scripps health formulary...scripps health formulary administered by medimpact effective october 2017...

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Scripps Health Formulary Administered by MedImpact Effective October 2017 Foreword This document represents the efforts of the MedImpact Healthcare Systems Pharmacy and Therapeutics (P & T) and Formulary Committees to provide physicians and pharmacists with a method to evaluate the safety, efficacy and cost- effectiveness of commercially available drug products. A structured approach to the drug selection process is essential in ensuring continuing patient access to rational drug therapies. This is accomplished through the auspices of the MedImpact P & T and Formulary Committees. These committees meet quarterly and more often as warranted to ensure clinical relevancy of the Formulary. To accommodate changes to this document, updates are made accessible as necessary. Access to the most current version of the Portfolio High Formulary can be obtained by visiting www.MedImpact.com. The MedImpact P & T and Formulary Committees use the following criteria in the evaluation of drug selection for the Marketplace Exchange Standard Formulary: • Drug safety profile • Drug efficacy • Comparison of relevant therapeutic benefits to current formulary agents of similar use, and to minimize therapeutic duplication where possible • Cost-effectiveness relative to comparable therapies How to Use the Formulary The Formulary is a list of medications available to MedImpact members under their pharmacy benefit. All drugs are listed by their generic names and most common proprietary (branded) name. The Formulary may be accessed by using the index, either by generic or proprietary name and by therapeutic drug category. In situations where an FDA-approved generic equivalent is available, brand names are listed for reference purposes only, and do not denote coverage for the brand, unless specifically noted. All drugs are listed in each category in alphabetical order by generic name. Where an FDA-approved generic is available for the listed generic name, the generic name is . For certain agents within the Formulary, a recommended prescribing guideline may apply. These are denoted throughout the document using the following symbols: Symbol Guideline Description AGE Age Edit Coverage may depend on patient age G Gender Edit Coverage may depend on patient gender PA Prior Authorization Requires specific physician request process QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period ST Step Therapy Coverage may depend on previous use of another drug Please refer to the prescribing guideline appendix within this document for details regarding specific agents. Benefit Coverage and Limitations This printed Formulary does not provide information regarding the specific coverage and limitations an individual member may be subject to. Many members have specific benefit inclusions, exclusions, copays, or a lack of coverage, which are not reflected in the Formulary. The Formulary applies only to outpatient drugs provided to members, and does not apply to medications used in inpatient settings. If a member has any specific questions regarding their coverage, they should contact their Plan Sponsor or MedImpact at (800) 788-2949. Depending upon a member’s specific benefit parameters, the following topics may apply: 1. Generic Substitution When available, FDA-approved generic drugs are to be used in all situations, regardless of the brand name indicated. The generic names are Bolded in the formulary listing wherever an FDA-approved generic drug product is available. Greater economy is realized through the use of

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  • Scripps Health Formulary Administered by MedImpact

    Effective October 2017

    ForewordThis document represents the efforts of the MedImpactHealthcare Systems Pharmacy and Therapeutics (P & T) andFormulary Committees to provide physicians and pharmacistswith a method to evaluate the safety, efficacy and cost-effectiveness of commercially available drug products. Astructured approach to the drug selection process is essential inensuring continuing patient access to rational drug therapies.

    This is accomplished through the auspices of the MedImpact P& T and Formulary Committees. These committees meetquarterly and more often as warranted to ensure clinicalrelevancy of the Formulary. To accommodate changes to thisdocument, updates are made accessible as necessary.

    Access to the most current version of the Portfolio HighFormulary can be obtained by visitingwww.MedImpact.com.

    The MedImpact P & T and Formulary Committees use thefollowing criteria in the evaluation of drug selection for theMarketplace Exchange Standard Formulary:• Drug safety profile• Drug efficacy• Comparison of relevant therapeutic benefits to currentformulary agents of similar use, and to minimize therapeuticduplication where possible

    • Cost-effectiveness relative to comparable therapies

    How to Use the FormularyThe Formulary is a list of medications available to MedImpactmembers under their pharmacy benefit. All drugs are listed bytheir generic names and most common proprietary (branded)name. The Formulary may be accessed by using the index,either by generic or proprietary name and by therapeutic drugcategory. In situations where an FDA-approved genericequivalent is available, brand names are listed for referencepurposes only, and do not denote coverage for the brand, unlessspecifically noted.

    All drugs are listed in each category in alphabetical order bygeneric name. Where an FDA-approved generic is available forthe listed generic name, the generic name is .

    For certain agents within the Formulary, a recommendedprescribing guideline may apply. These are denoted throughoutthe document using the following symbols:

    Symbol Guideline Description

    AGE Age Edit Coverage may depend on patientage

    G Gender Edit Coverage may depend on patientgender

    PA PriorAuthorization

    Requires specific physician requestprocess

    QL QuantityLimit

    Coverage may be limited to specificquantities per prescription and/ortime period

    ST Step Therapy Coverage may depend on previoususe of another drug

    Please refer to the prescribing guideline appendix within thisdocument for details regarding specific agents.

    Benefit Coverage and LimitationsThis printed Formulary does not provide information regardingthe specific coverage and limitations an individual member maybe subject to. Many members have specific benefit inclusions,exclusions, copays, or a lack of coverage, which are notreflected in the Formulary.

    The Formulary applies only to outpatient drugs provided tomembers, and does not apply to medications used in inpatientsettings. If a member has any specific questions regarding theircoverage, they should contact their Plan Sponsor or MedImpactat (800) 788-2949.

    Depending upon a member’s specificbenefit parameters, the following topicsmay apply:1.Generic SubstitutionWhen available, FDA-approved generic drugs are to beused in all situations, regardless of the brand nameindicated. The generic names are Bolded in the formularylisting wherever an FDA-approved generic drug product isavailable. Greater economy is realized through the use of

    804 Portfolio High Formulary Page 1 of 133

  • generic equivalents. This policy is not meant to preclude orsupplant any state statutes that may exist. All drugs that areor become available generically are subject to review byMedImpact’s Pharmacy and Therapeutics Committee.MedImpact approves such multi-source drugs for additionto the MAC list based on the following criteria:• A multi-source drug product manufactured by at leastone (1) nationally marketed company.

    • At least one (1) of the generic manufacturer’s productsmust have an “A” rating or the generic product has beendetermined to be unassociated with efficacy, safety orbioequivalency concerns by the MedImpact P & TCommittee.

    • Drug product will be approved for generic substitutionby the MedImpact P & T Committee.

    This list is reviewed and updated periodically based on theclinical literature and pharmacokinetic characteristics ofcurrently available versions of these drug products. If a member or physician requests a brand name product inlieu of an approved generic, the member, based upon theircoverage, will typically be required to pay the difference incost between the brand and the generic. If a physiciandetermines that there is a documented medical need for thebrand equivalent, a request for coverage may be made usingthe medication request process.

    2.Tier Benefit DesignThe Formulary may be applied to a tier benefit design,where the member shares the cost of prescription drugtherapy based on the drug’s tier and copayment orcoinsurance. In most instances, generically available drugswill be covered in a separate lower tier (low copay),preferred branded drugs listed on the Formulary will becovered under a higher tier, and branded drugs not on theFormulary will be covered under a separate non-preferredbranded drug copay tier. Specialty drugs will be coveredunder the highest tier (highest copay). Essential healthbenefit/preventative medications, if available on your plansformulary (applies to new and non-grandfathered plans),will be covered without cost sharing (zero copay). Tier Definitions

    Tier 0: EHB Zero Copay/PreventativeTier 1: Preferred generic medications (formulary

    agents)Tier 2: Preferred brand medications (formulary

    agents)Tier 3: Non-preferred medications (non-formulary

    agents)

    3.Medication Request ProcessDepending upon plan benefit design, a medication requestprocess may apply as follows:A.Coverage Exceptions

    Drugs that are listed in the Formulary with associatedPrior Authorization (PA) require evaluation, perMedImpact P & T Committee Prior Authorizationguidelines prior to dispensing at a pharmacy. Eachrequest will be reviewed on an individual patient needbasis. If the request does not meet the guidelinesestablished by the P & T Committee, the request willnot be approved and alternative therapy may berecommended.

    B.Obtaining CoverageCoverage, questions or information regarding themedication request or formulary process may beobtained by:1. Faxing a completed Medication Request Form to

    MedImpact at (858) 790-7100.2. Contacting MedImpact at (800) 788-2949 and

    providing all necessary information requested.MedImpact will provide an authorization number,specific for the medical need, for all approvedrequests. Non-approved requests may be appealed.The prescriber must provide information to support theappeal on the basis of medical necessity. PriorAuthorization is generally not available for drugs thatare specifically excluded by benefit design.

    4.General Exclusions

    A.Over the Counter (OTC) medications or theirequivalents, unless the individual's pharmacy benefitoffers coverage of OTC medications.

    B. Drugs specifically listed as not covered.C. Any drug products used for cosmetic purposes.D. Experimental drug products or any drug product used

    in an experimental manner.E. Replacement of lost or stolen medication.F. Non self-administered injectable drug products unless

    otherwise specified in the Formulary listing.G. Foreign sourced drugs or drugs not approved by the

    United States Food & Drug Administration, except incertain cases of drug shortage, when allowed under theindividual's pharmacy benefit.

    The P & T and Formulary Committees recognize that notall medical needs can be met with this document andencourage inquiries about alternative therapies.

    5.Pharmacist and Physician Communication

    804 Portfolio High Formulary Page 2 of 133

  • The Formulary is a tool to promote cost-effectiveprescription drug use. The P & T and FormularyCommittees have made every attempt to create a documentthat meets all therapeutic needs; however, the art ofmedicine makes this a formidable task. MedImpactwelcomes the participation of physicians, pharmacists, andancillary medical providers, in this dynamic process.Physicians and pharmacists are highly encouraged to directany suggestions, comments or formulary additions toMedImpact at the following address: Chairperson, Pharmacy & Therapeutics CommitteeMedImpact Healthcare Systems, Inc.10181 Scripps Gateway CourtSan Diego, CA 92131

    804 Portfolio High Formulary Page 3 of 133

  • Attn: Prior Authorization Department10181 Scripps Gateway CourtSan Diego, CA 92131Phone: (800) 788-2949Fax: (858) 790-7100

    DO NOT WRITE IN BLOCKED AREAS FOR INTERNAL USE ONLYContacted: Approved:

    Physician: Denied:

    Pharmacy: Returned:

    Patient: PA #:

    Medication Request FormMedImpact Healthcare systems, Inc.

    Instructions:This form is to be used by participating physicians and providers to obtain coverage for a non-formulary drug for which there is nosuitable alternative available. Please complete this form and fax to MedImpact Healthcare Systems, Inc. at (858) 790-7100 orplease call (800) 788-2949 with this information. If you have any questions regarding this process, please contact MedImpact’sCustomer Service at (800) 788-2949. Review Criteria:The following guidelines are used in reviewing medication requests:1.The use of Formulary Drug Products is contraindicated in the patient.2.The patient has failed an appropriate trial of Formulary or related agents.3.The choices available in the Formulary are not suited for the present patient care need and the drug selected is required forpatient safety.

    4.The use of a Formulary Drug Product may provoke an underlying medical condition, which would be detrimental to patientcare

    Medication Request Information (please complete each section of this form prior to transmittal): PATIENT NAME (REQUIRED):

    PATIENT'S HEALTH PLAN (REQUIRED):

    PATIENT ID # (REQUIRED):

    PHYSICIAN NAME/SPECIALTY:

    PHYSICIAN ID#/DEA#:

    PATIENT DOB (REQUIRED):

    PHYSICIAN AREA CODE AND TELEPHONE NUMBER:

    DIAGNOSIS (REQUIRED):

    PHYSICIAN AREA CODE AND FAX NUMBER (REQUIRED):

    PHARMACY USED BY MEMBER:

    PHARMACY AREA CODE AND TELEPHONE NUMBER:

    DRUG REQUESTED:

    QUANTITY (PER MONTH):

    DOSE:

    LENGTH OF TREATMENT (PLEASE BE SPECIFIC):

    STRENGTH:

    DOSAGE FORM (e.g., ORAL, INJECTION):

    REASON FOR MEDICATION REQUEST (PLEASE BE SPECIFIC, GIVE DETAIL):

    OTHER MEDICATIONS TRIED AND/OF FAILED (PLEASE BE SPECIFIC, GIVE DETAIL INCLUDING REASON FOR FAILURE):

    OTHER PERTINENT HISTORY (RELATIVE OR PERTAINING TO THIS REQUEST):

  • ALLERGY2ND GEN ANTIHISTAMINE & DECONGESTANTCOMBINATIONST3DESLORATADINE/PSEUD

    OEPHEDRINECLARINEX-D 12HOUR

    ST, QL

    T1FEXOFENADINE/PSEUDOEPHEDRINE

    ALLEGRA-D 24HOUR (180-240MG)(TAB ER 24H)

    T3 PSEUDOEPHEDRINEHCL/ACRIVAS

    SEMPREX-D

    ALLERGENIC EXTRACTS, THERAPEUTICST2GR POL-ORC/SW

    VER/RYE/KENT/TIMORALAIR (100 IR)(TAB SUBL)

    PA

    T3GR POL-ORC/SWVER/RYE/KENT/TIM

    ORALAIR (100-300IR) (TAB SUBL)

    PA

    T2GR POL-ORC/SWVER/RYE/KENT/TIM

    ORALAIR (300 IR)(TAB SUBL)

    PA

    T2GRASS POLLEN-TIMOTHY, STANDARD

    GRASTEK PA

    T2WEED POLLEN-SHORTRAGWEED

    RAGWITEK PA

    ANTIHISTAMINES - 1ST GENERATIONT1CARBINOXAMINEMALEATE

    CLISTIN AGE

    T3CARBINOXAMINEMALEATE

    KARBINAL ER ST,AGE,QL

    T3CARBINOXAMINEMALEATE

    RYVENT ST,AGE,QL

    T1CLEMASTINEFUMARATE

    TAVIST

    T1CYPROHEPTADINE HCLPERIACTINT1HYDROXYZINE HCL ATARAXT1HYDROXYZINEPAMOATE

    VISTARIL

    T1PROMETHAZINE HCL PHENERGANT1PROMETHAZINE HCL PHENERGAN VC

    ANTIHISTAMINES - 2ND GENERATIONT1CETIRIZINE HCL ZYRTEC (1 MG/ML)

    (SOLUTION)T1DESLORATADINE CLARINEX (2.5 MG)

    (TAB RAPDIS)ST, QL

    T3DESLORATADINE CLARINEX (2.5MG/5ML) (SYRUP)

    ST, QL

    T1DESLORATADINE CLARINEX (5 MG)(TAB RAPDIS)

    ST, QL

    T1DESLORATADINE CLARINEX (5 MG)(TABLET)

    QL

    T1LEVOCETIRIZINEDIHYDROCHLORIDE

    XYZAL (2.5MG/5ML)(SOLUTION)

    ST, QL

    T1LEVOCETIRIZINEDIHYDROCHLORIDE

    XYZAL (5 MG)(TABLET)

    NASAL ANTIHISTAMINET1AZELASTINE HCL ASTELIN QLT1AZELASTINE HCL ASTEPRO ST, QLT1OLOPATADINE HCL PATANASE ST, QL

    NASAL ANTIHISTAMINE & ANTI-INFLAM. STEROIDCOMB.T3AZELAS/FLUTICASONE/S

    OD CHLORIDTICALAST

    T3AZELASTINE/FLUTICASONE

    DYMISTA ST, QL

    NASAL ANTI-INFLAMMATORY STEROIDST3BECLOMETHASONE

    DIPROPIONATEBECONASE AQ ST, QL

    T2BECLOMETHASONEDIPROPIONATE

    QNASL ST, QL

    T2BECLOMETHASONEDIPROPIONATE

    QNASL CHILDREN ST, QL

    T3CICLESONIDE OMNARIS ST, QLT3CICLESONIDE ZETONNA ST, QLT1FLUNISOLIDE NASALIDE QLT1FLUTICASONEPROPIONATE

    FLONASE QL

    T3 FLUTICASONE/SODCHL/SOD BICARB

    TICANASE

    T3 FLUTICASONE/SODCHL/SOD BICARB

    TICASPRAY

    T1MOMETASONEFUROATE

    NASONEX QL

    ANTIEMESIS/ANTIVERTIGOANTIEMETIC/ANTIVERTIGO AGENTST1APREPITANT APREPITANT (125

    MG) (CAPSULE)QL

    T1APREPITANT APREPITANT(125MG-80MG) (CAPDS PK)

    QL

    T1APREPITANT APREPITANT (40MG) (CAPSULE)

    QL

    T1APREPITANT APREPITANT (80MG) (CAPSULE)

    QL

    T2APREPITANT EMEND (125 MG)(CAPSULE)

    QL

    T2APREPITANT EMEND (125 MG)(SUSP RECON)

    QL

    T2APREPITANT EMEND (40 MG)(CAPSULE)

    QL

    T3DOLASETRONMESYLATE

    ANZEMET (100 MG)(TABLET)

    ST, QL

    T3DOLASETRONMESYLATE

    ANZEMET (50 MG)(TABLET)

    ST, QL

    T3DOXYLAMINESUCCINATE/VIT B6

    DICLEGIS QL

    T1DRONABINOL MARINOL ST, QLT3DRONABINOL SYNDROS ST, QLT3GRANISETRON SANCUSO ST, QLT1GRANISETRON HCL KYTRIL ST, QLT1MECLIZINE HCL ANTIVERTT3NABILONE CESAMET ST, QLT2NETUPITANT/PALONOSE

