SELECT

2016 Comprehensive 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. This formulary was updated on 10/01/2016. For more recent information or other questions, please contact First United American - Select (PDP) at 1‑866‑524‑4171 or, for TTY/TDD users, 1‑866‑524‑4172, weekdays from 8:00am to 8:00pm Eastern, or visit http://www.firstuamedicarepartd.com.

Formulario integral de medicamentos aprobados para 2016 (Lista de medicamentos cubiertos) POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS CUBIERTOS POR ESTE PLAN Nota a los miembros actuales: El formulario no es el mismo del ano pasado. Revise este document para asegurarse de que todavia contiene los medicamentos que usted toma. Este formulario se ha actualizado el 10/01/2016. Para información más reciente o otras preguntas, comuníquese con First United American Select (PDP) servicio al cliente a 1‑866‑524‑4171 o, para los usuarios de TTY/TDD, 1‑866‑524‑4172, de lunes a viernes, de 8:00 am a 8:00 pm, Eastern, o visite http://www.firstuamedicarepartd.com.

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2016 First United American - Select Comprehensive Formulary When this drug list (formulary) refers to “we,” “us”, or “our,” it means First United American Life Insurance Company. When it refers to “plan” or “our plan,” it means First United American - Select. This document includes a list of the drugs (formulary) for our plan which is current as of 10/01/2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year.

What is the First United American - Select Formulary? A formulary is a list of covered drugs selected by First United American - Select in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. First United American - Select will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a First United American - Select network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 10/01/2016. To get updated information about the drugs covered by First United American - Select, please contact us. Our contact information appears on the front and back cover pages.

How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular/Hypertensive/Lipids.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

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Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 57. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? First United American - Select covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: First United American - Select requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from First United American - Select before you fill your prescriptions. If you don’t get approval, First United American Select may not cover the drug. • Quantity Limits: For certain drugs, First United American - Select limits the amount of the drug that we will cover. For example, First United American - Select provides 30 pills per prescription for simvastatin. This may be in addition to a standard one-month or three-month supply. • Step Therapy: In some cases, First United American - Select requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, First United American - Select may not cover Drug B unless you try Drug A first. If Drug A does not work for you, First United American - Select will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization, quantity limits and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask First United American - Select to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the First United American - Select’s formulary?” below for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that First United American - Select does not cover your drug, you have two options: • You can ask Customer Service for a list of similar drugs that are covered by First United American Select. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by First United American - Select . • You can ask First United American - Select to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the First United American - Select Formulary? You can ask First United American - Select to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. ii

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. • You can ask us to cover a formulary drug at a lower cost-sharing level (if this drug is not on the specialty tier). If approved this would lower the amount you must pay for your drug. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, First United American - Select limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, First United American - Select will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

What if there is a change in my level of care? A level of care change is defined as when enrollees: • Enter long term care (LTC) facilities from hospitals or other settings; • Leave LTC facilities and return to the community; • Are discharged from a hospital to a home; • End a skilled nursing facility (SNF) stay covered under Medicare Part A (where all pharmacy charges are covered), and must revert to coverage under their Part D plan formulary; • Revert from hospice status to standard Medicare Part A and B benefits; and • Are discharged from psychiatric hospitals with medication regimens that are highly individualized. iii

While Part A does provide reimbursement for “a limited supply” to facilitate beneficiary discharge, you must be permitted to have a full outpatient supply available to continue therapy once this limited supply is exhausted. Level of Care supplies will be available for your prescription, when appropriate, that are received at retail, home infusion, or mail order. We do not use an early-refill restriction to limit appropriate and necessary access to your Part D benefit. In instances where you are admitted to, or discharged from, a long term care facility, we allow you to access a refill upon admission or discharge. However, we may use early-refill restrictions for safety reasons.

For more information For more detailed information about your First United American - Select prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about First United American - Select, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

First United American - Select's Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by First United American - Select. If you have trouble finding your drug in the list, turn to the Index that begins on page 57. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PRILOSEC) and generic drugs are listed in lower‑case italics (e.g., omeprazole). The information in the Requirements/Limits column tells you if First United American - Select has any special requirements for coverage of your drug.

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Formulario integral de medicamentos aprobados para 2016 Cuando esta lista de medicamentos (formulario) se refiere a “nosotros”“nos” o “nuestro”, que significa First United American Life Insurance Company. Cuando se refiere al “plan” o “nuestro plan”, que significa First United American - Select. Este documento incluye una lista de los medicamentos (formulario) para nuestro plan que sera vigente al partir de 10/01/2016. Para un formulario actualizada, por favor contáctenos. Nuestra información de contacto, fechas, y formulario que aparecen en las portadas y contraportadas han sido actualizados. Generalmente se debe usar farmacias dentro de la red para usar su beneficio de medicamentos recetados. Tanto los beneficios, formularios, red de farmacias, y/o copagos/coaseguro pueden tener cambios el 01 de enero de 2017, y de tiempo a tiempo durante el ãno.

¿Qué es el formulario de First United American - Select? Un formulario de medicamentos aprobados es una lista de medicamentos cubiertos, seleccionados por la cobertura para recetas médicas (PDP) de First United American - Select con el asesoramiento de un equipo de proveedores de atención médica, que representa las terapias con medicamentos considerados parte necesarios en un programa de tratamiento de calidad. En general First United American - Select cubrirá los medicamentos incluidos en nuestro formulario de medicamentos aprobados siempre que los mismos sean médicamente necesarios, y se adquieran en una farmacia de la red de First United American - Select y se sigan otras normas del plan. Para obtener más información sobre cómo adquirir sus medicamentos con receta, consulte su Evidencia de cobertura.

¿Puede cambiar el formulario de medicamentos aprobados? En general, si está tomando un medicamento en nuestro formulario de 2016, que estaba cubierto a principios del año, no descontinuaremos ni reduciremos la cobertura de dicho medicamento durante 2016, excepto cuando exista un medicamento genérico nuevo, más económico o cuando se haya publicado información negativa respecto a la efectividad o seguridad del medicamento. Otros tipos de cambios en el formulario, como cuando se elimina un producto, no afectarán a los miembros que actualmente estén tomando dicho medicamento. Seguirá disponible al mismo costo compartido para aquellos miembros que lo tomen durante el resto del año de la cobertura. Consideramos que es importante que tenga acceso continuo durante el resto del año de la cobertura, a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto en los casos en los que pueda ahorrar dinero adicional o en los que podamos garantizar su seguridad. Si quitamos medicamentos de nuestro formulario de medicamentos aprobados, o agregamos autorizaciones previas, límites de cantidad y/o restricciones de tratamiento escalonado para un medicamento o pasamos un medicamento a una categoría de costo compartido superior, debemos notificar de esta situación a los afiliados afectados, al menos 60 días antes de que el cambio entre en vigencia, o en cuanto el afiliado solicite una reposición del medicamento, en cuyo momento el miembro recibirá un suministro de 60 días del mismo. Si la Administración de Alimentos y Medicamentos considera que un medicamento de nuestro formulario de medicamentos aprobados no es seguro o el fabricante del medicamento lo retira del mercado, quitaremos el medicamento de nuestro formulario de medicamentos aprobados de inmediato y notificaremos el cambio a los afiliados que toman el medicamento. El formulario de medicamentos aprobados que se adjunta entra en vigencia a partir del 10/01/2016. Para obtener información actualizada acerca de los medicamentos cubiertos por First United American - Select, por favor.

¿Cómo utilizo el formulario de medicamentos aprobados? Hay dos maneras de encontrar su medicamento dentro del formulario de medicamentos aprobados: Condicion Medica El formulario de medicamentos aprobados comienza en la página 1. Los medicamentos incluidos en este formulario de medicamentos aprobados están agrupados en categorías dependiendo de los tipos de afecciones que tratan. Por ejemplo, los medicamentos utilizados para tratar una afección v

cardiaca incluidos en la categoría “Cardiovascular/Hipertenso/Lípidos”. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página 1. Luego busque su medicamento bajo el nombre de la categoría. Listado alfabético Si no está seguro en qué categoría buscar, debe buscar su medicamento en el Índice que comienza en la página 57. El Índice presenta una lista por orden alfabético de todos los medicamentos incluidos en este documento. En el Índice se incluyen tanto medicamentos de marca como medicamentos genéricos. Busque en el Índice para encontrar su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar información sobre la cobertura. Diríjase a la página indicada en el Índice y busque el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos? First United American - Select cubrirá tanto medicamentos genéricos como de marca. Un medicamento genérico es un medicamento que ha sido aprobado por la FDA, quien ha declarado que contiene el mismo ingrediente o ingredientes activos que el medicamento de marca. Generalmente, los medicamentos genéricos cuestan menos que los de marca.

¿Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Estos requisitos y límites pueden incluir: • Autorización previa: First United American - Select requiere que usted [o su médico] obtenga una autorización previa para ciertos medicamentos. Esto significa que deberá obtener la aprobación de First United American - Select antes de adquirir su medicamento. Si no obtiene la aprobación, puede ser que First United American - Select no cubra el medicamento. • Límites de cantidad: En el caso de ciertos medicamentos, First United American - Select limita la cantidad de medicamento que cubriremos. Por ejemplo, First United American - Select suministra 30 pastillas de simvastatin por receta. Esto puede ser además del suministro estándar de uno a tres meses. • Tratamiento escalonado: En algunos casos, First United American - Select requiere que usted primero pruebe ciertos medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su afección, First United American - Select puede no cubrir el Medicamento B a menos que usted pruebe primero el Medicamento A. Si el medicamento A no le sirve, First United American - Select cubrirá el Medicamento B. Puede averiguar si su medicamento tiene algún requisito o límite adicional buscándolo en el formulario de medicamentos con receta que comienza en la página 1. También puede obtener más información sobre las restricciones que se aplican a medicamentos específicos cubiertos visitando nuestro sitio web. Hemos publicado documentos en la red de internet que explican las restricciones de nuestra Autorización Previa, Límites de Cantidad de Medicamentos y Terapia Escalonada. También puede pedir que se le envie una copia. Nuestra información de contacto, junto con la fecha en la que se actualizó por última vez el formulario, aparece en la portada y la contraportada páginas. Puede solicitarle a First United American - Select que haga una excepción a estas restricciones o límites, o para obtener una lista de medicamentos similares, que pueden tratar su condición de la salud. Consulte la sección “¿Cómo solicito una excepción al formulario de medicamentos aprobados de First United American Select?” de bajo para obtener información sobre cómo solicitar una excepción.

¿Qué sucede si mi medicamento no aparece en el formulario de medicamentos aprobados? Si su medicamento no está incluido en este formulario de medicamentos aprobados, debe comunicarse primero con Servicio al cliente y preguntar si su medicamento está cubierto. Si se entera que First United American - Select no cubre su medicamento, tiene dos opciones: • Puede pedirle a Servicio al cliente una lista de medicamentos similares que estén cubiertos por First United American - Select. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por First United American - Select. vi

• Puede pedirle a First United American - Select que haga una excepción y cubra su medicamento. Consulte las secciones que siguen para obtener información sobre cómo solicitar una excepción.

¿Cómo solicito una excepción al formulario de medicamentos aprobados de First United American - Select? Puede solicitarle a First United American - Select que haga una excepción a nuestras normas de cobertura. Existen varios tipos de excepciones que puede solicitarnos que hagamos. • Puede pedirnos que cubramos su medicamento aunque no esté incluido en nuestro formulario de medicamentos aprobados. Si aprobada, esta droga se cubre con un nivel de participación en los gastos predeterminado, y no sería capaz de pedir que suministrar el medicamento a un costo más bajo nivel de participación. • Usted puede pedirnos que cubramos un medicamento del formulario a un nivel mas bajo del gasto (si este medicamento no está en la categoría de medicamentos especializados). Si se aprueba esto reduciría la cantidad que debe pagar por su medicamento. • Puede pedirnos que no apliquemos las restricciones o límites de cobertura sobre su medicamento. Por ejemplo, para ciertos medicamentos, First United American - Select limita la cantidad de medicamento que cubriremos. Si su medicamento tiene un límite de cantidad puede pedirnos que no apliquemos el límite y cubramos más. En general, First United American - Select sólo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en el formulario de medicamentos aprobados del Plan, el medicamento de categoría inferior o las restricciones de utilización adicionales no son eficaces para el tratamiento de su afección y/o le causaran algún efecto médico adverso. Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para una excepción al formulario de medicamentos aprobados, la categorización, o la restricción de utilización. Cuando solicite una excepción al formulario de medicamentos aprobados, la categorización, o la restricción de utilización, debe enviar un certificado de su prescriptor o médico que respalde su solicitud. En general, debemos tomar una decisión dentro de las 72 horas posteriores a recepción del certificado médico. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que su salud podría verse seriamente afectada por esperar 72 horas una decisión. Si su solicitud de aceleración se acepta, le daremos una decisión a más tardar en 24 horas, después de recibir el certificado de su médico en apoyo al uso del medicamento.

¿Qué puedo hacer antes de hablar con mi médico acerca de cambiar mis medicamentos o de solicitar una excepción? Como miembro nuevo o continuo de nuestro plan, es posible que esté tomando medicamentos que no se encuentren en nuestro formulario. O podría estar tomando un medicamento que sí esté comprendido en el formulario, pero su habilidad para obtenerlo podría estar limitada. Por ejemplo, es posible que necesite una autorización previa nuestra antes de adquirir su medicamento. Debe hablar con su médico para decidir si debe cambiar a un medicamento apropiado que se encuentre cubierto o solicitar una excepción del formulario para que podamos cubrir el medicamento que está tomando. Mientras habla con su médico para determinar el curso de acción adecuado para usted, podemos proporcionarle el medicamento, en ciertos casos, durante los primeros 90 días en los que sea miembro del plan. Para cada uno de sus medicamentos que no se encuentre en el formulario o si su habilidad para obtener los medicamentos está limitada, cubriremos un suministro temporal de 30 días (a menos que cuente con una receta que establezca menos días) cuando acuda a una farmacia de la red. Después de su primer suministro por 30 días, no le pagaremos por estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días. Si es residente de una institución de cuidados a largo plazo, cubriremos un suministro de transición temporal de 93 días, consistente con incremento de dispensación (a menos que tenga una receta por menos días). Cubriremos más de una renovación de este medicamento durante los primeros 90 días en que sea miembro de nuestro plan. Si necesita un medicamento que no se encuentra en nuestro formulario o si su habilidad vii

para obtenerlo es limitada, pero ya han pasado los primeros 90 días de su afiliación al plan, cubriremos un suministro de emergencia del medicamento, por 31 días (a menos que tenga una receta por menos días) mientras solicita una excepción al formulario.

¿Que si hay un cambio en mi nivel de cuidado? Un nivel de cambio del cuidado se define como cuando inscribidos sean: • Internados en LTC (cuidado de largo plazo) de hospitales o de otros ajustes; • Retirados de LTC (cuidado de largo plazo) y vuelvan a la comunidad; • Dar de alta de un hospital a un hogar; • Terminados el cuidado en un Centro de Enfermería (SNF) bajo parte A de Medicare (donde se cubren todas las cargas de la farmacia), y debe invertir a la cobertura debajo de su formulario del plan de la parte D; • Invertidos de Hospicio a las ventajas estándar de la parte A y de B beneficios de Medicare; y • Se descargan de hospitales psiquiátricos con los regímenes de medicación que son altamente individualizados. Mientras que la Parte A proporciona el reembolso para un suministro de drogas limitado para facilitar el descargo de beneficiario, usted debe ser permitido para tener un suministro completo del paciente no internado disponible para continuar terapia cuando un suministro de droga limitada termine. El nivel de cuidado estará disponible para su prescripción, cuando es apropiado, que se reciben en la venta al por menor, la infusión casera, o el pedido por correo. No utilizamos restricciones de rellenos tempranos o limitamos acceso apropiado necesario a sus beneficios de la parte D. En los casos a donde se ingrese o se de alta de una facilidad de largo plazo, permitimos que usted tenga acceso a un repuesio sobre la admisión o la descarga. Sin embargo, podemos utilizar restricciones de rellenos tempranos por razones de la seguridad.

Para más información Para obtener información más detallada acerca de la cobertura de medicamentos con receta de First United American - Select, consulte su Evidencia de cobertura y otros materiales del plan. Si tiene preguntas sobre First United American - Select, por favor de contáctarse con nosotros. Nuestra información de contacto, junto con la fecha, que hemos actualizado el formulario aparece en las portadas y contraportada. Si tiene preguntas generales acerca de la cobertura de Medicare de medicamentos con receta, llame a Medicare al 1‑800‑MEDICARE (1‑800‑633‑4227) las 24 horas los 7 días de la semana. Los usuarios de TTY deben comunicarse al 1‑877‑486‑2048. O, visite http://www.medicare.gov.

Formulario de medicamentos aprobados de First United American - Select El formulario de medicamentos aprobados que comienza en la página 1 brinda información de cobertura de los medicamentos cubiertos por First United American - Select. Si tiene algún problema para encontrar su medicamento en la lista, diríjase al Índice que comienza en la página 57. El nombre del medicamento se encuentra en la primera columna de la tabla. Los medicamentos de marca aparecen en mayúscula (por ej., PRILOSEC) y los medicamentos genéricos aparecen en letra cursiva minúscula (por ej., omeprazole). La información en la columna Notas le informa si First United American - Select tiene algún requisito especial para la cobertura de su medicamento.

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Preferred Retail Cost-Sharing Costo de Compartimiento Minorista Preferida 30-Day supply at a Preferred Retail Pharmacy

90-Day Supply at a Preferred Retail Pharmacy

90-Day Supply using the plan's Preferred Mail-order service

Un suministro de 30 días en una Farmacia Minorista Preferida

Un suministro de 90 días en una Farmacia Minorista Preferida

Suministro de 90 días, utilizando el servicio de correspondencia Preferida del plan

$0

$0

$0

$3

$9

$33

Cost Sharing Tier 3 (Preferred Brand) Costo de compartimiento Nivel 3 (Marca Preferida)

16%

16%

21%

Cost Sharing Tier 4 (Non-Preferred Brand) Costo de compartimiento Nivel 4 (Marca No Preferidas)

26%

26%

31%

Cost Sharing Tier 1 (Preferred Generic) Costo de compartimiento Nivel 1 (Genéricos Preferidos) Cost Sharing Tier 2 (Generics) Costo de compartimiento Nivel 2 (Genéricos)

Cost Sharing Tier 5 (Specialty) Costo de compartimiento Nivel 5 (Especialidad)

A long term supply is not A long term supply is not available for drugs in Tier 5. available for drugs in Tier 5. 25%

Un suministro a largo plazo Un suministro a largo plazo no es disponible para las no es disponible para las drogas en el Nivel 5. drogas en el Nivel 5.

ix

Standard Retail Cost-Sharing Costo de Compartimiento Minorista Estándar 30-Day supply at a Standard Retail Pharmacy Un suministro de 30 días en una farmacia minorista estandar

90-Day supply at a Standard Retail Pharmacy

90-Day Supply using the plan’s Standard mail-order service

Un suministro de 90 días en una farmacia minorista estandar

Suministro de 90 días, utilizando el servicio de correspondencia Estándar del plan

Cost Sharing Tier 1 (Preferred Generic) Costo de compartimiento Nivel 1 (Genéricos Preferidos)

$9

$27

$27

Cost Sharing Tier 2 (Generics) Costo de compartimiento Nivel 2 (Genéricos)

$11

$33

$33

21%

21%

21%

31%

31%

31%

A long term supply is not available for drugs in Tier 5.

A long term supply is not available for drugs in Tier 5.

Cost Sharing Tier 3 (Preferred Brand) Costo de compartimiento Nivel 3 (Marca Preferida) Cost Sharing Tier 4 (Non-Preferred Brand) Costo de compartimiento Nivel 4 (Marca No Preferidas) Cost Sharing Tier 5 (Specialty) Costo de compartimiento Nivel 5 (Especialidad)

x

25%

Un suministro a Un suministro a largo plazo no es largo plazo no es disponible para las drogas disponible para las drogas en el Nivel 5. en el Nivel 5.

Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug. LIST OF ABBREVIATIONS B/D: Covered Under B or D. This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Access. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. NM: Non mail-order. This prescription is not available through the mail-order pharmacy. These prescriptions can only be filled at a retail pharmacy or other specialized pharmacy (where available). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

xi

La siguiente es una lista de abreviaturas que pueden aparecer en las siguientes páginas en la columna Notas para indicarle si su medicamento está sujeto a algún requisito especial de cobertura. Lista de abreviaturas (del inglés) B/D: Este medicamento recetado podría estar cubierto bajo Medicare Parte B o Parte D, dependiendo de las circunstancias. Puede ser necesario que se presente información que describa la utilización y las circunstancias en las que se administrará el medicamento, para que se pueda tomar una determinación. LA: Acceso limitado. Este medicamento recetado puede estar disponible solamente en ciertas farmacias. Para obtener más información, llame al servicio de Atención al cliente. NM: No está disponible por correo. Esta prescripción no está disponible a través de la farmacia de pedido por correo. Esta recetas sólo pueden ser llenadas en una farmacia minorista o en otra farmacia especializada (donde estén disponibles). PA: Autorización previa. El Plan requiere que usted o su médico obtengan autorización previa para obtener ciertos medicamentos. Esto significa que deberá obtener aprobación antes de que se surtan sus recetas. Si no obtiene aprobación, podríamos no cubrir el medicamento. QL: Límite de cantidad. En el caso de ciertos medicamentos, el Plan limita la cantidad del medicamento que cubriremos. ST: Tratamiento escalonado. En algunos casos, el Plan requiere que primero pruebe ciertos medicamentos para el tratamiento de su afección médica antes de que podamos cubrir otro medicamento para tratar esa afección. Por ejemplo, si puede utilizarse tanto un medicamento A como un medicamento B en el tratamiento de la misma afección médica, es posible que no cubramos el medicamento B a menos que usted pruebe.

xii

Commonly Prescribed Therapeutic Drug Categories (Categorías de productos farmacoterapéuticos que se recetan comúnmente) Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento)

ANALGESICS GOUT allopurinol tab colchicine w/ probenecid COLCRYS probenecid ULORIC

1 3 3 3 3

QL (120 tabs / 30 days) ST

NSAIDS celecoxib CAPS diclofenac potassium diclofenac sodium TB24 diclofenac sodium TBEC diflunisal flurbiprofen TABS ibuprofen SUSP ibuprofen TABS 400mg, 600mg, 800mg ketoprofen CAPS meloxicam TABS nabumetone TABS naproxen SUSP naproxen TABS naproxen TBEC naproxen sodium TABS 275mg, 550mg sulindac TABS

4 2 3 2 3 2 3 1

QL (60 caps / 30 days)

2 1 2 3 1 2 1 2

OPIOID ANALGESICS acetaminophen w/ codeine acetaminophen w/ codeine nalbuphine hcl SOLN tramadol hcl TABS

SOLN TABS

2 2 4 2

QL (5000 mL / 30 days) QL (400 tabs / 30 days)

3 3 3 3 5

B/D QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (120 lozenges / 30 days), PA

QL (240 tabs / 30 days)

OPIOID ANALGESICS, CII DURAMORPH endocet 5/325 endocet 7.5/325 endocet 10/325 fentanyl citrate LPOP

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

1

Drug Name (Nombre del medicamento) fentanyl patch 12 mcg/hr fentanyl patch 25 mcg/hr fentanyl patch 50 mcg/hr fentanyl patch 75 mcg/hr fentanyl patch 100 mcg/hr FENTORA

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 4 QL (10 patches / 30 days) 4 QL (10 patches / 30 days) 4 QL (10 patches / 30 days), PA 4 QL (10 patches / 30 days), PA 4 QL (10 patches / 30 days), PA 5 QL (120 tabs / 30 days), PA 2 QL (360 tabs / 30 days) 2 QL (360 tabs / 30 days) 2 QL (360 tabs / 30 days) 4 QL (5400 mL / 30 days)

hydroco/apap tab 5-325mg hydroco/apap tab 7.5-325 hydroco/apap tab 10-325mg hydrocodone-acetaminophen 7.5-325 mg/15ml hydrocodone-ibuprofen tab 7.5-200 mg 3 hydromorphon inj 10mg/ml 4 hydromorphone hcl LIQD 4 hydromorphone hcl TABS 3 lorcet hd tab 10-325mg 2 lorcet plus tab 7.5-325 2 lorcet tab 5-325mg 2 lortab tab 5-325mg 2 lortab tab 7.5-325 2 lortab tab 10-325mg 2 methadone hcl CONC 3 methadone hcl SOLN 5mg/5ml, 3 10mg/5ml methadone hcl TABS 2 morphine ext-rel tab 15mg, 30mg, 4 60mg, 100mg morphine ext-rel tab 200mg 4 MORPHINE SUL INJ 1MG/ML 3 MORPHINE SUL INJ 4MG/ML 3 MORPHINE SUL INJ 10MG/ML 3 MORPHINE SUL INJ 15MG/ML 3 morphine sulfate CP24 10mg, 20mg, 4 30mg, 50mg, 60mg morphine sulfate CP24 80mg, 100mg 5

QL (150 tabs / 30 days) B/D QL QL QL QL QL QL QL QL QL

(270 (360 (360 (360 (360 (360 (360 (120 (600

tabs / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days) mL / 30 days) mL / 30 days)

QL (240 tabs / 30 days) QL (90 tabs / 30 days) QL (60 tabs / 30 days) B/D B/D B/D B/D QL (60 caps / 30 days) QL (60 caps / 30 days)

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

2

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 3 B/D

MORPHINE SULFATE SOLN 2mg/ml, 8mg/ml morphine sulfate SOLN .5mg/ml, 3 1mg/ml, 4mg/ml, 8mg/ml MORPHINE SULFATE TABS 3 morphine sulfate beads 4 MORPHINE SULFATE ORAL SOL 3 oxycodone hcl CAPS 4 oxycodone hcl TABS 3 OXYCODONE SOLN 5MG/5ML 4 oxycodone w/ acetaminophen 3 2.5-325mg oxycodone w/ acetaminophen 5-325mg3 oxycodone w/ acetaminophen 3 7.5-325mg oxycodone w/ acetaminophen 3 10-325mg oxycodone w/ acetaminophen soln 3 5-325 mg/5ml roxicet tab 5-325mg 3

B/D QL (180 tabs / 30 days) QL (60 caps / 30 days) QL (180 caps / 30 days) QL (180 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (360 tabs / 30 days) QL (1800 mL / 30 days) QL (360 tabs / 30 days)

ANESTHETICS LOCAL ANESTHETICS lidocaine lidocaine lidocaine lidocaine lidocaine

hcl (local anesth.) inj 0.5% inj 1% inj 1.5% inj 2%

2 2 2 2 2

B/D B/D B/D B/D B/D

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN gentamicin in saline gentamicin sulfate SOLN neomycin sulfate TABS paromomycin sulfate CAPS streptomycin sulfate SOLR sulfadiazine TABS tobramycin NEBU tobramycin sulfate SOLN tobramycin sulfate SOLR

3 2 2 3 4 4 4 5 3 4

B/D, NM

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA

4

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

3

Drug Name (Nombre del medicamento) ALINIA atovaquone SUSP aztreonam BILTRICIDE CAYSTON clindamycin cap 75mg clindamycin cap 300 mg clindamycin hcl cap 150 mg clindamycin phosphate SOLN clindamycin phosphate in d5w clindamycin phosphate inj clindamycin soln colistimethate sodium SOLR CUBICIN dapsone TABS DARAPRIM emverm imipenem-cilastatin INVANZ ivermectin TABS linezolid SOLN LINEZOLID SUSR; TABS LINEZOLID IN SODIUM CHLORIDE meropenem methenamine hippurate metronidazole TABS metronidazole in nacl NEBUPENT nitrofurantoin macrocrystal 50mg, 100mg

Drug Tier (Nivel de medicamento) 4 5 3 3 5 1 1 1 2 3 2 4 4 5 3 4 4 4 4 3 5 5 5 4 3 2 2 4 4

nitrofurantoin monohyd macro

4

PENTAM 300 SIVEXTRO sulfamethoxazole-trimethoprim SUSP sulfamethoxazole-trimethoprim TABS sulfamethoxazole-trimethoprim inj SYNERCID trimethoprim TABS

4 5 3 1 4 5 2

Requirements/Limits (Requisitos/Limites)

NM, LA, PA

B/D PA; PA applies if 65 years and older after a 90 day supply in a calendar year PA; PA applies if 65 years and older after a 90 day supply in a calendar year

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

4

Drug Name (Nombre del medicamento) TYGACIL vancomycin hcl CAPS vancomycin hcl SOLR VANCOMYCIN IN NACL ZYVOX TABS

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 5 5 3 4 5

ANTIFUNGALS ABELCET AMBISOME amphotericin b SOLR CANCIDAS fluconazole SUSR fluconazole TABS fluconazole in dextrose fluconazole in nacl fluconazole in nacl 0.9% inj flucytosine CAPS griseofulvin microsize SUSP griseofulvin microsize TABS griseofulvin ultramicrosize itraconazole CAPS ketoconazole TABS MYCAMINE NOXAFIL SUSP; TBEC nystatin TABS terbinafine hcl TABS voriconazole SOLR voriconazole SUSR; TABS

5 5 4 5 3 2 3 3 3 5 3 4 4 4 3 5 5 3 2 4 5

B/D B/D B/D

PA PA

QL (90 tabs / 365 days)

ANTIMALARIALS atovaquone-proguanil hcl chloroquine phosphate TABS COARTEM mefloquine hcl PRIMAQUINE PHOSPHATE quinine sulfate CAPS

4 3 4 3 3 4

PA

ANTIRETROVIRAL AGENTS abacavir sulfate APTIVUS CRIXIVAN didanosine EDURANT

3 5 4 4 5

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

5

Drug Name (Nombre del medicamento) EMTRIVA FUZEON INTELENCE 25mg INTELENCE 100mg, 200mg INVIRASE ISENTRESS CHEW 25mg ISENTRESS CHEW 100mg ISENTRESS PACK ISENTRESS TABS lamivudine LEXIVA SUSP LEXIVA TABS NEVIRAPINE SUSP nevirapine TB24 nevirapine tab 200mg NORVIR PREZISTA SUSP PREZISTA TABS 75mg, 150mg PREZISTA TABS 600mg, 800mg RESCRIPTOR RETROVIR IV INFUSION REYATAZ SELZENTRY stavudine SUSTIVA CAPS SUSTIVA TABS TIVICAY 10mg TIVICAY 25mg, 50mg TYBOST VIDEX PEDIATRIC VIRACEPT VIRAMUNE XR 100mg VIREAD VITEKTA ZIAGEN SOLN zidovudine

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 3 5 NM 4 5 5 3 5 3 5 3 4 5 4 4 3 3 5 3 5 4 3 5 5 4 3 5 3 5 3 4 5 4 5 5 3 3

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine 5 ATRIPLA 5 COMPLERA 5 DESCOVY 5 You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

6

Drug Name (Nombre del medicamento) EPZICOM EVOTAZ GENVOYA KALETRA SOL KALETRA TAB 100-25MG KALETRA TAB 200-50MG lamivudine-zidovudine ODEFSEY PREZCOBIX STRIBILD TRIUMEQ TRUVADA TAB 100-150 TRUVADA TAB 133-200 TRUVADA TAB 167-250 TRUVADA TAB 200-300

Drug Tier (Nivel de medicamento) 5 5 5 5 3 5 5 5 5 5 5 5 5 5 5

Requirements/Limits (Requisitos/Limites)

QL QL QL QL

(60 (30 (30 (30

tabs tabs tabs tabs

/ / / /

30 30 30 30

days) days) days) days)

ANTITUBERCULAR AGENTS CAPASTAT SULFATE cycloserine CAPS ethambutol hcl TABS isoniazid TABS isoniazid syp 50mg/5ml paser 4gm PRIFTIN pyrazinamide TABS rifabutin rifampin CAPS rifampin SOLR RIFATER SIRTURO TRECATOR

4 5 3 1 4 3 4 4 4 3 4 4 5 4

LA, PA

ANTIVIRALS acyclovir CAPS; TABS acyclovir SUSP acyclovir sodium SOLN acyclovir sodium SOLR 500mg adefovir dipivoxil BARACLUDE SOLN DAKLINZA entecavir EPIVIR HBV SOLN famciclovir TABS

2 4 4 4 5 3 5 5 4 4

B/D B/D

NM, PA

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

7

Drug Name (Nombre del medicamento) ganciclovir inj 500mg HARVONI lamivudine (hbv) moderiba tab 200mg PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK PEGINTRON RELENZA DISKHALER ribasphere cap 200mg ribasphere tab 200mg ribavirin cap 200mg ribavirin tab 200mg rimantadine hydrochloride SOVALDI TAMIFLU TYZEKA valacyclovir hcl TABS VALCYTE SOLR valganciclovir hcl

Drug Tier (Nivel de medicamento) 3 5 4 3 5 5 5 5 3 3 3 3 3 3 5 3 5 3 5 5

Requirements/Limits (Requisitos/Limites) B/D NM, PA NM NM, NM, NM, NM,

PA PA PA PA

NM NM NM NM NM, PA

CEPHALOSPORINS cefaclor CAPS cefadroxil CAPS cefadroxil SUSR cefadroxil TABS cefazolin in dextrose 1gm/50ml-5% CEFAZOLIN IN DEXTROSE 2GM/100ML-4% cefazolin inj cefazolin sodium 1gm, 20gm cefdinir CAPS cefdinir SUSR cefepime hcl cefixime cefoxitin sodium cefpodoxime proxetil ceftazidime ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg cefuroxime axetil

3 1 3 4 3 3 3 3 3 4 4 3 4 4 4 3 3

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

8

Drug Name (Nombre del medicamento) cefuroxime sodium 1.5gm, 7.5gm, 750mg cephalexin CAPS 250mg, 500mg cephalexin SUSR SUPRAX CAPS suprax CHEW SUPRAX SUSR 500mg/5ml tazicef SOLR tazicef vial TEFLARO

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 3 1 3 3 4 3 4 4 4

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK azithromycin SOLR; SUSR azithromycin TABS clarithromycin TABS clarithromycin er clarithromycin for susp erythrocin lactobionate erythromycin base erythromycin cap 250mg ec erythromycin ethylsuccinate erythromycin stearate

3 3 1 4 3 4 4 4 4 4 4

FLUOROQUINOLONES ciprofloxacin hcl tab ciprofloxacin in d5w ciprofloxacin inj 200mg/20ml ciprofloxacin inj 400mg/40ml levofloxacin TABS levofloxacin in d5w levofloxacin inj 25mg/ml levofloxacin oral soln 25 mg/ml

1 4 4 4 1 3 4 4

PENICILLINS amoxicillin CAPS; SUSR; TABS amoxicillin CHEW amoxicillin & pot clavulanate CHEW; SUSR amoxicillin & pot clavulanate TABS ampicillin CAPS ampicillin SUSR ampicillin & sulbactam sodium ampicillin inj

1 2 3 2 1 3 4 4

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

9

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) ampicillin sodium 4 BICILLIN L-A 4 dicloxacillin sodium 3 nafcillin sodium 1gm 4 nafcillin sodium 2gm, 10gm 5 PENICILLIN G POT IN DEXTROSE 4 penicillin g procaine 4 penicillin g sodium 4 penicillin v potassium 1 penicilln gk inj 5mu 4 penicilln gk inj 20mu 4 pfizerpen-g inj 5mu 4 piperacillin sodium-tazobactam sodium 4

TETRACYCLINES doxycycline (monohydrate) CAPS 50mg, 100mg doxycycline (monohydrate) TABS 50mg, 75mg, 100mg doxycycline hyclate CAPS; TABS doxycycline hyclate SOLR minocycline hcl CAPS

2 3 3 4 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS CYCLOPHOSPHAMIDE CAPS dacarbazine EMCYT GLEOSTINE HEXALEN LEUKERAN

4 3 4 4 5 4

B/D B/D

3 4

B/D B/D

ANTIBIOTICS bleomycin sulfate mitomycin SOLR

ANTIMETABOLITES adrucil inj ALIMTA azacitidine fluorouracil SOLN mercaptopurine TABS METHOTREXATE SODIUM

3 5 5 3 3 50mg/2ml 2

B/D B/D B/D, NM B/D B/D

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

10

Drug Name (Nombre del medicamento) methotrexate sodium 50mg/2ml, 100mg/4ml, 200mg/8ml, 250mg/10ml methotrexate sodium inj NIPENT PURIXAN TABLOID

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 2 B/D 2 5 5 4

B/D B/D NM

5 5

B/D B/D

5 4 5

B/D B/D B/D

5

B/D

5 5 5 5 5 5 5 5 5 5 5 5 4 5 5 5 5

B/D, NM, LA NM, PA NM, LA, PA NM, LA, PA B/D, NM NM, LA, PA NM, PA NM, LA, PA NM, PA NM, LA, PA NM, LA, PA B/D, NM NM, LA, PA NM, LA, PA NM, LA, PA NM, PA NM, PA

ANTIMITOTIC, TAXOIDS ABRAXANE DOCETAXEL CONC 20mg/ml, 80mg/4ml docetaxel CONC 140mg/7ml DOCETAXEL SOLN 20mg/2ml DOCETAXEL SOLN 160mg/16ml, 200mg/20ml DOCETAXEL SOLN 80MG/8ML

BIOLOGIC RESPONSE MODIFIERS AVASTIN BELEODAQ ERIVEDGE FARYDAK HERCEPTIN IBRANCE KEYTRUDA LYNPARZA NINLARO RITUXAN TECENTRIQ VELCADE VENCLEXTA 10mg, 50mg VENCLEXTA 100mg VENCLEXTA STARTING PACK YERVOY ZOLINZA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS bicalutamide exemestane FARESTON FASLODEX flutamide

2 3 4 5 5 4

B/D

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

11

Drug Name (Nombre del medicamento) hydroxyprogesterone caproate (antineoplastic) letrozole TABS leuprolide inj 1mg/0.2 LUPRON DEPOT 3.75mg LYSODREN megestrol ac sus 40mg/ml

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 4 B/D 3 3 5 3 4

megestrol ac tab 20mg

4

megestrol ac tab 40mg

4

MEGESTROL SUS 625MG/5ML NILANDRON nilutamide SOLTAMOX tamoxifen citrate TABS TRELSTAR DEP INJ 3.75MG TRELSTAR LA INJ 11.25MG XTANDI ZYTIGA

5 5 5 4 1 5 5 5 5

NM, PA NM, PA PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older PA

NM, NM, NM, NM,

PA PA LA, PA LA, PA

NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM,

PA PA LA, PA LA, LA, LA, LA, LA, LA, LA, LA, PA LA, LA, LA, LA, LA, LA,

KINASE INHIBITORS AFINITOR AFINITOR DISPERZ ALECENSA BOSULIF CABOMETYX CAPRELSA COMETRIQ COTELLIC GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG ICLUSIG imatinib mesylate IMBRUVICA CAP 140MG INLYTA IRESSA JAKAFI LENVIMA 8 MG DAILY DOSE LENVIMA 10 MG DAILY DOSE

5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

12

Drug Name (Nombre del medicamento) LENVIMA 14 LENVIMA 18 LENVIMA 20 LENVIMA 24 MEKINIST NEXAVAR SPRYCEL STIVARGA SUTENT TAFINLAR TAGRISSO TARCEVA TASIGNA TYKERB VOTRIENT XALKORI ZELBORAF ZYDELIG ZYKADIA

MG MG MG MG

DAILY DAILY DAILY DAILY

DOSE DOSE DOSE DOSE

Drug Tier (Nivel de medicamento) 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

Requirements/Limits (Requisitos/Limites)

5 3 3 5 5 3 5 5 5 5 5 5 5 5 5 5 5

NM, PA

5 5 5

B/D B/D B/D, NM

NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM, NM,

LA, LA, LA, LA, LA, LA, PA LA, PA LA, LA, LA, PA LA, LA, LA, LA, LA, LA,

PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA

MISCELLANEOUS bexarotene DROXIA hydroxyurea CAPS LONSURF MATULANE mitoxantrone hcl ODOMZO POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG SYLATRON KIT 200MCG SYLATRON KIT 300MCG SYLATRON KIT 600MCG SYNRIBO tretinoin (chemotherapy) TRISENOX

NM, PA LA B/D, NM NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, PA NM, PA NM, PA NM, PA B/D

PROTECTIVE AGENTS amifostine crystalline ELITEK FUSILEV

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13

Drug Name (Nombre del medicamento) leucovorin calcium SOLR leucovorin calcium TABS leucovorin calcium for inj 500 mg levoleucovorin calcium mesna MESNEX TABS

Drug Tier (Nivel de medicamento) 4 3 4 5 4 5

Requirements/Limits (Requisitos/Limites)

3

B/D

5

B/D

B/D B/D B/D, NM B/D

TOPOISOMERASE INHIBITORS etoposide SOLN 1gm/50ml, 500mg/25ml topotecan hcl SOLR

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS benazepril & hydrochlorothiazide 1 enalapril maleate & hydrochlorothiazide1 fosinopril sodium & hydrochlorothiazide 1 lisinopril & hydrochlorothiazide 1 moexipril-hydrochlorothiazide 1 quinapril-hydrochlorothiazide 1

ACE INHIBITORS benazepril hcl TABS enalapril maleate TABS fosinopril sodium lisinopril TABS moexipril hcl perindopril erbumine quinapril hcl ramipril trandolapril

1 1 1 1 1 1 1 1 1

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone spironolactone

TABS

4 1

ALPHA BLOCKERS doxazosin mesylate doxazosin mesylate prazosin hcl terazosin hcl

1mg, 2mg, 4mg 3 8mg 3 2 1

QL (30 tabs / 30 days)

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-160 mg

1

QL (30 tabs / 30 days)

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14

Drug Name (Nombre del medicamento) amlodipine besylate-valsartan tab 5-320 mg amlodipine besylate-valsartan tab 10-160 mg amlodipine besylate-valsartan tab 10-320 mg amlodipine-valsartan-hydrochlorothiazi de 5-160-12.5mg amlodipine-valsartan-hydrochlorothiazi de 5-160-25mg amlodipine-valsartan-hydrochlorothiazi de 10-160-12.5mg amlodipine-valsartan-hydrochlorothiazi de 10-160-25mg amlodipine-valsartan-hydrochlorothiazi de 10-320-25mg AZOR 10-40MG AZOR TAB 5-20MG AZOR TAB 5-40MG AZOR TAB 10-20MG BENICAR HCT 40-25MG BENICAR HCT TAB 20-12.5MG BENICAR HCT TAB 40-12.5MG ENTRESTO irbesartan-hydrochlorothiazide losartan-hydrochlorothiazide TRIBENZOR TAB 20-5-12.5MG TRIBENZOR TAB 40-5-12.5MG TRIBENZOR TAB 40-5-25MG TRIBENZOR TAB 40-10-12.5 TRIBENZOR TAB 40-10-25MG valsartan & hctz tab 80-12.5mg valsartan & hctz tab 160-12.5mg valsartan & hctz tab 160-25mg valsartan & hctz tab 320-12.5mg valsartan & hctz tab 320-25mg

