 60
PANHEMATIN, 61                                  PEGANONE, 33
PANLOR DC, 30                                   PEGASYS 180 MCG/0.5 ML CONV.PK, 79
PANLOR SS, 30                                   PEGASYS 180 MCG/ML VIAL, 79
PANRETIN, 59                                    pegfilgrastim, 80
pantoprazole, 74                                peginterferon alfa-2a, 79
pantoprazole sod dr 20 mg tab, 74               peginterferon alfa-2b, 79
pantoprazole sod dr 40 mg tab, 74               PEGINTRON 120 MCG KIT, -150 MCG KIT, -
PARAFON FORTE DSC, 83                             80 MCG KIT, 79
parcaine, 107                                   PEGINTRON 50 MCG KIT, 79
PARCOPA, 36                                     PEGINTRON REDIPEN, 79
paregoric, 70                                   pegloticase, 84
PARENTERAL ANTIFUNGALS, 12                      pegvisomant, 69
paricalcitol, 93                                pemetrexed disodium, 18
PARLODEL, 36                                    pemirolast potassium, 106
PARNATE, 34                                     PEN 12MM 29G NEEDLES, -31GX3/16, -
paromomycin sulfate, 2                            31GX5/16, -6MM 31G, -8MM 31G
paroxetine, 39, 40                                NEEDLES, -AURORA 6MM 31G, -AURORA S
paroxetine hcl 10 mg tablet, -40 mg tablet,       12MM 29G, -AURORA S 8MM 31G, -BD
  39                                              29GX1/2, -BD 29GX3/16, -BD 29GX5/16, -
paroxetine hcl 20 mg tablet, -30 mg tablet, -     BD MINI 31GX3/16, -BD NANO 32GX5/32,
  tab sa, 39                                      -BD ORIG 29GX1/2, -BD SHORT 31GX5/16,
paroxetine hcl oral susp, 39                      -HLT PN NE, 81
paroxetine mesylate, 40                         pen g pot/dextrose-water, 14
Formulary ID 11155 V.4

pen g procaine/pen g benz, 13            phenadoz, 26
PEN NEEDLES, 81                          phenelzine, 34
penbutolol, 43                           phenelzine sulfate tablet, 34
penciclovir, 10                          PHENERGAN, 109
penicillamine, 85                        phenoxybenzamine, 46
penicillin g benzathine, 13              phentolamine, 46
penicillin g potassium, 14               PHENTOLAMINE MESYLATE INJECTION, 46
PENICILLIN G POTASSIUM IN D5W, 14        phenylephrine hcl, 107
penicillin g procaine, 14                phenylephrine hcl ophth drops, 107
penicillin g sodium, 14                  PHENYTEK, 33
PENICILLIN GK-ISO-OSM DEXTROSE, 14       phenytoin, 33
penicillin v potassium, 14               phenytoin oral susp, 33
PENICILLINS, 13                          phenytoin sodium, 33
PENLAC, 12                               phenytoin sodium extended, 33
PENNSAID, 56                             phenytoin sodium injection, 33
PENTACEL, 77                             PHISOHEX, 16
PENTAM 300, 9                            PHOS-FLUR, 90
pentamidine, 9                           PHOSLO, 93
pentamidine isethionate, 9               phospha 250 neutral, 93
PENTASA, 73                              PHOSPHOLINE IODIDE, 103
pentazocine, 22                          phosphorus, 93
pentazocine-acetaminophen, 21            physostigmine salicylate injection, 37
pentopak, 51                             pilocarpine hcl, 63, 103
pentosan polysulfate sodium, 113         pilocarpine hcl ophth drops, 103
pentoxifylline, 51                       pilocarpine hcl tablet, 63
pentoxifylline tab sa, 51                PILOPINE HS, 103
PEPCID INJECTION, 71                     pimecrolimus, 59
PEPCID ORAL SUSP, -TABLET, 71            pimozide, 24
PERANEX HC PAD, MEDICATED PAD, 58        pindolol, 43
PERCOCET, 29                             pioglitazone hcl, 66
PERCODAN, 29                             pioglitazone hcl/metformin hc, 66
perindopril erbumine, 42                 pioglitazone/glimepiride, 66
perio med, 90                            piperacillin, 14
periogard, 63                            piperacillin/tazobactam sodium, 14
PERIOSTAT, 63                            piperacillin-tazobactam, 14
permethrin cream, 56                     PIPRACIL IN DEXTROSE, 14
perphenazine, 24                         pirbuterol, 109
perphenazine-amitriptyline, 35           piroxicam, 84
PERSANTINE, 86                           piroxicam cap, 85
PEXEVA 10 MG TABLET, -40 MG TABLET, 40   pitavastatin calcium, 46
PEXEVA 20 MG TABLET, -30 MG TABLET, 40   PITOCIN, 99
PFIZERPEN, 14                            PLAN B, 96
Formulary ID 11155 V.4

PLAN B ONE-STEP, 96                              potassium chloride injection, 93
PLAQUENIL, 14                                    potassium chloride-nacl, 89
PLASBUMIN-25, 89                                 potassium citrate tab sa, 113
PLASMA-LYTE 148, 89                              potassium citrate-citric acid, 113
PLASMA-LYTE 148 IN DEXTROSE, 89                  POTASSIUM REMOVING RESINS, 92
PLASMA-LYTE 56, 89                               POTASSIUM SPARING DIURETICS, 51
PLASMA-LYTE 56 IN DEXTROSE, 89                   POTASSIUM SUPPLEMENTS, 92
PLASMA-LYTE A PH 7.4, 89                         povidone-iodine, 106
PLASMA-LYTE R, 89                                pr otic solution, 61
PLASMODICIDES, 14                                PRADAXA, 91
PLAVIX, 86                                       pralidoxime chloride, 61
plerixafor, 77                                   pramipexole, 36
PLETAL, 86                                       pramipexole dihydrochloride, 36
PLEXION, 54                                      pramlintide acetate, 65
podofilox, 55                                    PRAMOTIC, 61
poliomyelitis vac,killed, 77                     pramoxine hcl/chloroxylenol, 61
POLOCAINE, 2                                     PRANDIMET, 67
POLY IRON PN FORTE, 100                          PRANDIN, 67
polycin-b, 105                                   prascion, 54
poly-dex, 104                                    prascion fc, 54
polyethylene glycol 3350, -pkt, -powd, 72        prascion ts, 54
POLYGESIC, 30                                    prasugrel, 86
polymyxin b, 9                                   PRAVACHOL, 47
POLYMYXIN B SULFATE EA, 9                        pravastatin, 47
polymyxin b sulfate injection, 9                 pravastatin sodium, 47
polymyxin b sulfate/tmp, 105                     praziquantel, 3
polymyxin b sul-trimethoprim, 105                prazosin, 52
POLY-PRED, 104                                   prazosin hcl, 52
POLYTRIM, 105                                    PRECISION INSULIN SYRINGES -
PONSTEL, 85                                        DISPOSABLE, 82
portia, 96                                       PRECOSE, 67
posaconazole, 8                                  PRED FORTE, 104
pot acid phos/sod acid phos, 113                 PRED MILD, 104
potassium acetate injection, 93                  PRED-G, 104
potassium acid phosphate, 113                    prednicarbate, 57, 58
potassium bicarb/ca, 92                          prednisol, 104
potassium bicarbonate unique tablet              prednisolone, 64
  formulation, 93                                prednisolone acetate, 104
potassium chl-normal saline, 89                  prednisolone acetate ophth drops, 104
potassium chloride, 92, 93                       prednisolone sod phosphate, 63, 64
potassium chloride cap sa, -solution, -tab sa,   prednisolone sodium phosphate ophth drops,
  -unique tablet formulation, 93                   104
Formulary ID 11155 V.4