    TRON HCLAKYNZEO QL

    T1ONDANSETRON ZOFRAN ODTT3ONDANSETRON ZUPLENZ (4 MG)

    (FILM)ST, QL

    Commercial Formulary

    804 Portfolio High Formulary Page 5 of 133

  • T3ONDANSETRON ZUPLENZ (8 MG)(FILM)

    ST, QL

    T1ONDANSETRON HCL ZOFRAN (24 MG)(TABLET)

    T1ONDANSETRON HCL ZOFRAN (4 MG)(TABLET)

    T1ONDANSETRON HCL ZOFRAN (4 MG/5ML) (SOLUTION)

    QL

    T1ONDANSETRON HCL ZOFRAN (8 MG)(TABLET)

    T1PROCHLORPERAZINE COMPAZINET1PROCHLORPERAZINEMALEATE

    COMPAZINE

    T1PROMETHAZINE HCL PHENERGANT3ROLAPITANT HCL VARUBI QLT1 SCOPOLAMINE TRANSDERM-SCOPT1TRIMETHOBENZAMIDEHCL

    TIGAN

    ASTHMA AND COPD5-LIPOXYGENASE INHIBITORST3 ZILEUTON ZYFLO ST, QLT1ZILEUTON ZYFLO CR ST, QL

    ANTICHOLINERGIC, ORALLY INHALED SHORTACTINGT1 IPRATROPIUMBROMIDE

    ATROVENT

    T2 IPRATROPIUM BROMIDE ATROVENT HFA QL

    ANTICHOLINERGICS, ORALLY INHALED LONGACTINGT3ACLIDINIUM BROMIDE TUDORZA

    PRESSAIRST, QL

    T3GLYCOPYRROLATE SEEBRI NEOHALER ST, QLT2 TIOTROPIUM BROMIDE SPIRIVA QLT2 TIOTROPIUM BROMIDE SPIRIVA RESPIMAT QLT3UMECLIDINIUM

    BROMIDEINCRUSE ELLIPTA ST, QL

    BETA-ADRENERGIC AGENTST1METAPROTERENOLSULFATE

    ALUPENT

    BETA-ADRENERGIC AGENTS, INHALED, SHORTACTINGT1ALBUTEROL SULFATE ACCUNEBT1ALBUTEROL SULFATE ALBUTEROL

    SULFATET2ALBUTEROL SULFATE PROAIR HFAT2ALBUTEROL SULFATE PROAIR

    RESPICLICKT1ALBUTEROL SULFATE PROVENTILT3ALBUTEROL SULFATE PROVENTIL HFAT2ALBUTEROL SULFATE VENTOLIN HFAT1ALBUTEROL SULFATE VOSPIRE ERT1LEVALBUTEROL HCL XOPENEXT1LEVALBUTEROL HCL XOPENEX

    CONCENTRATET1LEVALBUTEROLTARTRATE

    XOPENEX HFA

    T1TERBUTALINESULFATE

    BRETHINE

    BETA-ADRENERGIC AGENTS, INHALED, ULTRA-LONG ACTINGT3 INDACATEROL MALEATEARCAPTA

    NEOHALERST, QL

    T2OLODATEROL HCL STRIVERDIRESPIMAT

    QL

    BETA-ADRENERGIC AGENTS, ORALLYINHALED,LONG ACTINGT3ARFORMOTEROL

    TARTRATEBROVANA QL

    T2 FORMOTEROLFUMARATE

    PERFOROMIST QL

    T2 SALMETEROLXINAFOATE

    SEREVENT DISKUS QL

    BETA-ADRENERGIC AND ANTICHOLINERGICCOMBINATIONST3GLYCOPYRROLATE/FOR

    MOTEROL FUMBEVESPIAEROSPHERE

    ST, QL

    T3 INDACATEROL/GLYCOPYRROLATE

    UTIBRONNEOHALER

    ST, QL

    T2 IPRATROPIUM/ALBUTEROL SULFATE

    COMBIVENTRESPIMAT

    T1 IPRATROPIUM/ALBUTEROL SULFATE

    DUONEB

    T2TIOTROPIUMBR/OLODATEROL HCL

    STIOLTO RESPIMATQL

    T3UMECLIDINIUMBRM/VILANTEROL TR

    ANORO ELLIPTA ST, QL

    BETA-ADRENERGIC AND GLUCOCORTICOIDCOMBINATIONST2BUDESONIDE/FORMOTE

    ROL FUMARATESYMBICORT QL

    T2 FLUTICASONE/SALMETEROL

    ADVAIR DISKUS QL

    T2 FLUTICASONE/SALMETEROL

    ADVAIR HFA QL

    T3 FLUTICASONE/SALMETEROL

    FLUTICASONE-SALMETEROL

    QL

    T2 FLUTICASONE/VILANTEROL

    BREO ELLIPTA QL

    T2MOMETASONE/FORMOTEROL

    DULERA QL

    GLUCOCORTICOIDS, ORALLY INHALEDT2BECLOMETHASONE

    DIPROPIONATEQVAR QL

    T1BUDESONIDE PULMICORT(0.25MG/2ML)(AMPUL-NEB)

    QL

    T1BUDESONIDE PULMICORT (0.5MG/2ML) (AMPUL-NEB)

    QL

    T1BUDESONIDE PULMICORT (1MG/2 ML) (AMPUL-NEB)

    QL

    T3BUDESONIDE PULMICORTFLEXHALER

    ST, QL

    T3CICLESONIDE ALVESCO ST, QL

    Commercial Formulary

    804 Portfolio High Formulary Page 6 of 133

  • T3 FLUNISOLIDE AEROSPAN ST, QLT2 FLUTICASONE FUROATE ARNUITY ELLIPTA QLT3 FLUTICASONE

    PROPIONATEARMONAIRRESPICLICK

    T2 FLUTICASONEPROPIONATE

    FLOVENT DISKUS(100 MCG) (BLSTW/DEV)

    QL

    T2 FLUTICASONEPROPIONATE

    FLOVENT DISKUS(250 MCG) (BLSTW/DEV)

    QL

    T2 FLUTICASONEPROPIONATE

    FLOVENT DISKUS(50 MCG) (BLSTW/DEV)

    QL

    T2 FLUTICASONEPROPIONATE

    FLOVENT HFA (110MCG) (AERW/ADAP)

    QL

    T2 FLUTICASONEPROPIONATE

    FLOVENT HFA (220MCG) (AERW/ADAP)

    QL

    T2 FLUTICASONEPROPIONATE

    FLOVENT HFA (44MCG) (AERW/ADAP)

    QL

    T3MOMETASONE FUROATE ASMANEX ST, QLT3MOMETASONE FUROATE ASMANEX HFA ST, QL

    LEUKOTRIENE RECEPTOR ANTAGONISTST1MONTELUKASTSODIUM

    SINGULAIR

    T1ZAFIRLUKAST ACCOLATE

    MAST CELL STABILIZERST1CROMOLYN SODIUM GASTROCROM

    MAST CELL STABILIZERS, ORALLY INHALEDT1CROMOLYN SODIUM CROMOLYN

    SODIUM

    PHOSPHODIESTERASE-4 (PDE4) INHIBITORST2ROFLUMILAST DALIRESP ST, QL

    RESPIRATORY AIDS,DEVICES,EQUIPMENTT3COMPRESSOR, FOR

    NEBULIZERDEVILBISS PULMO-AIDE

    T3COMPRESSOR, FORNEBULIZER

    EBASECONTROLLER

    T3COMPRESSOR, FORNEBULIZER

    PULMO-AIDE

    T3COMPRESSOR, FORNEBULIZER

    SUNRISECOMPRESSOR-NEBULIZER

    T3 INHALER, ASSISTDEVICES

    ACE AEROSOLCLOUD ENHANCER

    T3 INHALER, ASSISTDEVICES

    AEROCHAMBERMINI

    T3 INHALER, ASSISTDEVICES

    AEROCHAMBERMV

    T3 INHALER, ASSISTDEVICES

    AEROCHAMBERPLUS FLOW-VU

    T3 INHALER, ASSISTDEVICES

    AEROCHAMBERWITHFLOWSIGNAL

    T3 INHALER, ASSISTDEVICES

    AEROCHAMBER Z-STAT PLUS

    T3 INHALER, ASSISTDEVICES

    AEROTRACH PLUS

    T3 INHALER, ASSISTDEVICES

    AEROVENT PLUS

    T3 INHALER, ASSISTDEVICES

    BREATHERITE

    T3 INHALER, ASSISTDEVICES

    BREATHRITE

    T3 INHALER, ASSISTDEVICES

    CLEVER CHOICEHOLDINGCHAMBER

    T3 INHALER, ASSISTDEVICES

    COMPACT SPACECHAMBER

    T3 INHALER, ASSISTDEVICES

    COMPACT SPACECHAMBER PLUS

    T3 INHALER, ASSISTDEVICES

    EASIVENT

    T3 INHALER, ASSISTDEVICES

    E-Z SPACER

    T3 INHALER, ASSISTDEVICES

    FLEXICHAMBER

    T3 INHALER, ASSISTDEVICES

    INSPIRACHAMBER

    T3 INHALER, ASSISTDEVICES

    LITEAIRE

    T3 INHALER, ASSISTDEVICES

    MICROCHAMBER

    T3 INHALER, ASSISTDEVICES

    MICROSPACER

    T3 INHALER, ASSISTDEVICES

    OPTICHAMBERDIAMOND

    T3 INHALER, ASSISTDEVICES

    POCKET CHAMBER

    T3 INHALER, ASSISTDEVICES

    PRIMEAIRE

    T3 INHALER, ASSISTDEVICES

    PROCHAMBER

    T3 INHALER, ASSISTDEVICES

    RITEFLO

    T3 INHALER, ASSISTDEVICES

    SPACE CHAMBERPLUS

    T3 INHALER, ASSISTDEVICES

    VORTEX

    T3 INHALER, ASSISTDEVICES

    VORTEX VHC FROGMASK

    T3 INHALER, ASSISTDEVICES

    VORTEX VHCLADYBUG MASK

    T3 INHALER,ASSISTDEVICE,ACCESORY

    EASIVENT

    T3 INHALER,ASSISTDEVICE,ACCESORY

    FLEXICHAMBERMASK

    T3 INHALER,ASSISTDEVICE,ACCESORY

    LITETOUCH

    T3 INHALER,ASSISTDEVICE,ACCESORY

    OPTICHAMBER

    T3 INHALER,ASSISTDEVICE,ACCESORY

    SILICONE MASK

    T3MUCUS CLEARINGDEVICE

    AEROBIKA

    T3MUCUS CLEARINGDEVICE

    QUAKE

    Commercial Formulary

    804 Portfolio High Formulary Page 7 of 133

  • T3NASAL EXHALATIONRESISTANC.DEV

    PROVENT

    T3NEBULIZER AEROECLIPSE IIT3NEBULIZER AERONEB GO

    NEBULIZERT3NEBULIZER ALTERA

    NEBULIZERT3NEBULIZER BABY NEBULIZERT3NEBULIZER ERAPID

    NEBULIZERT3NEBULIZER LC D NEBULIZER

    SETT3NEBULIZER LC PLUST3NEBULIZER LC SPRINT

    NEBULIZERT3NEBULIZER LC START3NEBULIZER MINI PLUS

    NEBULIZERT3NEBULIZER PARI LC SPRINT

    SINUST3NEBULIZER PRODIGY MINI-

    MISTT3NEBULIZER SIDESTREAMT3NEBULIZER SIDESTREAM

    NEBULIZERT3NEBULIZER SIDESTREAM PLUST3NEBULIZER SINUSTART3NEBULIZER TRUNEB

    NEBULIZERT3NEBULIZER VIXONE

    NEBULIZERT3NEBULIZER AND

    COMPRESSORCLEVER CHOICENEBULIZER

    T3NEBULIZER ANDCOMPRESSOR

    CLEVER CHOICEWHISPER AIRE PED

    T3NEBULIZER ANDCOMPRESSOR

    COMP-AIRNEBULIZERCOMPRESSOR

    T3NEBULIZER ANDCOMPRESSOR

    DEVILBISSPULMONEB LTCOMP-NEB

    T3NEBULIZER ANDCOMPRESSOR

    DEVILBISSTRAVELER

    T3NEBULIZER ANDCOMPRESSOR

    HOME NEBULIZERPLUS SIDESTREAM

    T3NEBULIZER ANDCOMPRESSOR

    INNOSPIREDELUXE

    T3NEBULIZER ANDCOMPRESSOR

    INNOSPIREELEGANCE

    T3NEBULIZER ANDCOMPRESSOR

    INNOSPIREESSENCE

    T3NEBULIZER ANDCOMPRESSOR

    INNOSPIRE MINI

    T3NEBULIZER ANDCOMPRESSOR

    MY MDI PORTABLENEBULISER

    T3NEBULIZER ANDCOMPRESSOR

    PARI SINUSAEROSOL SYSTEM

    T3NEBULIZER ANDCOMPRESSOR

    PEDIATRICDINOSAURNEBULIZER

    T3NEBULIZER ANDCOMPRESSOR

    PEDIATRIC DOGNEBULIZER

    T3NEBULIZER ANDCOMPRESSOR

    PEDIATRIC FROGNEBULIZER

    T3NEBULIZER ANDCOMPRESSOR

    PORTABLENEBULIZERSYSTEM

    T3NEBULIZER ANDCOMPRESSOR

    PRONEB ULTRA II

    T3NEBULIZER ANDCOMPRESSOR

    SAMI THE SEAL

    T3NEBULIZER ANDCOMPRESSOR

    SINUSTAR

    T3NEBULIZER ANDCOMPRESSOR

    TREK S COMBOPACK

    T3NEBULIZER ANDCOMPRESSOR

    TREK S COMPACTCOMPRESSOR

    T3NEBULIZER ANDCOMPRESSOR

    VIOS AEROSOLDELIVERY SYSTEM

    T3 PEAK FLOW METER MINI-WRIGHTPEAK FLOWMETER

    T3 PEAK FLOW METER TRUZONE PEAKFLOW METER

    T3 PEAK FLOW METER/INHASSIT DEV

    AEROGEARASTHMA ACTIONKIT

    T3 PEAK FLOW METER/INHASSIT DEV

    ASTHMAPACKCHILDREN'S

    T3 SPIROMETER/DRUGDELIVERY ADAPT

    MISTASSIST KIT

    T3 SPIROMETERS ANDACCESSORIES

    MISTASSIST

    T3 SPIROMETERS ANDACCESSORIES

    PFLEX TRAINER

    T3 SPIROMETERS ANDACCESSORIES

    THRESHOLD IMT

    T3 SPIROMETERS ANDACCESSORIES

    THRESHOLD PEP

    XANTHINEST1CAFFEINE CITRATE CAFCITT1THEOPHYLLINEANHYDROUS

    ELIXOPHYLLIN

    T1THEOPHYLLINEANHYDROUS

    SLO-PHYLLIN

    T2 THEOPHYLLINEANHYDROUS

    THEO-24

    T1THEOPHYLLINEANHYDROUS

    THEO-DUR

    T1THEOPHYLLINEANHYDROUS

    UNIPHYL

    AUTONOMIC NERVOUS SYSTEMDISORDERS

    ALZHEIMER'S THERAPY, NMDA RECEPTORANTAGONISTST1MEMANTINE HCL NAMENDA (10 MG)

    (TABLET)QL

    T1MEMANTINE HCL NAMENDA (2MG/ML)(SOLUTION)

    QL

    Commercial Formulary

    804 Portfolio High Formulary Page 8 of 133

  • T1MEMANTINE HCL NAMENDA (5 MG)(TABLET)

    QL

    T1MEMANTINE HCL NAMENDA (5 MG-10 MG) (TAB DS PK)

    QL

    T2MEMANTINE HCL NAMENDA XR (14MG) (CAP SPR 24)

    QL

    T2MEMANTINE HCL NAMENDA XR (21MG) (CAP SPR 24)

    QL

    T2MEMANTINE HCL NAMENDA XR (28MG) (CAP SPR 24)

    QL

    T2MEMANTINE HCL NAMENDA XR (7MG) (CAP SPR 24)

    QL

    T2MEMANTINE HCL NAMENDA XR (7-14-21-28) (CAP24DSPK)

    QL

    ALZHEIMER'S THX,NMDA RECEPT ANTAG &CHOLINES INHIBT2MEMANTINE

    HCL/DONEPEZIL HCLNAMZARIC (14MG-10MG) (CAP SPR 24)

    ST, QL

    T2MEMANTINEHCL/DONEPEZIL HCL

    NAMZARIC (21 MG-10MG) (CAP SPR 24)

    ST, QL

    T2MEMANTINEHCL/DONEPEZIL HCL

    NAMZARIC (28 MG-10MG) (CAP SPR 24)

    ST, QL

    T2MEMANTINEHCL/DONEPEZIL HCL

    NAMZARIC (7 MG-10 MG) (CAP SPR24)

    ST, QL

    T2MEMANTINEHCL/DONEPEZIL HCL

    NAMZARIC (7-10/14-10) (CAP24DSPK)

    ST, QL

    CHOLINESTERASE INHIBITORST1DONEPEZIL HCL ARICEPTT1DONEPEZIL HCL ARICEPT ODTT1GALANTAMINE HBR RAZADYNE (12 MG)

    (TABLET)QL

    T1GALANTAMINE HBR RAZADYNE (4 MG)(TABLET)

    QL

    T1GALANTAMINE HBR RAZADYNE (4MG/ML)(SOLUTION)

    QL

    T1GALANTAMINE HBR RAZADYNE (8 MG)(TABLET)

    QL

    T1GALANTAMINE HBR RAZADYNE ER QLT1PYRIDOSTIGMINEBROMIDE

    MESTINON (180MG) (TABLET ER)