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 1 QL (30 tabs / 30 days) 1

QL (30 tabs / 30 days)

1 1

QL (30 tabs / 30 days)

1

QL (60 tabs / 30 days)

1

QL (30 tabs / 30 days)

1

QL (30 tabs / 30 days)

1 3 3 3 3 3 3 3 4 1 1 3 3 3 3 3 1 1 1 1 1

QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days)

PA

QL QL QL QL

(30 (30 (30 (30

tabs tabs tabs tabs

/ / / /

30 30 30 30

days) days) days) days)

ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR irbesartan losartan potassium valsartan

3 1 1 1

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15

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento)

ANTIARRHYTHMICS amiodarone hcl SOLN 2 amiodarone hcl TABS 100mg, 400mg 4 amiodarone hcl TABS 200mg 1 disopyramide phosphate 4 dofetilide flecainide acetate mexiletine hcl MULTAQ NORPACE CR

4 3 4 4 4

propafenone hcl CP12 propafenone hcl TABS propafenone hcl 12hr CP12 propafenone hcl 12hr TABS quinidine gluconate TBCR quinidine sulfate TABS sotalol hcl sotalol hcl (afib/afl) TIKOSYN

4 3 4 3 4 2 2 3 4

PA; PA if 65 years and older NM

PA; PA if 65 years and older

NM

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium TABS CRESTOR lovastatin 10mg lovastatin 20mg lovastatin 40mg pravastatin sodium rosuvastatin calcium simvastatin TABS

1 3 1 1 1 1 1 1

QL QL QL QL QL QL QL QL

(30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days)

ANTILIPEMICS, MISCELLANEOUS cholestyramine 4 cholestyramine light 4 colestipol hcl GRAN; PACK 4 colestipol hcl TABS 3 fenofibrate TABS 54mg, 160mg 3 fenofibrate micronized 67mg, 134mg, 3 200mg gemfibrozil TABS 2 JUXTAPID 5 KYNAMRO 5

NM, LA, PA NM, PA

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16

Drug Name (Nombre del medicamento) niacin (antihyperlipidemic) niacin er (antihyperlipidemic) niacin er (antihyperlipidemic) 1000mg omega-3-acid ethyl esters PRALUENT VASCEPA WELCHOL ZETIA TAB 10MG

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 3 500mg 4 QL (90 tabs / 30 days) 750mg, 4 4 5 4 3 3

NM, PA

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone bisoprolol & hydrochlorothiazide metoprolol & hydrochlorothiazide propranolol & hydrochlorothiazide

3 1 3 3

BETA-BLOCKERS acebutolol hcl CAPS atenolol TABS BYSTOLIC carvedilol labetalol hcl TABS metoprolol succinate 25mg, 50mg metoprolol succinate 100mg metoprolol succinate 200mg metoprolol tartrate SOLN metoprolol tartrate TABS 25mg, 50mg, 100mg pindolol propranolol cap er propranolol hcl SOLN propranolol hcl TABS timolol maleate TABS

2 1 4 1 3 3 3 3 3 1

QL (60 tabs / 30 days) QL (45 tabs / 30 days)

3 4 3 1 3

CALCIUM CHANNEL BLOCKERS amlodipine besylate TABS 2.5mg, 5mg1 amlodipine besylate TABS 10mg 1 cartia xt cap 120/24hr 3 cartia xt cap 180/24hr 3 cartia xt cap 240/24hr 3 cartia xt cap 300/24hr 3 dilt-xr cap 3 diltiazem cap 3 diltiazem cap 120mg/24hr 3

QL (45 tabs / 30 days)

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17

Drug Name (Nombre del medicamento) diltiazem cap 240mg/24hr diltiazem cap er/12hr diltiazem hcl SOLN; TABS diltiazem hcl coated beads CP24 nicardipine hcl CAPS nimodipine CAPS NYMALIZE taztia xt verapamil cap er 100mg, 120mg, 180mg, 200mg, 240mg, 300mg VERAPAMIL CAP ER 360mg verapamil hcl SOLN verapamil hcl TABS verapamil hcl TBCR verapamil tab er

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 3 3 2 3 4 5 5 3 3 3 4 1 2 2

DIGITALIS GLYCOSIDES digox digox digoxin

125mcg 250mcg

3 3

TABS .25mg, 250mcg

digoxin TABS .125mg, 125mcg digoxin inj DIGOXIN SOL 50MCG/ML

3 3 3 3

QL (30 PA; PA older PA; PA older QL (30

tabs / 30 days) if 65 years and if 65 years and tabs / 30 days)

PA; PA if 65 years and older

DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA TEKTURNA TEKTURNA TEKTURNA TEKTURNA TEKTURNA

150mg 300mg HCT TAB HCT TAB HCT TAB HCT TAB

150-12.5MG 150-25MG 300-12.5MG 300-25MG

3 3 3 3 3 3

QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days)

DIURETICS acetazolamide CP12; TABS amiloride & hydrochlorothiazide amiloride hcl TABS bumetanide inj 0.25/ml bumetanide tab chlorothiazide tabs chlorthalidone 25mg, 50mg furosemide SOLN

3 2 3 3 3 3 3 2

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18

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 1 2 2 1 2 4 3 3 2 2 1

furosemide TABS furosemide inj 10mg/ml FUROSEMIDE INJ 10mg/ml hydrochlorothiazide CAPS; TABS indapamide methazolamide TABS metolazone spironolactone & hydrochlorothiazide torsemide inj torsemide tabs triamterene & hydrochlorothiazide TABS triamterene & hydrochlorothiazide cap 1 37.5-25 mg

MISCELLANEOUS clonidine hcl TABS DEMSER hydralazine hcl SOLN hydralazine hcl TABS midodrine hcl minoxidil TABS RANEXA

1 5 3 2 4 2 3

NITRATES isosorb mononitrate tab isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate er nitroglycer dis 0.1mg/hr nitroglycer dis 0.2mg/hr nitroglycer dis 0.4mg/hr nitroglycer dis 0.6mg/hr nitroglycerin OINT nitroglycerin PT24 NITROSTAT

2 3 3 2 3 3 3 3 3 3 3

PULMONARY ARTERIAL HYPERTENSION ADEMPAS

5

LETAIRIS

5

OPSUMIT

5

QL (90 tabs / 30 days), NM, LA, PA QL (30 tabs / 30 days), NM, LA, PA QL (30 tabs / 30 days), NM, LA, PA

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19

Drug Name (Nombre del medicamento) REMODULIN REVATIO SUSR

Drug Tier (Nivel de medicamento) 5 5

sildenafil citrate (pulmonary hypertension) TABS TRACLEER 62.5mg

3

TRACLEER

5

125mg

5

UPTRAVI

TABS 200mcg

5

UPTRAVI

TABS 400mcg

5

UPTRAVI

TABS 600mcg

5

UPTRAVI

TABS 800mcg

5

UPTRAVI

TABS 1000mcg

5

UPTRAVI TABS 1200mcg, 1400mcg, 1600mcg UPTRAVI TBPK

5 5

Requirements/Limits (Requisitos/Limites) B/D, NM, LA QL (224 mL / 30 days), NM, PA QL (90 tabs / 30 days), NM, PA QL (120 tabs / 30 days), NM, LA, PA QL (60 tabs / 30 days), NM, LA, PA QL (480 tabs / 30 days), NM, LA, PA QL (240 tabs / 30 days), NM, LA, PA QL (150 tabs / 30 days), NM, LA, PA QL (120 tabs / 30 days), NM, LA, PA QL (90 tabs / 30 days), NM, LA, PA QL (60 tabs / 30 days), NM, LA, PA NM, LA, PA

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5mg alprazolam tab 0.25mg alprazolam tab 1mg alprazolam tab 2 mg buspirone hcl TABS 5mg, 7.5mg, 10mg, 15mg fluvoxamine maleate TABS 25mg, 50mg fluvoxamine maleate TABS 100mg lorazepam CONC lorazepam SOLN lorazepam TABS

1 1 1 1 3

QL QL QL QL

3

QL (45 tabs / 30 days)

3 3 2 1

(240 (480 (120 (150

tabs tabs tabs tabs

/ / / /

30 30 30 30

days) days) days) days)

QL (150 mL / 30 days) QL (150 tabs / 30 days)

ANTICONVULSANTS APTIOM APTIOM APTIOM APTIOM BANZEL

200mg 400mg 600mg 800mg SUS 40MG/ML

4 5 5 5 5

QL QL QL QL PA

(180 tabs / 30 days) (90 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days)

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20

Drug Name (Nombre del medicamento) BANZEL TAB 200MG BANZEL TAB 400MG BRIVIACT INJ BRIVIACT SOLN 10MG/ML BRIVIACT TABS carbamazepine CHEW; TABS carbamazepine CP12; SUSP; TB12 CELONTIN clonazepam TABS 1mg clonazepam TABS 2mg clonazepam TABS .5mg clonazepam TBDP 1mg clonazepam TBDP 2mg clonazepam TBDP .5mg clonazepam TBDP .25mg clonazepam TBDP .125mg clorazepate dipotassium 3.75mg, 7.5mg clorazepate dipotassium 15mg

Drug Tier (Nivel de medicamento) 4 5 4 5 5 3 4 4 1 1 1 3 3 3 3 3 2 2

diazepam

CONC

3

diazepam

SOLN

3

diazepam

TABS

1

DIAZEPAM GEL diazepam inj dilantin infatabs DILANTIN-125 SUS 125/5ML divalproex sodium CSDR; TB24 divalproex sodium TBEC ethosuximide CAPS; SOLN felbamate SUSP felbamate TABS FYCOMPA SUSP

4 3 3 3 4 2 4 5 4 4

FYCOMPA

TABS 2mg

4

FYCOMPA

TABS 4mg

4

Requirements/Limits (Requisitos/Limites) PA PA PA PA PA

QL QL QL QL QL QL QL QL QL PA QL PA QL PA QL PA QL PA

(120 (300 (240 (120 (300 (240 (480 (960 (120

tabs tabs tabs tabs tabs tabs tabs tabs tabs

/ / / / / / / / /

30 30 30 30 30 30 30 30 30

days) days) days) days) days) days) days) days) days),

(180 tabs / 30 days), (240 mL / 30 days), (1200 mL / 30 days), (120 tabs / 30 days),

QL (720 mL / 30 days), PA QL (180 tabs / 30 days), PA QL (90 tabs / 30 days), PA

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21

Drug Name (Nombre del medicamento) FYCOMPA

TABS 6mg

FYCOMPA

TABS 8mg, 10mg, 12mg

gabapentin CAPS 100mg gabapentin CAPS 300mg gabapentin CAPS 400mg gabapentin SOLN gabapentin TABS 600mg gabapentin TABS 800mg lamotrigine CHEW lamotrigine TABS levetiracetam TABS levetiracetam inj LEVETIRACETAM IV levetiracetam oral soln 100 mg/ml LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg LYRICA CAPS 200mg LYRICA CAPS 225mg, 300mg LYRICA SOLN ONFI SUSP ONFI TABS 10mg ONFI TABS 20mg oxcarbazepine SUSP oxcarbazepine TABS PEGANONE phenobarbital ELIX; TABS PHENOBARBITAL SODIUM SOLN 65mg/ml phenobarbital sodium SOLN 130mg/ml phenytoin CHEW; SUSP phenytoin sodium SOLN phenytoin sodium extended POTIGA 50mg POTIGA 200mg POTIGA 300mg, 400mg primidone TABS SABRIL PACK

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 4 QL (60 tabs / 30 days), PA 4 QL (30 tabs / 30 days), PA 2 QL (1080 caps / 30 days) 2 QL (360 caps / 30 days) 2 QL (270 caps / 30 days) 3 QL (2160 mL / 30 days) 3 QL (180 tabs / 30 days) 3 QL (120 tabs / 30 days) 3 2 3 4 4 3 3 QL (120 caps / 30 days) 3 3 3 5 4 5 4 3 4 4 4 4 3 3 3 4 5 5 2 5

QL (90 caps / 30 days) QL (60 caps / 30 days) QL (946 mL / 30 days) PA PA PA

PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older

QL (180 tabs / 30 days) QL (90 tabs / 30 days) QL (180 packets / 30 days), NM, LA, PA

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22

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) SABRIL TABS 5 QL (180 tabs / 30 days), NM, LA, PA SPRITAM 4 TEGRETOL 4 TEGRETOL-XR 4 tiagabine hcl 4 topiramate CPSP 4 topiramate TABS 2 valproate sodium SOLN 4 valproate sodium SYRP 2 valproic acid 3 VIMPAT SOLN 10mg/ml 4 QL (1200 mL / 30 days) VIMPAT SOLN 200mg/20ml 4 VIMPAT TABS 50mg 4 QL (180 tabs / 30 days) VIMPAT TABS 100mg, 150mg, 200mg 5 QL (60 tabs / 30 days) zonisamide CAPS 3

ANTIDEMENTIA donepezil hydrochloride donepezil hydrochloride donepezil hydrochloride donepezil hydrochloride EXELON PATCHES

TABS TABS TBDP TBDP

5mg 10mg 5mg 10mg

2 2 4 4 4

galantamine hydrobromide SOLN 4 galantamine hydrobromide TABS 4mg 4 galantamine hydrobromide TABS 8mg 4 galantamine hydrobromide TABS 4 12mg galantamine hydrobromide er 8mg, 4 16mg galantamine hydrobromide er 24mg 4 memantine hcl SOLN 3 memantine hcl TABS 4 NAMENDA XR 4 NAMENDA XR TITRATION PACK 4 NAMZARIC 4 rivastigmine td patch 24hr 4.6 mg/24hr4 rivastigmine td patch 24hr 9.5 mg/24hr4

QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 patches / 30 days) QL (180 tabs / 30 days) QL (90 tabs / 30 days)

QL (30 caps / 30 days)

PA; PA; PA; PA;

PA PA PA PA

if if if if

< < < <

30 30 30 30

yrs yrs yrs yrs

QL (30 patches / 30 days) QL (30 patches / 30 days)

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23

Drug Name (Nombre del medicamento) rivastigmine td patch 24hr 13.3 mg/24hr

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 4 QL (30 patches / 30 days)

ANTIDEPRESSANTS amitriptyline hcl

TABS

4

amoxapine 3 BRINTELLIX 5mg 4 BRINTELLIX 10mg 4 BRINTELLIX 20mg 4 bupropion hcl TABS 3 bupropion hcl TB12 2 bupropion hcl TB24 150mg 3 bupropion hcl TB24 300mg 3 citalopram hydrobromide SOLN 3 citalopram hydrobromide TABS 10mg, 1 20mg citalopram hydrobromide TABS 40mg 1 clomipramine hcl CAPS 4 desipramine hcl TABS doxepin hcl CAPS; CONC

4 4

duloxetine hcl CPEP 20mg, 30mg, 60mg EMSAM

4 5

escitalopram oxalate SOLN 4 escitalopram oxalate TABS 5mg, 10mg2 escitalopram oxalate TABS 20mg 2 FETZIMA 20mg 4 FETZIMA 40mg 4 FETZIMA 80mg, 120mg 4 FETZIMA TITRATION PACK 4 fluoxetine cap 10mg 1 fluoxetine cap 20mg 1 fluoxetine cap 40mg 1 fluoxetine hcl SOLN 3 fluoxetine hcl TABS 10mg 3 fluoxetine hcl TABS 20mg 3 imipramine hcl TABS 4 maprotiline hcl

PA; PA if 65 years and older QL (120 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days)

QL (90 tabs / 30 days) QL (30 tabs / 30 days) QL (45 tabs / 30 days) QL (30 tabs / 30 days) PA; PA if 65 years and older PA; PA if 65 years and older QL (60 caps / 30 days) QL (30 patches / 30 days), PA QL (600 mL / 30 days) QL (45 tabs / 30 days) QL (60 tabs / 30 days) QL (180 caps / 30 days) QL (90 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (120 caps / 30 days)

QL (45 tabs / 30 days) PA; PA if 65 years and older

4

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24

Drug Name (Nombre del medicamento) MARPLAN TAB 10MG mirtazapine TABS 7.5mg, 15mg mirtazapine TABS 30mg, 45mg mirtazapine TBDP 15mg mirtazapine TBDP 30mg, 45mg nefazodone hcl nortriptyline hcl CAPS nortriptyline hcl SOLN paroxetine hcl tabs 10mg, 20mg, 40mg paroxetine hcl tabs 30mg PAXIL SUSP phenelzine sulfate TABS PRISTIQ protriptyline hcl sertraline hcl CONC sertraline hcl TABS 25mg, 50mg sertraline hcl TABS 100mg SURMONTIL CAP 25MG

Drug Tier (Nivel de medicamento) 4 2 2 3 3 4 1 4 1

Requirements/Limits (Requisitos/Limites)

1 4 3 3 4 3 1 1 4

QL (60 tabs / 30 days) QL (900 mL / 30 days)

SURMONTIL CAP 50MG

4

SURMONTIL CAP 100MG

4

tranylcypromine sulfate trazodone hcl TABS 50mg, 100mg, 150mg trimipramine maleate CAPS 25mg

4 1

trimipramine maleate CAPS 50mg

4

trimipramine maleate CAPS 100mg

4

TRINTELLIX TRINTELLIX TRINTELLIX

4 4 4

5mg 10mg 20mg

4

QL (180 tabs / 30 days) QL (45 tabs / 30 days) QL (30 tabs / 30 days)

QL (45 tabs / 30 days)

QL (30 tabs / 30 days)

QL (45 tabs / 30 days) QL (240 caps / 30 days), PA; PA if 65 years and older QL (120 caps / 30 days), PA; PA if 65 years and older QL (60 caps / 30 days), PA; PA if 65 years and older

QL (240 caps / 30 days), PA; PA if 65 years and older QL (120 caps / 30 days), PA; PA if 65 years and older QL (60 caps / 30 days), PA; PA if 65 years and older QL (120 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days)

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25

Drug Name (Nombre del medicamento) venlafaxine hcl CP24 37.5mg, 75mg venlafaxine hcl CP24 150mg venlafaxine hcl TABS VIIBRYD KIT VIIBRYD TABS VIIBRYD STARTER PACK

Drug Tier (Nivel de medicamento) 2 2 3 4 4 4

Requirements/Limits (Requisitos/Limites) QL (30 caps / 30 days) QL (60 caps / 30 days)

QL (30 tabs / 30 days)

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; TABS amantadine hcl SYRP APOKYN AZILECT BENZTROPINE MESYLATE SOLN benztropine mesylate TABS

4 2 5 3 3 4

bromocriptine mesylate CAPS; TABS carbidopa-levodopa TABS; TBDP carbidopa-levodopa TBCR ENTACAPONE NEUPRO pramipexole dihydrochloride TABS ropinirole hydrochloride TABS selegiline hcl CAPS; TABS

4 2 3 4 4 2 2 4

NM, LA, PA

PA; PA if 65 years and older

ANTIPSYCHOTICS ABILIFY DISCMELT TAB 10MG ABILIFY MAINTENA aripiprazole aripiprazole oral solution 1 mg/ml aripiprazole tabs chlorpromazine hcl TABS chlorpromazine inj clozapine TABS 100mg clozapine TABS 200mg CLOZAPINE TBDP 12.5mg, 25mg CLOZAPINE TBDP 100mg

5 5 5 5 5 4 4 4 4 4 4

QL (60 tabs / 30 days) QL (1 injection / 28 days) QL (60 tabs / 30 days) QL (900ml / 30 days) QL (30 tabs / 30 days)

CLOZAPINE

TBDP 150mg

5

(180 tabs / 30 days),

CLOZAPINE

TBDP 200mg

5

clozapine tab 25mg clozapine tab 50mg

QL QL PA QL PA QL PA QL PA

(270 tabs / 30 days) (135 tabs / 30 days) (270 tabs / 30 days),

(135 tabs / 30 days),

3 3

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26

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) FANAPT 4 QL (60 tabs / 30 days), ST FANAPT TITRATION PACK 4 ST FAZACLO 150mg 5 QL (180 tabs / 30 days), PA FAZACLO 200mg 5 QL (135 tabs / 30 days), PA fluphenazine decanoate SOLN 4 fluphenazine hcl CONC; ELIX; SOLN 4 fluphenazine hcl TABS 2 GEODON SOLR 4 QL (6 mL / 3 days) haloperidol TABS 3 haloperidol con lactate 3 haloperidol decanoate SOLN 3 haloperidol lactate inj 5 mg/ml 3 INVEGA 1.5mg, 3mg, 9mg 4 QL (30 tabs / 30 days) INVEGA 6mg 4 QL (60 tabs / 30 days) INVEGA SUST INJ 39 MG/0.25 ML 4 QL (1 injection / 28 days) INVEGA SUST INJ 78 MG/0.5 ML 5 QL (1 injection / 28 days) INVEGA SUST INJ 117 MG/0.75 ML 5 QL (1 injection / 28 days) INVEGA SUST INJ 156MG/ML 5 QL (1 injection / 28 days) INVEGA SUST INJ 234 MG/1.5 ML 5 QL (1 injection / 28 days) INVEGA TRINZA 5 QL (1 syringe / 90 days) LATUDA 20mg 4 QL (240 tabs / 30 days) LATUDA 40mg, 120mg 4 QL (30 tabs / 30 days) LATUDA 60mg, 80mg 4 QL (60 tabs / 30 days) loxapine succinate 3 molindone hcl 4 NUPLAZID 5 QL (60 tabs / 30 days), NM, LA, PA olanzapine SOLR 4 QL (3 vials / 1 day) olanzapine TABS 2.5mg, 5mg, 7.5mg 3 QL (30 tabs / 30 days) olanzapine TABS 10mg, 15mg, 20mg 3 QL (60 tabs / 30 days) olanzapine TBDP 5mg 4 QL (30 tabs / 30 days) olanzapine TBDP 10mg, 15mg, 20mg 4 QL (60 tabs / 30 days) paliperidone 1.5mg, 3mg, 9mg 4 QL (30 tabs / 30 days) paliperidone 6mg 4 QL (60 tabs / 30 days) perphenazine TABS 4 pimozide 4 quetiapine fumarate 3 QL (90 tabs / 30 days)