prednisolone sodium phosphate solution, 64   PREVACID DR 15 MG CAPSULE, -15 MG
prednisolone syrup, 64                         SOLUTAB, 74
prednisone intensol, 64                      prevalite, 48
prednisone solution, -tab(in convenience     PREVIDENT, 90
  package), -tablet, 64                      PREVIDENT 5000, 90
PREFERA OB, 100                              PREVIDENT 5000 PLUS, 90
PREFERA-OB, 100                              PREVIDENT 5000 SENSITIVE, 90
PREFERA-OB ONE, 100                          previfem, 96
PREFERA-OB PLUS DHA, 100                     PREVPAC, 73
PREFEST, 98                                  PREZISTA 150 MG TABLET, -75 MG TABLET,
pregabalin, 34                                 4
PRELONE, 64                                  PREZISTA 400 MG TABLET, -600 MG
PREMARIN INJECTION, 98                         TABLET, 4
PREMARIN TABLET, -VAGINAL PRODUCTS,          PRIALT, 21
  98                                         PRIFTIN, 5
PREMASOL, 89                                 PRILOSEC DR 10 MG CAPSULE, -DR 20 MG
PREMPHASE, 98                                  CAPSULE, 74
PREMPRO, 98                                  PRILOSEC DR 10 MG SUSPENSION, 74
prenacare, 100                               PRILOSEC DR 2.5 MG SUSPENSION, 74
prenafirst, 100                              PRILOSEC DR 40 MG CAPSULE, 74
prenaplus, 100                               primaquine, 14
prenatabs fa, 100                            PRIMAQUINE, 14
prenatabs obn, 100                           PRIMAXIN 250 MG VIAL, 9
prenatabs rx, 100                            PRIMAXIN 500 MG VIAL, 9
prenatal 19, 100                             PRIMAXIN I.M., 9
prenatal ad, 100                             primidone, 34, 35
prenatal low iron tablet, 100                PRIMLEV, 29
prenatal multivitamin w-iron, 100            PRIMSOL, 17
prenatal plus, 100                           PRINIVIL, 42
prenatal vit( = or > 1mg fa), 99, 100, 101   PRINZIDE, 50
PRENATAL VITAMINS, 99                        PRISTIQ, 36
prenatal vitamins (< 1mg fa), 99, 100        PRIVIGEN, 77
prenatal-u, 100                              PROAIR HFA, 109
PRENATE DHA, 100                             PROAMATINE, 51
PRENATE ELITE, 100                           probenecid, 84
PRENATE ESSENTIAL, 100                       probenecid-colchicine, 84
PRENEXA, 100                                 procainamide, 43
PRENEXA PREMIER, 100                         procainamide hcl injection, 43
PREPIDIL, 102                                procaine, 2
PREQUE 10, 100                               PROCALAMINE, 89
PREVACID 30 MG SOLUTAB, -DR 30 MG            procarbazine, 19
  CAPSULE, 74                                PROCARDIA, 45
Formulary ID 11155 V.4

PROCARDIA XL, 45                               proparacaine, 106
PROCENTRA, 31                                  proparacaine hcl, 107
PROCHIEVE, 102                                 PROPINE, 103
prochlorperazine edisylate, 25, 26             propranolol, 43
prochlorperazine maleate rectal, -tablet, 26   propranolol hcl cap sa, -solution, -tablet, 44
PROCRIT 10,000 UNITS/ML VIAL, -2,000           propranolol hcl injection, 44
  UNITS/ML VIAL, -3,000 UNITS/ML VIAL, -       propranolol-hydrochlorothiazid, 50
  4,000 UNITS/ML VIAL, 77                      propylthiouracil, 63
PROCRIT 20,000 UNITS/ML VIAL, -40,000          PROQUAD, 78
  UNITS/ML VIAL, 77                            PROQUIN XR, 15
PROCTOCORT, 73                                 PROSCAR, 113
PROCTOCREAM-HC, 73                             PROSOL, 89
procto-pak, 73                                 PROSTIGMIN, 37
proctosol-hc, 73                               PROSTIN E2 VAGINAL SUPPOSITORY, 94
proctozone-hc, 73                              PROSTIN VR PEDIATRIC, 51
PRODIGY INSULIN SYRINGE, 82                    protamine, 90
PRODIGY PEN NEEDLE, 82                         PROTAMINE SULFATE, 90
progesterone, 101, 102                         PROTON PUMP INHIBITORS, 73
progesterone in oil, 102                       PROTONIX DR 20 MG TABLET, 74
progesterone injection, 102                    PROTONIX DR 40 MG TABLET, -PKT, 74
PROGESTIN DRUGS, 101                           PROTONIX IV, 74
PROGLYCEM, 65                                  PROTOPAM CHLORIDE, 61
PROGRAF 0.5 MG CAPSULE, -1 MG CAPSULE,         PROTOPIC, 59
  20                                           protriptyline, 38
PROGRAF 5 MG CAPSULE, 20                       protriptyline hcl, 38
PROGRAF INJECTION, 20                          PROVENTIL HFA, 109
PROLASTIN, 112                                 PROVERA, 102
PROLASTIN C, 112                               PROVIGIL, 31
PROLEUKIN, 80                                  PROZAC 10 MG PULVULE, 40
PROLIA, 69                                     PROZAC 20 MG PULVULE, 40
PROMACTA, 80                                   PROZAC 40 MG PULVULE, 40
promethazine, 109                              PROZAC WEEKLY, 40
promethazine hcl injection, 109                PRUDOXIN, 59
promethazine hcl rectal, 26                    pruet dha, 100
promethazine hcl syrup, -tablet, 109           pruet dha ec, 100
promethazine vc, 108                           pse/acrivas, 108
promethegan, 26                                pse/desloratadine, 108
PROMETRIUM, 102                                pse/fexofenadine, 108
PRONESTYL, 43                                  PULMICORT 180 MCG FLEXHALER, 111
propafenone, 43                                PULMICORT 90 MCG FLEXHALER, 112
propafenone hcl, 43                            PURINETHOL, 20
propantheline bromide, 71                      PYLERA, 73
Formulary ID 11155 V.4