    T1PYRIDOSTIGMINEBROMIDE

    MESTINON (60 MG)(TABLET)

    T2 PYRIDOSTIGMINEBROMIDE

    MESTINON (60MG/5 ML) (SYRUP)

    T1RIVASTIGMINE EXELON QLT1RIVASTIGMINETARTRATE

    EXELON

    BEHAVIORAL HEALTH -ANTIDEPRESSANTS

    ALPHA-2 RECEPTOR ANTAGONISTANTIDEPRESSANTST1MIRTAZAPINE REMERON

    MAOIS - NON-SELECTIVE & IRREVERSIBLET3 ISOCARBOXAZID MARPLAN

    T1PHENELZINE SULFATE NARDILT1TRANYLCYPROMINESULFATE

    PARNATE

    NOREPINEPHRINE AND DOPAMINE REUPTAKEINHIB (NDRIS)T3BUPROPION HBR APLENZIN ST, QLT3BUPROPION HCL FORFIVO XL ST, QLT1BUPROPION HCL WELLBUTRINT1BUPROPION HCL WELLBUTRIN SRT1BUPROPION HCL WELLBUTRIN XL

    SELECTIVE SEROTONIN REUPTAKE INHIBITOR(SSRIS)T1CITALOPRAMHYDROBROMIDE

    CELEXA

    T1ESCITALOPRAMOXALATE

    LEXAPRO

    T3 FLUOXETINE HCL FLUOXETINE HCL(60 MG) (TABLET)

    T1FLUOXETINE HCL FLUOXETINE HCL(90 MG) (CAPSULEDR)

    T1FLUOXETINE HCL PROZACT3 FLUOXETINE HCL SARAFEMT1FLUVOXAMINEMALEATE

    LUVOX

    T1FLUVOXAMINEMALEATE

    LUVOX CR ST, QL

    T1PAROXETINE HCL PAXIL (10 MG)(TABLET)

    T2 PAROXETINE HCL PAXIL (10 MG/5 ML)(ORAL SUSP)

    T1PAROXETINE HCL PAXIL (20 MG)(TABLET)

    T1PAROXETINE HCL PAXIL (30 MG)(TABLET)

    T1PAROXETINE HCL PAXIL (40 MG)(TABLET)

    T1PAROXETINE HCL PAXIL CRT3 PAROXETINE MESYLATE BRISDELLE ST, QLT3 PAROXETINE MESYLATE PEXEVA ST, QLT1 SERTRALINE HCL ZOLOFT

    SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS(SARIS)T1NEFAZODONE HCL SERZONET1TRAZODONE HCL DESYREL

    SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB(SNRIS)T2DESVENLAFAXINE DESVENLAFAXINE

    ERST, QL

    T1DESVENLAFAXINE KHEDEZLA ST, QLT3DESVENLAFAXINE

    FUMARATEDESVENLAFAXINEFUMARATE ER

    ST, QL

    T1DESVENLAFAXINESUCCINATE

    PRISTIQ QL

    T1DULOXETINE HCL CYMBALTA QLT1DULOXETINE HCL IRENKA ST, QLT2 LEVOMILNACIPRAN HCLFETZIMA ST, QLT1VENLAFAXINE HCL EFFEXORT1VENLAFAXINE HCL EFFEXOR XR

    Commercial Formulary

    804 Portfolio High Formulary Page 9 of 133

  • T1VENLAFAXINE HCL VENLAFAXINE HCLER

    SSRI & 5HT1A PARTIAL AGONIST ANTIDEPRESSANTT2VILAZODONE HCL VIIBRYD ST, QL

    SSRI & SEROTONIN RECEPTOR MODULATORANTIDEPRESSANTT2VORTIOXETINE

    HYDROBROMIDETRINTELLIX ST, QL

    TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINECOMBINATNST1AMITRIPTYLINE/CHLORDIAZEPOXIDE

    LIMBITROL

    T1AMITRIPTYLINE/CHLORDIAZEPOXIDE

    LIMBITROL DS

    TRICYCLIC ANTIDEPRESSANT/PHENOTHIAZINECOMBINATNST1PERPHENAZINE/AMITRIPTYLINE HCL

    ETRAFON-A

    T1PERPHENAZINE/AMITRIPTYLINE HCL

    TRIAVIL 2-10

    T1PERPHENAZINE/AMITRIPTYLINE HCL

    TRIAVIL 2-25

    T1PERPHENAZINE/AMITRIPTYLINE HCL

    TRIAVIL 4-25

    T1PERPHENAZINE/AMITRIPTYLINE HCL

    TRIAVIL 4-50

    TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL.RU-INHIBT1AMITRIPTYLINE HCL ELAVILT1AMOXAPINE ASENDINT1CLOMIPRAMINE HCL ANAFRANILT1DESIPRAMINE HCL NORPRAMINT1DOXEPIN HCL SINEQUANT1 IMIPRAMINE HCL TOFRANILT1 IMIPRAMINE PAMOATE TOFRANIL-PMT1MAPROTILINE HCL LUDIOMILT1NORTRIPTYLINE HCL PAMELORT1PROTRIPTYLINE HCL VIVACTILT1TRIMIPRAMINEMALEATE

    SURMONTIL

    BEHAVIORAL HEALTH - OTHERADRENERGICS, AROMATIC, NON-CATECHOLAMINET3AMPHETAMINE ADZENYS XR-ODT ST, QLT3AMPHETAMINE DYANAVEL XR ST, QLT3AMPHETAMINE SULFATEEVEKEO PAT1DEXTROAMPHETAMINE SULFATE

    DEXTROAMPHETAMINE SULFATE (10MG) (CAPSULE ER)

    QL

    T1DEXTROAMPHETAMINE SULFATE

    DEXTROAMPHETAMINE SULFATE (10MG) (TABLET)

    QL

    T1DEXTROAMPHETAMINE SULFATE

    DEXTROAMPHETAMINE SULFATE (15MG) (CAPSULE ER)

    QL

    T1DEXTROAMPHETAMINE SULFATE

    DEXTROAMPHETAMINE SULFATE (5MG) (CAPSULE ER)

    QL

    T1DEXTROAMPHETAMINE SULFATE

    DEXTROAMPHETAMINE SULFATE (5MG) (TABLET)

    QL

    T1DEXTROAMPHETAMINE SULFATE

    DEXTROAMPHETAMINE SULFATE (5MG/5 ML)(SOLUTION)

    QL

    T2DEXTROAMPHETAMINESULFATE

    ZENZEDI (15 MG)(TABLET)

    QL

    T2DEXTROAMPHETAMINESULFATE

    ZENZEDI (2.5 MG)(TABLET)

    ST, QL

    T2DEXTROAMPHETAMINESULFATE

    ZENZEDI (20 MG)(TABLET)

    QL

    T2DEXTROAMPHETAMINESULFATE

    ZENZEDI (30 MG)(TABLET)

    QL

    T2DEXTROAMPHETAMINESULFATE

    ZENZEDI (7.5 MG)(TABLET)

    ST, QL

    T1DEXTROAMPHETAMINE/AMPHETAMINE

    ADDERALL QL

    T1DEXTROAMPHETAMINE/AMPHETAMINE

    ADDERALL XR (10MG) (CAP ER 24H)

    QL

    T1DEXTROAMPHETAMINE/AMPHETAMINE

    ADDERALL XR (15MG) (CAP ER 24H)

    QL

    T1DEXTROAMPHETAMINE/AMPHETAMINE

    ADDERALL XR (20MG) (CAP ER 24H)

    QL

    T1DEXTROAMPHETAMINE/AMPHETAMINE

    ADDERALL XR (25MG) (CAP ER 24H)

    QL

    T1DEXTROAMPHETAMINE/AMPHETAMINE

    ADDERALL XR (30MG) (CAP ER 24H)

    QL

    T1DEXTROAMPHETAMINE/AMPHETAMINE

    ADDERALL XR (5MG) (CAP ER 24H)

    QL

    T3DEXTROAMPHETAMINE/AMPHETAMINE

    MYDAYIS

    T2 LISDEXAMFETAMINEDIMESYLATE

    VYVANSE ST, QL

    T1METHAMPHETAMINEHCL

    DESOXYN QL

    ANTI-ALCOHOLIC PREPARATIONST1ACAMPROSATECALCIUM

    CAMPRAL

    T1DISULFIRAM ANTABUSE

    ANTI-ANXIETY DRUGST2ALPRAZOLAM ALPRAZOLAM

    INTENSOLT1ALPRAZOLAM NIRAVAMT1ALPRAZOLAM XANAXT1ALPRAZOLAM XANAX XRT1BUSPIRONE HCL BUSPART1CHLORDIAZEPOXIDEHCL

    LIBRIUM

    T1CLORAZEPATEDIPOTASSIUM

    TRANXENE T-TAB

    T1DIAZEPAM DIAZEPAMT1DIAZEPAM DIAZEPAM

    INTENSOLT2DIAZEPAM VALIUM (10 MG)

    (TABLET)T2DIAZEPAM VALIUM (2 MG)

    (TABLET)T2DIAZEPAM VALIUM (5 MG)

    (TABLET)

    Commercial Formulary

    804 Portfolio High Formulary Page 10 of 133

  • T1DIAZEPAM VALIUM (5 MG/5ML) (SOLUTION)

    T1LORAZEPAM ATIVANT1LORAZEPAM LORAZEPAM

    INTENSOLT1MEPROBAMATE MEPROBAMATET1OXAZEPAM SERAX

    ANTI-MANIA DRUGST3CARBAMAZEPINE EQUETROT1LITHIUM CARBONATE ESKALITHT1LITHIUM CARBONATE ESKALITH CRT1LITHIUM CARBONATE LITHIUM

    CARBONATET2 LITHIUM CARBONATE LITHOBIDT1LITHIUM CARBONATE LITHOTABST1LITHIUM CITRATE LITHIUM CITRATE

    ANTI-NARCOLEPSY & ANTI-CATAPLEXY,SEDATIVE-TYPE AGTT3 SODIUM OXYBATE XYREM PA

    ANTIPSYCH,DOPAMINEANTAG.,DIPHENYLBUTYLPIPERIDINEST1PIMOZIDE ORAP

    ANTIPSYCHOTIC-ATYPICAL,D3/D2 PARTIAL AG-5HTMIXEDT2CARIPRAZINE HCL VRAYLAR (1.5 MG)

    (CAPSULE)ST, QL

    T2CARIPRAZINE HCL VRAYLAR (1.5 MG-3MG) (CAP DS PK)

    ST, QL

    T2CARIPRAZINE HCL VRAYLAR (3 MG)(CAPSULE)

    ST, QL

    T2CARIPRAZINE HCL VRAYLAR (4.5 MG)(CAPSULE)

    ST, QL

    T2CARIPRAZINE HCL VRAYLAR (6 MG)(CAPSULE)

    ST, QL

    ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HTMIXEDT1ARIPIPRAZOLE ABILIFY (1 MG/ML)

    (SOLUTION)ST, QL

    T1ARIPIPRAZOLE ABILIFY (10 MG)(TABLET)

    QL

    T1ARIPIPRAZOLE ABILIFY (15 MG)(TABLET)

    QL

    T1ARIPIPRAZOLE ABILIFY (2 MG)(TABLET)

    QL

    T1ARIPIPRAZOLE ABILIFY (20 MG)(TABLET)

    QL

    T1ARIPIPRAZOLE ABILIFY (30 MG)(TABLET)

    QL

    T1ARIPIPRAZOLE ABILIFY (5 MG)(TABLET)

    QL

    T1ARIPIPRAZOLE ABILIFY DISCMELT(10 MG) (TABRAPDIS)

    ST, QL

    T1ARIPIPRAZOLE ABILIFY DISCMELT(15 MG) (TABRAPDIS)

    ST, QL

    T2BREXPIPRAZOLE REXULTI ST, QL

    ANTIPSYCHOTICS, DOPAMINE & SEROTONINANTAGONISTST3 LOXAPINE ADASUVET1LOXAPINE SUCCINATE LOXITANE

    ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,&SEROTONIN ANTAGT2ASENAPINE MALEATE SAPHRIS ST, QLT1CLOZAPINE CLOZAPINE QLT1CLOZAPINE CLOZARIL QLT1CLOZAPINE FAZACLO ST, QLT3CLOZAPINE VERSACLOZ ST, QLT3 ILOPERIDONE FANAPT (1 MG)

    (TABLET)ST, QL

    T3 ILOPERIDONE FANAPT (10 MG)(TABLET)

    ST, QL

    T3 ILOPERIDONE FANAPT (12 MG)(TABLET)

    ST, QL

    T3 ILOPERIDONE FANAPT (1-2-4-6MG) (TAB DS PK)

    ST, QL

    T3 ILOPERIDONE FANAPT (2 MG)(TABLET)

    ST, QL

    T3 ILOPERIDONE FANAPT (4 MG)(TABLET)

    ST, QL

    T3 ILOPERIDONE FANAPT (6 MG)(TABLET)

    ST, QL

    T3 ILOPERIDONE FANAPT (8 MG)(TABLET)

    ST, QL

    T2 LURASIDONE HCL LATUDA (120 MG)(TABLET)

    ST, QL

    T2 LURASIDONE HCL LATUDA (20 MG)(TABLET)

    ST, QL

    T2 LURASIDONE HCL LATUDA (40 MG)(TABLET)

    ST, QL

    T2 LURASIDONE HCL LATUDA (60 MG)(TABLET)

    ST, QL

    T2 LURASIDONE HCL LATUDA (80 MG)(TABLET)

    ST, QL

    T1OLANZAPINE ZYPREXA QLT1OLANZAPINE ZYPREXA ZYDIS QLT1PALIPERIDONE INVEGA (1.5 MG)

    (TAB ER 24)ST, QL

    T1PALIPERIDONE INVEGA (3 MG)(TAB ER 24)

    ST, QL

    T1PALIPERIDONE INVEGA (6 MG)(TAB ER 24)

    ST, QL

    T1PALIPERIDONE INVEGA (9 MG)(TAB ER 24)

    ST, QL

    T1QUETIAPINEFUMARATE

    SEROQUEL QL

    T1QUETIAPINEFUMARATE

    SEROQUEL XR (150MG) (TAB ER 24H)

    QL

    T1QUETIAPINEFUMARATE

    SEROQUEL XR (200MG) (TAB ER 24H)

    QL

    T1QUETIAPINEFUMARATE

    SEROQUEL XR (300MG) (TAB ER 24H)

    QL

    T1QUETIAPINEFUMARATE

    SEROQUEL XR (400MG) (TAB ER 24H)

    QL

    T1QUETIAPINEFUMARATE

    SEROQUEL XR (50MG) (TAB ER 24H)

    QL

    Commercial Formulary

    804 Portfolio High Formulary Page 11 of 133

  • T3QUETIAPINE FUMARATE SEROQUEL XR (50-200-300)(TAB24HDSPK)

    T1RISPERIDONE RISPERDAL (0.25MG) (TABLET)

    QL

    T1RISPERIDONE RISPERDAL (0.5MG) (TABLET)

    QL

    T1RISPERIDONE RISPERDAL (1 MG)(TABLET)

    QL

    T1RISPERIDONE RISPERDAL (1MG/ML)(SOLUTION)

    QL

    T1RISPERIDONE RISPERDAL (2 MG)(TABLET)

    QL

    T1RISPERIDONE RISPERDAL (3 MG)(TABLET)

    QL

    T1RISPERIDONE RISPERDAL (4 MG)(TABLET)

    QL

    T1RISPERIDONE RISPERDAL M-TAB QLT1RISPERIDONE RISPERIDONE ODT QLT1ZIPRASIDONE HCL GEODON QL

    ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,THIOXANTHENEST1THIOTHIXENE NAVANE

    ANTIPSYCHOTICS,DOPAMINEANTAGONISTS,BUTYROPHENONEST1HALOPERIDOL HALDOLT1HALOPERIDOLLACTATE

    HALDOL

    ANTI-PSYCHOTICS,PHENOTHIAZINEST1CHLORPROMAZINEHCL

    THORAZINE

    T1FLUPHENAZINE HCL PROLIXINT1PERPHENAZINE TRILAFONT1THIORIDAZINE HCL MELLARILT1TRIFLUOPERAZINEHCL

    STELAZINE

    BARBITURATEST3BUTABARBITAL SODIUMBUTISOL SODIUMT1PHENOBARBITAL PHENOBARBITALT3 SECOBARBITAL SODIUM SECONAL SODIUM

    HSDD AGENTS-MIXED SEROTONINAGONIST/ANTAGONISTST3 FLIBANSERIN ADDYI PA

    HYPNOTICS, MELATONIN MT1/MT2 RECEPTORAGONISTST3RAMELTEON ROZEREM ST, QLT3 TASIMELTEON HETLIOZ PA

    MONOAMINE OXIDASE(MAO) INHIBITORST3 SELEGILINE EMSAM QL

    NARCOLEPSY AND SLEEP DISORDER THERAPYAGENTST1ARMODAFINIL NUVIGIL (150 MG)

    (TABLET)QL

    T1ARMODAFINIL NUVIGIL (200 MG)(TABLET)

    QL

    T1ARMODAFINIL NUVIGIL (250 MG)(TABLET)

    QL

    T1ARMODAFINIL NUVIGIL (50 MG)(TABLET)

    QL

    T1MODAFINIL PROVIGIL QL

    NARCOTIC ANTAGONISTST3NALOXONE HCL EVZIO ST, QLT1NALOXONE HCL NARCAN (0.4

    MG/ML) (SYRINGE)T1NALOXONE HCL NARCAN (1 MG/ML)