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27

Drug Name (Nombre del medicamento) REXULTI

1mg

REXULTI

2mg

REXULTI

3mg, 4mg

REXULTI

.5mg

REXULTI

.25mg

RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG risperidone SOLN risperidone TABS 1mg, 2mg, 3mg risperidone TABS 4mg risperidone TABS .25mg, .5mg risperidone TBDP 1mg, 2mg, 3mg risperidone TBDP 4mg risperidone TBDP .25mg, .5mg SAPHRIS 2.5mg SAPHRIS 5mg SAPHRIS 10mg SEROQUEL XR 50mg SEROQUEL XR 150mg, 200mg SEROQUEL XR 300mg, 400mg thioridazine hcl TABS thiothixene trifluoperazine hcl VERSACLOZ VRAYLAR CAPS 1.5mg VRAYLAR CAPS 3mg

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 5 QL (90 tabs / 30 days), ST 5 QL (60 tabs / 30 days), ST 5 QL (30 tabs / 30 days), ST 5 QL (180 tabs / 30 days), ST 5 QL (360 tabs / 30 days), ST 4 QL (2 injections / 28 days) 4 QL (2 injections / 28 days) 5 QL (2 injections / 28 days) 5 QL (2 injections / 28 days) 4 QL (240 mL / 30 days) 2 QL (60 tabs / 30 days) 2 QL (120 tabs / 30 days) 2 QL (90 tabs / 30 days) 4 QL (60 tabs / 30 days) 4 QL (120 tabs / 30 days) 4 QL (90 tabs / 30 days) 4 QL (240 tabs / 30 days) 4 QL (120 tabs / 30 days) 4 QL (60 tabs / 30 days) 4 QL (120 tabs / 30 days) 4 QL (30 tabs / 30 days) 4 QL (60 tabs / 30 days) 4 PA; PA if 65 years and older 3 3 5 QL (600 mL / 30 days), PA 5 QL (120 caps / 30 days), ST 5 QL (60 caps / 30 days), ST

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28

Drug Name (Nombre del medicamento) VRAYLAR CAPS 4.5mg, 6mg VRAYLAR CPPK ziprasidone hcl 20mg, 40mg ziprasidone hcl 60mg, 80mg ZYPREXA RELPREVV 300mg ZYPREXA RELPREVV 405mg ZYPREXA RELPREVV INJ 210MG

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 5 QL (30 caps / 30 days), ST 4 ST 4 QL (60 caps / 30 days) 4 QL (90 caps / 30 days) 5 QL (2 vials / 28 days), PA 5 QL (1 vial / 28 days), PA 5 QL (2 vials / 28 days), PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine sr 24hr 5 mg amphetamine-dextroamphetamine sr 24hr 10 mg amphetamine-dextroamphetamine sr 24hr 15 mg amphetamine-dextroamphetamine sr 24hr 20 mg amphetamine-dextroamphetamine sr 24hr 25 mg amphetamine-dextroamphetamine sr 24hr 30 mg amphetamine-dextroamphetamine 5 mg amphetamine-dextroamphetamine 7.5 mg amphetamine-dextroamphetamine 10 mg amphetamine-dextroamphetamine 12.5 mg amphetamine-dextroamphetamine 15 mg amphetamine-dextroamphetamine 20 mg amphetamine-dextroamphetamine 30 mg guanfacine er (adhd)

cap 4

QL (90 caps / 30 days)

cap 4

QL (90 caps / 30 days)

cap 4

QL (30 caps / 30 days)

cap 4

QL (30 caps / 30 days)

cap 4

QL (30 caps / 30 days)

cap 4

QL (30 caps / 30 days)

tab 3

QL (360 tabs / 30 days)

tab 3

QL (240 tabs / 30 days)

tab 3

QL (180 tabs / 30 days)

tab 3

QL (144 tabs / 30 days)

tab 3

QL (120 tabs / 30 days)

tab 3

QL (90 tabs / 30 days)

tab 3

QL (60 tabs / 30 days)

4

metadate er tab 20mg 4 methylphenidate hcl TABS 5mg, 10mg3 methylphenidate hcl TABS 20mg 3 methylphenidate hcl TBCR 4

PA; PA if 65 years and older QL (90 tabs / 30 days) QL (180 tabs / 30 days) QL (90 tabs / 30 days) QL (90 tabs / 30 days)

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29

Drug Name (Nombre del medicamento) methylphenidate hcl oral soln 5mg/5ml methylphenidate hcl oral soln 10mg/5ml STRATTERA 10mg, 18mg, 25mg STRATTERA 40mg STRATTERA 60mg, 80mg, 100mg

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 4 QL (1800 mL / 30 days) 4

QL (900 mL / 30 days)

4 4 4

QL (120 caps / 30 days) QL (60 caps / 30 days) QL (30 caps / 30 days)

HETLIOZ ROZEREM SILENOR 3mg SILENOR 6mg temazepam 7.5mg

5 4 3 3 2

temazepam

2

NM, LA, PA QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (30 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year QL (60 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year QL (30 tabs / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year

HYPNOTICS

15mg

zolpidem tartrate

TABS

4

MIGRAINE dihydroergotamine mesylate 1mg/ml RELPAX rizatriptan benzoate TABS SUMATRIPTAN SOLN 5mg/act

3 3 3 4

SUMATRIPTAN

4

SOLN 20mg/act

sumatriptan inj 4mg/0.5ml

SOAJ

SUMATRIPTAN INJ 4MG/0.5ML

4

SOCT 4

sumatriptan inj 6mg/0.5ml SOAJ; 4 SOLN; SOSY SUMATRIPTAN INJ 6MG/0.5ML SOCT 4 sumatriptan succinate TABS

2

QL (12 tabs / 30 days) QL (18 tabs / 30 days) QL (24 inhalers / 30 days) QL (12 inhalers / 30 days) QL (12 injections / 30 days) QL (12 injections / 30 days) QL (12 injections / 30 days) QL (12 injections / 30 days) QL (9 tabs / 30 days)

MISCELLANEOUS You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

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Drug Name (Nombre del medicamento) lithium carbonate CAPS lithium carbonate TABS lithium carbonate er LITHIUM SOLN 8MEQ/5ML NUEDEXTA pyridostigmine bromide TABS riluzole tetrabenazine 12.5mg

Drug Tier (Nivel de medicamento) 1 2 2 3 3 3 4 5

tetrabenazine

5

25mg

Requirements/Limits (Requisitos/Limites)

PA

QL (240 tabs / 30 days), NM, PA QL (120 tabs / 30 days), NM, PA

MULTIPLE SCLEROSIS AGENTS AMPYRA BETASERON

5 5

COPAXONE INJ 40MG/ML

5

GILENYA CAP 0.5MG

5

glatiramer acetate

5

TYSABRI

5

NM, LA, PA QL (14 syringes / 28 days), NM, PA QL (12 syringes / 28 days), NM, PA QL (28 caps / 28 days), NM, PA QL (30 syringes / 30 days), NM, PA NM, LA, PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS dantrolene sodium CAPS tizanidine hcl TABS

2 4 2

NARCOLEPSY/CATAPLEXY armodafinil 50mg

4

armodafinil 150mg

4

ARMODAFINIL

4

200mg

armodafinil 250mg

4

NUVIGIL 50mg

4

NUVIGIL 150mg

4

NUVIGIL 200mg, 250mg

4

QL PA QL PA QL PA QL PA QL PA QL PA QL PA

(150 tabs / 30 days), (60 tabs / 30 days), (30 tabs / 30 days), (30 tabs / 30 days), (150 tabs / 30 days), (60 tabs / 30 days), (30 tabs / 30 days),

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Drug Name (Nombre del medicamento) XYREM

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 5 QL (540 mL / 30 days), LA, PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium buprenorphine hcl SUBL buprenorphine hcl-naloxone hcl sl

4 4 4

buproban tab (smoking deterrent) bupropion hcl (smoking deterrent) CHANTIX CHANTIX CONTINUING MONTH CHANTIX STARTER PACK disulfiram TABS naloxone inj 0.4mg/ml naloxone inj 1mg/ml naltrexone hcl TABS NICOTROL NS SUBOXONE MIS 2-0.5MG

3 3 4 4 4 4 3 3 3 4 4

SUBOXONE MIS 4-1MG

4

SUBOXONE MIS 8-2MG

4

SUBOXONE MIS 12-3MG

4

PA QL (120 tabs / 30 days), PA

PA PA PA

QL (120 SL films / 30 days), PA QL (120 SL films / 30 days), PA QL (120 SL films / 30 days), PA QL (60 SL films / 30 days), PA

ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM

4

AXIRON

3

oxandrolone tab 2.5mg oxandrolone tab 10mg testosterone cypionate SOLN testosterone enanthate SOLN

3 5 3 3

QL (30 patches / 30 days), PA QL (440 mL / 30 days), PA PA PA PA PA

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS BYDUREON BYDUREON PEN BYETTA GAUZE PADS 2" X 2"

3 3 3 4 3

QL (4 vials / 28 days) QL (4 pens / 28 days) QL (1 pen / 30 days)

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32

Drug Name (Nombre del medicamento) HUMULIN R U-500 KWIKPEN HUMULIN R U-500 VIAL (CONCENTRATE) INSULIN PEN NEEDLE INSULIN SAFETY NEEDLES INSULIN SYRINGE LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH NOVOLIN 70/30

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 5 5 B/D 3 3 3 3 3 3 3 3

NOVOLIN N

3

NOVOLIN R

3

NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 PREFILL NOVOLOG PENFILL SYMLINPEN 60 SYMLINPEN 120 TOUJEO SOLOSTAR TRESIBA FLEXTOUCH TRULICITY VICTOZA

3 3 3 3 3 4 5 3 3 4 3

(brand RELION not covered) (brand RELION not covered) (brand RELION not covered)

QL (8 pens / 30 days), PA QL (4 pens / 30 days), PA

QL (4 pens / 28 days) QL (3 pens / 30 days)

ANTIDIABETICS, ORAL acarbose FARXIGA 5mg FARXIGA 10mg glimepiride 1mg glimepiride 2mg glimepiride 4mg glip/metform tab 5-500mg glipizide TABS 5mg glipizide TABS 10mg glipizide TB24 2.5mg glipizide TB24 5mg glipizide TB24 10mg GLIPIZIDE XL TB24 2.5MG

3 3 3 1 1 1 1 1 1 1 1 1 1

QL QL QL QL QL QL QL QL QL QL QL QL

(60 tabs / 30 days) (30 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (120 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (240 tabs / 30 days)

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33

Drug Name (Nombre del medicamento)

Drug Tier (Nivel de medicamento) GLIPIZIDE XL TB24 5MG 1 glipizide-metformin hcl tab 2.5-250 mg 1 glipizide-metformin hcl tab 2.5-500 mg 1 INVOKAMET TAB 50-500MG 3 INVOKAMET TAB 50-1000 3 INVOKAMET TAB 150-500 3 INVOKAMET TAB 150-1000 3 INVOKANA 100mg 3 INVOKANA 300mg 3 JANUMET 3 JANUMET XR TAB 50-500MG 3 JANUMET XR TAB 50-1000 3 JANUMET XR TAB 100-1000 3 JANUVIA 3 JENTADUETO 3 JENTADUETO XR 2.5-1000MG 3 JENTADUETO XR 5-1000MG 3 metformin er 500mg 1 metformin er 750mg 1 metformin hcl TABS 500mg 1 metformin hcl TABS 850mg 1 metformin hcl TABS 1000mg 1 nateglinide 1 pioglitazone hcl 1 TRADJENTA 3 XIGDUO XR TAB 5-500MG 3 XIGDUO XR TAB 5-1000MG 3 XIGDUO XR TAB 10-500MG 3 XIGDUO XR TAB 10-1000MG 3

Requirements/Limits (Requisitos/Limites) QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL

(120 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (90 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (150 tabs / 30 days) (90 tabs / 30 days) (75 tabs / 30 days) (90 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days)

BISPHOSPHONATES alendronate sodium TABS 5mg, 10mg,1 40mg alendronate sodium TABS 35mg, 1 70mg pamidronate disodium SOLN 3 zoledronic acid SOLN 5mg/100ml 4 zoledronic inj 4mg/5ml 4

QL (4 tabs / 28 days) B/D B/D, NM B/D, NM

CALCIUM RECEPTOR AGONISTS SENSIPAR 30mg

3

QL (120 tabs / 30 days), NM

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34

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 5 QL (60 tabs / 30 days), NM 5 QL (120 tabs / 30 days), NM

SENSIPAR 60mg SENSIPAR 90mg

CHELATING AGENTS CHEMET DEPEN TITRATABS EXJADE FERRIPROX kionex powder sodium polystyrene sulfonate sodium polystyrene sulfonate SYPRINE

POWD SUSP

4 5 5 5 4 4 3 5

NM, LA, PA NM, LA, PA

CONTRACEPTIVES cryselle-28 3 desogestrel-ethinyl estradiol (triphasic) 3 ELLA 4 estarylla tab 0.25-35 3 ethynodiol diacet & eth estrad 3 heather 3 JOLIVETTE 3 levonor/ethi tab 2 levonorgestrel (emergency oc) 3 levonorgestrel-eth estradiol (triphasic) 2 low-ogestrel 3 medroxyprogesterone acetate 150 2 mg/ml MEDROXYPROGESTERONE ACETATE 2 (CONTRACEPTIVE) MICROGESTIN FE 1.5/30 3 MICROGESTIN FE 1/20 2 mono-linyah tab 0.25-35 3 MONONESSA 3 myzilra 2 necon 1/35-28 3 NORA-BE TAB 0.35MG 3 norethin acet & estrad-fe 2 norethin acet & estrad-fe 3 norethindrone & eth estradiol 3 norethindrone (contraceptive) 3 norgest/ethi tab 0.25/35 3 You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

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Drug Name (Nombre del medicamento) norgestimate-ethinyl estradiol norgestimate-ethinyl estradiol (triphasic) norlyroc 0.35mg NUVARING sharobel 0.35mg tri-linyah tab TRINESSA xulane dis 150-35

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 3 2 3 4 3 2 2 4

ENDOMETRIOSIS danazol CAPS SYNAREL

4 5

ENZYME REPLACEMENTS ADAGEN ALDURAZYME CARBAGLU CERDELGA CEREZYME CYSTADANE CYSTAGON FABRAZYME KUVAN levocarnitine (metabolic modifiers) LUMIZYME MYOZYME NAGLAZYME ORFADIN RAVICTI ZAVESCA

5 5 5 5 5 5 4 5 5 3 5 5 5 5 5 5

NM, NM, NM, NM, NM, NM, NM, NM, NM, B/D NM, NM, NM, NM, NM, NM,

LA, LA, LA, PA LA, LA LA, LA, LA,

PA PA PA

LA, LA, LA, LA, PA LA,

PA PA PA PA

PA PA PA PA

PA

ESTROGENS DELESTROGEN 10mg/ml estrace CREA estradiol PTWK

4 4 4

estradiol TABS

4

estradiol valerate OIL fyavolv tab 1 mg-5 mcg

3 4

norethindrone acetate-ethinyl estradiol 4

PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older

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36

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento)

GLUCOCORTICOIDS a-hydrocort cortisone acetate TABS dexamethasone CONC; ELIX; SOLN dexamethasone TABS dexamethasone sodium phosphate fludrocortisone acetate TABS hydrocortisone TABS methylpr ace inj 40mg/ml methylpr ace inj 80mg/ml methylpr ss inj 1gm methylpr ss inj 40mg methylpr ss inj 125 mg methylpred pak 4mg methylpred tab 4mg methylpred tab 8mg methylpred tab 16mg methylpred tab 32mg prednisolone sol 15mg/5ml prednisolone syp 15mg/5ml prednisone con 5mg/ml prednisone pak 5mg prednisone pak 10mg prednisone sol 5mg/5ml prednisone tab 1mg prednisone tab 2.5mg prednisone tab 5mg prednisone tab 10mg prednisone tab 20mg prednisone tab 50mg SOLU-CORTEF 250mg

2 4 3 2 2 2 3 2 2 3 3 3 3 3 3 3 3 2 1 3 2 2 3 1 1 1 1 1 1 4

B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

B/D B/D B/D B/D B/D B/D B/D

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT KORLYM PROGLYCEM SUS 50MG/ML

3 3 5 4

NM, LA, PA

HUMAN GROWTH HORMONES NORDITROPIN FLEXPRO

5

NM, PA

MISCELLANEOUS cabergoline

4

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37

Drug Name (Nombre del medicamento) calcitonin (salmon) FORTICAL INCRELEX MIACALCIN 200unit/ml octreotide acetate 50mcg/ml, 100mcg/ml octreotide acetate 200mcg/ml, 500mcg/ml, 1000mcg/ml PROLIA raloxifene tab 60mg SIGNIFOR SOMATULINE DEPOT SOMAVERT XGEVA

Drug Tier (Nivel de medicamento) 3 3 5 5 4

Requirements/Limits (Requisitos/Limites)

5

NM, PA

4

QL (1 syringe / 180 days), NM

3 5 5 5 5

NM, LA, PA B/D NM, PA

NM, NM, NM, NM,

LA, PA PA LA, PA PA

PARATHYROID HORMONES FORTEO

5

NATPARA

5

QL (1 pen / 28 days), NM, PA NM, PA

PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) RENVELA PAK RENVELA TAB 800MG

3 5 5

PROGESTINS medroxyprogesterone acetate tab norethindrone acetate TABS

1 3

THYROID AGENTS levothyroxine sodium TABS LEVOXYL liothyronine sodium TABS methimazole TABS propylthiouracil TABS SYNTHROID UNITHROID

2 2 3 2 3 4 2

VASOPRESSINS desmopressin acetate spray desmopressin acetate spray refrigerated desmopressin acetate tabs desmopressin inj 4mcg/ml DESMOPRESSIN SOL 0.01%

4 4 3 4 4

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38

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento)

GASTROINTESTINAL ANTIEMETICS compro supp dronabinol 2.5mg, 5mg

4 4

dronabinol

5

10mg

EMEND SUSR EMEND CAP 40MG EMEND CAP 80MG EMEND CAP 125MG EMEND PAK 80 & 125 granisetron hcl SOLN granisetron hcl TABS meclizine hcl TABS metoclopramide hcl SOLN metoclopramide hcl TABS metoclopramide inj ondansetron hcl TABS ondansetron hcl inj ondansetron hcl oral soln ondansetron odt phenadoz

4 4 4 4 4 3 4 2 2 1 2 3 3 4 2 4

prochlorperazine inj 3 prochlorperazine maleate TABS 1 prochlorperazine supp 4 promethazine hcl SOLN; SUPP; SYRP; 4 TABS promethegan 4 TRANSDERM-SCOP

4

B/D, QL (60 caps / 30 days) B/D, QL (60 caps / 30 days) B/D B/D B/D B/D B/D B/D

B/D B/D B/D PA; PA if 65 years and older

PA; PA if 65 years and older PA; PA if 65 years and older QL (10 patches / 30 days), PA; PA if 65 years and older

ANTISPASMODICS dicyclomine hcl CAPS dicyclomine hcl SOLN 10mg/5ml dicyclomine hcl TABS glycopyrrolate TABS glycopyrrolate inj

1 3 1 3 4

H2-RECEPTOR ANTAGONISTS You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

39

Drug Name (Nombre del medicamento) famotidine TABS 20mg, 40mg famotidine inj ranitidine hcl SOLN ranitidine hcl TABS 150mg, 300mg ranitidine hcl inj ranitidine syrup

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 1 2 2 1 3 3

INFLAMMATORY BOWEL DISEASE APRISO ASACOL HD balsalazide disodium budesonide ec CANASA colocort DELZICOL DIPENTUM HYDROCORTISONE (INTRARECTAL) mesalamine enema mesalamine w/ cleanser sulfasalazine TABS sulfasalazine ec UCERIS TB24

3 4 4 5 5 4 4 5 4 4 4 3 3 5

LAXATIVES gavilyte-h 2 generlac 2 GOLYTELY 3 lactulose 2 lactulose (encephalopathy) 2 MOVIPREP 4 NULYTELY/FLAVOR PACKS 3 peg 3350-kcl-sod bicarb-sod 2 chloride-sod sulfate PEG 3350-KCL-SOD BICARB-SOD 2 CHLORIDE-SOD SULFATE peg 3350-potassium chloride-sod 2 bicarbonate-sod chloride PEG 3350/ELECTROLYTES 2 polyethylene glycol 3350 PACK; POWD2 RELISTOR SOLN 5 SUPREP BOWEL PREP 4

PA

MISCELLANEOUS alosetron hcl

5

PA

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40

Drug Name (Nombre del medicamento) AMITIZA CAP 8MCG AMITIZA CAP 24MCG cromolyn sodium (mastocytosis) diphenoxylate w/ atropine GATTEX LINZESS 145mcg LINZESS 290mcg loperamide hcl CAPS misoprostol TABS MOVANTIK 12.5mg MOVANTIK 25mg sucralfate TABS ursodiol CAPS; TABS XIFAXAN 550mg

Drug Tier (Nivel de medicamento) 3 3 5 3 5 3 3 2 3 3 3 3 4 5

Requirements/Limits (Requisitos/Limites) QL (60 caps / 30 days) QL (60 caps / 30 days)

NM, LA, PA QL (60 caps / 30 days) QL (30 caps / 30 days)