pyrazinamide, 5                               RAZADYNE, 22
pyridostigmine, 37, 38                        RAZADYNE ER, 22
pyridostigmine bromide, 37                    REBETOL SOLUTION, -CAP, 10
pyrimethamine, 14                             REBIF 22 MCG/0.5 ML SYRINGE, -44
QUALAQUIN, 14                                   MCG/0.5 ML SYRINGE, 79
quasense, 96                                  REBIF TITRATION PACK, 79
QUESTRAN, 48                                  RECLAST, 69
QUESTRAN LIGHT, 48                            reclipsen, 96
quetiapine fumarate, 24, 25                   RECOMBIVAX HB, 78
quinapril, 42                                 REFLUDAN, 92
quinapril hcl, 42                             REGLAN INJECTION, 71
quinapril/hctz, 49                            REGLAN TABLET, 71
quinapril-hydrochlorothiazide, 50             REGONOL, 38
quinidine gluconate injection, 43             REGRANEX, 59
quinidine gluconate tab sa, 43                RELAGARD, 98
quinidine sulfate tab sa, -tablet, 43         RELENZA, 10
quinine sulfate, 14                           RELION NOVOLIN 70-30 VIAL, -RELION
QUINOLONES, 14                                  VIAL, 66
quinupristin/dalfopristin, 9                  RELION NOVOLIN N 100 UNITS/ML, -RELION
QUIXIN, 105                                     100 UNITS/ML, 66
QVAR, 112                                     RELISTOR, 73
RABAVERT, 78                                  RELPAX, 33
rabeprazole sodium, 73                        REMERON, 36
rabies immune globulin, 77                    remeven, 59
rabies vac,pf chick-emb cell, 78              REMICADE, 20
rabies vaccine,human diploid, 77              remifentanil, 22
raloxifene, 68                                REMODULIN, 51
raltegravir potassium, 4                      RENACIDIN, 113
ramelteon, 38                                 renaf, 90
ramipril, 42                                  RENAGEL, 86
RANEXA, 51                                    RENAMIN, 89
ranibizumab, 107                              re-nata 29, 100
ranitidine, 71                                re-nata 29 ob, 100
ranitidine 150 mg tablet, -300 mg tablet, -   RENVELA, 86
   cap, -syrup, 71                            REOPRO, 86
ranitidine hcl injection, 71                  repaglinide, 67
ranolazine, 51                                repaglinide/metformin hcl, 67
RAPAFLO, 113                                  reprexain, 30
RAPAMUNE, 20                                  REQUIP, 37
rapiflux 20 mg tablet, 40                     REQUIP XL, 37
rasagiline mesylate, 36                       RESCRIPTOR, 4
rasburicase, 18                               RESECTISOL, 89
Formulary ID 11155 V.4

reserpine, 50                                    rifampin/inh/pyrazinamide, 5
RESPIRATORY MEDICATIONS, 108                     rifampin/isoniazid, 5
RESTASIS, 107                                    rifapentine, 5
retapamulin, 16                                  RIFATER, 5
RETIN-A, 54                                      rifaximin, 9
RETIN-A MICRO, 54                                rilonacept, 79
RETIN-A MICRO PUMP, 54                           RILUTEK, 83
RETISERT, 104                                    riluzole, 83
RETROVIR CAP, -SYRUP, -TABLET, 4                 rimantadine, 10
RETROVIR INJECTION, 4                            rimantadine hcl, 10
re-u40, 59                                       rimexolone, 104
revatio (sildenafil citrate), 51                 RIMSO-50, 113
REVATIO INJECTION, 51                            ringers injection, 89
REVATIO TABLET, 51                               RIOMET, 67
REVIA, 38                                        risedron sod/calcium carbona, 68
REVLIMID, 20                                     risedronate, 68
revonto, 83                                      RISPERDAL CONSTA 12.5 MG SYR, -25 MG
REYATAZ, 4                                          SYR, 24
R-GENE 10, 89                                    RISPERDAL CONSTA 37.5 MG SYR, -50 MG
RHEUMATREX, 20                                      SYR, 24
RHINOCORT AQUA, 62                               RISPERDAL M-TAB, 24
rho(d) immune globulin, 77, 78                   RISPERDAL SOLUTION, 24
RHOGAM, 78                                       RISPERDAL TABLET, 24
RHOGAM PLUS, 78                                  risperidone, 24
RHOPHYLAC, 78                                    risperidone m-tab, 24
ribapak, 10                                      risperidone odt, 24
ribasphere 200 mg tablet, 10                     risperidone solution, 24
ribasphere 400 mg tablet, -600 mg tablet, -      risperidone tablet, 24
   cap, 10                                       RITALIN, 31
RIBATAB, 10                                      RITALIN LA, 31
ribavirin, 10, 11                                RITALIN-SR, 31
ribavirin 200 mg tablet, 10                      ritonavir, 4
ribavirin 400 mg tablet, -600 mg tablet, -cap,   ritonavir/lopinavir, 4
   10                                            RITUXAN, 20
RIDAURA, 85                                      rituximab, 20
rifabutin, 5                                     rivastigmine, 22
RIFADIN CAP, 5                                   rivastigmine tartrate, 22
RIFADIN INJECTION, 5                             rizatriptan benzoate, 32
RIFAMATE, 5                                      ROBAXIN INJECTION, 83
rifampin, 5                                      ROBAXIN TABLET, 83
rifampin cap, 5                                  ROBAXIN-750, 83
rifampin injection, 5                            ROBINUL FORTE, 71
Formulary ID 11155 V.4