    (SYRINGE)T2NALOXONE HCL NARCAN (4 MG)

    (SPRAY)QL

    T1NALTREXONE HCL REVIA

    SEDATIVE-HYPNOTICS,NON-BARBITURATET2DOXEPIN HCL SILENOR ST, QLT1ESTAZOLAM PROSOMT1ESZOPICLONE LUNESTA QLT1FLURAZEPAM HCL DALMANET1MIDAZOLAM HCL VERSEDT1QUAZEPAM DORALT2 SUVOREXANT BELSOMRA ST, QLT1TEMAZEPAM RESTORILT1TRIAZOLAM HALCIONT1ZALEPLON SONATA QLT1ZOLPIDEM TARTRATE AMBIEN QLT1ZOLPIDEM TARTRATE AMBIEN CR QLT3 ZOLPIDEM TARTRATE EDLUAR ST, QLT1ZOLPIDEM TARTRATE INTERMEZZO ST, QLT3 ZOLPIDEM TARTRATE ZOLPIMIST ST, QL

    SELECTIVE SEROTONIN 5-HT2A INVERSE AGONISTS(SSIA)T3 PIMAVANSERIN

    TARTRATENUPLAZID PA

    SSRI &ANTIPSYCH,ATYP,DOPAMINE&SEROTONINANTAG COMBT1OLANZAPINE/FLUOXETINE HCL

    SYMBYAX QL

    TX FOR ADHD - SELECTIVE ALPHA-2A RECEPTORAGONISTT1CLONIDINE HCL KAPVAY QLT1GUANFACINE HCL INTUNIV QL

    TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSYT1DEXMETHYLPHENIDATE HCL

    FOCALIN QL

    T1DEXMETHYLPHENIDATE HCL

    FOCALIN XR AGE,QL

    T3METHYLPHENIDATE COTEMPLA XR-ODT

    ST

    T3METHYLPHENIDATE DAYTRANA ST, QLT3METHYLPHENIDATE

    HCLAPTENSIO XR ST,

    AGE,QL

    T1METHYLPHENIDATEHCL

    CONCERTA (18 MG)(TAB ER 24)

    AGE,QL

    Commercial Formulary

    804 Portfolio High Formulary Page 12 of 133

  • T1METHYLPHENIDATEHCL

    CONCERTA (27 MG)(TAB ER 24)

    AGE,QL

    T1METHYLPHENIDATEHCL

    CONCERTA (36 MG)(TAB ER 24)

    AGE,QL

    T1METHYLPHENIDATEHCL

    CONCERTA (54 MG)(TAB ER 24)

    AGE,QL

    T1METHYLPHENIDATEHCL

    METADATE ER (10MG) (TABLET ER)

    AGE,QL

    T1METHYLPHENIDATEHCL

    METADATE ER (20MG) (TABLET ER)

    AGE,QL

    T1METHYLPHENIDATEHCL

    METHYLIN

    T1METHYLPHENIDATEHCL

    METHYLPHENIDATE HCL (10 MG)(CPBP 30-70)

    AGE,QL

    T1METHYLPHENIDATEHCL

    METHYLPHENIDATE HCL (10 MG) (TABCHEW)

    QL

    T1METHYLPHENIDATEHCL

    METHYLPHENIDATE HCL (2.5 MG)(TAB CHEW)

    QL

    T1METHYLPHENIDATEHCL

    METHYLPHENIDATE HCL (20 MG)(CPBP 30-70)

    AGE,QL

    T1METHYLPHENIDATEHCL

    METHYLPHENIDATE HCL (30 MG)(CPBP 30-70)

    AGE,QL

    T1METHYLPHENIDATEHCL

    METHYLPHENIDATE HCL (40 MG)(CPBP 30-70)

    AGE,QL

    T1METHYLPHENIDATEHCL

    METHYLPHENIDATE HCL (5 MG) (TABCHEW)

    QL

    T1METHYLPHENIDATEHCL

    METHYLPHENIDATE HCL (50 MG)(CPBP 30-70)

    AGE,QL

    T1METHYLPHENIDATEHCL

    METHYLPHENIDATE HCL (60 MG)(CPBP 30-70)

    AGE,QL

    T2METHYLPHENIDATEHCL

    QUILLICHEW ER(20 MG) (TABCBP24H)

    ST, QL

    T2METHYLPHENIDATEHCL

    QUILLICHEW ER(30 MG) (TABCBP24H)

    ST, QL

    T2METHYLPHENIDATEHCL

    QUILLICHEW ER(40 MG) (TABCBP24H)

    ST, QL

    T2METHYLPHENIDATEHCL

    QUILLIVANT XR (5MG/ML) (SU ERRC24)

    ST, QL

    T1METHYLPHENIDATEHCL

    RITALIN QL

    T2METHYLPHENIDATEHCL

    RITALIN LA (10 MG)(CPBP 50-50)

    AGE,QL

    T1METHYLPHENIDATEHCL

    RITALIN LA (20 MG)(CPBP 50-50)

    AGE,QL

    T1METHYLPHENIDATEHCL

    RITALIN LA (30 MG)(CPBP 50-50)

    AGE,QL

    T1METHYLPHENIDATEHCL

    RITALIN LA (40 MG)(CPBP 50-50)

    AGE,QL

    T1METHYLPHENIDATEHCL

    RITALIN LA (60 MG)(CPBP 50-50)

    AGE,QL

    T1METHYLPHENIDATEHCL

    RITALIN-SR AGE,QL

    TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD),NRI-TYPET1ATOMOXETINE HCL STRATTERA (10

    MG) (CAPSULE)QL

    T1ATOMOXETINE HCL STRATTERA (100MG) (CAPSULE)

    QL

    T1ATOMOXETINE HCL STRATTERA (18MG) (CAPSULE)

    QL

    T1ATOMOXETINE HCL STRATTERA (25MG) (CAPSULE)

    QL

    T1ATOMOXETINE HCL STRATTERA (40MG) (CAPSULE)

    QL

    T1ATOMOXETINE HCL STRATTERA (60MG) (CAPSULE)

    QL

    T1ATOMOXETINE HCL STRATTERA (80MG) (CAPSULE)

    QL

    CARDIOVASCULAR DISEASE -ARRHYTHMIA

    ANTIARRHYTHMICST1AMIODARONE HCL CORDARONET1DISOPYRAMIDEPHOSPHATE

    NORPACE

    T2DISOPYRAMIDEPHOSPHATE

    NORPACE CR

    T1DOFETILIDE TIKOSYNT2DRONEDARONE HCL MULTAQT1FLECAINIDE ACETATE TAMBOCORT1MEXILETINE HCL MEXITILT1PROPAFENONE HCL RYTHMOLT1PROPAFENONE HCL RYTHMOL SRT1QUINIDINEGLUCONATE

    QUINAGLUTE

    T1QUINIDINE SULFATE QUINIDINESULFATE

    T1QUINIDINE SULFATE QUINORA

    CARDIOVASCULAR DISEASE -CARDIAC STIMULANT

    ADRENERGIC AGENTS,CATECHOLAMINEST1EPINEPHRINE EPIPEN

    DIGITALIS GLYCOSIDEST1DIGOXIN DIGOXIN (125 MCG)

    (TABLET)T1DIGOXIN DIGOXIN (250 MCG)

    (TABLET)T2DIGOXIN DIGOXIN (50

    MCG/ML)(SOLUTION)

    T2DIGOXIN LANOXIN (125MCG) (TABLET)

    T3DIGOXIN LANOXIN (187.5MCG) (TABLET)

    T2DIGOXIN LANOXIN (250MCG) (TABLET)

    Commercial Formulary

    804 Portfolio High Formulary Page 13 of 133

  • T3DIGOXIN LANOXIN (62.5MCG) (TABLET)

    CARDIOVASCULAR DISEASE -HYPERTENSION

    ACE INHIBITOR/CALCIUM CHANNEL BLOCKERCOMBINATIONT1AMLODIPINEBESYLATE/BENAZEPRIL

    LOTREL

    T3 PERINDOPRILARG/AMLODIPINE BES

    PRESTALIA ST, QL

    T1TRANDOLAPRIL/VERAPAMIL HCL

    TARKA

    ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKEDIURETICT1BENAZEPRIL/HYDROCHLOROTHIAZIDE

    LOTENSIN HCT

    T1CAPTOPRIL/HYDROCHLOROTHIAZIDE

    CAPOZIDE

    T1ENALAPRIL/HYDROCHLOROTHIAZIDE

    VASERETIC

    T1FOSINOPRIL/HYDROCHLOROTHIAZIDE

    MONOPRIL-HCT

    T1LISINOPRIL/HYDROCHLOROTHIAZIDE

    ZESTORETIC

    T1MOEXIPRIL/HYDROCHLOROTHIAZIDE

    UNIRETIC

    T1QUINAPRIL/HYDROCHLOROTHIAZIDE

    ACCURETIC

    ALPHA/BETA-ADRENERGIC BLOCKING AGENTST1CARVEDILOL COREGT2CARVEDILOL

    PHOSPHATECOREG CR

    T1LABETALOL HCL TRANDATE

    ALPHA-ADRENERGIC BLOCKING AGENTST1DOXAZOSIN MESYLATECARDURAT3DOXAZOSIN MESYLATE CARDURA XLT1PHENOXYBENZAMINEHCL

    DIBENZYLINE

    T1PRAZOSIN HCL MINIPRESST1TERAZOSIN HCL HYTRIN

    ANGIOTEN.RECEPTR ANTAG./CAL.CHANLBLKR/THIAZIDE CBT1AMLODIPINE/VALSARTAN/HCTHIAZID

    EXFORGE HCT

    T1OLMESARTAN/AMLODIPIN/HCTHIAZID

    TRIBENZOR

    ANGIOTENSIN II RECEPTOR BLOCKER-BETABLOCKER COMB.T2NEBIVOLOL

    HCL/VALSARTANBYVALSON

    ANGIOTENSIN RECEPTOR ANTAG./THIAZIDEDIURETIC COMBT2AZILSARTAN

    MED/CHLORTHALIDONEEDARBYCLOR ST

    T1CANDESARTAN/HYDROCHLOROTHIAZID

    ATACAND HCT

    T1 IRBESARTAN/HYDROCHLOROTHIAZIDE

    AVALIDE

    T1LOSARTAN/HYDROCHLOROTHIAZIDE

    HYZAAR

    T1OLMESARTAN/HYDROCHLOROTHIAZIDE

    BENICAR HCT

    T1TELMISARTAN/HYDROCHLOROTHIAZID

    MICARDIS HCT

    T1VALSARTAN/HYDROCHLOROTHIAZIDE

    DIOVAN HCT

    ANGIOTENSIN RECEPTOR ANTGNST &CALC.CHANNEL BLOCKRT1AMLODIPINEBES/OLMESARTAN MED

    AZOR

    T1AMLODIPINEBESYLATE/VALSARTAN

    EXFORGE

    T1TELMISARTAN/AMLODIPINE

    TWYNSTA

    ANTIHYPERTENSIVES, ACE INHIBITORST1BENAZEPRIL HCL LOTENSINT1CAPTOPRIL CAPOTENT3ENALAPRIL MALEATE EPANED ST,

    AGE,QL

    T1ENALAPRIL MALEATE VASOTECT1FOSINOPRIL SODIUM MONOPRILT1LISINOPRIL PRINIVILT3 LISINOPRIL QBRELIS ST,

    AGE,QL

    T1LISINOPRIL ZESTRILT1MOEXIPRIL HCL UNIVASCT1PERINDOPRILERBUMINE

    ACEON

    T1QUINAPRIL HCL ACCUPRILT1RAMIPRIL ALTACET1TRANDOLAPRIL MAVIKT1TRANDOLAPRIL TRANDOLAPRIL

    ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTORANTAGONISTT2AZILSARTAN

    MEDOXOMILEDARBI ST

    T1CANDESARTANCILEXETIL

    ATACAND

    T1EPROSARTANMESYLATE

    TEVETEN

    T1 IRBESARTAN AVAPROT1LOSARTAN POTASSIUM COZAART1OLMESARTANMEDOXOMIL

    BENICAR

    T1TELMISARTAN MICARDIST1VALSARTAN DIOVAN

    ANTIHYPERTENSIVES, GANGLIONIC BLOCKERST3MECAMYLAMINE HCL VECAMYL PA

    ANTIHYPERTENSIVES, MISCELLANEOUST3METYROSINE DEMSER

    Commercial Formulary

    804 Portfolio High Formulary Page 14 of 133

  • ANTIHYPERTENSIVES, SYMPATHOLYTICT1CLONIDINE CATAPRES-TTS 1T1CLONIDINE CATAPRES-TTS 2T1CLONIDINE CATAPRES-TTS 3T1CLONIDINE HCL CATAPREST1CLONIDINEHCL/CHLORTHALIDONE

    COMBIPRES

    T1GUANFACINE HCL TENEXT1METHYLDOPA ALDOMETT1METHYLDOPA/HYDROCHLOROTHIAZIDE

    ALDORIL 15

    T1METHYLDOPA/HYDROCHLOROTHIAZIDE

    ALDORIL 25

    ANTIHYPERTENSIVES, VASODILATORST1HYDRALAZINE HCL APRESOLINET1MINOXIDIL LONITEN

    BETA-ADRENERGIC BLOCKING AGENTST1ACEBUTOLOL HCL SECTRALT1ATENOLOL TENORMINT1BETAXOLOL HCL KERLONET1BISOPROLOLFUMARATE

    BISOPROLOLFUMARATE

    T1BISOPROLOLFUMARATE

    ZEBETA

    T1METOPROLOLSUCCINATE

    TOPROL XL

    T1METOPROLOLTARTRATE

    LOPRESSOR

    T1METOPROLOLTARTRATE

    METOPROLOLTARTRATE

    T1NADOLOL CORGARDT2NEBIVOLOL HCL BYSTOLICT3 PENBUTOLOL SULFATE LEVATOLT1PINDOLOL VISKENT3 PROPRANOLOL HCL HEMANGEOL ST,

    AGE,QL

    T1PROPRANOLOL HCL INDERALT1PROPRANOLOL HCL INDERAL LAT3 PROPRANOLOL HCL INDERAL XLT3 PROPRANOLOL HCL INNOPRAN XLT1 SOTALOL HCL SOTALOL HCLT3 SOTALOL HCL SOTYLIZE (5

    MG/ML)(SOLUTION)

    ST, QL

    T1TIMOLOL MALEATE BLOCADREN

    BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE& RELATEDT1ATENOLOL/CHLORTHALIDONE

    TENORETIC 100

    T1ATENOLOL/CHLORTHALIDONE

    TENORETIC 50

    T1BISOPROLOL/HYDROCHLOROTHIAZIDE

    ZIAC

    T1METOPROLOLSU/HYDROCHLOROTHIAZ

    DUTOPROL (100-12.5MG) (TAB ER24H)

    QL

    T1METOPROLOLSU/HYDROCHLOROTHIAZ

    DUTOPROL (25-12.5MG) (TAB ER 24H)

    QL

    T1METOPROLOLSU/HYDROCHLOROTHIAZ

    DUTOPROL (50-12.5MG) (TAB ER 24H)

    QL

    T1METOPROLOL/HYDROCHLOROTHIAZIDE

    LOPRESSOR HCT

    T1NADOLOL/BENDROFLUMETHIAZIDE

    CORZIDE

    T1PROPRANOLOL/HYDROCHLOROTHIAZID

    INDERIDE-40/25

    T1PROPRANOLOL/HYDROCHLOROTHIAZID

    INDERIDE-80/25

    CALCIUM CHANNEL BLOCKING AGENTST1AMLODIPINEBESYLATE

    NORVASC

    T1DILTIAZEM HCL CARDIZEMT1DILTIAZEM HCL CARDIZEM CDT3DILTIAZEM HCL CARDIZEM LA (120

    MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM LA (180

    MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM LA (240

    MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM LA (300

    MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM LA (360

    MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM LA (420

    MG) (TAB ER 24H)T1DILTIAZEM HCL CARDIZEM SRT1DILTIAZEM HCL DILACOR XRT1DILTIAZEM HCL TIAZACT1FELODIPINE PLENDILT1 ISRADIPINE DYNACIRCT1NICARDIPINE HCL CARDENET1NIFEDIPINE ADALAT CCT1NIFEDIPINE PROCARDIAT1NIFEDIPINE PROCARDIA XLT1NIMODIPINE NIMOTOPT3NIMODIPINE NYMALIZE PAT1NISOLDIPINE SULART1VERAPAMIL HCL CALANT1VERAPAMIL HCL CALAN SRT1VERAPAMIL HCL VERELANT1VERAPAMIL HCL VERELAN PM

    LOOP DIURETICST1BUMETANIDE BUMEXT1ETHACRYNIC ACID EDECRINT1FUROSEMIDE LASIXT1TORSEMIDE DEMADEX

    OSMOTIC DIURETICST3MANNITOL RESECTISOL

    POTASSIUM SPARING DIURETICST1AMILORIDE HCL MIDAMORT1EPLERENONE INSPRAT1 SPIRONOLACTONE ALDACTONET3 SPIRONOLACTONE CAROSPIR

    Commercial Formulary

    804 Portfolio High Formulary Page 15 of 133

  • T3 TRIAMTERENE DYRENIUM

    POTASSIUM SPARING DIURETICS IN COMBINATIONT1AMILORIDE/HYDROCHLOROTHIAZIDE

    MODURETIC 5-50

    T1 SPIRONOLACT/HYDROCHLOROTHIAZID

    ALDACTAZIDE (25MG-25MG)(TABLET)