QL (60 tabs / 30 days) QL (30 tabs / 30 days)

PA

PANCREATIC ENZYMES CREON ZENPEP

3 4

PROTON PUMP INHIBITORS DEXILANT esomeprazole magnesium esomeprazole sodium inj NEXIUM CAP 20MG NEXIUM CAP 40MG NEXIUM GRA 2.5MG DR NEXIUM GRA 5MG DR NEXIUM GRA 10MG DR

3 3 4 3 3 3 3 3

NEXIUM GRA 20MG DR

3

NEXIUM GRA 40MG DR

3

omeprazole CPDR 10mg, 40mg omeprazole CPDR 20mg pantoprazole sodium tbec

1 1 2

QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days)

QL (30 days) QL (30 days) QL (30 days) QL (30 QL (60 QL (30

packets / 30 packets / 30 packets / 30 caps / 30 days) caps / 30 days) tabs / 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl dutasteride dutasteride-tamsulosin hcl finasteride TABS 5mg tamsulosin hcl

2 4 4 2 3

QL (30 tabs / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days)

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41

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento)

MISCELLANEOUS bethanechol chloride TABS ELMIRON POTASSIUM CITRATE (ALKALINIZER) 540mg, 1080mg

3 4 4

URINARY ANTISPASMODICS MYRBETRIQ 25mg 4 MYRBETRIQ 50mg 4 oxybutynin chloride SYRP 1 oxybutynin chloride TABS 3 oxybutynin chloride TB24 5mg 3 oxybutynin chloride TB24 10mg, 15mg3 tolterodine tartrate CP24 4 tolterodine tartrate TABS 4 TOVIAZ 3 VESICARE 4

QL (60 tabs / 30 days) QL (30 tabs / 30 days)

QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 caps / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days)

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal metronidazole vaginal terconazole vaginal CREA terconazole vaginal SUPP VANDAZOLE ZAZOLE CRE 0.8%

4 3 3 4 3 3

HEMATOLOGIC ANTICOAGULANTS COUMADIN ELIQUIS enoxaparin sodium 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml enoxaparin sodium 100mg/ml, 120mg/0.8ml, 150mg/ml fondaparinux sodium 2.5mg/0.5ml fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml HEPARIN SOD (PORCINE) IN D5W heparin sod inj 1000/ml HEPARIN SOD INJ 2000/ML HEPARIN SOD INJ 2500/ML heparin sod inj 5000/ml heparin sod inj 10000/ml

4 3 4 5 4 5 3 3 3 3 3 3

B/D B/D B/D B/D B/D

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42

Drug Name (Nombre del medicamento) heparin sod inj 20000/ml HEPARIN SODIUM/D5W HEPARIN SODIUM/NACL 0.45% PRADAXA warfarin sodium XARELTO XARELTO STARTER PACK

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 3 B/D 3 3 3 1 3 3

HEMATOPOIETIC GROWTH FACTORS GRANIX 5 LEUKINE 5 MOZOBIL 5 NEUMEGA 5 NEUPOGEN 5 PROCRIT 2000unit/ml, 3000unit/ml, 3 4000unit/ml, 10000unit/ml PROCRIT 20000unit/ml, 40000unit/ml 5

NM, NM, NM, NM NM, NM,

PA PA PA PA PA

NM, PA

MISCELLANEOUS anagrelide hcl cilostazol CINRYZE FIRAZYR pentoxifylline TBCR PROMACTA 12.5mg

4 2 5 5 3 5

PROMACTA

25mg

5

PROMACTA

50mg

5

PROMACTA

75mg

5

tranexamic acid SOLN tranexamic acid TABS

NM, LA, PA NM, PA QL (360 tabs / 30 days), NM, LA, PA QL (180 tabs / 30 days), NM, LA, PA QL (90 tabs / 30 days), NM, LA, PA QL (60 tabs / 30 days), NM, LA, PA

3 4

PLATELET AGGREGATION INHIBITORS AGGRENOX ASPIRIN-DIPYRIDAMOLE BRILINTA clopidogrel tab 75mg EFFIENT ZONTIVITY

4 4 3 2 4 4

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

43

Drug Name (Nombre del medicamento) CIMZIA CIMZIA STARTER KIT HUMIRA INJ 10MG/0.2ML HUMIRA KIT 20MG/0.4ML HUMIRA KIT 40MG/0.8ML HUMIRA PEDIATRIC CROHNS HUMIRA PEN HUMIRA PEN-CROHNS DISEASE HUMIRA PEN-PSORIASIS STAR hydroxychloroquine sulfate leflunomide TABS methotrexate sodium tabs REMICADE

Drug Tier (Nivel de medicamento) 5 5 5 5 5 5 5 5 5 4 3 3 5

Requirements/Limits (Requisitos/Limites)

5 5 5 5 3 5 5 5 5

NM, PA NM, PA NM, PA NM, PA B/D, NM NM, PA NM, PA NM, PA NM, PA

5 5

NM, PA NM, PA

5

NM, PA

5 5 5 5 5 5 5 5

NM, LA, PA NM, PA B/D, NM B/D, NM B/D, NM B/D, NM NM, LA, PA NM, PA

4 3

B/D B/D

NM, NM, NM, NM, NM, NM, NM, NM, NM,

PA PA PA PA PA PA PA PA PA

NM, PA

IMMUNOGLOBULINS BIVIGAM CARIMUNE NANOFILTERED FLEBOGAMMA FLEBOGAMMA DIF GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 10gm/200ml GAMUNEX-C OCTAGAM 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml PRIVIGEN

IMMUNOMODULATORS ACTIMMUNE ARCALYST INTRON-A INJ INTRON-A INJ INTRON-A INJ INTRON-A INJ REVLIMID THALOMID

10MU 18MU 25MU 50MU

IMMUNOSUPPRESSANTS azathioprine azathioprine

SOLR TABS

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44

Drug Name (Nombre del medicamento) BENLYSTA cyclosporine CAPS cyclosporine modified (for microemulsion) mycophenolate mofetil CAPS; TABS mycophenolate mofetil SUSR mycophenolate sodium 180mg mycophenolate sodium 360mg NEORAL NULOJIX PROGRAF CAPS 5mg PROGRAF CAPS .5mg, 1mg RAPAMUNE SOLN SANDIMMUNE SOLN 100mg/ml SIROLIMUS TABS 2mg sirolimus TABS .5mg, 1mg tacrolimus CAPS 5mg tacrolimus CAPS .5mg, 1mg ZORTRESS TAB 0.5MG ZORTRESS TAB 0.25MG ZORTRESS TAB 0.75MG

Drug Tier (Nivel de medicamento) 5 4 3

Requirements/Limits (Requisitos/Limites)

4 5 4 5 3 5 5 4 5 3 5 4 5 4 5 4 5

B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

NM, PA B/D B/D

VACCINES ACTHIB ADACEL BCG VACCINE BEXSERO BOOSTRIX CERVARIX COMVAX DAPTACEL DIPHTHERIA/TETANUS TOXOID ENGERIX-B SUSP GARDASIL GARDASIL 9 HAVRIX HIBERIX IMOVAX RABIES (H.D.C.V.) INFANRIX IPOL INACTIVATED IPV IXIARO KINRIX

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

B/D B/D

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45

Drug Name (Nombre del medicamento) M-M-R II MENACTRA MENHIBRIX MENOMUNE-A/C/Y/W-135 MENVEO PEDIARIX PEDVAX HIB PENTACEL PROQUAD QUADRACEL RABAVERT RECOMBIVAX HB ROTARIX ROTATEQ SYNAGIS TENIVAC TETANUS/DIPHTHERIA TOXOID TRUMENBA TWINRIX INJ TYPHIM VI VAQTA VARIVAX YF-VAX ZOSTAVAX

Drug Tier (Nivel de medicamento) 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 3 3 3 3 3 3 3 3 3

Requirements/Limits (Requisitos/Limites)

B/D

NM B/D B/D

QL (1 vial per lifetime)

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES KLOR-CON 8 KLOR-CON 10 klor-con m10 klor-con m15 klor-con m20 klor-con pow 20meq klor-con spr cap 8meq klor-con spr cap 10meq MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml magnesium sulfate SOLN 2gm/50ml, 50% MAGNESIUM SULFATE SOLN 50% MAGNESIUM SULFATE IN D5W

3 3 2 2 2 4 3 3 3 2 2 3

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46

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 3 3

potassium chloride CPCR POTASSIUM CHLORIDE SOLN 10%, 20% potassium chloride TBCR 8meq 3 POTASSIUM CHLORIDE TBCR 20meq 3 potassium chloride microencapsulated 2 crystals cr POTASSIUM CHLORIDE TAB CR 10 MEQ3 SODIUM CHLORIDE SOLN 2.5meq/ml 2 SODIUM FLUORIDE CHEW; TAB; 1.1 2 (0.5 F) MG/ML SOLN TPN ELECTROLYTES 4

B/D

IV NUTRITION AMINOSYN AMINOSYN 7%/ELECTROLYTES AMINOSYN 8.5%/ELECTROLYTE AMINOSYN II AMINOSYN II 8.5%/ELECTROL AMINOSYN M AMINOSYN-HBC AMINOSYN-PF 7% AMINOSYN-PF INJ 10% AMINOSYN-RF CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 25% CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINIMIX INJ 4.25/D10 CLINIMIX INJ 4.25/D20 FREAMINE HBC 6.9% FREAMINE III HEPATAMINE INTRALIPID INJ 20% INTRALIPID INJ 30% NEPHRAMINE NUTRILIPID INJ 20% premasol 6% premasol 10% PROCALAMINE

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 2 4 4

B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

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47

Drug Name (Nombre del medicamento) PROSOL TRAVASOL TROPHAMINE INJ 10%

Drug Tier (Nivel de medicamento) 4 4 4

Requirements/Limits (Requisitos/Limites) B/D B/D B/D

IV REPLACEMENT SOLUTIONS DEXTROSE 2.5%/NACL 0.45% DEXTROSE 5% DEXTROSE 5% /ELECTROLYTE DEXTROSE 5%/LACTATED RING DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.3% DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/POTASSIUM CHL DEXTROSE 10% FLEX CONTAIN DEXTROSE 10%/NACL 0.2% DEXTROSE 10%/NACL 0.45% DEXTROSE 50% DEXTROSE INJ 70% ISOLYTE P ISOLYTE S KCL0.15%/D5W/NACL0.2% KCL0.15%/D5W/NACL0.225% KCL 0.3%/D5W/NACL 0.9% KCL 0.3%/D5W/NACL 0.45% KCL 0.15%/D5W/NACL 0.9% KCL 0.075%/D5W/NACL 0.45% KCL IN NACL INJ .15-0.45 KCL/D5W INJ 0.3% KCL/D5W/NACL INJ 0.22%/0.45% KCL/D5W/NACL INJ .15/.33% KCL/D5W/NACL INJ .15/.45% KCL/NACL INJ 0.3-0.9 KCL/NACL INJ 0.15%-0.9% LACTATED RINGER'S INJ NORMOSOL-M IN D5W NORMOSOL-R NORMOSOL-R IN D5W PLASMA-LYTE A PLASMA-LYTE-56/D5W

2 2 3 2 2 2 2 2 2 2 2 2 3 2 2 2 4 4 2 3 2 2 2 2 2 2 2 2 2 2 2 2 4 4 4 4 4

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48

Drug Name (Nombre del medicamento) PLASMA-LYTE-148 pot chloride inj 2meq/ml POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml potassium chloride in nacl RINGER'S SODIUM CHLORIDE SOLN 3%, 5% SODIUM CHLORIDE 0.45% VIA SODIUM CHLORIDE INJ 0.9%

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 4 2 2

2 2 2 2 2

VITAMINS calcitriol CAPS calcitriol inj calcitriol oral soln 1 mcg/ml paricalcitol CAPS PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

3 4 4 4 2

B/D B/D B/D B/D

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc blephamide s.o.p. neomycin-polymy-dexameth sulfacetamide sod-prednisolone TOBRADEX OINT TOBRADEX ST tobramycin-dexamethasone ZYLET

3 4 2 2 3 3 4 3

ANTI-INFECTIVES bacitracin (ophthalmic) bacitracin-polymyxin b (ophth) BESIVANCE CILOXAN OINT ciprofloxacin hcl (ophth) erythromycin (ophth) gentamicin sulfate (ophth) MOXEZA NATACYN neomycin-bacitracin zn-polymyxin neomycin-polymyxin-gramicidin ofloxacin (ophth)

3 2 3 3 2 2 2 3 4 3 3 2

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49

Drug Name (Nombre del medicamento) polymyxin b-trimethoprim sulfacet sod oin 10% op sulfacetamide sodium (ophth) tobramycin (ophth) trifluridine SOLN VIGAMOX ZIRGAN

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 2 3 3 2 4 3 4

ANTI-INFLAMMATORIES ALREX 3 bromfenac sodium (ophth) 4 BROMFENAC SODIUM 4 (OPHTH)(ONCE-DAILY) dexamethasone sodium phosphate 2 (ophth) diclofenac sodium (ophth) 2 DUREZOL 3 FLUOROMETHOLONE 3 flurbiprofen sodium 2 ILEVRO 3 ketorolac tromethamine (ophth) 3 LOTEMAX 3 PREDNISOLONE ACETATE (OPHTH) 3 prednisolone sodium phosphate (ophth)3

ANTIALLERGICS azelastine drop 0.05% BEPREVE cromolyn sodium (ophth) LASTACAFT PATADAY PAZEO

3 3 2 4 3 3

ANTIGLAUCOMA ALPHAGAN P SOL 0.1% AZOPT betaxolol hcl (ophth) BETOPTIC-S brimonidine sol 0.2% BRIMONIDINE SOL 0.15% carteolol hcl (ophth) COMBIGAN dorzolamide hcl dorzolamide hcl-timolol maleate

3 3 3 3 2 3 2 3 3 3

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50

Drug Name (Nombre del medicamento)

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 3 2 3 3 3 4 3 3 1 4 3

ISTALOL latanoprost SOLN levobunolol hcl LUMIGAN metipranolol PHOSPHOLINE IODIDE PILOCARPINE HCL SOLN SIMBRINZA timolol maleate (ophth) TIMOLOL MALEATE GEL TRAVATAN Z

MISCELLANEOUS naphazoline hcl SOLN PROLENSA proparacaine hcl SOLN RESTASIS

1 3 2 3

QL (64 vials / 30 days)

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA

3

COMBIVENT RESPIMAT ipratropium-albuterol nebu

4 3

QL (60 inhalations / 30 days) QL (2 inhalers / 30 days) B/D

ANTICHOLINERGICS ATROVENT HFA INCRUSE ELLIPTA ipratropium bromide SOLN ipratropium bromide (nasal)

4 3 2 3

QL (2 inhalers / 30 days) QL (1 inhaler / 30 days) B/D

ANTIHISTAMINES ASTEPRO azelastine spr 0.1% azelastine spr 0.15% cetirizine syrup diphenhydramine hcl inj hydroxyzine hcl SOLN levocetirizine dihydrochloride levocetirizine dihydrochloride olopatadine hcl (nasal)

3 3 3 3 2 4 SOLN TABS

PA; PA if 65 years and older

4 3 4

BETA AGONISTS albuterol sulfate

NEBU

2

B/D

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51

Drug Name (Nombre del medicamento) albuterol sulfate SYRP albuterol sulfate TABS PERFOROMIST SEREVENT DISKUS

Drug Tier (Nivel de medicamento) 1 4 4 3

terbutaline sulfate terbutaline sulfate VENTOLIN HFA XOPENEX HFA

5 3 3 3

SOLN TABS

Requirements/Limits (Requisitos/Limites)

B/D QL (60 inhalations / 30 days)

QL (2 inhalers / 30 days) QL (2 inhalers / 30 days)

LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW; TABS montelukast sodium PACK zafirlukast

3 4 4

MAST CELL STABILIZERS cromolyn sod neb 20mg/2ml

3

B/D

3 5 4 3 3 5 5 5 5 5 5 5 5

B/D NM, LA, PA

3 2 3 3

QL QL QL QL

ARNUITY ELLIPTA

3

budesonide (inhalation) .25mg/2ml, .5mg/2ml FLOVENT DISKUS 50mcg/blist, 100mcg/blist

4

QL (30 inhalations / 30 days) B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20% ARALAST NP DALIRESP EPIPEN 2-PAK EPIPEN-JR 2-PAK ESBRIET KALYDECO OFEV ORKAMBI PROLASTIN-C PULMOZYME XOLAIR ZEMAIRA

NM, PA NM, PA NM, PA NM, PA NM, LA, PA B/D, NM NM, LA, PA NM, LA, PA

NASAL STEROIDS flunisolide (nasal) fluticasone propionate (nasal) mometasone furoate (nasal) NASONEX

(2 (1 (2 (2

bottles / 30 days) bottle / 30 days) bottles / 30 days) inhalers / 30 days)

STEROID INHALANTS

3

QL (120 inhalations / 30 days)

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52

Drug Name (Nombre del medicamento) FLOVENT DISKUS

250mcg/blist

FLOVENT HFA PULMICORT FLEXHALER

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 3 QL (240 inhalations / 30 days) 3 QL (2 inhalers / 30 days) 3 QL (2 inhalers / 30 days)

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS

3

ADVAIR HFA BREO ELLIPTA SYMBICORT

3 3 3

QL (60 inhalations / 30 days) QL (1 inhaler / 30 days) QL (60 blisters / 30 days) QL (1 inhaler / 30 days)

XANTHINES aminophylline inj theophylline TB12; TB24

3 3

TOPICAL DERMATOLOGY, ACNE amnesteem 4 AVITA 4 clindamycin phosphate (topical) GEL; 4 LOTN clindamycin phosphate (topical) SOLN 3 erythromycin (acne aid) GEL; SOLN 3 isotretinoin CAPS 4 sulfacetamide sodium (acne) 3 tretinoin CREA 4 TRETINOIN GEL .01% 4 tretinoin GEL .025% 4

DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) mupirocin OINT SILVER SULFADIAZINE CREA SSD SULFAMYLON CREA SULFAMYLON PACK

3 2 2 2 4 5

DERMATOLOGY, ANTIFUNGALS clotrimazole (topical) CREA econazole nitrate CREA ketoconazole cream nystatin (topical)

3 4 3 3

DERMATOLOGY, ANTIPRURITIC DOXEPIN HCL (ANTIPRURITIC)

4

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53

Drug Name (Nombre del medicamento) hydrocortisone (rectal) procto-pak cre 1% proctosol hc cre 2.5% proctozone cre -hc 2.5% PRUDOXIN CRE 5%

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 2 2 2 2 4

DERMATOLOGY, ANTIPSORIATICS acitretin calcipotriene CREA; OINT; SOLN calcitrene oin 0.005% 8-MOP TAZORAC CREA

5 4 4 4 4

PA

PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo selenium sulfide LOTN

2 2

DERMATOLOGY, CORTICOSTEROIDS alclometasone dipropionate 3 betamethasone dipropionate (topical) 3 CREA; LOTN betamethasone dipropionate (topical) 4 OINT betamethasone dipropionate 3 augmented CREA betamethasone dipropionate 4 augmented GEL; LOTN; OINT betamethasone valerate CREA; LOTN; 3 OINT clobetasol e cream 0.05% 4 clobetasol propionate CREA 4 clobetasol propionate GEL 4 clobetasol propionate OINT 4 clobetasol propionate SOLN 4 fluocinolone acetonide SOLN 4 fluocinonide CREA .05% 4 fluocinonide GEL 3 fluocinonide OINT 4 fluocinonide SOLN 4 fluocinonide-e 0.05% cream 4 fluticasone propionate CREA 2 fluticasone propionate OINT 2 hydrocortisone (topical) CREA; OINT 1 hydrocortisone (topical) LOTN 3 You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

54

Drug Name (Nombre del medicamento) hydrocortisone butyrate mometasone furoate CREA; OINT; SOLN triamcinolone acetonide (topical) CREA; OINT triamcinolone acetonide (topical) LOTN

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 4 3 2 3

DERMATOLOGY, LOCAL ANESTHETICS lidocaine PTCH

4

lidocaine hcl GEL lidocaine hcl SOLN 4% lidocaine oint 5% lidocaine-prilocaine

2 1 4 3

QL (3 patches / 1 day), PA

B/D

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical ammonium lactate CREA ammonium lactate LOTN diclofenac sodium (topical) 1% gel ELIDEL fluorouracil (topical) CREA 5% fluorouracil (topical) SOLN imiquimod CREA metronidazole (topical) CREA metronidazole gel 0.75% PANRETIN podofilox SOLN rosadan cre 0.75% tacrolimus (topical) TARGRETIN GEL VALCHLOR VOLTAREN

4 3 2 3 4 4 4 4 4 4 5 3 4 4 5 5 3

PA

PA NM, PA NM, LA, PA

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX malathion permethrin

4 4 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% REGRANEX SANTYL SODIUM CHLORIDE 0.9%

2 5 4 1

PA

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

55

Drug Name (Nombre del medicamento) STERILE WATER IRRIGATION

Drug Tier Requirements/Limits (Nivel de (Requisitos/Limites) medicamento) 3

MOUTH/THROAT/DENTAL AGENTS chlorhexidine gluconate (mouth-throat) 1 clotrimazole TROC 4 lidocaine hcl (mouth-throat) 1 nystatin (mouth-throat) 3 paroex sol 0.12% 1 PILOCARPINE HCL (ORAL) 5mg 4 pilocarpine hcl (oral) 7.5mg 4 triamcinolone acetonide (mouth) 3

OTIC acetic acid (otic) acetic acid-aluminum acetate CIPRODEX neomycin-polymyxin-hc (otic) ofloxacin (otic)

3 3 3 2 2

You can find information on what the symbols and abbreviations on this table mean by reviewing the LIST OF ABBREVIATIONS page. Usted puede encontrar información sobre lo que los símbolos y abreviaturas en esta tabla significan revisando la lista de la página ABREVIATURAS.