ROBINUL INJECTION, 71                  salsalate tablet, 86
ROBINUL TABLET, 71                     SAL-TROPINE, 71
ROCALTROL, 93                          SAMSCA, 69
ROCEPHIN, 6                            SANCTURA, 113
ROMAZICON, 38                          SANCTURA XR, 113
romycin, 105                           SANCUSO, 26
ropinirole, 37                         SANDIMMUNE CAP, 20
ropinirole hcl, 37                     SANDIMMUNE INJECTION, 20
ropivacaine, 1                         SANDIMMUNE SOLUTION, 20
rosaderm emulsion, 54                  SANDOSTATIN, 20
ROSANIL, 54                            SANDOSTATIN LAR 10 MG KIT, -30 MG KIT,
rosiglitazone maleate, 66                20
rosiglitazone maleate/glimepir, 66     SANDOSTATIN LAR 20 MG KIT, 20
rosiglitazone/metformin hcl, 66        SANTYL, 59
rosuvastatin calcium, 46               SAPHRIS, 24
ROTARIX, 78                            sapropterin dihydrochloride, 69
ROTATEQ, 78                            saquinavir mesylate, 4
rotavirus vac, live att, 89-12, 78     SARAFEM 10 MG TABLET, 40
rotavirus vac, live pentav, 78         SARAFEM 15 MG TABLET, 40
ROWASA, 73                             SARAFEM 20 MG TABLET, 40
ROXICET SOLUTION, 29                   sargramostim, 80
roxicet tablet, 29                     SAVELLA 100 MG TABLET, -12.5 MG TABLET,
ROXICODONE, 29                           -25 MG TABLET, -50 MG TABLET, 36
ROXICODONE INTENSOL, 29                SAVELLA TITRATION PACK, 36
ROZEREM, 38                            saxagliptin hcl/metformin hcl, 67
rubella vaccine, 77                    saxagliptin hydrochloride, 67
rufinamide, 34                         SCABICIDES, 56
RYBIX ODT, 21                          SCALACORT, 58
RYTHMOL, 43                            SCOPACE, 71
RYTHMOL SR, 43                         scopolamine, 26, 71, 107
RYZOLT, 21                             SCOPOLAMINE HYDROBROMIDE INJECTION,
SABRIL, 35                               71
SAFESNAP INSULIN SYRINGE, 82           SEASONALE, 96
SAFETYGLIDE INSULIN SYRINGE, 82        SEASONIQUE, 96
SAFETYGLIDE SYRINGE INSULIN SYRINGES   seb-prev cream, -gel, 55
  - DISPOSABLE, 82                     SECONDARY AMINES, 38
SAFYRAL, 96                            SECTRAL, 44
SAIZEN, 75                             SEDATIVE/HYPNOTIC DRUGS, 38
SALAGEN, 63                            SELECTIVE SEROTONIN REUPTAKE
SALICYLATES AND RELATED DRUGS, 86        INHIBITORS, 39
salmeterol, 109                        SELECT-OB, 100
salmeterol/fluticasone, 110            SELECT-OB + DHA, 100
Formulary ID 11155 V.4

selegiline, 34, 36, 37                         sf, 90
selegiline hcl cap, -tablet, 37                sf 5000 plus, 90
selenium sulfide, 55                           SFROWASA, 73
selenium sulfide 2.25% shampoo, -2.5%          SILENOR, 38
  lotion, -sulf 2.5% shampoo, 55               silodosin, 113
selenos, 55                                    SILVADENE, 16
selfemra 10 mg capsule, 40                     silver sulfadiazine, 16
selfemra 20 mg capsule, 40                     SIMCOR 1,000-20 MG TABLET, -750-20 MG
SELSEB, 55                                        TABLET, 47
SELZENTRY, 4                                   SIMCOR 1,000-40 MG TABLET, -500-20 MG
SEMPREX-D, 108                                    TABLET, -500-40 MG TABLET, 47
se-natal one, 100                              SIMPONI, 20
SENSIPAR, 69                                   SIMULECT, 20
SENSORCAINE, 2                                 simvastatin, 47
SENSORCAINE WITH DEXTROSE, 2                   simvastatin tablet, 47
SENSORCAINE WITH EPINEPHRINE, 2                sinecatechins, 60
SENSORCAINE-MPF, 2                             SINEMET 10-100, 37
SENSORCAINE-MPF EPINEPHRINE, 2                 SINEMET 25-100, 37
SEPTRA, 15                                     SINEMET 25-250, 37
SEPTRA DS, 15                                  SINEMET CR, 37
SEREVENT DISKUS, 109                           SINGLE USE SWAB, 82
SEROMYCIN, 5                                   SINGULAIR, 110
SEROQUEL 100 MG TABLET, -200 MG                sirolimus, 20
  TABLET, -25 MG TABLET, -50 MG TABLET,        sitagliptin phos/metformin hcl, 67
  24                                           sitagliptin phosphate, 67
SEROQUEL 300 MG TABLET, -400 MG                SKELAXIN, 83
  TABLET, 25                                   SKELID, 69
SEROQUEL XR 150 MG TABLET, -200 MG             SMOKING CESSATION PRODUCTS, 40
  TABLET, 25                                   sodium acetate injection, 89
SEROQUEL XR 300 MG TABLET, -400 MG             sodium benzoate/na ph-acetate, 60
  TABLET, -50 MG TABLET, 25                    sodium bicarbonate, 88
SEROSTIM, 75                                   sodium bicarbonate injection, 89
sertaconazole nitrate, 12                      sodium chloride 0.45% irrig, -0.9% irrig., -
sertraline, 40                                    sterile saline 0.9% irr, 89
sertraline hcl 100 mg tablet, -50 mg tablet,   sodium chloride 0.45% soln, -0.45% soln-
  40                                              excel con, -0.9% soln, -0.9% soln., -0.9%
sertraline hcl 25 mg tablet, 40                   soln-excel cont, -0.9% solution, -3% iv
sertraline hcl solution, 40                       soln, -4 meq/ml vl, -5% iv soln, -cl 2.5
setonet, 100                                      meq/ml vial, 89
setonet-ec, 101                                sodium citrate & citric acid, 93
sevelamer, 86                                  sodium citrate/citric acid, 93
sevelamer carbonate, 86                        SODIUM EDECRIN, 48
Formulary ID 11155 V.4