    T3 SPIRONOLACT/HYDROCHLOROTHIAZID

    ALDACTAZIDE (50MG-50MG)(TABLET)

    T1TRIAMTERENE/HYDROCHLOROTHIAZID

    DYAZIDE

    T1TRIAMTERENE/HYDROCHLOROTHIAZID

    MAXZIDE

    T1TRIAMTERENE/HYDROCHLOROTHIAZID

    MAXZIDE-25 MG

    PULM ANTI-HTN,SOLUBLE GUANYLATE CYCLASESTIMULATORT2RIOCIGUAT ADEMPAS PA

    PULM.ANTI-HTN,SEL.C-GMP PHOSPHODIESTERASET5 INHIBT3 SILDENAFIL CITRATE REVATIO (10

    MG/ML) (SUSPRECON)

    PA

    T1 SILDENAFIL CITRATE REVATIO (20 MG)(TABLET)

    PA

    T2 TADALAFIL ADCIRCA PA

    PULMONARY ANTI-HTN, ENDOTHELIN RECEPTORANTAGONISTT2AMBRISENTAN LETAIRIS PAT2BOSENTAN TRACLEER PAT2MACITENTAN OPSUMIT PA

    PULMONARY ANTIHYPERTENSIVES,PROSTACYCLIN-TYPET3 ILOPROST

    TROMETHAMINEVENTAVIS PA

    T2 SELEXIPAG UPTRAVI PAT3 TREPROSTINIL TYVASO PAT3TREPROSTINIL

    DIOLAMINEORENITRAM ER PA

    T3TREPROSTINIL SODIUM REMODULIN PAT3TREPROSTINIL/NEB

    ACCESSORIESTYVASO REFILLKIT

    PA

    T3 TREPROSTINIL/NEBULIZER/ACCESOR

    TYVASOINSTITUTIONALSTART KIT

    PA

    T3 TREPROSTINIL/NEBULIZER/ACCESOR

    TYVASO STARTERKIT

    PA

    RENIN INHIBITOR, DIRECTT3ALISKIREN

    HEMIFUMARATETEKTURNA PA

    RENIN INHIBITOR, DIRECT & CALCIUM CHANNELBLOCKERT3ALISKIREN/AMLODIPINE

    BESYLATETEKAMLO PA

    RENIN INHIBITOR, DIRECT/THIAZIDE DIURETICCOMBT3ALISKIREN/HYDROCHLO

    ROTHIAZIDETEKTURNA HCT PA

    THIAZIDE AND RELATED DIURETICST1CHLOROTHIAZIDE DIURIL (250 MG)

    (TABLET)T3CHLOROTHIAZIDE DIURIL (250

    MG/5ML) (ORALSUSP)

    T1CHLOROTHIAZIDE DIURIL (500 MG)(TABLET)

    T1CHLORTHALIDONE HYGROTONT1HYDROCHLOROTHIAZIDE

    HYDROCHLOROTHIAZIDE

    T1HYDROCHLOROTHIAZIDE

    HYDRODIURIL

    T1HYDROCHLOROTHIAZIDE

    MICROZIDE

    T1 INDAPAMIDE LOZOLT1METHYCLOTHIAZIDE METHYCLOTHIAZI

    DET1METOLAZONE ZAROXOLYNT1PHENOXYBENZAMINEHCL

    DIBENZYLINE

    VASODILATORS, COMBINATIONT2 ISOSORBIBE

    DINIT/HYDRALAZINEBIDIL

    CARDIOVASCULAR DISEASE - LIPIDIRREGULARITY

    ANTIHYPERLIP.HMG COA REDUCTINHIB&CHOLEST.AB.INHIBT1EZETIMIBE/SIMVASTATIN

    VYTORIN (10 MG-10MG) (TABLET)

    QL

    T1EZETIMIBE/SIMVASTATIN

    VYTORIN (10 MG-20MG) (TABLET)

    QL

    T1EZETIMIBE/SIMVASTATIN

    VYTORIN (10 MG-40MG) (TABLET)

    QL

    T1EZETIMIBE/SIMVASTATIN

    VYTORIN (10 MG-80MG) (TABLET)

    ST, QL

    ANTIHYPERLIPIDEMIC - APO B-100 SYNTHESISINHIBITORT2MIPOMERSEN SODIUM KYNAMRO PA

    ANTIHYPERLIPIDEMIC - HMG COA REDUCTASEINHIBITORST1ATORVASTATINCALCIUM

    LIPITOR QL

    T1FLUVASTATIN SODIUM LESCOL ST, QLT1FLUVASTATIN SODIUM LESCOL XL ST, QLT3 LOVASTATIN ALTOPREV ST, QLT1LOVASTATIN MEVACOR QLT2 PITAVASTATIN CALCIUM LIVALO QLT1PRAVASTATIN SODIUM PRAVACHOL QLT1ROSUVASTATINCALCIUM

    CRESTOR QL

    T3 SIMVASTATIN FLOLIPID ST, QL

    Commercial Formulary

    804 Portfolio High Formulary Page 16 of 133

  • T1 SIMVASTATIN ZOCOR (10 MG)(TABLET)

    QL

    T1 SIMVASTATIN ZOCOR (20 MG)(TABLET)

    QL

    T1 SIMVASTATIN ZOCOR (40 MG)(TABLET)

    QL

    T1 SIMVASTATIN ZOCOR (5 MG)(TABLET)

    QL

    T1 SIMVASTATIN ZOCOR (80 MG)(TABLET)

    ST, QL

    ANTIHYPERLIPIDEMIC - MTP INHIBITORT2 LOMITAPIDE MESYLATE JUXTAPID PA

    ANTIHYPERLIPIDEMIC - PCSK9 INHIBITORST2ALIROCUMAB PRALUENT PEN PAT2EVOLOCUMAB REPATHA

    PUSHTRONEXPA

    T2EVOLOCUMAB REPATHASURECLICK

    PA

    T2EVOLOCUMAB REPATHA SYRINGE PA

    BILE SALT SEQUESTRANTST1CHOLESTYRAMINE(WITH SUGAR)

    QUESTRAN

    T1CHOLESTYRAMINE/ASPARTAME

    QUESTRAN LIGHT

    T2COLESEVELAM HCL WELCHOLT1COLESTIPOL HCL COLESTID (1 G)

    (TABLET)T1COLESTIPOL HCL COLESTID (5 G)

    (GRANULES)T1COLESTIPOL HCL COLESTID (5 G)

    (PACKET)T3COLESTIPOL HCL COLESTID (7.5 G)

    (PACKET)

    LIPOTROPICST1EZETIMIBE ZETIA QLT1FENOFIBRATE FENOGLIDET1FENOFIBRATE LIPOFENT1FENOFIBRATE LOFIBRAT1FENOFIBRATENANOCRYSTALLIZED

    TRICOR

    T2 FENOFIBRATENANOCRYSTALLIZED

    TRIGLIDE ST

    T1FENOFIBRATE,MICRONIZED

    ANTARA (130 MG)(CAPSULE)

    T3 FENOFIBRATE,MICRONIZED

    ANTARA (30 MG)(CAPSULE)

    ST

    T1FENOFIBRATE,MICRONIZED

    ANTARA (43 MG)(CAPSULE)

    T3 FENOFIBRATE,MICRONIZED

    ANTARA (90 MG)(CAPSULE)

    ST

    T1FENOFIBRATE,MICRONIZED

    LOFIBRA

    T1FENOFIBRIC ACID FIBRICORT1FENOFIBRIC ACID(CHOLINE)

    TRILIPIX

    T1GEMFIBROZIL LOPIDT2 ICOSAPENT ETHYL VASCEPA (0.5

    GRAM) (CAPSULE)QL

    T2 ICOSAPENT ETHYL VASCEPA (1 G)(CAPSULE)

    QL

    T3METHIONINE/INOSI/CHOL/FOLIC AC

    LIPOCHOL PLUS

    T1NIACIN NIACORT1NIACIN NIASPAN STT1OMEGA-3 ACID ETHYLESTERS

    LOVAZA QL

    CARDIOVASCULAR DISEASE -MISCELLANEOUS AGENTS

    ADRENERGIC VASOPRESSOR AGENTST3DROXIDOPA NORTHERA PAT1MIDODRINE HCL PROAMATINE

    ANGIOTENSIN RECEPT-NEPRILYSIN INHIBITORCOMB(ARNI)T2 SACUBITRIL/VALSARTA

    NENTRESTO QL

    ANTIANGINAL & ANTI-ISCHEMIC AGENTS,NON-HEMODYNAMICT2RANOLAZINE RANEXA (1000 MG)

    (TAB ER 12H)QL

    T2RANOLAZINE RANEXA (500 MG)(TAB ER 12H)

    QL

    ANTIANGINAL, HEART RATE REDUCING, I(F)INHIBITORT2 IVABRADINE HCL CORLANOR PA, QL

    ANTIHYPERLIP - HMG-COA&CALCIUM CHANNELBLOCKER CBT1AMLODIPINE/ATORVASTATIN

    CADUET QL

    CARDIOVASCULAR DISEASE -VASODILATION

    VASODILATORS,CORONARYT1AMYL NITRITE AMYL NITRITET3 ISOSORBIDE DINITRATE DILATRATE-SRT1 ISOSORBIDEDINITRATE

    ISOCHRON

    T1 ISOSORBIDEDINITRATE

    ISORDIL (10 MG)(TABLET)

    T1 ISOSORBIDEDINITRATE

    ISORDIL (20 MG)(TABLET)

    T1 ISOSORBIDEDINITRATE

    ISORDIL (30 MG)(TABLET)

    T2 ISOSORBIDE DINITRATE ISORDIL (40 MG)(TABLET)

    T1 ISOSORBIDEDINITRATE

    ISORDILTITRADOSE

    T1 ISOSORBIDEMONONITRATE

    IMDUR

    T1 ISOSORBIDEMONONITRATE

    MONOKET

    T3NITROGLYCERIN GONITRO STT2NITROGLYCERIN NITRO-BID

    Commercial Formulary

    804 Portfolio High Formulary Page 17 of 133

  • T1NITROGLYCERIN NITRO-DUR(0.1MG/HR) (PATCHTD24)

    T1NITROGLYCERIN NITRO-DUR(0.2MG/HR) (PATCHTD24)

    T2NITROGLYCERIN NITRO-DUR (0.3MG/HR) (PATCHTD24)

    T1NITROGLYCERIN NITRO-DUR(0.4MG/HR) (PATCHTD24)

    T1NITROGLYCERIN NITRO-DUR(0.6MG/HR) (PATCHTD24)

    T2NITROGLYCERIN NITRO-DUR(0.8MG/HR) (PATCHTD24)

    T1NITROGLYCERIN NITROLINGUALT1NITROGLYCERIN NITROMISTT1NITROGLYCERIN NITROSTATT1NITROGLYCERIN NITRO-TIME

    VASODILATORS,PERIPHERALT1ERGOLOID MESYLATESHYDERGINET1 ISOXSUPRINE HCL ISOXSUPRINE HCLT1 ISOXSUPRINE HCL VASODILANT1PAPAVERINE HCL PAPAVERINE HCLT1PAPAVERINE/PHENTOLAMINE/WATER

    PAPAVERINE/PHENTOLAMINE/WATER

    CONTRACEPTION/OXYTOCICSCONTRACEPTIVES, INTRAVAGINAL, SYSTEMICT0 ETONOGESTREL/ETHINY

    L ESTRADIOLNUVARING QL

    CONTRACEPTIVES,INJECTABLET0MEDROXYPROGESTERONE ACETATE

    DEPO-PROVERA QL

    T0MEDROXYPROGESTERONE ACETATE

    DEPO-SUBQPROVERA 104

    QL

    CONTRACEPTIVES,INTRAVAGINALT0NONOXYNOL 9 CONCEPTROLT0NONOXYNOL 9 DELFENT0NONOXYNOL 9 GYNOL IIT0NONOXYNOL 9 TODAY

    CONTRACEPTIVESPONGE

    T0NONOXYNOL 9 VCF

    CONTRACEPTIVES,ORALT0DESOG-E.ESTRADIOL/E.ESTRADIOL

    MIRCETTE

    T0DESOGESTREL-ETHINYL ESTRADIOL

    CYCLESSA

    T0DESOGESTREL-ETHINYL ESTRADIOL

    DESOGEN

    T0DROSPIR/ETHESTRA/LEVOMEFOL CA

    BEYAZ ST

    T3DROSPIR/ETHESTRA/LEVOMEFOL CA

    SAFYRAL ST

    T3 ESTRADIOLVALERATE/DIENOGEST

    NATAZIA ST

    T0ETHINYLESTRADIOL/DROSPIRENONE

    YASMIN 28 ST

    T0ETHINYLESTRADIOL/DROSPIRENONE

    YAZ ST

    T0ETHYNODIOL D-ETHINYL ESTRADIOL

    DEMULEN

    T0ETHYNODIOL D-ETHINYL ESTRADIOL

    DEMULEN 1-50-21

    T0ETHYNODIOL D-ETHINYL ESTRADIOL

    ETHYNODIOL D-ETHINYLESTRADIOL

    T0LEVONORGESTREL PLAN B ONE-STEPT0LEVONORGESTREL TAKE ACTIONT0LEVONORGESTREL-ETHIN ESTRADIOL

    AMETHYST

    T0LEVONORGESTREL-ETHIN ESTRADIOL

    AVIANE

    T0LEVONORGESTREL-ETHIN ESTRADIOL

    LEVONORGESTREL-ETHIN ESTRADIOL

    T0LEVONORGESTREL-ETHIN ESTRADIOL

    NORDETTE-28

    T0LEVONORGESTREL-ETHIN ESTRADIOL

    SEASONALE QL

    T0LEVONORGESTREL-ETHIN ESTRADIOL

    TRIVORA

    T0L-NORGEST/E.ESTRADIOL-E.ESTRAD

    LOSEASONIQUE QL

    T0L-NORGEST/E.ESTRADIOL-E.ESTRAD

    QUARTETTE

    T0L-NORGEST/E.ESTRADIOL-E.ESTRAD

    SEASONIQUE QL

    T0NORETH-ETHINYLESTRADIOL/IRON

    NORETH-ETHINYLESTRADIOL/IRON

    T0NORETHINDRONE ORTHO MICRONORT0NORETHINDRONE AC-ETH ESTRADIOL

    LOESTRIN

    T2NORETHINDRONE-E.ESTRADIOL-IRON

    LO LOESTRIN FE ST

    T0NORETHINDRONE-E.ESTRADIOL-IRON

    NORETHINDRONE-E.ESTRADIOL-IRON

    T3NORETHINDRONE-E.ESTRADIOL-IRON

    TAYTULLA

    T0NORETHINDRONE-ETHINYL ESTRAD

    MODICON

    T0NORETHINDRONE-ETHINYL ESTRAD

    ORTHO-NOVUM

    T0NORETHINDRONE-ETHINYL ESTRAD

    OVCON-35

    T0NORETHINDRONE-ETHINYL ESTRAD

    TRI-NORINYL

    T0NORETHINDRONE-MESTRANOL

    NORINYL 1+50

    T0NORGESTIMATE-ETHINYL ESTRADIOL

    ORTHO TRI-CYCLEN

    Commercial Formulary

    804 Portfolio High Formulary Page 18 of 133

  • T0NORGESTIMATE-ETHINYL ESTRADIOL

    ORTHO TRI-CYCLEN LO

    T0NORGESTIMATE-ETHINYL ESTRADIOL

    ORTHO-CYCLEN

    T0NORGESTREL-ETHINYL ESTRADIOL

    LO-OVRAL-28

    T0NORGESTREL-ETHINYL ESTRADIOL

    LO-OVRAL-8

    T0NORGESTREL-ETHINYL ESTRADIOL

    NORGESTREL-ETHINYLESTRADIOL

    T0ULIPRISTAL ACETATE ELLA

    CONTRACEPTIVES,TRANSDERMALT0NORELGESTROMIN/ETHIN.ESTRADIOL

    ORTHO EVRA QL

    DIAPHRAGMS/CERVICAL CAPT0CERVICAL CAP FEMCAPT3DIAPHRAGMS,

    CONTOUREDCAYA CONTOURED

    T0DIAPHRAGMS, WIDESEAL

    WIDE SEALDIAPHRAGM

    OXYTOCICST3DINOPROSTONE CERVIDILT3DINOPROSTONE PREPIDILT3DINOPROSTONE PROSTIN E2

    VAGINALSUPPOSITORY

    T2METHYLERGONOVINEMALEATE

    METHERGINE

    COUGH AND COLD1ST GEN ANTIHISTAMINE & DECONGESTANTCOMBINATIONST1CHLORPHENIRAMINE/PHENYLEPHRINE

    CHLORPHENIRAMINE/PHENYLEPHRINE

    T1PHENYLEPHRINEHCL/PROMETH HCL

    PHENERGAN VC

    T1PHENYLEPHRINEHCL/PROMETH HCL

    PHEN-TUSS AD

    1ST GEN ANTIHIST-DECONGEST-ANTICHOLINERGIC COMBT1PSEUDOEPHED/CHLOR-MAL/BELL ALK

    PSEUDOEPHED/CHLOR-MAL/BELLALK

    ANTITUSSIVES,NON-NARCOTICT1BENZONATATE TESSALONT1BENZONATATE TESSALON PERLET1BENZONATATE ZONATUSS

    NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTT1HYDROCODONE/CPM/PSEUDOEPHED