56

Index 8 8-MOP .............................................54 A abacavir sulfate ................................. 5 abacavir sulfate-lamivudine-zidovudine 6 ABELCET ........................................... 5 ABILIFY DISCMELT TAB 10MG ............26 ABILIFY MAINTENA ...........................26 ABRAXANE .......................................11 acamprosate calcium .........................32 acarbose ..........................................33 acebutolol hcl ...................................17 acetaminophen w/ codeine .................. 1 acetazolamide ..................................18 acetic acid........................................55 acetic acid (otic) ...............................56 acetic acid-aluminum acetate .............56 acetylcysteine ..................................52 acitretin ...........................................54 ACTHIB ...........................................45 ACTIMMUNE .....................................44 acyclovir ........................................... 7 acyclovir sodium ................................ 7 acyclovir topical ................................55 ADACEL ...........................................45 ADAGEN ..........................................36 adefovir dipivoxil ............................... 7 ADEMPAS.........................................19 adrucil inj ........................................10 ADVAIR DISKUS ...............................53 ADVAIR HFA .....................................53 AFINITOR ........................................12 AFINITOR DISPERZ ...........................12 AGGRENOX ......................................43 a-hydrocort ......................................37 ALBENZA .......................................... 3 albuterol sulfate.......................... 51, 52 alclometasone dipropionate ................54 ALCOHOL SWABS .............................32 ALDURAZYME ...................................36 ALECENSA .......................................12 alendronate sodium ..........................34 alfuzosin hcl .....................................41 ALIMTA ............................................10

ALINIA .............................................. 4 allopurinol tab.................................... 1 alosetron hcl .................................... 40 ALPHAGAN P SOL 0.1%..................... 50 alprazolam tab 0.25mg ..................... 20 alprazolam tab 0.5mg ....................... 20 alprazolam tab 1mg .......................... 20 alprazolam tab 2 mg ......................... 20 ALREX ............................................ 50 amantadine hcl ................................ 26 AMBISOME ........................................ 5 amifostine crystalline ........................ 13 amikacin sulfate ................................. 3 amiloride & hydrochlorothiazide ......... 18 amiloride hcl .................................... 18 aminophylline inj .............................. 53 AMINOSYN ...................................... 47 AMINOSYN 7%/ELECTROLYTES .......... 47 AMINOSYN 8.5%/ELECTROLYTE ......... 47 AMINOSYN II ................................... 47 AMINOSYN II 8.5%/ELECTROL ........... 47 AMINOSYN M ................................... 47 AMINOSYN-HBC ............................... 47 AMINOSYN-PF 7% ............................ 47 AMINOSYN-PF INJ 10% ..................... 47 AMINOSYN-RF ................................. 47 amiodarone hcl ................................ 16 AMITIZA CAP 24MCG ........................ 41 AMITIZA CAP 8MCG .......................... 41 amitriptyline hcl ............................... 24 amlodipine besylate .......................... 17 amlodipine besylate-valsartan tab 10-160 mg ................................................. 15 amlodipine besylate-valsartan tab 10-320 mg ................................................. 15 amlodipine besylate-valsartan tab 5-160 mg ................................................. 14 amlodipine besylate-valsartan tab 5-320 mg ................................................. 15 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg ............................... 15 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg .................................. 15 amlodipine-valsartan-hydrochlorothiazide 57

10-320-25mg ...................................15 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ..................................15 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg .....................................15 ammonium lactate ............................55 amnesteem ......................................53 amoxapine .......................................24 amoxicillin ........................................ 9 amoxicillin & pot clavulanate ............... 9 amphetamine-dextroamphetamine cap sr 24hr 10 mg ......................................29 amphetamine-dextroamphetamine cap sr 24hr 15 mg ......................................29 amphetamine-dextroamphetamine cap sr 24hr 20 mg ......................................29 amphetamine-dextroamphetamine cap sr 24hr 25 mg ......................................29 amphetamine-dextroamphetamine cap sr 24hr 30 mg ......................................29 amphetamine-dextroamphetamine cap sr 24hr 5 mg........................................29 amphetamine-dextroamphetamine tab 10 mg ..................................................29 amphetamine-dextroamphetamine tab 12.5 mg ..........................................29 amphetamine-dextroamphetamine tab 15 mg ..................................................29 amphetamine-dextroamphetamine tab 20 mg ..................................................29 amphetamine-dextroamphetamine tab 30 mg ..................................................29 amphetamine-dextroamphetamine tab 5 mg ..................................................29 amphetamine-dextroamphetamine tab 7.5 mg ............................................29 amphotericin b .................................. 5 ampicillin .......................................... 9 ampicillin & sulbactam sodium ............. 9 ampicillin inj ...................................... 9 ampicillin sodium ..............................10 AMPYRA ...........................................31 anagrelide hcl ...................................43 anastrozole ......................................11 ANDRODERM ....................................32 ANORO ELLIPTA ................................51

APOKYN .......................................... 26 APRISO ........................................... 40 APTIOM........................................... 20 APTIVUS ........................................... 5 ARALAST NP .................................... 52 ARCALYST ....................................... 44 aripiprazole ..................................... 26 aripiprazole oral solution 1 mg/ml ...... 26 aripiprazole tabs .............................. 26 armodafinil ...................................... 31 ARMODAFINIL.................................. 31 ARNUITY ELLIPTA ............................. 52 ASACOL HD ..................................... 40 ASPIRIN-DIPYRIDAMOLE ................... 43 ASTEPRO ........................................ 51 atenolol .......................................... 17 atenolol & chlorthalidone ................... 17 atorvastatin calcium ......................... 16 atovaquone ....................................... 4 atovaquone-proguanil hcl .................... 5 ATRIPLA ............................................ 6 ATROVENT HFA ................................ 51 AVASTIN ......................................... 11 AVITA ............................................. 53 AXIRON .......................................... 32 azacitidine ....................................... 10 azathioprine .................................... 44 azelastine drop 0.05% ...................... 50 azelastine spr 0.1% .......................... 51 azelastine spr 0.15% ........................ 51 AZILECT.......................................... 26 azithromycin ...................................... 9 AZITHROMYCIN ................................. 9 AZOPT ............................................ 50 AZOR 10-40MG ................................ 15 AZOR TAB 10-20MG ......................... 15 AZOR TAB 5-20MG ........................... 15 AZOR TAB 5-40MG ........................... 15 aztreonam ......................................... 4 B bacitracin (ophthalmic) ..................... 49 bacitracin-polymyxin b (ophth) .......... 49 bacitracin-poly-neomycin-hc .............. 49 baclofen .......................................... 31 balsalazide disodium ......................... 40 BANZEL SUS 40MG/ML ..................... 20 58

BANZEL TAB 200MG ..........................21 BANZEL TAB 400MG ..........................21 BARACLUDE ...................................... 7 BCG VACCINE...................................45 BELEODAQ .......................................11 benazepril & hydrochlorothiazide ........14 benazepril hcl ...................................14 BENICAR..........................................15 BENICAR HCT 40-25MG .....................15 BENICAR HCT TAB 20-12.5MG ............15 BENICAR HCT TAB 40-12.5MG ............15 BENLYSTA ........................................45 benztropine mesylate ........................26 BENZTROPINE MESYLATE ..................26 BEPREVE..........................................50 BESIVANCE ......................................49 betamethasone dipropionate (topical)..54 betamethasone dipropionate augmented ......................................................54 betamethasone valerate ....................54 BETASERON .....................................31 betaxolol hcl (ophth) .........................50 bethanechol chloride .........................42 BETOPTIC-S .....................................50 bexarotene ......................................13 BEXSERO .........................................45 bicalutamide ....................................11 BICILLIN L-A ....................................10 BILTRICIDE ....................................... 4 bisoprolol & hydrochlorothiazide .........17 BIVIGAM ..........................................44 bleomycin sulfate ..............................10 blephamide s.o.p. .............................49 BOOSTRIX .......................................45 BOSULIF ..........................................12 BREO ELLIPTA ..................................53 BRILINTA .........................................43 BRIMONIDINE SOL 0.15% .................50 brimonidine sol 0.2% ........................50 BRINTELLIX .....................................24 BRIVIACT INJ ...................................21 BRIVIACT SOLN 10MG/ML ..................21 BRIVIACT TABS ................................21 bromfenac sodium (ophth) .................50 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) ......................50

bromocriptine mesylate..................... 26 budesonide (inhalation) .................... 52 budesonide ec.................................. 40 bumetanide inj 0.25/ml..................... 18 bumetanide tab................................ 18 buprenorphine hcl ............................ 32 buprenorphine hcl-naloxone hcl sl ...... 32 buproban tab (smoking deterrent) ...... 32 bupropion hcl................................... 24 bupropion hcl (smoking deterrent) ..... 32 buspirone hcl ................................... 20 BYDUREON ...................................... 32 BYDUREON PEN ............................... 32 BYETTA ........................................... 32 BYSTOLIC ....................................... 17 C cabergoline ..................................... 37 CABOMETYX .................................... 12 calcipotriene .................................... 54 calcitonin (salmon) ........................... 38 calcitrene oin 0.005% ....................... 54 calcitriol .......................................... 49 calcitriol inj ..................................... 49 calcitriol oral soln 1 mcg/ml ............... 49 calcium acetate (phosphate binder) .... 38 CANASA .......................................... 40 CANCIDAS......................................... 5 CAPASTAT SULFATE ........................... 7 CAPRELSA ....................................... 12 CARBAGLU ...................................... 36 carbamazepine ................................ 21 carbidopa-levodopa .......................... 26 CARIMUNE NANOFILTERED................ 44 carteolol hcl (ophth) ......................... 50 cartia xt cap 120/24hr ...................... 17 cartia xt cap 180/24hr ...................... 17 cartia xt cap 240/24hr ...................... 17 cartia xt cap 300/24hr ...................... 17 carvedilol ........................................ 17 CAYSTON .......................................... 4 cefaclor ............................................. 8 cefadroxil .......................................... 8 cefazolin in dextrose 1gm/50ml-5% ..... 8 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ................................. 8 cefazolin inj ....................................... 8 59

cefazolin sodium ................................ 8 cefdinir ............................................. 8 cefepime hcl ...................................... 8 cefixime ............................................ 8 cefoxitin sodium ................................ 8 cefpodoxime proxetil .......................... 8 ceftazidime ....................................... 8 ceftriaxone sodium ............................. 8 cefuroxime axetil ............................... 8 cefuroxime sodium ............................. 9 celecoxib .......................................... 1 CELONTIN ........................................21 cephalexin ........................................ 9 CERDELGA .......................................36 CEREZYME .......................................36 CERVARIX ........................................45 cetirizine syrup .................................51 CHANTIX .........................................32 CHANTIX CONTINUING MONTH ..........32 CHANTIX STARTER PACK ...................32 CHEMET ...........................................35 chlorhexidine gluconate (mouth-throat) ......................................................56 chloroquine phosphate ....................... 5 chlorothiazide tabs ............................18 chlorpromazine hcl ............................26 chlorpromazine inj ............................26 chlorthalidone ..................................18 cholestyramine .................................16 cholestyramine light ..........................16 cilostazol .........................................43 CILOXAN .........................................49 CIMZIA ............................................44 CIMZIA STARTER KIT ........................44 CINRYZE ..........................................43 CIPRODEX .......................................56 ciprofloxacin hcl (ophth) ....................49 ciprofloxacin hcl tab ........................... 9 ciprofloxacin in d5w ........................... 9 ciprofloxacin inj 200mg/20ml .............. 9 ciprofloxacin inj 400mg/40ml .............. 9 citalopram hydrobromide ...................24 clarithromycin ................................... 9 clarithromycin er................................ 9 clarithromycin for susp ....................... 9 clindamycin cap 300 mg ..................... 4

clindamycin cap 75mg ........................ 4 clindamycin hcl cap 150 mg ................. 4 clindamycin phosphate ........................ 4 clindamycin phosphate (topical) ......... 53 clindamycin phosphate in d5w ............. 4 clindamycin phosphate inj ................... 4 clindamycin phosphate vaginal ........... 42 clindamycin soln ................................ 4 CLINIMIX 2.75%/DEXTROSE 5% ........ 47 CLINIMIX 4.25%/DEXTROSE 25% ...... 47 CLINIMIX 4.25%/DEXTROSE 5% ........ 47 CLINIMIX 5%/DEXTROSE 15% .......... 47 CLINIMIX 5%/DEXTROSE 20% .......... 47 CLINIMIX 5%/DEXTROSE 25% .......... 47 CLINIMIX INJ 4.25/D10 .................... 47 CLINIMIX INJ 4.25/D20 .................... 47 clobetasol e cream 0.05% ................. 54 clobetasol propionate ........................ 54 clomipramine hcl .............................. 24 clonazepam ..................................... 21 clonidine hcl .................................... 19 clopidogrel tab 75mg ........................ 43 clorazepate dipotassium .................... 21 clotrimazole ..................................... 56 clotrimazole (topical) ........................ 53 clozapine ......................................... 26 CLOZAPINE ..................................... 26 clozapine tab 25mg .......................... 26 clozapine tab 50mg .......................... 26 COARTEM .......................................... 5 colchicine w/ probenecid ..................... 1 COLCRYS .......................................... 1 colestipol hcl.................................... 16 colistimethate sodium ......................... 4 colocort........................................... 40 COMBIGAN ...................................... 50 COMBIVENT RESPIMAT ..................... 51 COMETRIQ ...................................... 12 COMPLERA ........................................ 6 compro supp ................................... 39 COMVAX ......................................... 45 COPAXONE INJ 40MG/ML .................. 31 cortisone acetate.............................. 37 COTELLIC ........................................ 12 COUMADIN ...................................... 42 CREON ............................................ 41 60

CRESTOR .........................................16 CRIXIVAN ......................................... 5 cromolyn sod neb 20mg/2ml ..............52 cromolyn sodium (mastocytosis) .........41 cromolyn sodium (ophth) ...................50 cryselle-28 .......................................35 CUBICIN ........................................... 4 CYCLOPHOSPHAMIDE ........................10 cycloserine ........................................ 7 cyclosporine .....................................45 cyclosporine modified (for microemulsion) ......................................................45 CYSTADANE .....................................36 CYSTAGON.......................................36 D dacarbazine .....................................10 DAKLINZA ......................................... 7 DALIRESP ........................................52 danazol ...........................................36 dantrolene sodium ............................31 dapsone............................................ 4 DAPTACEL ........................................45 DARAPRIM ........................................ 4 DELESTROGEN .................................36 DELZICOL ........................................40 DEMSER ..........................................19 DEPEN TITRATABS ............................35 DESCOVY .......................................... 6 desipramine hcl ................................24 desmopressin acetate spray ...............38 desmopressin acetate spray refrigerated ......................................................38 desmopressin acetate tabs .................38 desmopressin inj 4mcg/ml .................38 DESMOPRESSIN SOL 0.01%...............38 desogestrel-ethinyl estradiol (triphasic) ......................................................35 dexamethasone ................................37 dexamethasone sodium phosphate .....37 dexamethasone sodium phosphate (ophth) ............................................50 DEXILANT ........................................41 DEXTROSE 10% FLEX CONTAIN..........48 DEXTROSE 10%/NACL 0.2% ..............48 DEXTROSE 10%/NACL 0.45% ............48 DEXTROSE 2.5%/NACL 0.45% ...........48

DEXTROSE 5% ................................ 48 DEXTROSE 5% /ELECTROLYTE ........... 48 DEXTROSE 5%/LACTATED RING ........ 48 DEXTROSE 5%/NACL 0.2% ............... 48 DEXTROSE 5%/NACL 0.225% ............ 48 DEXTROSE 5%/NACL 0.3% ............... 48 DEXTROSE 5%/NACL 0.33% ............. 48 DEXTROSE 5%/NACL 0.45% ............. 48 DEXTROSE 5%/NACL 0.9% ............... 48 DEXTROSE 5%/POTASSIUM CHL ........ 48 DEXTROSE 50% ............................... 48 DEXTROSE INJ 70% ......................... 48 diazepam ........................................ 21 DIAZEPAM GEL ................................ 21 diazepam inj .................................... 21 diclofenac potassium .......................... 1 diclofenac sodium............................... 1 diclofenac sodium (ophth) ................. 50 diclofenac sodium (topical) 1% gel ..... 55 dicloxacillin sodium .......................... 10 dicyclomine hcl ................................ 39 didanosine......................................... 5 diflunisal ........................................... 1 digox .............................................. 18 digoxin ........................................... 18 digoxin inj ....................................... 18 DIGOXIN SOL 50MCG/ML .................. 18 dihydroergotamine mesylate.............. 30 dilantin infatabs ............................... 21 DILANTIN-125 SUS 125/5ML ............. 21 diltiazem cap ................................... 17 diltiazem cap 120mg/24hr ................. 17 diltiazem cap 240mg/24hr ................. 18 diltiazem cap er/12hr........................ 18 diltiazem hcl .................................... 18 diltiazem hcl coated beads ................ 18 dilt-xr cap ....................................... 17 DIPENTUM ....................................... 40 diphenhydramine hcl inj .................... 51 diphenoxylate w/ atropine ................. 41 DIPHTHERIA/TETANUS TOXOID ......... 45 disopyramide phosphate ................... 16 disulfiram ........................................ 32 divalproex sodium ............................ 21 docetaxel ........................................ 11 DOCETAXEL ..................................... 11 61

DOCETAXEL SOLN 80MG/8ML .............11 dofetilide .........................................16 donepezil hydrochloride .....................23 dorzolamide hcl ................................50 dorzolamide hcl-timolol maleate .........50 doxazosin mesylate ...........................14 doxepin hcl ......................................24 DOXEPIN HCL (ANTIPRURITIC) ...........53 doxycycline (monohydrate) ................10 doxycycline hyclate ...........................10 dronabinol .......................................39 DROXIA ...........................................13 duloxetine hcl ...................................24 DURAMORPH ..................................... 1 DUREZOL .........................................50 dutasteride ......................................41 dutasteride-tamsulosin hcl .................41 E econazole nitrate ..............................53 EDURANT .......................................... 5 EFFIENT...........................................43 ELIDEL ............................................55 ELIQUIS ..........................................42 ELITEK ............................................13 ELLA ...............................................35 ELMIRON .........................................42 EMCYT .............................................10 EMEND ............................................39 EMEND CAP 125MG ...........................39 EMEND CAP 40MG .............................39 EMEND CAP 80MG .............................39 EMEND PAK 80 & 125 ........................39 EMSAM ............................................24 EMTRIVA .......................................... 6 emverm ............................................ 4 enalapril maleate ..............................14 enalapril maleate & hydrochlorothiazide ......................................................14 endocet 10/325 ................................. 1 endocet 5/325 ................................... 1 endocet 7.5/325 ................................ 1 ENGERIX-B ......................................45 enoxaparin sodium ............................42 ENTACAPONE ...................................26 entecavir .......................................... 7 ENTRESTO .......................................15

EPIPEN 2-PAK .................................. 52 EPIPEN-JR 2-PAK ............................. 52 EPIVIR HBV ....................................... 7 eplerenone ...................................... 14 EPZICOM........................................... 7 ERIVEDGE ....................................... 11 erythrocin lactobionate ....................... 9 erythromycin (acne aid) .................... 53 erythromycin (ophth) ....................... 49 erythromycin base.............................. 9 erythromycin cap 250mg ec ................ 9 erythromycin ethylsuccinate ................ 9 erythromycin stearate......................... 9 ESBRIET ......................................... 52 escitalopram oxalate......................... 24 esomeprazole magnesium ................. 41 esomeprazole sodium inj ................... 41 estarylla tab 0.25-35 ........................ 35 estrace ........................................... 36 estradiol.......................................... 36 estradiol valerate ............................. 36 ethambutol hcl ................................... 7 ethosuximide ................................... 21 ethynodiol diacet & eth estrad ........... 35 etoposide ........................................ 14 EURAX ............................................ 55 EVOTAZ ............................................ 7 EXELON PATCHES ............................ 23 exemestane..................................... 11 EXJADE ........................................... 35 F FABRAZYME..................................... 36 famciclovir ........................................ 7 famotidine ....................................... 40 famotidine inj .................................. 40 FANAPT ........................................... 27 FANAPT TITRATION PACK .................. 27 FARESTON ...................................... 11 FARXIGA ......................................... 33 FARYDAK ........................................ 11 FASLODEX ....................................... 11 FAZACLO......................................... 27 felbamate ........................................ 21 fenofibrate ...................................... 16 fenofibrate micronized ...................... 16 fentanyl citrate .................................. 1 62

fentanyl patch 100 mcg/hr .................. 2 fentanyl patch 12 mcg/hr .................... 2 fentanyl patch 25 mcg/hr .................... 2 fentanyl patch 50 mcg/hr .................... 2 fentanyl patch 75 mcg/hr .................... 2 FENTORA .......................................... 2 FERRIPROX ......................................35 FETZIMA ..........................................24 FETZIMA TITRATION PACK .................24 finasteride .......................................41 FIRAZYR ..........................................43 FLEBOGAMMA...................................44 FLEBOGAMMA DIF .............................44 flecainide acetate ..............................16 FLOVENT DISKUS ....................... 52, 53 FLOVENT HFA ...................................53 fluconazole........................................ 5 fluconazole in dextrose ....................... 5 fluconazole in nacl ............................. 5 fluconazole in nacl 0.9% inj................. 5 flucytosine ........................................ 5 fludrocortisone acetate ......................37 flunisolide (nasal) .............................52 fluocinolone acetonide .......................54 fluocinonide .....................................54 fluocinonide-e 0.05% cream ...............54 FLUOROMETHOLONE .........................50 fluorouracil.......................................10 fluorouracil (topical) ..........................55 fluoxetine cap 10mg ..........................24 fluoxetine cap 20mg ..........................24 fluoxetine cap 40mg ..........................24 fluoxetine hcl ...................................24 fluphenazine decanoate .....................27 fluphenazine hcl................................27 flurbiprofen ....................................... 1 flurbiprofen sodium ...........................50 flutamide .........................................11 fluticasone propionate .......................54 fluticasone propionate (nasal) ............52 fluvoxamine maleate .........................20 fondaparinux sodium .........................42 FORTEO ...........................................38 FORTICAL ........................................38 fosinopril sodium ..............................14 fosinopril sodium & hydrochlorothiazide