sodium fluoride, 90                             sotret, 56
sodium fluoride chew tab, -dental/mucous        SPECIALIZED OB/GYN DRUGS, 102
  membrn products, -oral drops, -tablet, 90     SPECTRACEF, 6
sodium fluoride/pot nitrate, 90                 SPIRIVA, 112
sodium lactate, 89                              spironolactone, 51
sodium oxybate, 38                              spironolactone tablet, 52
sodium phenylbutyrate, 60                       spironolactone/hctz, 51
sodium phosphate injection, 89                  spironolactone-hctz, 52
sodium phosphate/na biphos, 71, 72              SPORANOX CAP, 8
sodium polystyrene sulfonate, 92                SPORANOX SOLUTION, 8
sodium sulfacetamide-sulfur foam (non-          sprintec, 96
  contraceptive), -oil,shampoo,cleanser, -      SPRYCEL, 20
  pad, medicated pad, -sulfacetamide-sulfur     sps, 92
  lotn, -sulf-sulfur wash, -suspensions, (not   sronyx, 96
  oral), 54                                     ssd, 16
sodium tetradecyl sulfate, 61                   ssd af, 16
sodium,potassium,&mag sulfate, 73               stagesic, 30
sodium/calcium/mag/potassium, 106               STALEVO 100, 37
SOLARAZE, 59                                    STALEVO 125, 37
solia, 96                                       STALEVO 150, 37
solifenacin succinate, 113                      STALEVO 200, 37
SOLODYN, 16                                     STALEVO 50, 37
SOLU-CORTEF, 64                                 STALEVO 75, 37
SOLU-CORTEF (PF), 64                            stannous fluoride, 90
SOLU-MEDROL (PF), 64                            stannous fluoride dental/mucous membrn
SOLU-MEDROL 1 GM VIAL, -2,000 MG VIAL,             products, 90
  -40 MG VIAL, -125 MG VIAL, -500 MG            STARLIX, 67
  VIAL, 64                                      stavudine, 4, 5
SOMA, 83                                        STAVZOR, 41
somatropin, 75                                  STELARA, 20
SOMATULINE DEPOT, 20                            STIMATE, 69
SOMAVERT, 69                                    STRATTERA, 38
SONATA 10 MG CAPSULE, 38                        streptomycin, 5
SONATA 5 MG CAPSULE, 38                         STREPTOMYCIN SULFATE INJECTION, 5
sorafenib tosylate, 19                          STRIANT, 94
SORIATANE, 55                                   STROMECTOL, 3
SORIATANE CK, 55                                sublimaze, 29
sorine, 49                                      SUBOXONE ORALLY DISSOLVING STRIPS, 30
sotalol, 49                                     SUBOXONE TAB, SL, 30
sotalol af, 49                                  SUBUTEX, 30
SOTALOL HCL, 49                                 succimer, 60
SOTRADECOL, 61                                  SUCCINIMIDES, 41
Formulary ID 11155 V.4

succinylcholine, 83                               sumatriptan succinate tablet, 33
sucralfate, 72                                    SUMAXIN, 54
sucralfate oral susp, -tablet, 72                 SUMAXIN TS, 54
sufenta, 21                                       sunitinib malate, 20
sufentanil 50 mcg/ml ampul, 22                    SUPPRELIN LA, 102
SULAR, 45                                         SUPRAX, 6
sulconazole nitrate, 12                           SUPREP, 73
sulfac, 105                                       SURE COMFORT, 82
sulfacetamide sodium, 55, 105                     SURE COMFORT ALCOHOL, 82
sulfacetamide sodium lotion, 55                   SURE-FINE PEN NEEDLES, 82
sulfacetamide sodium ophth drops, 105             SURE-JECT INSULIN SYRINGE, 82
sulfacetamide/prednisolone ac, 103, 104           SURE-PREP ALCOHOL PREP PADS, 82
sulfacetamide/sulfur, 53, 54                      SURMONTIL, 41
sulfacetamide-prednisolone, 104                   SUSTIVA, 4
sulfadiazine tablet, 15                           SUTENT, 20
sulfamethoxazole/trimethoprim, 15                 SYMBICORT, 112
sulfamethoxazole-trimethoprim injection, 15       SYMBYAX, 25
sulfamethoxazole-trimethoprim oral susp, -        SYMLIN, 65
  tablet, 15                                      SYMLINPEN 120, 65
sulfamide, 105                                    SYMLINPEN 60, 65
SULFAMYLON, 16                                    SYNAGIS, 78
sulfanilamide, 98                                 SYNALGOS-DC, 30
sulfasalazine, 72                                 SYNAREL, 102
sulfasalazine dr, 73                              SYNERA, 2
sulfasalazine tablet, 73                          SYNERCID, 9
sulfatol c, 54                                    SYNTHROID, 70
sulfatrim, 15                                     SYPRINE, 85
sulfazine, 73                                     TABLOID, 20
sulfazine ec, 73                                  TACLONEX, 55
SULFONAMIDES, 15                                  TACLONEX SCALP, 55
sulfuric acid/sulf phenol, 63                     tacrine, 22
sulindac, 84                                      tacrolimus, 20, 59
sulindac tablet, 85                               tacrolimus 0.5 mg capsule, -1 mg capsule, 20
sumatriptan, 32, 33                               tacrolimus 5 mg capsule, 20
SUMATRIPTAN 20 MG NASAL SPRAY, 33                 TALWIN 30 MG/ML AMPUL, 22
sumatriptan 4 mg/0.5 ml kit, -4 mg/0.5 ml         TALWIN 30 MG/ML VIAL, 22
  refill, -4 mg/0.5 ml syrng, -6 mg/0.5 ml kit,   TAMBOCOR, 43
  -6 mg/0.5 ml refill, -6 mg/0.5 ml syrng, 33     TAMIFLU 30 MG GELCAP, 11
sumatriptan 4 mg/0.5 ml vial, -6 mg/0.5 ml        TAMIFLU 45 MG GELCAP, -75 MG GELCAP,
  vial, 33                                          11
SUMATRIPTAN 5 MG NASAL SPRAY, 33                  TAMIFLU SUSPENSION, 11
sumatriptan suc/naproxen sod, 33                  tamoxifen citrate tablet, 20
Formulary ID 11155 V.4

tamsulosin, 113                             terbinafine, 8, 12
tamsulosin hcl, 113                         terbinafine hcl, 8
TANDEM DHA, 101                             terbinafine/hydroxy chitosan, 8
TANDEM OB, 101                              TERBINEX, 8
TAPAZOLE, 63                                terbutaline sulfate injection, 109
tapentadol hcl, 29                          terbutaline sulfate tablet, 109
TARCEVA, 20                                 terconazole, 17
TARGRETIN, 21                               terconazole 0.4% cream, 17
TARKA, 50                                   terconazole 0.8% cream, 17
TASIGNA, 21                                 terconazole 80 mg suppository, 17
TASMAR, 37                                  teriparatide, 69
tazarotene, 55                              TERRAMYCIN, 16
TAZICEF, 6                                  TERRAMYCIN IM, 16
TAZORAC, 55                                 TERRAMYCIN WITH POLYMYXIN, 105
taztia xt, 45                               TERSI FOAM, 55
TEFLARO, 6                                  TERTIARY AMINES, 41
TEGRETOL, 27                                TERUMO INSULIN SYRINGE, 82
TEGRETOL XR 100 MG TABLET, 27               TERUMO SURGUARD, 82
TEGRETOL XR 200 MG TABLET, -400 MG          tesamorelin acetate, 75
   TABLET, 27                               TESTIM, 94
TEKAMLO, 50                                 TESTOPEL, 94
TEKTURNA, 50                                testosterone, 94
TEKTURNA HCT, 50                            testosterone cypionate, 94
telavancin, 9                               testosterone cypionate injection, 94
telbivudine, 11                             testosterone enanthate, 94
telithromycin, 7                            testosterone propionate, 94
telmisartan, 42                             TESTRED, 94
telmisartan/amlodipine, 50                  TETANUS DIPHTHERIA TOXOIDS, 78
telmisartan/hctz, 50                        tetanus immune globulin, 77
TEMOVATE, 58                                tetanus toxoid adsorbed, 78
TEMOVATE EMOLLIENT, 58                      tetanus,diphtheria toxoid, 76, 78
TENEX, 46                                   TETANUS-DIPHTERIA-DECAVAC, 78
tenofovir disproxil fumarate, 5             tetrabenazine, 38
TENORETIC 100, 50                           tetracyc hcl/bis ss/metronid, 72
TENORETIC 50, 50                            tetracycline hcl cap, 16
TENORMIN, 44                                TETRACYCLINES, 15
TERAZOL 3 80 MG SUPPOSITORY, 17             tetrahydrozoline, 62
TERAZOL 3 CREAM, 17                         TEVETEN, 42
TERAZOL 7, 17                               TEVETEN HCT, 50
terazosin 1 mg capsule, -2 mg capsule, -5   TEV-TROPIN, 75
   mg capsule, 52                           TEXACORT, 58
terazosin 10 mg capsule, 53                 thalidomide, 61
Formulary ID 11155 V.4