    ZUTRIPRO

    T1PROMETHAZINE/PHENYLEPH/CODEINE

    PENTAZINE VCWITH CODEINE

    AGE

    T1PROMETHAZINE/PHENYLEPH/CODEINE

    PHENERGAN VCWITH CODEINE

    AGE

    NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMBT3HYDROCODONE/PSEUD

    OEPHED/GUAIFHYCOFENIX ST, QL

    NARCOTIC ANTITUSSIVE-1ST GENERATIONANTIHISTAMINET3CODEINE

    POLI/CHLORPHENIRPOLIS

    TUZISTRA XR ST,AGE,QL

    T3HYDROCODONE/CHLORPHEN P-STIREX

    TUSSICAPS

    T1HYDROCODONE/CHLORPHEN P-STIREX

    TUSSIONEX

    T3HYDROCODONE/CHLORPHENIRAMINE

    VITUZ

    T1PROMETHAZINEHCL/CODEINE

    PHENERGAN WITHCODEINE

    AGE

    NARCOTIC ANTITUSSIVE-ANTICHOLINERGICCOMB.T1HYDROCODONEBIT/HOMATROP ME-BR

    HYDROCODONEBIT/HOMATROPME-BR

    NARCOTIC ANTITUSSIVE-DECONGESTANTCOMBINATIONST3 PSEUDOEPHED/HYDROC

    ODONEREZIRA

    NARCOTIC ANTITUSSIVE-EXPECTORANTCOMBINATIONT3GUAIFENESIN/HYDROCO

    DONEFLOWTUSS ST, QL

    T3GUAIFENESIN/HYDROCODONE

    OBREDON ST, QL

    NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGESTT1BROMPHENIRAMINE/PSEUDOEPHED/DM

    BROMFED DM

    T1BROMPHENIRAMINE/PSEUDOEPHED/DM

    BROMPHENIRAMINE/PSEUDOEPHED/DM

    T1CHLORPHENIRAMINE/PHENYLEPH/DM

    CHLORPHENIRAMINE/PHENYLEPH/DM

    NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINECOMB.T1PROMETHAZINE/DEXTROMETHORPHAN

    PHEN TUSS DM

    NOSE PREPARATIONS, VASOCONSTRICTORS (RX)T3 EPINEPHRINE HCL ADRENALIN

    CHLORIDET3 TETRAHYDROZOLINE

    HCLTYZINE

    DERMATOLOGY - ACNEACNE AGENTS,SYSTEMICT3 ISOTRETINOIN ABSORICA STT1 ISOTRETINOIN ACCUTANET1 ISOTRETINOIN ISOTRETINOIN

    Commercial Formulary

    804 Portfolio High Formulary Page 19 of 133

  • ACNE AGENTS,TOPICALT1ADAPALENE/BENZOYLPEROXIDE

    EPIDUO ST,AGE

    T2ADAPALENE/BENZOYLPEROXIDE

    EPIDUO FORTE ST,AGE

    T3AZELAIC ACID AZELEXT3CLINDAMYCIN

    PHOS/BENZOYL PEROXACANYA ST

    T1CLINDAMYCINPHOS/BENZOYL PEROX

    BENZACLIN

    T1CLINDAMYCINPHOS/BENZOYL PEROX

    DUAC

    T2CLINDAMYCINPHOS/BENZOYL PEROX

    ONEXTON ST

    T3CLINDAMYCIN/BENZOYL/EMOL CMB94

    NEUAC

    T3CLINDAMYCIN/TRETINOIN

    VELTIN ST

    T1CLINDAMYCIN/TRETINOIN

    ZIANA

    T3DAPSONE ACZONET1 SULFACETAMIDESODIUM

    KLARON

    ANTICORROSIVE AGENTST3BUTYLATED

    HYDROXYTOLUENEBUTYLATEDHYDROXYTOLUENE(BHT)

    KERATOLYTIC-GLUCOCORTICOID COMBINATIONST2BENZOYL

    PEROXIDE/HYDROCORTISON

    VANOXIDE-HC

    ROSACEA AGENTS, TOPICALT2AZELAIC ACID FINACEAT3BRIMONIDINE

    TARTRATEMIRVASO

    T3 IVERMECTIN SOOLANTRA STT1METRONIDAZOLE METROCREAMT1METRONIDAZOLE METROGELT1METRONIDAZOLE METROLOTIONT3METRONIDAZOLE NORITATE STT1METRONIDAZOLE ROSADANT3METRONIDAZOLE/SKIN

    CLEANSER 23ROSADAN

    T3OXYMETAZOLINE HCL RHOFADE

    TOPICAL PREPARATIONS,ANTIBACTERIALST3CADEXOMER IODINE IODOFLEXT3CADEXOMER IODINE IODOSORBT3CLIOQUINOL/HYDROCO

    RTIS/EMOL 88DERMASORB AF

    T3CLIOQUINOL/HYDROCORTISONE

    ALA-QUIN

    T3HYDROCORTISONE/IODOQUIN/ALOE 2

    ALCORTIN A

    T1HYDROCORTISONE/IODOQUINOL

    DERMAZENE

    T1HYDROCORTISONE/IODOQUINOL/ALOE

    VYTONE

    T1 IODINE/POTASSIUMIODIDE

    LUGOL'S

    T3 IODOQUINOL/ALOE P-SACCHARIDE 1

    ALOQUIN

    T3 IODOQUINOL/ALOE P-SACCHARIDE 1

    QUINJA

    T3 SILVER SILVRSTATT3 SILVER CARBONATE NORMLGEL AGT1 SILVER NITRATE SILVER NITRATE

    VITAMIN A DERIVATIVEST1ADAPALENE DIFFERIN AGET1TRETINOIN ATRALIN AGET1TRETINOIN RETIN-A AGET3TRETINOIN TRETIN-XT1TRETINOINMICROSPHERES

    RETIN-A MICRO AGE

    T1TRETINOINMICROSPHERES

    RETIN-A MICROPUMP (0.04 %) (GELW/PUMP)

    AGE

    T3 TRETINOINMICROSPHERES

    RETIN-A MICROPUMP (0.08 %) (GELW/PUMP)

    ST,AGE

    T1TRETINOINMICROSPHERES

    RETIN-A MICROPUMP (0.1 %) (GELW/PUMP)

    AGE

    T3 TRETINOIN/EMOL 9/SKINCLEANSR1

    TRETIN-X AGE

    VITAMIN A DERIVATIVES, TOPICAL ACNE AGENTST2 TAZAROTENE FABIOR AGE

    DERMATOLOGY - ANTIINFECTIVETOPICAL ANTIBIOTICST3CLINDAMYCIN

    PHOS/SKIN CLNSR 19CLINDACIN ETZ

    T3CLINDAMYCINPHOS/SKIN CLNSR 19

    CLINDACIN PAC

    T1CLINDAMYCINPHOSPHATE

    CLEOCIN T

    T1CLINDAMYCINPHOSPHATE

    CLINDACIN ETZ

    T1CLINDAMYCINPHOSPHATE

    CLINDACIN P

    T3CLINDAMYCINPHOSPHATE

    CLINDAGEL ST

    T1CLINDAMYCINPHOSPHATE

    EVOCLIN

    T1ERYTHROMYCINBASE/ETHANOL

    ERY

    T1ERYTHROMYCINBASE/ETHANOL

    ERYGEL

    T1ERYTHROMYCINBASE/ETHANOL

    ERYMAX

    T2ERYTHROMYCIN/BENZOYL PEROXIDE

    AKTIPAK

    T1ERYTHROMYCIN/BENZOYL PEROXIDE

    BENZAMYCIN

    T1GENTAMICIN SULFATE GENTAMICINSULFATE

    T1MUPIROCIN CENTANYT3MUPIROCIN CENTANY ATT1MUPIROCIN CALCIUM BACTROBAN

    Commercial Formulary

    804 Portfolio High Formulary Page 20 of 133

  • TOPICALANTIFUNGAL/ANTIINFLAMMATORY,STERIODAGENTT3CLOTRIMAZOLE/BETAM

    ETH DIP/ZINCDERMACINRXTHERAZOLE PAK

    T1CLOTRIMAZOLE/BETAMETHASONE DIP

    LOTRISONE

    TOPICAL ANTIFUNGALST3BUTENAFINE HCL MENTAXT1CICLOPIROX CICLODANT1CICLOPIROX LOPROXT1CICLOPIROX PENLACT1CICLOPIROX OLAMINE CICLODANT1CICLOPIROX OLAMINE LOPROXT3CICLOPIROX/SKIN

    CLEANSER NO.28CICLODAN

    T3CICLOPIROX/SKINCLEANSER NO.40

    LOPROX

    T1CICLOPIROX/UREA/CAMPH/MEN/EUC

    CICLODAN

    T1CLOTRIMAZOLE LOTRIMINT3 ECONAZOLE NITRATE ECOZAT1ECONAZOLE NITRATE SPECTAZOLET3 EFINACONAZOLE JUBLIA PAT1GENTIANVIOLET/BRGREEN/PROFLAV

    GENTIANVIOLET/BRGREEN/PROFLAV

    T1KETOCONAZOLE EXTINA (2 %)(FOAM)

    T3KETOCONAZOLE EXTINA (2 %)(FOAM)

    T1KETOCONAZOLE NIZORALT3KETOCONAZOLE XOLEGELT3 LULICONAZOLE LUZU ST, QLT3MICONAZOLE

    NITRATE/ZINC OX/PETVUSION

    T1NAFTIFINE HCL NAFTIN (1 %)(CREAM (G))

    T2NAFTIFINE HCL NAFTIN (1 %) (GEL(GRAM))

    T1NAFTIFINE HCL NAFTIN (2 %)(CREAM (G))

    T2NAFTIFINE HCL NAFTIN (2 %) (GEL(GRAM))

    T1NYSTATIN MYCOSTATINT1NYSTATIN NYAMYCT1NYSTATIN NYSTATINT1NYSTATIN NYSTEXT1NYSTATIN NYSTOPT1NYSTATIN/TRIAMCIN MYCOGEN IIT1OXICONAZOLENITRATE

    OXISTAT (1 %)(CREAM (G))

    T3OXICONAZOLE NITRATE OXISTAT (1 %)(LOTION)

    T3 SERTACONAZOLENITRATE

    ERTACZO

    T1 SODIUMTHIOSULFATE/SALACID

    VERSICLEAR

    T2 SULCONAZOLE NITRATE EXELDERMT3TAVABOROLE KERYDIN PA

    TOPICAL ANTIPARASITICST3BENZYL ALCOHOL ULESFIAT2CROTAMITON EURAXT3 IVERMECTIN SKLICET1LINDANE KWELLT1MALATHION OVIDET1PERMETHRIN PERMETHRINT1 SPINOSAD NATROBA

    TOPICAL ANTIVIRALST2ACYCLOVIR ZOVIRAX (5 %)

    (CREAM (G))T1ACYCLOVIR ZOVIRAX (5 %)

    (OINT. (G))T3 PENCICLOVIR DENAVIR

    TOPICAL ANTIVIRALS/ANTIINFLAMMATORY,STEROID AGENTT3ACYCLOVIR/HYDROCOR

    TISONEXERESE ST, QL

    TOPICAL GENITAL WART-HPV TREATMENTAGENTST3 SINECATECHINS VEREGEN ST

    TOPICAL PLEUROMUTILIN DERIVATIVEST3RETAPAMULIN ALTABAX

    TOPICAL SULFONAMIDEST3MAFENIDE ACETATE SULFAMYLONT1 SILVER SULFADIAZINE SILVADENET1 SILVER SULFADIAZINE THERMAZENET1 SULFACETAMIDESOD/SULFUR/UREA

    CLARIS

    T1 SULFACETAMIDESOD/SULFUR/UREA

    SULFACETAMIDESOD/SULFUR/UREA

    T1 SULFACETAMIDESODIUM/SULFUR

    AVAR (10-5%(W/W))(CLEANSER)

    T3 SULFACETAMIDESODIUM/SULFUR

    AVAR (9.5 %-5 %)(FOAM)

    T3 SULFACETAMIDESODIUM/SULFUR

    AVAR (9.5 %-5 %)(MED. PAD)

    T1 SULFACETAMIDESODIUM/SULFUR

    AVAR LS (10 %-2 %)(CLEANSER)

    T3 SULFACETAMIDESODIUM/SULFUR

    AVAR LS (10 %-2 %)(FOAM)

    T3 SULFACETAMIDESODIUM/SULFUR

    AVAR LS (10 %-2 %)(MED. PAD)

    T1 SULFACETAMIDESODIUM/SULFUR

    AVAR-E

    T1 SULFACETAMIDESODIUM/SULFUR

    AVAR-E GREEN

    T1 SULFACETAMIDESODIUM/SULFUR

    AVAR-E LS

    T1 SULFACETAMIDESODIUM/SULFUR

    BP 10-1

    T1 SULFACETAMIDESODIUM/SULFUR

    CLARIFOAM EF

    T1 SULFACETAMIDESODIUM/SULFUR

    PLEXION (10-5%(W/W)) (LOTION)

    T1 SULFACETAMIDESODIUM/SULFUR

    PLEXION (9.8%-4.8%) (CLEANSER)

    Commercial Formulary

    804 Portfolio High Formulary Page 21 of 133

  • T1 SULFACETAMIDESODIUM/SULFUR

    PLEXION (9.8%-4.8%) (CREAM (G))

    T1 SULFACETAMIDESODIUM/SULFUR

    PLEXION (9.8%-4.8%) (LOTION)

    T3 SULFACETAMIDESODIUM/SULFUR

    PLEXION (9.8%-4.8%) (MED. PAD)

    T1 SULFACETAMIDESODIUM/SULFUR

    PLEXION TS

    T3 SULFACETAMIDESODIUM/SULFUR

    ROSANIL

    T3 SULFACETAMIDESODIUM/SULFUR

    ROSULA (10 %-4.5%) (CLEANSER)

    T1 SULFACETAMIDESODIUM/SULFUR

    ROSULA (10 %-5 %)(MED. PAD)

    T1 SULFACETAMIDESODIUM/SULFUR

    SODIUMSULFACETAMIDE-SULFUR

    T1 SULFACETAMIDESODIUM/SULFUR

    SULFACET-R

    T1 SULFACETAMIDESODIUM/SULFUR

    SUMADAN

    T1 SULFACETAMIDESODIUM/SULFUR

    SUMAXIN

    T1 SULFACETAMIDESODIUM/SULFUR

    SUMAXIN TS

    T1 SULFACETAMIDE/SULFUR/CLEANSR23

    PLEXION

    T3 SULFACETAMIDE/SULFUR/CLEANSR23

    SUMADAN

    T3 SULFACETAMIDE/SULFUR/CLEANSR23

    SUMAXIN CP

    T1 SULFACTSOD/SULUR/AVOB/OTN/OCT

    SUMADAN XLT

    DERMATOLOGY -ANTIINFLAMMATORY

    TOP. ANTI-INFLAM.,PHOSPHODIESTERASE-4 (PDE4)INHIBT2CRISABOROLE EUCRISA

    TOPICALANTIBIOTICS/ANTIINFLAMMATORY,STEROIDALT2NEOMYC/BACIT/POLYM

    YX/HYDROCORTCORTISPORIN

    T3NEOMYCINSULFATE/FLUOCINOLONE

    NEO-SYNALAR ST

    T3NEOMYCIN/FLUOCINOLONE/EMOLL 65

    NEO-SYNALAR ST

    T2NEOMYCIN/POLYMYXINB/HYDROCORT

    CORTISPORIN

    TOPICAL ANTI-INFLAMMATORY STEROIDALT1ALCLOMETASONEDIPROPIONATE

    ACLOVATE

    T1AMCINONIDE CYCLOCORTT1BETAMETHASONEDIPROPIONATE

    DIPROLENE

    T3BETAMETHASONEDIPROPIONATE

    SERNIVO ST

    T1BETAMETHASONEVALERATE

    LUXIQ

    T1BETAMETHASONEVALERATE

    VALISONE

    T1BETAMETHASONE/PROPYLENE GLYC

    DIPROLENE

    T1BETAMETHASONE/PROPYLENE GLYC

    DIPROLENE AF

    T1CLOBETASOLPROPIONATE

    CLOBEX

    T1CLOBETASOLPROPIONATE

    CLODAN

    T1CLOBETASOLPROPIONATE

    OLUX

    T1CLOBETASOLPROPIONATE

    TEMOVATE

    T1CLOBETASOLPROPIONATE/EMOLL

    OLUX-E

    T1CLOBETASOLPROPIONATE/EMOLL

    TEMOVATE E

    T1CLOBETASOLPROPIONATE/EMOLL

    TEMOVATEEMOLLIENT

    T3CLOBETASOL/SKINCLEANSER NO.28

    CLODAN

    T1CLOCORTOLONEPIVALATE

    CLODERM

    T3DESONIDE DESONATET1DESONIDE DESONIDET1DESONIDE DESOWENT3DESONIDE VERDESOT1DESOXIMETASONE TOPICORT (0.05 %)

    (CREAM (G))T1DESOXIMETASONE TOPICORT (0.05 %)

    (GEL (GRAM))T1DESOXIMETASONE TOPICORT (0.05 %)

    (OINT. (G))T1DESOXIMETASONE TOPICORT (0.25 %)

    (CREAM (G))T1DESOXIMETASONE TOPICORT (0.25 %)

    (OINT. (G))T3DESOXIMETASONE TOPICORT (0.25 %)