...................................................... 14 FREAMINE HBC 6.9% ........................ 47 FREAMINE III................................... 47 furosemide ................................. 18, 19 furosemide inj.................................. 19 FUROSEMIDE INJ ............................. 19 FUSILEV .......................................... 13 FUZEON ............................................ 6 fyavolv tab 1 mg-5 mcg .................... 36 FYCOMPA ................................... 21, 22 G gabapentin ...................................... 22 galantamine hydrobromide ................ 23 galantamine hydrobromide er ............ 23 GAMASTAN S/D ............................... 44 GAMMAGARD LIQUID........................ 44 GAMMAGARD S/D ............................ 44 GAMMAKED ..................................... 44 GAMMAPLEX .................................... 44 GAMUNEX-C .................................... 44 ganciclovir inj 500mg.......................... 8 GARDASIL ....................................... 45 GARDASIL 9 .................................... 45 GATTEX .......................................... 41 GAUZE PADS 2" X 2" ........................ 32 gavilyte-h........................................ 40 gemfibrozil ...................................... 16 generlac .......................................... 40 gentamicin in saline ............................ 3 gentamicin sulfate .............................. 3 gentamicin sulfate (ophth) ................ 49 gentamicin sulfate (topical) ............... 53 GENVOYA .......................................... 7 GEODON ......................................... 27 GILENYA CAP 0.5MG ......................... 31 GILOTRIF TAB 20MG......................... 12 GILOTRIF TAB 30MG......................... 12 GILOTRIF TAB 40MG......................... 12 glatiramer acetate ............................ 31 GLEOSTINE ..................................... 10 glimepiride ...................................... 33 glip/metform tab 5-500mg ................ 33 glipizide .......................................... 33 GLIPIZIDE XL TB24 2.5MG ................ 33 GLIPIZIDE XL TB24 5MG ................... 34 glipizide-metformin hcl tab 2.5-250 mg 63

......................................................34 glipizide-metformin hcl tab 2.5-500 mg ......................................................34 GLUCAGEN HYPOKIT .........................37 GLUCAGON EMERGENCY KIT ..............37 glycopyrrolate ..................................39 glycopyrrolate inj ..............................39 GOLYTELY ........................................40 granisetron hcl .................................39 GRANIX ...........................................43 griseofulvin microsize ......................... 5 griseofulvin ultramicrosize................... 5 guanfacine er (adhd) .........................29 H haloperidol .......................................27 haloperidol con lactate .......................27 haloperidol decanoate .......................27 haloperidol lactate inj 5 mg/ml ...........27 HARVONI .......................................... 8 HAVRIX ...........................................45 heather ...........................................35 HEPARIN SOD (PORCINE) IN D5W ......42 heparin sod inj 1000/ml .....................42 heparin sod inj 10000/ml ...................42 HEPARIN SOD INJ 2000/ML ................42 heparin sod inj 20000/ml ...................43 HEPARIN SOD INJ 2500/ML ................42 heparin sod inj 5000/ml .....................42 HEPARIN SODIUM/D5W .....................43 HEPARIN SODIUM/NACL 0.45% ..........43 HEPATAMINE ....................................47 HERCEPTIN ......................................11 HETLIOZ ..........................................30 HEXALEN .........................................10 HIBERIX ..........................................45 HUMIRA INJ 10MG/0.2ML...................44 HUMIRA KIT 20MG/0.4ML ..................44 HUMIRA KIT 40MG/0.8ML ..................44 HUMIRA PEDIATRIC CROHNS .............44 HUMIRA PEN ....................................44 HUMIRA PEN-CROHNS DISEASE .........44 HUMIRA PEN-PSORIASIS STAR ...........44 HUMULIN R U-500 KWIKPEN ..............33 HUMULIN R U-500 VIAL (CONCENTRATE) ......................................................33 hydralazine hcl .................................19

hydrochlorothiazide .......................... 19 hydroco/apap tab 10-325mg ............... 2 hydroco/apap tab 5-325mg ................. 2 hydroco/apap tab 7.5-325 ................... 2 hydrocodone-acetaminophen 7.5-325 mg/15ml ........................................... 2 hydrocodone-ibuprofen tab 7.5-200 mg 2 hydrocortisone ................................. 37 HYDROCORTISONE (INTRARECTAL).... 40 hydrocortisone (rectal) ..................... 54 hydrocortisone (topical) .................... 54 hydrocortisone butyrate .................... 55 hydromorphon inj 10mg/ml ................. 2 hydromorphone hcl ............................ 2 hydroxychloroquine sulfate ................ 44 hydroxyprogesterone caproate (antineoplastic) ................................ 12 hydroxyurea .................................... 13 hydroxyzine hcl ................................ 51 I IBRANCE ......................................... 11 ibuprofen .......................................... 1 ICLUSIG .......................................... 12 ILEVRO ........................................... 50 imatinib mesylate ............................. 12 IMBRUVICA CAP 140MG .................... 12 imipenem-cilastatin ............................ 4 imipramine hcl ................................. 24 imiquimod ....................................... 55 IMOVAX RABIES (H.D.C.V.) ............... 45 INCRELEX ....................................... 38 INCRUSE ELLIPTA ............................ 51 indapamide ..................................... 19 INFANRIX ........................................ 45 INLYTA ........................................... 12 INSULIN PEN NEEDLE ....................... 33 INSULIN SAFETY NEEDLES ................ 33 INSULIN SYRINGE ............................ 33 INTELENCE ........................................ 6 INTRALIPID INJ 20% ........................ 47 INTRALIPID INJ 30% ........................ 47 INTRON-A INJ 10MU ......................... 44 INTRON-A INJ 18MU ......................... 44 INTRON-A INJ 25MU ......................... 44 INTRON-A INJ 50MU ......................... 44 INVANZ ............................................ 4 64

INVEGA ...........................................27 INVEGA SUST INJ 117 MG/0.75 ML .....27 INVEGA SUST INJ 156MG/ML .............27 INVEGA SUST INJ 234 MG/1.5 ML .......27 INVEGA SUST INJ 39 MG/0.25 ML .......27 INVEGA SUST INJ 78 MG/0.5 ML .........27 INVEGA TRINZA................................27 INVIRASE ......................................... 6 INVOKAMET TAB 150-1000 ................34 INVOKAMET TAB 150-500 ..................34 INVOKAMET TAB 50-1000 ..................34 INVOKAMET TAB 50-500MG ...............34 INVOKANA .......................................34 IPOL INACTIVATED IPV......................45 ipratropium bromide .........................51 ipratropium bromide (nasal) ...............51 ipratropium-albuterol nebu ................51 irbesartan ........................................15 irbesartan-hydrochlorothiazide ...........15 IRESSA ............................................12 ISENTRESS ....................................... 6 ISOLYTE P........................................48 ISOLYTE S .......................................48 isoniazid ........................................... 7 isoniazid syp 50mg/5ml ...................... 7 isosorb mononitrate tab .....................19 isosorbide dinitrate ...........................19 isosorbide dinitrate er ........................19 isosorbide mononitrate er ..................19 isotretinoin.......................................53 ISTALOL ..........................................51 itraconazole ...................................... 5 ivermectin......................................... 4 IXIARO ............................................45 J JAKAFI ............................................12 JANUMET .........................................34 JANUMET XR TAB 100-1000 ...............34 JANUMET XR TAB 50-1000 .................34 JANUMET XR TAB 50-500MG ..............34 JANUVIA ..........................................34 JENTADUETO ....................................34 JENTADUETO XR 2.5-1000MG ............34 JENTADUETO XR 5-1000MG ...............34 JOLIVETTE .......................................35 JUXTAPID ........................................16

K KALETRA SOL .................................... 7 KALETRA TAB 100-25MG ..................... 7 KALETRA TAB 200-50MG ..................... 7 KALYDECO ...................................... 52 KCL 0.075%/D5W/NACL 0.45% ......... 48 KCL 0.15%/D5W/NACL 0.9% ............. 48 KCL 0.3%/D5W/NACL 0.45% ............. 48 KCL 0.3%/D5W/NACL 0.9% .............. 48 KCL IN NACL INJ .15-0.45 ................. 48 KCL/D5W INJ 0.3% .......................... 48 KCL/D5W/NACL INJ .15/.33% ............ 48 KCL/D5W/NACL INJ .15/.45% ............ 48 KCL/D5W/NACL INJ 0.22%/0.45% ..... 48 KCL/NACL INJ 0.15%-0.9% ............... 48 KCL/NACL INJ 0.3-0.9....................... 48 KCL0.15%/D5W/NACL0.2% ............... 48 KCL0.15%/D5W/NACL0.225% ........... 48 ketoconazole ..................................... 5 ketoconazole cream .......................... 53 ketoconazole shampoo ...................... 54 ketoprofen ........................................ 1 ketorolac tromethamine (ophth) ........ 50 KEYTRUDA ...................................... 11 KINRIX ........................................... 45 kionex powder ................................. 35 KLOR-CON 10 .................................. 46 KLOR-CON 8 .................................... 46 klor-con m10 ................................... 46 klor-con m15 ................................... 46 klor-con m20 ................................... 46 klor-con pow 20meq ......................... 46 klor-con spr cap 10meq .................... 46 klor-con spr cap 8meq ...................... 46 KORLYM .......................................... 37 KUVAN ............................................ 36 KYNAMRO ....................................... 16 L labetalol hcl ..................................... 17 LACTATED RINGER'S INJ ................... 48 lactulose ......................................... 40 lactulose (encephalopathy) ................ 40 lamivudine ........................................ 6 lamivudine (hbv) ................................ 8 lamivudine-zidovudine ........................ 7 lamotrigine ...................................... 22 65

LANTUS ...........................................33 LANTUS SOLOSTAR ...........................33 LASTACAFT ......................................50 latanoprost ......................................51 LATUDA ...........................................27 leflunomide ......................................44 LENVIMA 10 MG DAILY DOSE .............12 LENVIMA 14 MG DAILY DOSE .............13 LENVIMA 18 MG DAILY DOSE .............13 LENVIMA 20 MG DAILY DOSE .............13 LENVIMA 24 MG DAILY DOSE .............13 LENVIMA 8 MG DAILY DOSE ...............12 LETAIRIS .........................................19 letrozole ..........................................12 leucovorin calcium ............................14 leucovorin calcium for inj 500 mg .......14 LEUKERAN .......................................10 LEUKINE ..........................................43 leuprolide inj 1mg/0.2 .......................12 LEVEMIR ..........................................33 LEVEMIR FLEXTOUCH ........................33 levetiracetam ...................................22 levetiracetam inj ...............................22 LEVETIRACETAM IV ...........................22 levetiracetam oral soln 100 mg/ml ......22 levobunolol hcl .................................51 levocarnitine (metabolic modifiers) .....36 levocetirizine dihydrochloride .............51 levofloxacin ....................................... 9 levofloxacin in d5w ............................ 9 levofloxacin inj 25mg/ml ..................... 9 levofloxacin oral soln 25 mg/ml ........... 9 levoleucovorin calcium .......................14 levonor/ethi tab ................................35 levonorgestrel (emergency oc) ...........35 levonorgestrel-eth estradiol (triphasic) 35 levothyroxine sodium ........................38 LEVOXYL ..........................................38 LEXIVA ............................................. 6 lidocaine ..........................................55 lidocaine hcl .....................................55 lidocaine hcl (local anesth.) ................. 3 lidocaine hcl (mouth-throat) ...............56 lidocaine inj 0.5% .............................. 3 lidocaine inj 1% ................................. 3 lidocaine inj 1.5% .............................. 3

lidocaine inj 2% ................................. 3 lidocaine oint 5% ............................. 55 lidocaine-prilocaine ........................... 55 linezolid ............................................ 4 LINEZOLID ........................................ 4 LINEZOLID IN SODIUM CHLORIDE ....... 4 LINZESS ......................................... 41 liothyronine sodium .......................... 38 lisinopril .......................................... 14 lisinopril & hydrochlorothiazide........... 14 lithium carbonate ............................. 31 lithium carbonate er ......................... 31 LITHIUM SOLN 8MEQ/5ML ................. 31 LONSURF ........................................ 13 loperamide hcl ................................. 41 lorazepam ....................................... 20 lorcet hd tab 10-325mg ...................... 2 lorcet plus tab 7.5-325 ....................... 2 lorcet tab 5-325mg ............................ 2 lortab tab 10-325mg .......................... 2 lortab tab 5-325mg ............................ 2 lortab tab 7.5-325 .............................. 2 losartan potassium ........................... 15 losartan-hydrochlorothiazide .............. 15 LOTEMAX ........................................ 50 lovastatin ........................................ 16 low-ogestrel .................................... 35 loxapine succinate ............................ 27 LUMIGAN ........................................ 51 LUMIZYME ....................................... 36 LUPRON DEPOT ................................ 12 LYNPARZA ....................................... 11 LYRICA ........................................... 22 LYSODREN ...................................... 12 M magnesium sulfate ........................... 46 MAGNESIUM SULFATE ...................... 46 MAGNESIUM SULFATE IN D5W........... 46 malathion ........................................ 55 maprotiline hcl ................................. 24 MARPLAN TAB 10MG ......................... 25 MATULANE ...................................... 13 meclizine hcl .................................... 39 MEDROXYPROGESTERONE ACETATE (CONTRACEPTIVE) ........................... 35 medroxyprogesterone acetate 150 mg/ml 66

......................................................35 medroxyprogesterone acetate tab .......38 mefloquine hcl ................................... 5 megestrol ac sus 40mg/ml .................12 megestrol ac tab 20mg ......................12 megestrol ac tab 40mg ......................12 MEGESTROL SUS 625MG/5ML ............12 MEKINIST ........................................13 meloxicam ........................................ 1 memantine hcl .................................23 MENACTRA .......................................46 MENHIBRIX ......................................46 MENOMUNE-A/C/Y/W-135 ..................46 MENVEO ..........................................46 mercaptopurine ................................10 meropenem ...................................... 4 mesalamine enema ...........................40 mesalamine w/ cleanser ....................40 mesna .............................................14 MESNEX ..........................................14 metadate er tab 20mg .......................29 metformin er ....................................34 metformin hcl ...................................34 methadone hcl................................... 2 methazolamide .................................19 methenamine hippurate ...................... 4 methimazole ....................................38 methotrexate sodium ........................11 METHOTREXATE SODIUM ...................10 methotrexate sodium inj ....................11 methotrexate sodium tabs .................44 methylphenidate hcl ..........................29 methylphenidate hcl oral soln .............30 methylpr ace inj 40mg/ml ..................37 methylpr ace inj 80mg/ml ..................37 methylpr ss inj 125 mg ......................37 methylpr ss inj 1gm ..........................37 methylpr ss inj 40mg ........................37 methylpred pak 4mg .........................37 methylpred tab 16mg ........................37 methylpred tab 32mg ........................37 methylpred tab 4mg ..........................37 methylpred tab 8mg ..........................37 metipranolol .....................................51 metoclopramide hcl ...........................39 metoclopramide inj ...........................39

metolazone ..................................... 19 metoprolol & hydrochlorothiazide ....... 17 metoprolol succinate......................... 17 metoprolol tartrate ........................... 17 metronidazole .................................... 4 metronidazole (topical) ..................... 55 metronidazole gel 0.75% .................. 55 metronidazole in nacl .......................... 4 metronidazole vaginal ....................... 42 mexiletine hcl .................................. 16 MIACALCIN...................................... 38 MICROGESTIN FE 1.5/30................... 35 MICROGESTIN FE 1/20 ..................... 35 midodrine hcl ................................... 19 minocycline hcl ................................ 10 minoxidil ......................................... 19 mirtazapine ..................................... 25 misoprostol ..................................... 41 mitomycin ....................................... 10 mitoxantrone hcl .............................. 13 M-M-R II ......................................... 46 moderiba tab 200mg .......................... 8 moexipril hcl .................................... 14 moexipril-hydrochlorothiazide ............ 14 molindone hcl .................................. 27 mometasone furoate ........................ 55 mometasone furoate (nasal) .............. 52 mono-linyah tab 0.25-35................... 35 MONONESSA ................................... 35 montelukast sodium ......................... 52 morphine ext-rel tab........................... 2 MORPHINE SUL INJ 10MG/ML .............. 2 MORPHINE SUL INJ 15MG/ML .............. 2 MORPHINE SUL INJ 1MG/ML ................ 2 MORPHINE SUL INJ 4MG/ML ................ 2 morphine sulfate ............................ 2, 3 MORPHINE SULFATE ........................... 3 morphine sulfate beads ....................... 3 MORPHINE SULFATE ORAL SOL ............ 3 MOVANTIK ...................................... 41 MOVIPREP ....................................... 40 MOXEZA.......................................... 49 MOZOBIL ........................................ 43 MULTAQ .......................................... 16 mupirocin ........................................ 53 MYCAMINE ........................................ 5 67

mycophenolate mofetil ......................45 mycophenolate sodium ......................45 MYOZYME ........................................36 MYRBETRIQ......................................42 myzilra ............................................35 N nabumetone ...................................... 1 nafcillin sodium ................................10 NAGLAZYME .....................................36 nalbuphine hcl ................................... 1 naloxone inj 0.4mg/ml ......................32 naloxone inj 1mg/ml .........................32 naltrexone hcl ..................................32 NAMENDA XR ...................................23 NAMENDA XR TITRATION PACK ..........23 NAMZARIC .......................................23 naphazoline hcl .................................51 naproxen .......................................... 1 naproxen sodium ............................... 1 NASONEX ........................................52 NATACYN .........................................49 nateglinide .......................................34 NATPARA .........................................38 NEBUPENT ........................................ 4 necon 1/35-28..................................35 nefazodone hcl .................................25 neomycin sulfate ............................... 3 neomycin-bacitracin zn-polymyxin ......49 neomycin-polymy-dexameth ..............49 neomycin-polymyxin-gramicidin .........49 neomycin-polymyxin-hc (otic) ............56 NEORAL ...........................................45 NEPHRAMINE ...................................47 NEUMEGA ........................................43 NEUPOGEN ......................................43 NEUPRO...........................................26 nevirapine ......................................... 6 NEVIRAPINE ...................................... 6 nevirapine tab 200mg ........................ 6 NEXAVAR .........................................13 NEXIUM CAP 20MG ...........................41 NEXIUM CAP 40MG ...........................41 NEXIUM GRA 10MG DR ......................41 NEXIUM GRA 2.5MG DR .....................41 NEXIUM GRA 20MG DR ......................41 NEXIUM GRA 40MG DR ......................41

NEXIUM GRA 5MG DR ....................... 41 niacin (antihyperlipidemic) ................ 17 niacin er (antihyperlipidemic) ............ 17 nicardipine hcl ................................. 18 NICOTROL NS .................................. 32 NILANDRON .................................... 12 nilutamide ....................................... 12 nimodipine ...................................... 18 NINLARO ......................................... 11 NIPENT ........................................... 11 nitrofurantoin macrocrystal ................. 4 nitrofurantoin monohyd macro ............. 4 nitroglycer dis 0.1mg/hr.................... 19 nitroglycer dis 0.2mg/hr.................... 19 nitroglycer dis 0.4mg/hr.................... 19 nitroglycer dis 0.6mg/hr.................... 19 nitroglycerin .................................... 19 NITROSTAT ..................................... 19 NORA-BE TAB 0.35MG ...................... 35 NORDITROPIN FLEXPRO .................... 37 norethin acet & estrad-fe .................. 35 norethindrone & eth estradiol ............ 35 norethindrone (contraceptive)............ 35 norethindrone acetate ....................... 38 norethindrone acetate-ethinyl estradiol 36 norgest/ethi tab 0.25/35 ................... 35 norgestimate-ethinyl estradiol ........... 36 norgestimate-ethinyl estradiol (triphasic) ...................................................... 36 norlyroc 0.35mg .............................. 36 NORMOSOL-M IN D5W ...................... 48 NORMOSOL-R .................................. 48 NORMOSOL-R IN D5W ...................... 48 NORPACE CR ................................... 16 nortriptyline hcl ............................... 25 NORVIR ............................................ 6 NOVOLIN 70/30 ............................... 33 NOVOLIN N ..................................... 33 NOVOLIN R ..................................... 33 NOVOLOG ....................................... 33 NOVOLOG FLEXPEN .......................... 33 NOVOLOG MIX 70/30 ........................ 33 NOVOLOG MIX 70/30 PREFILL ........... 33 NOVOLOG PENFILL ........................... 33 NOXAFIL ........................................... 5 NUEDEXTA ...................................... 31 68