THALITONE, 52                           tiotropium bromide, 112
THALOMID, 61                            tipranavir/vitamin e tpgs, 4
THEO-24, 110                            tirofib hc m-hyd/na chlor, 86
theochron, 110                          TIROSINT, 70
theophylline, 110                       tizanidine, 83
theophylline anhydrous tab sa, 110      tizanidine hcl, 83
THERACYS, 21                            TOBRADEX, 104
THERAPEUTIC VITAMINS AND MINERALS, 93   TOBRADEX ST, 104
thermazene, 16                          tobramycin, 105
THIAZIDE AND RELATED DRUGS, 52          tobramycin sulfate in ns, 3
THINPRO INSULIN SYRINGE, 82             tobramycin sulfate injection, 3
thioguanine, 20                         tobramycin sulfate ophth drops, 105
thioridazine hcl, 25                    tobramycin sulfate/dexameth, 104
thiothixene, 24, 25                     tobramycin/lotepred etab, 104
THROMBATE III, 92                       tobramycin-dexamethasone, 104
THROMBOPOIETIC AGENTS, 80               tobrasol, 105
THYMOGLOBULIN, 78                       TOBREX, 105
thyroid, 69                             tocilizumab, 79
THYROID SUPPLEMENTS, 69                 TOFRANIL, 41
THYROLAR-1, 70                          TOFRANIL-PM, 41
THYROLAR-1/2, 70                        tolazamide, 67
THYROLAR-1/4, 70                        tolbutamide, 67
THYROLAR-2, 70                          tolcapone, 37
THYROLAR-3, 70                          tolmetin sodium, 85
tiagabine, 34                           tolterodine tartrate, 112
TIAZAC, 45                              tolvaptan, 69
ticarcillin/k clavulanate, 14           TOPAMAX, 35
ticlopidine hcl, 86                     TOPCARE CLICKFINE, 82
TIGAN CAP, 26                           TOPCARE ULTRA COMFORT, 82
TIGAN INJECTION, 26                     TOPICAL ANESTHETICS, 2
tigecycline, 9                          TOPICAL ANTIBACTERIAL DRUGS, 16
TIKOSYN, 49                             TOPICAL ANTIFUNGAL-CORTICOSTEROID
tilia fe, 96                               COMB., 16
tiludronate, 69                         TOPICAL ANTI-INFLAMMATORY DRUGS, 56
TIMENTIN, 14                            TOPICAL CORTICOSTEROID DRUGS, 56
timolol, 103                            TOPICAL DERMATOLOGICAL DRUGS, 59
timolol maleate ophth drops, 103        TOPICORT, 58
timolol maleate tablet, 44              TOPICORT LP, 58
TIMOPTIC, 103                           topiragen, 35
TIMOPTIC OCUDOSE, 103                   topiramate, 35
TIMOPTIC-XE, 103                        topiramate sprinkle, -tablet, 35
tinzaparin sodium, porcine, 91          topisulf, 54
Formulary ID 11155 V.4

TOPROL XL, 44                         tretinoin 0.025% cream, -0.05% cream, -
TORADOL, 85                              0.1% cream, -gel, 54
toremifene, 19                        tretinoin cap, 21
torsemide, 48                         tretinoin/emol cmb9/skin cln1, 54
torsemide injection, 48               TRETIN-X, 54
torsemide tablet, 48                  TREXALL, 21
TOTACILLIN-N, 14                      TREXIMET, 33
TOVIAZ, 113                           trezix, 30
TPN ELECTROLYTES, 89                  triamcinolone acetonide, 58, 62, 63, 64, 104
TPN ELECTROLYTES II, 89               triamcinolone acetonide cream, -lotion, -oint,
TRACLEER, 46                             58
tramadol, 21, 22                      triamcinolone acetonide injection, 64
tramadol hcl tab sa, 22               triamcinolone acetonide paste, 63
tramadol hcl tablet, 22               triamcinolone hexacetonide, 63
tramadol hcl-acetaminophen, 22        triamterene, 51
tramadol/apap, 22                     triamterene-hctz, 52
TRANDATE, 44                          TRIBENZOR, 50
trandolapril, 42                      TRICARE, 101
trandolapril/verapamil, 50            TRICARE PRENATAL DHA ONE, 101
trandolapril-verapamil, 50            tricitrates, 113
tranexamic acid, 60                   TRICOR, 48
TRANSDERM-SCOP, 26                    triderm, 58
tranylcypromine, 34                   trientine, 85
tranylcypromine sulfate, 34           TRIESENCE, 104
TRAVASOL, 89                          trifluoperazine hcl, 25
TRAVASOL WITH ELECTROLYTES, 89        trifluridine, 106
TRAVATAN, 103                         TRIGLIDE, 48
TRAVATAN Z, 103                       trihexyphenidyl hcl, 23
travoprost, 103                       TRIHIBIT, 78
trazodone, 35                         tri-legest fe, 97
trazodone hcl tablet, 36              TRILEPTAL, 27
treagan otic, 61                      TRILIPIX, 48
TRECATOR, 5                           trilyte with flavor packets, 73
TRELSTAR 11.25 MG SYRINGE, -3.75 MG   trimethobenzamide, 26
   SYRINGE, 21                        trimethobenzamide hcl cap, 26
TRELSTAR 22.5 MG SYRINGE, -22.5 MG    trimethobenzamide hcl injection, 26
   VIAL, 21                           trimethoprim, 17
TRELSTAR DEPOT, 21                    trimethoprim tablet, 17
TRELSTAR LA, 21                       trimipramine, 41
TRENTAL, 51                           trinate, 101
treprostinil sodium, 51               trinessa, 97
tretinoin, 53, 54                     TRI-NORINYL, 97
Formulary ID 11155 V.4