    (SPRAY)ST

    T1DIFLORASONEDIACETATE

    APEXICON

    T1DIFLORASONEDIACETATE

    PSORCON

    T2DIFLORASONEDIACETATE/EMOLL

    APEXICON E

    T3 FLUOCINOLONEACETONIDE

    CAPEX SHAMPOO

    T1FLUOCINOLONEACETONIDE

    DERMA-SMOOTHE-FS

    T1FLUOCINOLONEACETONIDE

    SYNALAR

    T3 FLUOCINOLONE/EMOLCOMB NO.65

    SYNALAR

    T1FLUOCINOLONE/SHOWER CAP

    DERMA-SMOOTHE-FS

    T3 FLUOCINOLONE/SKINCLNSR10/TAPE

    XILAPAK

    T3 FLUOCINOLONE/SKINCLNSR28

    SYNALAR TS

    Commercial Formulary

    804 Portfolio High Formulary Page 22 of 133

  • T3 FLUOCINOLONE/UREA/SILICONE,ADH

    NOXIPAK

    T1FLUOCINONIDE LIDEXT1FLUOCINONIDE VANOST1FLUOCINONIDE/EMOLLIENT BASE

    LIDEX-E

    T1FLURANDRENOLIDE CORDRAN (0.05 %)(CREAM (G))

    T1FLURANDRENOLIDE CORDRAN (0.05 %)(LOTION)

    T1FLURANDRENOLIDE CORDRAN (0.05 %)(OINT. (G))

    T3 FLURANDRENOLIDE CORDRAN(4MCG/SQ CM)(MED. TAPE)

    ST, QL

    T1FLURANDRENOLIDE NOLIXT1FLUTICASONEPROPIONATE

    CUTIVATE

    T3HALCINONIDE HALOGT1HALOBETASOLPROPIONATE

    ULTRAVATE (0.05%) (CREAM (G))

    T3HALOBETASOLPROPIONATE

    ULTRAVATE (0.05%) (LOTION)

    T1HALOBETASOLPROPIONATE

    ULTRAVATE (0.05%) (OINT. (G))

    T3HALOBETASOL/LACTICACID

    ULTRAVATE X

    T1HYDROCORT/MINOIL/PETROLAT,WHT

    HYDROCORT/MINOIL/PETROLAT,WHT

    T2HYDROCORT/SALACID/SULF/SHAMP1

    SCALACORT DK

    T1HYDROCORTISONE ALACORTT1HYDROCORTISONE ANUSOL HCT1HYDROCORTISONE CORTAIDT1HYDROCORTISONE HYDROCORTISONET1HYDROCORTISONE HYTONET1HYDROCORTISONE NUCORTT1HYDROCORTISONE PROCTOZONE-HCT1HYDROCORTISONE SCALACORTT2HYDROCORTISONE TEXACORTT3HYDROCORTISONE

    ACET/ALOE VERANUCORT

    T1HYDROCORTISONEACETATE

    HYDROCORTISONEACETATE

    T3HYDROCORTISONEACETATE

    MICORT-HC

    T1HYDROCORTISONEBUTYRATE

    LOCOID (0.1 %)(CREAM (G))

    T3HYDROCORTISONEBUTYRATE

    LOCOID (0.1 %)(LOTION)

    T1HYDROCORTISONEBUTYRATE

    LOCOID (0.1 %)(OINT. (G))

    T1HYDROCORTISONEBUTYRATE

    LOCOID (0.1 %)(SOLUTION)

    T1HYDROCORTISONEBUTYRATE/EMOLL

    LOCOIDLIPOCREAM

    T2HYDROCORTISONEPROBUTATE

    PANDEL

    T1HYDROCORTISONEVALERATE

    HYDROCORTISONEVALERATE

    T1HYDROCORTISONEVALERATE

    WESTCORT

    T3HYDROCORTISONE/SKINCLEANSER25

    AQUA GLYCOLICHC

    T3HYDROCORTISONE/SKINCLEANSER35

    DERMASORB HC

    T1MOMETASONEFUROATE

    ELOCON

    T1PREDNICARBATE DERMATOPT3 TRIAMCINOLONE

    ACETON/SILICONESDERMACINRXSILAZONE

    T3TRIAMCINOLONEACETON/SILICONES

    DERMAZONE

    T3TRIAMCINOLONEACETON/SILICONES

    SILAZONE-II

    T1TRIAMCINOLONEACETONIDE

    KENALOG

    T1TRIAMCINOLONEACETONIDE

    TRIAMCINOLONEACETONIDE

    T1TRIAMCINOLONE/DIMETH/SILICONE

    DERMACINRXSILAPAK

    ST, QL

    T1TRIAMCINOLONE/DIMETH/SILICONE

    DERMAWERX SDS ST, QL

    T1TRIAMCINOLONE/DIMETH/SILICONE

    NUTRIARX ST, QL

    T1TRIAMCINOLONE/DIMETH/SILICONE

    SURE RESULT TACPAK

    ST, QL

    T1TRIAMCINOLONE/DIMETH/SILICONE

    TRI-SILA ST, QL

    T3 TRIAMCINOLONE/DIMETH/SILICONE

    WHYTEDERMTDPAK

    T3TRIAMCINOLONE/DIMETH/SILICONE

    WHYTEDERMTRILASIL PAK

    T3TRIAMCINOLONE/EMOLLIENT COMB86

    DERMASORB TA

    TOPICAL ANTI-INFLAMMATORY, NSAIDST3DICLOFEN

    SOD/KINESIOLOGY TAPEDICLO GEL-XRYLIX SHEET

    T3DICLOFENSOD/KINESIOLOGY TAPE

    XRYLIX

    T3DICLOFENACEPOLAMINE

    FLECTOR

    T3DICLOFENAC SODIUM DICLOZORT1DICLOFENAC SODIUM PENNSAID (1.5 %)

    (DROPS)T3DICLOFENAC SODIUM PENNSAID

    (20MG/G(2%)) (SOLMD PMP)

    ST

    T1DICLOFENAC SODIUM VOLTARENT3DICLOFENAC SODIUM VOPAC MDST3DICLOFENAC

    SODIUM/CAPSAICINNUDICLO

    T3DICLOFENAC/BENZALKONIUM CHLOR

    DS PREP PAK

    T3DICLOFENAC/CAPSICUMOLEORESIN

    DERMACINRXLEXITRAL

    T3DICLOFENAC/CAPSICUMOLEORESIN

    DICLOTRAL

    T3DICLOFENAC/CAPSICUMOLEORESIN

    SURE RESULT DSSPREMIUM PACK

    Commercial Formulary

    804 Portfolio High Formulary Page 23 of 133

  • T3DICLOFENAC/CAPSICUMOLEORESIN

    XELITRAL

    T3DICLOFENAC/ME-SALIC/MENTH/CAMP

    INFLAMMA-K

    DERMATOLOGY - ANTIPRURITICDRUGS

    ANTIPRURITICS,TOPICALT1DOXEPIN HCL PRUDOXIN STT1DOXEPIN HCL ZONALON STT3 E101/NAMG FL/NA

    PH/NACL/HA-NAHALEVICYN PLUS

    T3NA MG FL/NAPHO/NACL/HA/NA HYP

    ALEVICYN

    T3NA MG FL/NAPHO/NACL/HA/NA HYP

    SP ANTIPRURITIC

    DERMATOLOGY - MISCELLANEOUSANTIPERSPIRANTST2ALUMINUM CHLORIDE DRYSOL

    ANTISEBORRHEIC AGENTST3 EMOLLIENT

    COMBINATION NO.43PROMISEB

    T1EMOLLIENTCOMBINATION NO.85

    EMOLLIENTCOMBINATIONNO.85

    T3 EMOLLIENT NO43/SKINCLEANSER27

    PROMISEBCOMPLETE

    T1 SELENIUM SULFIDE SELENIUMSULFIDE

    T3 SELENIUM SULFIDE SELRXT1 SELENIUM SULFIDE SELSUNT3 SELENIUM SULFIDE TERSI FOAMT1 SULFACETAMIDESODIUM

    OVACE

    T3 SULFACETAMIDESODIUM

    OVACE PLUS (10 %)(CLEANSR ER)

    T3 SULFACETAMIDESODIUM

    OVACE PLUS (10 %)(CREAM (G))

    T2 SULFACETAMIDESODIUM

    OVACE PLUS (10 %)(SHAMPOO)

    T3 SULFACETAMIDESODIUM

    OVACE PLUS (9.8 %)(FOAM)

    T3 SULFACETAMIDESODIUM

    OVACE PLUS (9.8 %)(LOTION)

    ST

    T1 SULFACETAMIDESODIUM

    SULFACETAMIDESODIUM

    ANTISEPTICS,MISCELLANEOUST3GUAIACOL GUAIACOL

    EMOLLIENTST1AMMONIUM LACTATE LAC-HYDRINT1EMOL53/NAMGFS/HA/NAHYPOCHLORIT

    EMOL53/NAMGFS/HA/NAHYPOCHLORIT

    T1EMOL53/SOD MAGFL.SIL/CYCLOMET

    EMOL53/SOD MAGFL.SIL/CYCLOMET

    T1EMOLLIENTCOMBINATION NO.10

    BIAFINE

    T3 EMOLLIENTCOMBINATION NO.10

    LUXAMEND

    T3EMOLLIENTCOMBINATION NO.101

    CERAMAX

    T3EMOLLIENTCOMBINATION NO.103

    CERACADE

    T3EMOLLIENTCOMBINATION NO.104

    DEXERYL

    T3 EMOLLIENTCOMBINATION NO.107

    NUTRASEB

    T1EMOLLIENTCOMBINATION NO.32

    EMOLLIENTCOMBINATIONNO.32

    T3 EMOLLIENTCOMBINATION NO.32

    EPICERAM

    T1EMOLLIENTCOMBINATION NO.35

    EMOLLIENTCOMBINATIONNO.35

    T3 EMOLLIENTCOMBINATION NO.38

    NEOSALUS

    T3 EMOLLIENTCOMBINATION NO.44

    HPR

    T3 EMOLLIENTCOMBINATION NO.44

    HYLATOPIC

    T3 EMOLLIENTCOMBINATION NO.47

    NEOSALUS

    T3 EMOLLIENTCOMBINATION NO.47

    NEOSALUS CP

    T3 EMOLLIENTCOMBINATION NO.53

    HPR PLUS

    T3 EMOLLIENTCOMBINATION NO.53

    HYLATOPICPLUS

    T3 EMOLLIENTCOMBINATION NO.53

    NIVATOPIC PLUS

    T3 EMOLLIENTCOMBINATION NO.60

    ALEVICYNANTIPRURITIC SG

    T3 EMOLLIENTCOMBINATION NO.60

    ATRAPROHYDROGEL

    T3 EMOLLIENTCOMBINATION NO.60

    CELACYN

    T3EMOLLIENTCOMBINATION NO.60

    RESTIZAN

    T3EMOLLIENTCOMBINATION NO.60

    SEBUDERM

    T3EMOLLIENTCOMBINATION NO.60

    SP SCARMANAGEMENT

    T3EMOLLIENTCOMBINATION NO.80

    PRESERA

    T3EMOLLIENT COMBOSNO.47, NO.60

    ATRAPRO CP

    T3HYALURONT/E/EMOL12/ALLAN/SHEA

    XCLAIR

    T3 PALM OIL SYNERDERMT3 PALM OIL/EUCALYPTUS

    OILPHLAG SPRAY

    T3 PALMOIL/HYALURONATESODIUM

    ENTTY

    T1VITEAC/GRAPE/HYALURONIC ACID

    ATOPICLAIR

    Commercial Formulary

    804 Portfolio High Formulary Page 24 of 133

  • IODINE ANTISEPTICST1POVIDONE-IODINE POVIDONE-IODINE

    IRRIGANTST1ACETIC ACID ACETIC ACIDT1MANNITOL/SORBITOLSOLUTION

    MANNITOL/SORBITOL SOLUTION

    T1NEOMYCINSULF/POLYMYXIN BSULF

    NEOSPORIN G.U.IRRIGANT

    T3 PHYSIOLOGICAL IRRIGSOLN NO.1

    PHYSIOLYTE

    T3 PHYSIOLOGICAL IRRIGSOLN NO.1

    PHYSIOSOL

    T1RINGER'S SOLUTION RINGER'SSOLUTION

    T3RINGER'SSOLUTION,LACTATED

    LACTATEDRINGERS

    T3 SOD,POTCHLOR/MAG/SOD,POTPHOS

    TIS-U-SOLPENTALYTE

    T3 SODIUMCHLOR/HYPOCHLOROUSACID

    VASHE WOUND

    T3 SODIUMCHLOR/HYPOCHLOROUSACID

    VASHE WOUNDTHERAPY

    T1 SODIUM CHLORIDEIRRIG SOLUTION

    SODIUM CHLORIDEIRRIG SOLUTION

    T1 SORBITOL SOLUTION SORBITOLSOLUTION

    T1WATER FORIRRIGATION,STERILE

    WATER FORIRRIGATION,STERILE

    IRRITANTS/COUNTER-IRRITANTST3CAPSAICIN/SKIN

    CLEANSERQUTENZA PA

    KERATOLYTICST1BENZOYL PEROXIDE BENZEFOAMT1BENZOYL PEROXIDE BENZEFOAM

    ULTRAT1BENZOYL PEROXIDE BENZOYL

    PEROXIDET1BENZOYL PEROXIDE PACNEXT3BENZOYL PEROXIDE PACNEX HPT3BENZOYL PEROXIDE PACNEX LPT1BENZOYL PEROXIDEMICROSPHERES

    BENZOYLPEROXIDEMICROSPHERES

    T3BENZOYLPEROXIDE/SULFUR

    NUOX

    T3BENZOYL PEROXIDE/VITE MIX

    INOVA

    T3 PODOFILOX CONDYLOX STT1PODOFILOX PODOFILOXT1PODOPHYLLUM RESIN PODOPHYLLUM

    RESINT1POTASSIUMHYDROXIDE

    POTASSIUMHYDROXIDE

    T3 SALICYLIC AC/BENZOYLPER/VIT E

    INOVA 4-1

    T3 SALICYLIC AC/BENZOYLPER/VIT E

    INOVA 8-2

    T3 SALICYLIC ACID BENSAL HPT3 SALICYLIC ACID KERALYT SCALPT1 SALICYLIC ACID SALICYLIC ACIDT3 SALICYLIC ACID ULTRASAL-ERT1 SALICYLICACID/AMMONLACT/ALOE

    SALKERA

    T1 SALICYLICACID/CERAMIDE COMB1

    SALICYLICACID/CERAMIDECOMB 1

    T3 SALICYLIC ACID/UREA SALVAX DUO PLUST1 SILVER NITRATE SILVER NITRATET1 SILVER NITRATEAPPLICATOR

    SILVER NITRATEAPPLICATOR

    T3UREA GORDO-UREAT3UREA HYDRO 35T1UREA HYDRO 40T3UREA KERAFOAMT1UREA KERALACT1UREA REA LO 39T1UREA REA LO 40T3UREA RYNODERMT3UREA URAMAXIN (20 %)

    (FOAM)T1UREA URAMAXIN (45 %)

    (CREAM (G))T1UREA URAMAXIN (45 %)

    (GEL (ML))T1UREA URAMAXIN (45 %)

    (LOTION)T1UREA URAMAXIN GTT1UREA UREAT1UREA URE-KT3UREA UREVAZT3UREA UTOPICT3UREA/EMOLLIENT

    COMBINATION 65URAMAXIN GT

    T1UREA/LACTICACID/ZINC UNDECYL

    UREA/LACTICACID/ZINCUNDECYL

    OXIDIZING AGENTST3HYP AC/SOD CHL/SOD

    SUL/SOD PHOALEVICYN

    T3HYPOC ACID/SODHYPO/NACL/WATER

    ATRAPRO DERMALSPRAY

    T3HYPOC ACID/SODHYPO/NACL/WATER

    MICROCYN

    PROTECTIVEST3BIO/CARB/EQUIS/ETHAN

    /CHIT/MSMGENADUR

    T3CARBIT/EQUISXT/ETHAN/CHIT/MSM

    GENADUR

    T3DI-MESILOX/DIMETHIC/HEXAMETHY

    BEAU RX ST, QL

    T3HOCL/NA HY/NAMGF/NAPH/NACL/WA

    MICROCYNHYDROGEL

    T3HYALURONATE SODIUM BIONECT

    Commercial Formulary

    804 Portfolio High Formulary Page 25 of 133

  • T3HYALURONATESODIUM/HE-CELL/PEG

    HYGEL

    T3HYALURONATE/ALLANTOIN/ALOE EXT

    RADIAPLEXRX

    T1PETROLATUM,WHITE PETROLATUM,WHITE

    T3 POLYDIMETHYLSILOXANES/SILICON

    RECEDO

    T3 POLY-UREAURETHANE NUVAILT3 PROTECTIVES

    COMBINATION NO.2TETRIX

    T1PROTECTIVES2/CERAMIDE 1,3,6-11

    PROTECTIVES2/CERAMIDE 1,3,6-11

    TOPICAL ANTI-INFLAMMATORY STEROID-LOCALANESTHETICT2HYDROCORTISONE/PRA

    MOXINEANALPRAM HC

    T3HYDROCORTISONE/PRAMOXINE

    EPIFOAM

    T3HYDROCORTISONE/PRAMOXINE

    NOVACORT

    T2HYDROCORTISONE/PRAMOXINE

    PRAMOSONE (1 %-1%) (CREAM (G))

    T2HYDROCORTISONE/PRAMOXINE

    PRAMOSONE (1 %-1%) (LOTION)

    T2HYDROCORTISONE/PRAMOXINE

    PRAMOSONE (1 %-1%) (OINT. (G))

    T1HYDROCORTISONE/PRAMOXINE

    PRAMOSONE (2.5%-1 %) (CREAM (G))

    T2HYDROCORTISONE/PRAMOXINE

    PRAMOSONE (2.5%-1 %) (LOTION)

    T2HYDROCORTISONE/PRAMOXINE

    PRAMOSONE (2.5%-1 %) (OINT. (G))