NULOJIX ..........................................45 NULYTELY/FLAVOR PACKS .................40 NUPLAZID ........................................27 NUTRILIPID INJ 20%.........................47 NUVARING .......................................36 NUVIGIL ..........................................31 NYMALIZE ........................................18 nystatin ............................................ 5 nystatin (mouth-throat) .....................56 nystatin (topical) ..............................53 O OCTAGAM ........................................44 octreotide acetate .............................38 ODEFSEY .......................................... 7 ODOMZO .........................................13 OFEV ...............................................52 ofloxacin (ophth) ..............................49 ofloxacin (otic) .................................56 olanzapine .......................................27 olopatadine hcl (nasal) ......................51 omega-3-acid ethyl esters..................17 omeprazole ......................................41 ondansetron hcl ................................39 ondansetron hcl inj ...........................39 ondansetron hcl oral soln ...................39 ondansetron odt ...............................39 ONFI ...............................................22 OPSUMIT .........................................19 ORFADIN .........................................36 ORKAMBI .........................................52 oxandrolone tab 10mg.......................32 oxandrolone tab 2.5mg......................32 oxcarbazepine ..................................22 oxybutynin chloride ...........................42 oxycodone hcl ................................... 3 OXYCODONE SOLN 5MG/5ML .............. 3 oxycodone w/ acetaminophen 10-325mg ....................................................... 3 oxycodone w/ acetaminophen 2.5-325mg ....................................................... 3 oxycodone w/ acetaminophen 5-325mg 3 oxycodone w/ acetaminophen 7.5-325mg ....................................................... 3 oxycodone w/ acetaminophen soln 5-325 mg/5ml ............................................ 3

P paliperidone .................................... 27 pamidronate disodium ...................... 34 PANRETIN ....................................... 55 pantoprazole sodium tbec ................. 41 paricalcitol....................................... 49 paroex sol 0.12% ............................. 56 paromomycin sulfate .......................... 3 paroxetine hcl tabs ........................... 25 paser 4gm ......................................... 7 PATADAY ......................................... 50 PAXIL ............................................. 25 PAZEO ............................................ 50 PEDIARIX ........................................ 46 PEDVAX HIB .................................... 46 PEG 3350/ELECTROLYTES ................. 40 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ............................................ 40 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE .................. 40 peg 3350-potassium chloride-sod bicarbonate-sod chloride ................... 40 PEGANONE ...................................... 22 PEGASYS........................................... 8 PEGASYS PROCLICK ........................... 8 PEGINTRON ....................................... 8 PEG-INTRON REDIPEN ........................ 8 PENICILLIN G POT IN DEXTROSE ....... 10 penicillin g procaine .......................... 10 penicillin g sodium ............................ 10 penicillin v potassium ....................... 10 penicilln gk inj 20mu ........................ 10 penicilln gk inj 5mu .......................... 10 PENTACEL ....................................... 46 PENTAM 300 ...................................... 4 pentoxifylline ................................... 43 PERFOROMIST ................................. 52 perindopril erbumine ........................ 14 permethrin ...................................... 55 perphenazine ................................... 27 pfizerpen-g inj 5mu .......................... 10 phenadoz ........................................ 39 phenelzine sulfate ............................ 25 phenobarbital .................................. 22 phenobarbital sodium ....................... 22 PHENOBARBITAL SODIUM ................. 22 69

phenytoin ........................................22 phenytoin sodium .............................22 phenytoin sodium extended ...............22 PHOSPHOLINE IODIDE ......................51 PILOCARPINE HCL .............................51 pilocarpine hcl (oral) .........................56 PILOCARPINE HCL (ORAL)..................56 pimozide ..........................................27 pindolol ...........................................17 pioglitazone hcl ................................34 piperacillin sodium-tazobactam sodium 10 PLASMA-LYTE A ................................48 PLASMA-LYTE-148 ............................49 PLASMA-LYTE-56/D5W ......................48 podofilox..........................................55 polyethylene glycol 3350 ...................40 polymyxin b-trimethoprim..................50 POMALYST CAP 1MG .........................13 POMALYST CAP 2MG .........................13 POMALYST CAP 3MG .........................13 POMALYST CAP 4MG .........................13 pot chloride inj 2meq/ml ....................49 potassium chloride ............................47 POTASSIUM CHLORIDE ................ 47, 49 potassium chloride in nacl ..................49 potassium chloride microencapsulated crystals cr ........................................47 POTASSIUM CHLORIDE TAB CR 10 MEQ ......................................................47 POTASSIUM CITRATE (ALKALINIZER) ..42 POTIGA ...........................................22 PRADAXA .........................................43 PRALUENT........................................17 pramipexole dihydrochloride...............26 pravastatin sodium ...........................16 prazosin hcl......................................14 PREDNISOLONE ACETATE (OPHTH) .....50 prednisolone sodium phosphate (ophth) ......................................................50 prednisolone sol 15mg/5ml ................37 prednisolone syp 15mg/5ml ...............37 prednisone con 5mg/ml .....................37 prednisone pak 10mg ........................37 prednisone pak 5mg ..........................37 prednisone sol 5mg/5ml ....................37 prednisone tab 10mg ........................37

prednisone tab 1mg.......................... 37 prednisone tab 2.5mg ....................... 37 prednisone tab 20mg ........................ 37 prednisone tab 50mg ........................ 37 prednisone tab 5mg.......................... 37 premasol 10% ................................. 47 premasol 6% ................................... 47 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) ................................. 49 PREZCOBIX ....................................... 7 PREZISTA.......................................... 6 PRIFTIN ............................................ 7 PRIMAQUINE PHOSPHATE ................... 5 primidone........................................ 22 PRISTIQ .......................................... 25 PRIVIGEN ........................................ 44 probenecid ........................................ 1 PROCALAMINE ................................. 47 prochlorperazine inj .......................... 39 prochlorperazine maleate .................. 39 prochlorperazine supp....................... 39 PROCRIT ......................................... 43 procto-pak cre 1% ........................... 54 proctosol hc cre 2.5% ....................... 54 proctozone cre -hc 2.5% ................... 54 PROGLYCEM SUS 50MG/ML ............... 37 PROGRAF ........................................ 45 PROLASTIN-C .................................. 52 PROLENSA....................................... 51 PROLIA ........................................... 38 PROMACTA ...................................... 43 promethazine hcl ............................. 39 promethegan ................................... 39 propafenone hcl ............................... 16 propafenone hcl 12hr ........................ 16 proparacaine hcl .............................. 51 propranolol & hydrochlorothiazide ...... 17 propranolol cap er ............................ 17 propranolol hcl ................................. 17 propylthiouracil ................................ 38 PROQUAD ....................................... 46 PROSOL .......................................... 48 protriptyline hcl................................ 25 PRUDOXIN CRE 5% .......................... 54 PULMICORT FLEXHALER .................... 53 PULMOZYME .................................... 52 70

PURIXAN .........................................11 pyrazinamide .................................... 7 pyridostigmine bromide .....................31 Q QUADRACEL .....................................46 quetiapine fumarate ..........................27 quinapril hcl .....................................14 quinapril-hydrochlorothiazide .............14 quinidine gluconate ...........................16 quinidine sulfate ...............................16 quinine sulfate ................................... 5 R RABAVERT .......................................46 raloxifene tab 60mg ..........................38 ramipril ...........................................14 RANEXA ...........................................19 ranitidine hcl ....................................40 ranitidine hcl inj ................................40 ranitidine syrup ................................40 RAPAMUNE .......................................45 RAVICTI ..........................................36 RECOMBIVAX HB ..............................46 REGRANEX .......................................55 RELENZA DISKHALER ......................... 8 RELISTOR ........................................40 RELPAX ...........................................30 REMICADE .......................................44 REMODULIN .....................................20 RENVELA PAK ...................................38 RENVELA TAB 800MG ........................38 RESCRIPTOR ..................................... 6 RESTASIS ........................................51 RETROVIR IV INFUSION ..................... 6 REVATIO ..........................................20 REVLIMID ........................................44 REXULTI ..........................................28 REYATAZ .......................................... 6 ribasphere cap 200mg ........................ 8 ribasphere tab 200mg ........................ 8 ribavirin cap 200mg ........................... 8 ribavirin tab 200mg............................ 8 rifabutin ........................................... 7 rifampin ............................................ 7 RIFATER ........................................... 7 riluzole ............................................31 rimantadine hydrochloride .................. 8

RINGER'S ........................................ 49 RISPERDAL INJ 12.5MG .................... 28 RISPERDAL INJ 25MG ....................... 28 RISPERDAL INJ 37.5MG .................... 28 RISPERDAL INJ 50MG ....................... 28 risperidone ...................................... 28 RITUXAN ......................................... 11 rivastigmine td patch 24hr 13.3 mg/24hr ...................................................... 24 rivastigmine td patch 24hr 4.6 mg/24hr ...................................................... 23 rivastigmine td patch 24hr 9.5 mg/24hr ...................................................... 23 rizatriptan benzoate ......................... 30 ropinirole hydrochloride .................... 26 rosadan cre 0.75% ........................... 55 rosuvastatin calcium ......................... 16 ROTARIX ......................................... 46 ROTATEQ ........................................ 46 roxicet tab 5-325mg ........................... 3 ROZEREM ........................................ 30 S SABRIL ...................................... 22, 23 SANDIMMUNE .................................. 45 SANTYL ........................................... 55 SAPHRIS ......................................... 28 selegiline hcl .................................... 26 selenium sulfide ............................... 54 SELZENTRY ....................................... 6 SENSIPAR .................................. 34, 35 SEREVENT DISKUS ........................... 52 SEROQUEL XR ................................. 28 sertraline hcl ................................... 25 sharobel 0.35mg .............................. 36 SIGNIFOR ....................................... 38 sildenafil citrate (pulmonary hypertension) .................................. 20 SILENOR ......................................... 30 SILVER SULFADIAZINE ..................... 53 SIMBRINZA ..................................... 51 simvastatin ..................................... 16 sirolimus ......................................... 45 SIROLIMUS ..................................... 45 SIRTURO ........................................... 7 SIVEXTRO ......................................... 4 SODIUM CHLORIDE ..................... 47, 49 71

SODIUM CHLORIDE 0.45% VIA ..........49 SODIUM CHLORIDE 0.9% ..................55 SODIUM CHLORIDE INJ 0.9% .............49 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ................................47 sodium polystyrene sulfonate .............35 SOLTAMOX.......................................12 SOLU-CORTEF ..................................37 SOMATULINE DEPOT .........................38 SOMAVERT.......................................38 sotalol hcl ........................................16 sotalol hcl (afib/afl) ...........................16 SOVALDI .......................................... 8 spironolactone ..................................14 spironolactone & hydrochlorothiazide ..19 SPRITAM..........................................23 SPRYCEL ..........................................13 SSD ................................................53 stavudine .......................................... 6 STERILE WATER IRRIGATION .............56 STIVARGA ........................................13 STRATTERA ......................................30 streptomycin sulfate ........................... 3 STRIBILD .......................................... 7 SUBOXONE MIS 12-3MG ....................32 SUBOXONE MIS 2-0.5MG ...................32 SUBOXONE MIS 4-1MG......................32 SUBOXONE MIS 8-2MG......................32 sucralfate.........................................41 sulfacet sod oin 10% op ....................50 sulfacetamide sodium (acne) ..............53 sulfacetamide sodium (ophth) ............50 sulfacetamide sod-prednisolone ..........49 sulfadiazine ....................................... 3 sulfamethoxazole-trimethoprim ........... 4 sulfamethoxazole-trimethoprim inj ....... 4 SULFAMYLON ...................................53 sulfasalazine ....................................40 sulfasalazine ec ................................40 sulindac ............................................ 1 SUMATRIPTAN ..................................30 sumatriptan inj 4mg/0.5ml ................30 SUMATRIPTAN INJ 4MG/0.5ML ...........30 sumatriptan inj 6mg/0.5ml ................30 SUMATRIPTAN INJ 6MG/0.5ML ...........30 sumatriptan succinate .......................30

suprax .............................................. 9 SUPRAX ............................................ 9 SUPREP BOWEL PREP ....................... 40 SURMONTIL CAP 100MG ................... 25 SURMONTIL CAP 25MG ..................... 25 SURMONTIL CAP 50MG ..................... 25 SUSTIVA ........................................... 6 SUTENT .......................................... 13 SYLATRON KIT 200MCG .................... 13 SYLATRON KIT 300MCG .................... 13 SYLATRON KIT 600MCG .................... 13 SYMBICORT ..................................... 53 SYMLINPEN 120 ............................... 33 SYMLINPEN 60 ................................. 33 SYNAGIS ......................................... 46 SYNAREL ......................................... 36 SYNERCID ......................................... 4 SYNRIBO ......................................... 13 SYNTHROID..................................... 38 SYPRINE ......................................... 35 T TABLOID ......................................... 11 tacrolimus ....................................... 45 tacrolimus (topical) .......................... 55 TAFINLAR ........................................ 13 TAGRISSO ....................................... 13 TAMIFLU ........................................... 8 tamoxifen citrate .............................. 12 tamsulosin hcl ................................. 41 TARCEVA ........................................ 13 TARGRETIN ..................................... 55 TASIGNA ......................................... 13 tazicef .............................................. 9 tazicef vial ......................................... 9 TAZORAC ........................................ 54 taztia xt .......................................... 18 TECENTRIQ ..................................... 11 TEFLARO ........................................... 9 TEGRETOL ....................................... 23 TEGRETOL-XR .................................. 23 TEKTURNA ...................................... 18 TEKTURNA HCT TAB 150-12.5MG ....... 18 TEKTURNA HCT TAB 150-25MG .......... 18 TEKTURNA HCT TAB 300-12.5MG ....... 18 TEKTURNA HCT TAB 300-25MG .......... 18 temazepam ..................................... 30 72

TENIVAC ..........................................46 terazosin hcl.....................................14 terbinafine hcl ................................... 5 terbutaline sulfate .............................52 terconazole vaginal ...........................42 testosterone cypionate ......................32 testosterone enanthate ......................32 TETANUS/DIPHTHERIA TOXOID ..........46 tetrabenazine ...................................31 THALOMID .......................................44 theophylline .....................................53 thioridazine hcl .................................28 thiothixene.......................................28 tiagabine hcl ....................................23 TIKOSYN..........................................16 timolol maleate.................................17 timolol maleate (ophth) .....................51 TIMOLOL MALEATE GEL .....................51 TIVICAY ............................................ 6 tizanidine hcl ....................................31 TOBRADEX .......................................49 TOBRADEX ST ..................................49 tobramycin........................................ 3 tobramycin (ophth) ...........................50 tobramycin sulfate ............................. 3 tobramycin-dexamethasone ...............49 tolterodine tartrate ...........................42 topiramate .......................................23 topotecan hcl ...................................14 torsemide inj ....................................19 torsemide tabs .................................19 TOUJEO SOLOSTAR ...........................33 TOVIAZ ...........................................42 TPN ELECTROLYTES ..........................47 TRACLEER ........................................20 TRADJENTA ......................................34 tramadol hcl ...................................... 1 trandolapril ......................................14 tranexamic acid ................................43 TRANSDERM-SCOP............................39 tranylcypromine sulfate .....................25 TRAVASOL .......................................48 TRAVATAN Z ....................................51 trazodone hcl ...................................25 TRECATOR ........................................ 7 TRELSTAR DEP INJ 3.75MG ................12

TRELSTAR LA INJ 11.25MG ................ 12 TRESIBA FLEXTOUCH........................ 33 tretinoin .......................................... 53 TRETINOIN ...................................... 53 tretinoin (chemotherapy) .................. 13 triamcinolone acetonide (mouth) ........ 56 triamcinolone acetonide (topical)........ 55 triamterene & hydrochlorothiazide ...... 19 triamterene & hydrochlorothiazide cap 37.5-25 mg ..................................... 19 TRIBENZOR TAB 20-5-12.5MG ........... 15 TRIBENZOR TAB 40-10-12.5.............. 15 TRIBENZOR TAB 40-10-25MG ............ 15 TRIBENZOR TAB 40-5-12.5MG ........... 15 TRIBENZOR TAB 40-5-25MG .............. 15 trifluoperazine hcl ............................ 28 trifluridine ....................................... 50 tri-linyah tab ................................... 36 trimethoprim ..................................... 4 trimipramine maleate ....................... 25 TRINESSA ....................................... 36 TRINTELLIX ..................................... 25 TRISENOX ....................................... 13 TRIUMEQ .......................................... 7 TROPHAMINE INJ 10% ...................... 48 TRULICITY....................................... 33 TRUMENBA ...................................... 46 TRUVADA TAB 100-150 ....................... 7 TRUVADA TAB 133-200 ....................... 7 TRUVADA TAB 167-250 ....................... 7 TRUVADA TAB 200-300 ....................... 7 TWINRIX INJ ................................... 46 TYBOST ............................................ 6 TYGACIL ........................................... 5 TYKERB........................................... 13 TYPHIM VI ....................................... 46 TYSABRI ......................................... 31 TYZEKA............................................. 8 U UCERIS ........................................... 40 ULORIC ............................................. 1 UNITHROID ..................................... 38 UPTRAVI ......................................... 20 ursodiol .......................................... 41 V valacyclovir hcl .................................. 8 73

VALCHLOR .......................................55 VALCYTE ........................................... 8 valganciclovir hcl ............................... 8 valproate sodium ..............................23 valproic acid .....................................23 valsartan .........................................15 valsartan & hctz tab 160-12.5mg ........15 valsartan & hctz tab 160-25mg...........15 valsartan & hctz tab 320-12.5mg ........15 valsartan & hctz tab 320-25mg...........15 valsartan & hctz tab 80-12.5mg..........15 vancomycin hcl .................................. 5 VANCOMYCIN IN NACL ....................... 5 VANDAZOLE .....................................42 VAQTA.............................................46 VARIVAX ..........................................46 VASCEPA .........................................17 VELCADE .........................................11 VENCLEXTA ......................................11 VENCLEXTA STARTING PACK ..............11 venlafaxine hcl .................................26 VENTOLIN HFA .................................52 verapamil cap er ...............................18 VERAPAMIL CAP ER ...........................18 verapamil hcl ...................................18 verapamil tab er ...............................18 VERSACLOZ .....................................28 VESICARE ........................................42 VICTOZA .........................................33 VIDEX PEDIATRIC .............................. 6 VIGAMOX .........................................50 VIIBRYD ..........................................26 VIIBRYD STARTER PACK ....................26 VIMPAT ...........................................23 VIRACEPT ......................................... 6 VIRAMUNE XR ................................... 6 VIREAD ............................................ 6 VITEKTA ........................................... 6 VOLTAREN .......................................55 voriconazole ...................................... 5 VOTRIENT ........................................13 VRAYLAR ................................... 28, 29 W warfarin sodium ................................43 WELCHOL ........................................17

X XALKORI ......................................... 13 XARELTO......................................... 43 XARELTO STARTER PACK .................. 43 XGEVA ............................................ 38 XIFAXAN ......................................... 41 XIGDUO XR TAB 10-1000MG ............. 34 XIGDUO XR TAB 10-500MG ............... 34 XIGDUO XR TAB 5-1000MG ............... 34 XIGDUO XR TAB 5-500MG ................. 34 XOLAIR ........................................... 52 XOPENEX HFA .................................. 52 XTANDI ........................................... 12 xulane dis 150-35 ............................ 36 XYREM ............................................ 32 Y YERVOY .......................................... 11 YF-VAX ........................................... 46 Z zafirlukast ....................................... 52 ZAVESCA ........................................ 36 ZAZOLE CRE 0.8% ........................... 42 ZELBORAF ....................................... 13 ZEMAIRA ......................................... 52 ZENPEP ........................................... 41 ZETIA TAB 10MG.............................. 17 ZIAGEN............................................. 6 zidovudine ......................................... 6 ziprasidone hcl ................................. 29 ZIRGAN .......................................... 50 zoledronic acid ................................. 34 zoledronic inj 4mg/5ml ..................... 34 ZOLINZA ......................................... 11 zolpidem tartrate ............................. 30 zonisamide ...................................... 23 ZONTIVITY ...................................... 43 ZORTRESS TAB 0.25MG .................... 45 ZORTRESS TAB 0.5MG ...................... 45 ZORTRESS TAB 0.75MG .................... 45 ZOSTAVAX ...................................... 46 ZYDELIG ......................................... 13 ZYKADIA ......................................... 13 ZYLET ............................................. 49 ZYPREXA RELPREVV ......................... 29 ZYPREXA RELPREVV INJ 210MG ......... 29 ZYTIGA ........................................... 12 74

ZYVOX.............................................. 5

GS9

75

This formulary was updated on 10/01/2016. For more recent information or other questions, please contact First United American - Select (PDP) at 1‑866‑524‑4171 or, for TTY/TDD users, 1‑866‑524‑4172, weekdays from 8:00am to 8:00pm Eastern, or visit http://www.firstuamedicarepartd.com. First United American - Select (PDP) is a PDP plan with a Medicare contract. Enrollment in First United American - Select (PDP) depends on contract renewal. This information is available for free in other languages. Please call our customer service number at 1-866-524-4171 (TTY/TDD users should call 1-866-524-4172). The Formulary may change at any time. You will receive a notice when necessary. Este formulario condensado se actualizó en 10/01/2016 y no es una lista completa de medicamentos cubiertos por nuestro plan. Para una lista completa o otras preguntas, por favor de contactar a First United American - Select (PDP) en 1‑866‑524‑4171 o, para los usuarios de TTY/TDD, 1‑866‑524‑4172, lunes a viernes de 8:00 am a 8:00 pm en su zona horaria local o visite http://www.firstuamedicarepartd.com. First United American - Select (PDP) es un plan de medicamentos recetados con un contrato de Medicare. La inscripción en First United American - Select (PDP) depende de la renovación del contrato. Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de servicio al cliente al 1-866-524-4171 (usuarios de TTY / TDD deben llamar al 1-866-524-4172). El formulario puede cambiar en cualquier momento. Usted recibirá un aviso cuando sea necesario.

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