TRIOSTAT, 70                             ULTRA COMFORT, 82
TRIPEDIA, 78                             ULTRACET, 22
tripohist, 109                           ULTRACOMFORT INSULIN NEEDLES -
tri-previfem, 97                           DISPOSABLE, -INSULIN SYRINGES -
triprolidine hcl syrup, 109                DISPOSABLE, 82
triptorelin pamoate, 21                  ULTRAM, 22
tri-sprintec, 97                         ULTRAM ER, 22
trivora-28, 97                           ULTRAVATE, 58
TRIZIVIR, 4                              ULTRAVATE PAC, 58
TROPHAMINE, 89                           UMECTA, 59
tropicacyl, 107                          UMECTA PD, 59
tropicamide, 107                         UNASYN, 14
trospium chloride, 113                   UNIFINE PENTIPS, 82
TRUSOPT, 103                             UNIPHYL, 110
TRUVADA, 4                               UNIRETIC, 50
TWINJECT, 112                            unithroid, 70
TWINRIX, 78                              UNIVASC, 42
TWYNSTA, 50                              URAMAXIN, 59
TYGACIL, 9                               URAMAXIN GT, 59
TYKERB, 21                               urea, 59
TYLENOL-CODEINE NO.3, 30                 urea 35% lotion, -40% cream, -40% lotion, -
TYLENOL-CODEINE NO.4, 30                   45% cream, -50% cream, -50% nail stick,
TYLOX, 29                                  -50% nailstik, -foam (non-contraceptive), -
TYPHIM VI, 78                              gel, -oint, -pad, medicated pad, 60
typhoid vaccine, 78                      urea 40, 60
TYSABRI, 21                              URECHOLINE, 113
TYZEKA, 11                               URINARY ANTIINFECTIVES, 17
TYZINE, 62                               UROLOGICAL MEDICATIONS, 112
u40, 59                                  UROQID-ACID NO.2, 17
U-CORT, 58                               UROXATRAL, 113
ULESFIA, 56                              URSO, 73
ulipristal acetate, 95                   URSO FORTE, 73
ULORIC, 84                               ursodiol, 72, 73
ULTICARE INSULIN NEEDLES - DISPOSABLE,   ursodiol cap, -tablet, 73
   -INSULIN SYRINGES - DISPOSABLE, 82    ustekinumab, 20
ULTIGUARD 30GX0.5 ML SYRINGE, -30GX1     utac, 17
   ML SYRINGE, -INSULIN SYRINGES -       VAGIFEM, 98
   DISPOSABLE, 82                        VAGINAL ANTIFUNGALS, 17
ULTILET ALCOHOL SWAB, 82                 valacyclovir, 11
ULTILET INSULIN SYRINGE, 82              VALCYTE, 11
ULTILET PEN NEEDLE, 82                   valganciclovir, 11
ULTIVA, 22                               valproate sodium, 41
Formulary ID 11155 V.4

valproate sodium injection, 41                 venlafaxine hcl er 150 mg tab, 225 mg tab, -
valproic acid, 41                                37.5 mg tab, -75 mg tab, (Schwarz
VALPROIC ACID AND DERIVATIVES, 41                Pharmac, Sun Pharma), 36
valproic acid cap, -syrup, 41                  venlafaxine hcl er 75 mg cap, 36
valsartan, 42                                  VENTOLIN HFA, 109
VALTREX, 11                                    VERAMYST, 63
VALTURNA, 50                                   verapamil, 44, 45
VANCOCIN HCL, 9                                verapamil er, 45
vancomycin, 9                                  verapamil er pm, 45
vancomycin 1 gm add-van vial, -1 gm vial, -    verapamil hcl cap sa, -tab sa, -tablet, 45
  10 gm vial, -1g/200 ml bag, -5 gm vial, -    verapamil hcl injection, 45
  500 mg vial, -750 mg vial, 9                 VERDESO, 58
vancomycin 500 mg a/v vial, 9                  VEREGEN, 60
VANCOMYCIN-D5W, 9                              VERELAN, 45
vandazole, 98                                  VERELAN PM, 45
VANISHPOINT INSULIN SYRINGES -                 veripred 20, 64
  DISPOSABLE, 82                               VERSALON ALL PURPOSE SPONGE, 82
VANOS, 58                                      verteporfin, 107
VANTAS, 21                                     VESICARE, 113
VANTIN, 6                                      VEXOL, 104
VAQTA, 78                                      VFEND, 8
varenicline tartrate, 40                       VFEND IV, 13
varicella vacc/pf, 78                          VIBATIV, 9
varicella virus vaccine live, 78               VIBRAMYCIN 50 MG CAPSULE, 16
VARIVAX VACCINE, 78                            VIBRAMYCIN SUSPENSION, -SYRUP, -100
VASERETIC, 50                                    MG CAPSULE, 16
VASODILATOR ANTIHYPERTENSIVES, 52              VIBRA-TABS, 16
VASOTEC, 42                                    VICODIN, 30
VECTICAL, 55                                   VICODIN ES, 30
velaglucerase alfa, 69                         VICODIN HP, 30
VELCADE, 21                                    VICOPROFEN, 30
veletri, 51                                    VICTOZA 2-PAK, 65
velivet, 97                                    VICTOZA 3-PAK, 65
VELTIN, 54                                     VIDAZA, 21
venlafaxine, 35, 36                            VIDEX, 4
venlafaxine hcl, 36                            VIDEX EC, 4
venlafaxine hcl er 150 mg cap, -37.5 mg cap,   vigabatrin, 35
  36                                           VIGAMOX, 106
VENLAFAXINE HCL ER 150 MG TAB, -225 MG         VIMOVO, 85
  TAB, -37.5 MG TAB, -75 MG TAB (Upstate       VIMPAT INJECTION, 35
  Pharma), 36                                  VIMPAT SOLUTION, -TABLET, 35
                                               vinacal, 101
Formulary ID 11155 V.4