    T3HYDROCORTISONE/PRAMOXINE/EMOLL

    PRAMOSONE E

    T1LIDOCAINE/HYDROCORTISONE AC

    LIDAMANTLE HC

    TOPICAL ANTINEOPLASTIC & PREMALIGNANTLESION AGNTST3ALITRETINOIN PANRETINT2BEXAROTENE TARGRETIN PAT1DICLOFENAC SODIUM SOLARAZE PA, QLT1FLUOROURACIL CARACT1FLUOROURACIL EFUDEXT3 FLUOROURACIL FLUOROPLEXT3 FLUOROURACIL TOLAKT2 INGENOL MEBUTATE PICATO (0.015 %)

    (GEL (EA))QL

    T2 INGENOL MEBUTATE PICATO (0.05 %)(GEL (EA))

    QL

    T2MECHLORETHAMINEHCL

    VALCHLOR PA

    TOPICAL LOCAL ANESTHETICST3BENZOCAINE ANACAINET1COCAINE HCL COCAINE HCLT1ETHYL CHLORIDE ETHYL CHLORIDET1LIDOCAINE LIDODERMT3LIDOCAINE LIDOPACT3LIDOCAINE LIDOVEXT3LIDOCAINE TRANZAREL

    T1LIDOCAINE XYLOCAINE ST, QLT3 LIDOCAINE HCL ANASTIAT3 LIDOCAINE HCL ASTEROT1LIDOCAINE HCL CIDALEAZET3 LIDOCAINE HCL LDO PLUST1LIDOCAINE HCL LIDO-KT1LIDOCAINE HCL LIDOPIN (3 %)

    (CREAM (G))T3 LIDOCAINE HCL LIDOPIN (3.25 %)

    (CREAM (G))T3 LIDOCAINE HCL LIDORXT3LIDOCAINE HCL LIDOTRALT3 LIDOCAINE HCL NUMBONEXT1LIDOCAINE HCL PRE-ATTACHED

    LTA KITT3 LIDOCAINE

    HCL/COLLAGENREGENECARE

    T3 LIDOCAINE/BENZOCAIN/ME-SAL/CAP

    ADAZIN

    T3 LIDOCAINE/DIMETHICONE

    DERMACINRX ZRMPAK

    T3LIDOCAINE/DIMETHICONE

    DERMAZYL

    T3LIDOCAINE/EMOLLIENTCMB NO.102

    DERMACINRX PHNPAK

    T3LIDOCAINE/GAUZE/ALGINATE

    WOUNDDEBRIDEMENT-LIDOCAINE

    T3 LIDOCAINE/KINESIOLOGY TAPE

    XRYLIDERM

    T3LIDOCAINE/MENTHOL MENTHO-CAINET3 LIDOCAINE/METHYL

    SAL/MENTHOLSOLUPAK

    T3LIDOCAINE/PRILO/M.SALICY/MENTH

    PAINGO KFT

    T1LIDOCAINE/PRILOCAINE

    AGONEAZE

    T1LIDOCAINE/PRILOCAINE

    DERMACINRXEMPRICAINE

    T1LIDOCAINE/PRILOCAINE

    DERMACINRXPRIZOPAK

    T3LIDOCAINE/PRILOCAINEDOLOTRANZT1LIDOCAINE/PRILOCAINE

    EMLA

    T1LIDOCAINE/PRILOCAINE

    LEVA SET

    T1LIDOCAINE/PRILOCAINE

    LIDOPRIL

    T1LIDOCAINE/PRILOCAINE

    LIDOPRIL XR

    T1LIDOCAINE/PRILOCAINE

    LIDO-PRILO CAINEPACK

    T1LIDOCAINE/PRILOCAINE

    LIPROZONEPAK

    T1LIDOCAINE/PRILOCAINE

    LIVIXIL PAK

    T1LIDOCAINE/PRILOCAINE

    LP LITE PAK

    T1LIDOCAINE/PRILOCAINE

    MEDOLOR PAK

    T1LIDOCAINE/PRILOCAINE

    PRILOLID

    Commercial Formulary

    804 Portfolio High Formulary Page 26 of 133

  • T1LIDOCAINE/PRILOCAINE

    RELADOR PAK

    T1LIDOCAINE/PRILOCAINE

    RELADOR PAKPLUS

    T3 LIDOCAINE/RACEPINEP/TETRACAINE

    L.E.T. (LIDO-EPINEPH-TETRA)

    T3 LIDOCAINE/SKINCLEANSER NO.37

    LIDORXKIT

    T1LIDOCAINE/TETRACAINE

    PLIAGLIS

    T3 LIDOCAINE/TETRACAINE

    SYNERA

    T3LIDOCAINE/TRANSPARENT DRESSING

    LIDOTRANS 5 PAK

    T3NORFLURANE/PENTAFLUOROPROPANE

    PAIN EASE

    T3NORFLURANE/PENTAFLUOROPROPANE

    SPRAY ANDSTRETCH

    T3TETRACAINE HCL PONTOCAINET3 TETRACAINE/BENZOCAI

    NE/BUTAMBENCETACAINE

    T3 TETRACAINE/BENZOCAINE/BUTAMBEN

    CETACAINEANESTHETIC

    T3VITE/LIDOCAINE/ALOE/COLLAGEN

    LIDOTREX

    T3VITE/LIDOCAINE/ALOE/COLLAGEN

    REGENECARE

    TOPICAL/MUCOUS MEMBR./SUBCUT. ENZYMEST3COLLAGENASE

    CLOSTRIDIUM HIST.SANTYL

    T3HYALURONIDASE,HUMAN RECOMB.

    HYQVIA HYCOMPONENT

    DERMATOLOGY -PSORIASIS/ECZEMA

    ANTIPSORIATIC AGENTS,SYSTEMICT1ACITRETIN SORIATANET3BRODALUMAB SILIQ PAT3GUSELKUMAB TREMFYA PAT3 IXEKIZUMAB TALTZ

    AUTOINJECTORPA

    T3 IXEKIZUMAB TALTZAUTOINJECTOR (2PACK)

    PA

    T3 IXEKIZUMAB TALTZAUTOINJECTOR (3PACK)

    PA

    T3 IXEKIZUMAB TALTZ SYRINGE PAT3 IXEKIZUMAB TALTZ SYRINGE (2

    PACK)PA

    T3 IXEKIZUMAB TALTZ SYRINGE (3PACK)

    PA

    T1METHOXSALEN METHOXSALENT2 SECUKINUMAB COSENTYX (2

    SYRINGES)PA

    T2 SECUKINUMAB COSENTYX PEN PAT2 SECUKINUMAB COSENTYX PEN (2

    PENS)PA

    T2 SECUKINUMAB COSENTYXSYRINGE

    PA

    ANTIPSORIATICS AGENTST2ANTHRALIN DRITHOCREME HP STT3ANTHRALIN

    MICRONIZEDZITHRANOL ST

    T1CALCIPOTRIENE DOVONEX STT3CALCIPOTRIENE SORILUX STT1CALCITRIOL VECTICAL STT2 TAZAROTENE TAZORAC (0.05 %)

    (CREAM (G))T2 TAZAROTENE TAZORAC (0.05 %)

    (GEL (GRAM))T1TAZAROTENE TAZORAC (0.1 %)

    (CREAM (G))T2 TAZAROTENE TAZORAC (0.1 %)

    (GEL (GRAM))

    ECZEMA AGENTS,SYSTEMIC,INTERLEUKIN-4REC.ANTAG MABT3DUPILUMAB DUPIXENT PA

    TOPICAL AGENTS,MISCELLANEOUST3 PYROGALLOL PYROGALLIC ACIDT3UREA GORDO-UREA

    TOPICAL IMMUNOSUPPRESSIVE AGENTST2 PIMECROLIMUS ELIDEL STT1TACROLIMUS TACROLIMUS

    TOPICAL VIT D ANALOG/ANTIINFLAMMATORY,STEROIDALT3CALCIPOTRIENE/BETAM

    ETHASONEENSTILAR ST

    T1CALCIPOTRIENE/BETAMETHASONE

    TACLONEX (0.005-.064) (OINT. (G))

    ST

    T3CALCIPOTRIENE/BETAMETHASONE

    TACLONEX (0.005-.064) (SUSPENSION)

    ST

    DIABETESANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDECOMB.T3ALOGLIPTIN

    BENZ/METFORMIN HCLALOGLIPTIN-METFORMIN

    ST, QL

    T2 LINAGLIPTIN/METFORMIN HCL

    JENTADUETO QL

    T2LINAGLIPTIN/METFORMIN HCL

    JENTADUETO XR(2.5-1000MG) (TABBP 24H)

    QL

    T2 LINAGLIPTIN/METFORMIN HCL

    JENTADUETO XR(5MG-1000MG) (TABBP 24H)

    QL

    T3 SAXAGLIPTINHCL/METFORMIN HCL

    KOMBIGLYZE XR(2.5-1000MG) (TBMP24HR)

    ST, QL

    T3 SAXAGLIPTINHCL/METFORMIN HCL

    KOMBIGLYZE XR (5MG-500MG) (TBMP24HR)

    ST, QL

    T3 SAXAGLIPTINHCL/METFORMIN HCL

    KOMBIGLYZE XR(5MG-1000MG)(TBMP 24HR)

    ST, QL

    Commercial Formulary

    804 Portfolio High Formulary Page 27 of 133

  • T2 SITAGLIPTINPHOS/METFORMIN HCL

    JANUMET QL

    T2 SITAGLIPTINPHOS/METFORMIN HCL

    JANUMET XR (100-1000MG) (TBMP24HR)

    QL

    T2 SITAGLIPTINPHOS/METFORMIN HCL

    JANUMET XR (50-1000 MG) (TBMP24HR)

    QL

    T2 SITAGLIPTINPHOS/METFORMIN HCL

    JANUMET XR(50MG-500MG)(TBMP 24HR)

    QL

    ANTIHYPERGLY,DPP-4 ENZYME INHIB&THIAZOLIDINEDIONET3ALOGLIPTIN

    BENZ/PIOGLITAZONEALOGLIPTIN-PIOGLITAZONE

    ST, QL

    ANTIHYPERGLY,INCRETIN MIMETIC(GLP-1RECEP.AGONIST)T3ALBIGLUTIDE TANZEUM ST, QLT2DULAGLUTIDE TRULICITY ST, QLT3 EXENATIDE BYETTA

    (10MCG/0.04) (PENINJCTR)

    ST, QL

    T3 EXENATIDE BYETTA(5MCG/0.02) (PENINJCTR)

    ST, QL

    T3 EXENATIDEMICROSPHERES

    BYDUREON ST, QL

    T3 EXENATIDEMICROSPHERES

    BYDUREON PEN ST, QL

    T2 LIRAGLUTIDE VICTOZA 2-PAK ST, QLT2 LIRAGLUTIDE VICTOZA 3-PAK ST, QLT3 LIXISENATIDE ADLYXIN ST, QL

    ANTIHYPERGLYCEMC-SOD/GLUCCOTRANSPORT2(SGLT2)INHIBT2CANAGLIFLOZIN INVOKANA ST, QLT3DAPAGLIFLOZIN

    PROPANEDIOLFARXIGA ST, QL

    T2 EMPAGLIFLOZIN JARDIANCE ST, QL

    ANTIHYPERGLYCEMIC - DOPAMINE RECEPTORAGONISTST3BROMOCRIPTINE

    MESYLATECYCLOSET ST

    ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASEINHIB (N-S)T1ACARBOSE PRECOSET1MIGLITOL GLYSET

    ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPET2 PRAMLINTIDE ACETATE SYMLINPEN 120T2 PRAMLINTIDE ACETATE SYMLINPEN 60

    ANTIHYPERGLYCEMIC, DPP-4 INHIBITORST3ALOGLIPTIN BENZOATE ALOGLIPTIN ST, QLT2 LINAGLIPTIN TRADJENTA QLT3 SAXAGLIPTIN HCL ONGLYZA ST, QLT2 SITAGLIPTIN

    PHOSPHATEJANUVIA QL

    ANTIHYPERGLYCEMIC, INSULIN-RELEASESTIMULANT TYPET1CHLORPROPAMIDE DIABINESET1GLIMEPIRIDE AMARYLT1GLIPIZIDE GLUCOTROLT1GLIPIZIDE GLUCOTROL XLT1GLYBURIDE GLYBURIDET1GLYBURIDE,MICRONIZED

    GLYNASE

    T1NATEGLINIDE STARLIXT1REPAGLINIDE PRANDINT1TOLAZAMIDE TOLINASET1TOLBUTAMIDE ORINASE

    ANTIHYPERGLYCEMIC, INSULIN-RESPONSEENHANCER (N-S)T1PIOGLITAZONE HCL ACTOST3ROSIGLITAZONE

    MALEATEAVANDIA ST

    ANTIHYPERGLYCEMIC, SGLT-2 & DPP-4 INHIBITORCOMB.T2 EMPAGLIFLOZIN/LINAGL

    IPTINGLYXAMBI ST, QL

    ANTIHYPERGLYCEMIC,BIGUANIDE TYPE(NON-SULFONYLUREA)T1METFORMIN HCL FORTAMET STT1METFORMIN HCL GLUCOPHAGET1METFORMIN HCL GLUCOPHAGE XRT1METFORMIN HCL GLUMETZA STT2METFORMIN HCL RIOMETT3METFORMIN/BLOOD

    SUGAR DIAGNOSTDM2 ST

    ANTIHYPERGLYCEMIC,INSULIN & GLP-1RECEPTOR AGONISTT2 INSULIN

    DEGLUDEC/LIRAGLUTIDE

    XULTOPHY 100-3.6 ST, QL

    T2 INSULINGLARGINE/LIXISENATIDE

    SOLIQUA 100-33 ST, QL

    ANTIHYPERGLYCEMIC,INSULIN-REL STIM.&BIGUANIDE CMBT1GLIPIZIDE/METFORMIN HCL

    METAGLIP

    T1GLYBURIDE/METFORMIN HCL

    GLUCOVANCE

    T1REPAGLINIDE/METFORMIN HCL

    PRANDIMET

    ANTIHYPERGLYCEMIC,INSULIN-RESPONSE &RELEASE COMB.T1PIOGLITAZONEHCL/GLIMEPIRIDE

    DUETACT ST

    ANTIHYPERGLYCEMIC-GLUCOCORTICOIDRECEPTOR BLOCKERT2MIFEPRISTONE KORLYM PA

    Commercial Formulary

    804 Portfolio High Formulary Page 28 of 133

  • ANTIHYPERGLYCEMIC-SGLT2 INHIBITOR &BIGUANIDE COMBT2CANAGLIFLOZIN/METFO

    RMIN HCLINVOKAMET ST, QL

    T2CANAGLIFLOZIN/METFORMIN HCL

    INVOKAMET XR ST, QL

    T3DAPAGLIFLOZIN/METFORMIN HCL

    XIGDUO XR ST, QL

    T2 EMPAGLIFLOZIN/METFORMIN HCL

    SYNJARDY ST, QL

    T2 EMPAGLIFLOZIN/METFORMIN HCL

    SYNJARDY XR (10-1000 MG) (TAB BP24H)

    ST, QL

    T2 EMPAGLIFLOZIN/METFORMIN HCL

    SYNJARDY XR(12.5-1000) (TAB BP24H)

    ST, QL

    T2 EMPAGLIFLOZIN/METFORMIN HCL

    SYNJARDY XR (25-1000 MG) (TAB BP24H)

    ST, QL

    T2 EMPAGLIFLOZIN/METFORMIN HCL

    SYNJARDY XR(5MG-1000MG) (TABBP 24H)

    ST, QL

    ANTIHYPERGLYCM,INSUL-RESP.ENHANCER &BIGUANIDE CMBT1PIOGLITAZONEHCL/METFORMIN HCL

    ACTOPLUS MET ST

    T2 PIOGLITAZONEHCL/METFORMIN HCL

    ACTOPLUS MET XRST

    T3ROSIGLITAZONE/METFORMIN HCL

    AVANDAMET ST

    BLOOD SUGAR DIAGNOSTICST3BLOOD SUGAR

    DIAGNOSTICACCU-CHEK AVIVAPLUS

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    ACCU-CHEK GUIDETEST STRIP

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    ACCU-CHEKSMARTVIEW

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    ACCUTRENDGLUCOSE

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    ADVANCEDGLUCOSE TESTSTRIPS

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    ADVOCATE REDI-CODE

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    ADVOCATE REDI-CODE+

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    ADVOCATE TESTSTRIP

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    AGAMATRIX AMP ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    ASSURE 4 ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    ASSURE PLATINUMST, QL

    T3BLOOD SUGARDIAGNOSTIC

    ASSURE PRISMMULTI

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    BLOOD GLUCOSETEST

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    BLOOD GLUCOSETEST STRIP

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    CARESENS N ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    CHOICEDMCLARUS TESTSTRIPS

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    CLEVER CHOICEMICRO TEST STRIP

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    CLEVER CHOICEPRO

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    CLEVER CHOICETALK

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    CLEVER CHOICETEST STRIPS

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    CLEVER CHOICEVOICE+ TST STRIP

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    CONTOUR ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    CONTOUR NEXT ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    COOL GLUCOSETEST STRIP

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    DIATRUE PLUS ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    EASY GLUCO G2 ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    EASY PLUS II ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    EASY STEP ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    EASY TALK ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    EASY TOUCH TESTSTRIP

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    EASY TRAK ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    EASYGLUCO PLUS ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    EASYGLUCO TESTSTRIPS

    ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    EASYMAX ST, QL

    T3BLOOD SUGARDIAGNOSTIC

    EASYMAX 15 ST, QL