vinate az, 101                      voriconazole, 8, 13
vinate az extra, 101                vorinostat, 21
vinate c, 101                       VOSOL, 62
vinate calcium, 101                 VOSOL HC, 62
vinate care, 101                    VOSPIRE ER, 109
vinate gt, 101                      VOTRIENT, 21
vinate ic, 101                      VPRIV, 69
vinate ii, 101                      VUSION, 12
vinate one, 101                     VYTORIN 10-10 MG TABLET, 47
vinate pn care, 101                 VYTORIN 10-20 MG TABLET, -10-40 MG
vinate ultra, 101                     TABLET, -10-80 MG TABLET, 47
vinate-m, 101                       VYVANSE, 31
VIRACEPT, 4                         warfarin sodium, 91, 92
VIRAMUNE, 4                         WEBCOL, 82
VIRAZOLE, 11                        WELCHOL, 48
VIREAD, 5                           WELLBUTRIN, 36
VIROPTIC, 106                       WELLBUTRIN SR, 36
VISICOL, 72                         WELLBUTRIN XL, 36
vis-phos n, 93                      WESTCORT, 58
visqid a-a, 17                      WINRHO SDF, 78
VISTARIL, 55                        XALATAN, 103
VISTIDE, 11                         XENAZINE, 38
VISUDYNE, 107                       XEOMIN, 83
vitafol-ob, 101                     XERAC AC, 60
VITAFOL-OB+DHA, 101                 XERESE, 11
vitafol-pn, 101                     XGEVA, 69
VITAMINS AND MINERALS AND RELATED   XIAFLEX, 61
   PRODUCTS, 93                     XIBROM, 107
vitaphil, 101                       XIFAXAN 200 MG TABLET, 9
vitaphil + dha, 101                 XIFAXAN 550 MG TABLET, 9
vitazol, 54                         XODOL 10-300, 30
VITRASERT, 107                      XODOL 5-300, 30
VIVACTIL, 38                        XODOL 7.5-300, 30
VIVAGLOBIN, 78                      XOLAIR, 112
VIVELLE-DOT, 98                     XOLEGEL, 12
VIVITROL, 38                        XOLOX, 29
vol-nate, 101                       XOPENEX HFA, 109
VOLTAREN E.C. TAB, 85               x-viate, 60
VOLTAREN GEL, 56                    XYLOCAINE DENTAL/MUCOUS MEMBRN
VOLTAREN OPHTH DROPS, 107             PRODUCTS, -GEL, 2
VOLTAREN-XR, 85                     XYLOCAINE INJECTION, 2
VOLUVEN, 61                         XYLOCAINE IV, 2
Formulary ID 11155 V.4

XYLOCAINE WITH EPINEPHRINE, 2       ZESTORETIC, 50
XYLOCAINE-MPF, 2                    ZESTRIL, 42
XYLOCAINE-MPF WITH EPINEPHRINE, 2   ZETIA, 48
XYREM, 38                           ZIAC, 50
XYZAL SOLUTION, 109                 ZIAGEN, 5
XYZAL TABLET, 109                   ZIANA, 54
YASMIN 28, 97                       ziconotide acetate, 21
YAZ, 97                             zidovudine, 4, 5
yellow fever vaccine, 78            zidovudine/lamivudine/abacavir, 4
YF-VAX, 78                          zileuton, 110
zafirlukast, 110                    ZINACEF, 6
zaleplon, 38                        ZINACEF IN ISO-OSMOTIC WATER, 7
zaleplon 10 mg capsule, 38          ZINACEF ISO-OSMOTIC DEXTROSE, 7
zaleplon 5 mg capsule, 38           ziprasidone, 23
zamicet, 30                         ZIPSOR, 85
ZANAFLEX, 83                        ZIRGAN, 107
zanamivir, 10                       ZITHRANOL-RR, 55
ZANTAC 25, 71                       ZITHROMAX 100 MG/5 ML SUSP, 11
ZANTAC INJECTION, 71                ZITHROMAX 200 MG/5 ML SUSP, 11
ZANTAC SYRUP, -TABLET, 71           ZITHROMAX 250 MG TABLET, -250 MG Z-
zarah, 97                              PAK TABLET, 11
ZARONTIN, 41                        ZITHROMAX 500 MG TABLET, 11
ZAROXOLYN, 52                       ZITHROMAX INJECTION, 11
ZAVESCA, 69                         ZITHROMAX PKT, -600 MG TABLET, 12
ZAZOLE 0.8% VAGINAL CREAM, 17       ZITHROMAX TRI-PAK, 12
ZAZOLE 80 MG VAGINAL SUPP, 17       ZMAX ADULT-PEDIATRIC, 12
ZAZOLE VAGINAL 0.4% CREAM, 17       ZOCOR, 47
ZEBETA, 44                          ZOFRAN INJECTION, 26
ZEGERID 20 MG CAPSULE, 74           ZOFRAN ODT, 26
ZEGERID 20 MG PACKET, 75            ZOFRAN SOLUTION, 26
ZEGERID 40 MG CAPSULE, 75           ZOFRAN TABLET, 27
ZEGERID 40 MG PACKET, 75            ZOLADEX, 21
ZELAPAR, 37                         zoledronic acid, 69
ZEMAIRA, 112                        ZOLINZA, 21
zema-pak, 64                        zolmitriptan, 33
ZEMPLAR CAP, 93                     ZOLOFT 100 MG TABLET, -50 MG TABLET,
ZEMPLAR INJECTION, 93                  40
zenchent, 97                        ZOLOFT 25 MG TABLET, 40
ZENCIA, 54                          ZOLOFT SOLUTION, 40
ZENPEP, 73                          zolpidem, 38, 39
ZERIT, 5                            zolpidem tartrate, 39
ZERLOR, 30                          ZOLPIMIST, 39
Formulary ID 11155 V.4

ZOLVIT, 30                             ZOVIRAX CREAM, -OINT, 11
ZOMETA, 69                             ZUPLENZ, 27
ZOMIG NASAL DROPS/SPRAYS, 33           ZYBAN, 40
ZOMIG TABLET, 33                       ZYCLARA, 60
ZOMIG ZMT, 33                          ZYDONE, 30
ZONALON, 60                            ZYFLO, 110
ZONEGRAN, 35                           ZYFLO CR, 110
zonisamide, 35                         ZYLET, 104
ZORBTIVE, 75                           ZYLOPRIM, 84
ZORPRIN, 86                            ZYMAR, 106
ZORTRESS 0.25 MG TABLET, 21            ZYMAXID, 106
ZORTRESS 0.5 MG TABLET, -0.75 MG       ZYPREXA INJECTION, 25
  TABLET, 21                           ZYPREXA RELPREVV, 25
ZOSTAVAX, 78                           ZYPREXA TABLET, 25
ZOSYN, 14                              ZYPREXA ZYDIS, 25
zovia 1-35e, 97                        ZYVOX INJECTION, 9
zovia 1-50e, 97                        ZYVOX ORAL SUSP, -TABLET, 9
ZOVIRAX CAP, -ORAL SUSP, -TABLET, 11
                                                  one                       TO                 one

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Y0010_BCI_CS 11148 File and Use 10/3/2010                                                                           Form 3-218TB PDF11/12/2010

								
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