Created 11/1/2015. Please note this document is subject to change. Any changes/updates to this document can be viewed at emhp.welldynerx.com. 2015 All Rights Reserved Page 00 Preferred Universal Formulary

Comp8109bp-15 (11/01/15)

2016 Preferred Universal Formulary List

The 2016 Universal Formulary drug list is shown below. The formulary is the list of drugs included in your prescription drug benefit plan. Inclusion on the list does not guarantee coverage.

PLEASE NOTE: Brand-name drugs may move to non-formulary status if a generic version becomes available during the year. Not all the drugs listed are covered by all prescription drug benefit programs; check your benefit materials for the specific drugs covered and the copayments for your prescription drug benefit program. For specific questions about your coverage, please call the phone number printed on your member ID card.

KEY[INJ] – Injectable Drug[OTC] – Over-the-Counter Product[SP] – Specialty Drug[PA] – Prior Authorization[QLL] – Quantity Level Limits[ST] – Step Therapy

Brand-name drugs are listed in CAPITAL letters. Example: ASMANEXGeneric drugs are listed in lower-case letters. Example: ibuprofen

For the member: Generic medications contain the same active ingredients as their corresponding brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards.

For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate.

A

abacavir[SP]abacavir/lamivudine/zidovudine [SP] ABELCET [INJ]ABILIFY [INJ] [QLL]ABILIFY DISCMELT [QLL]ABILIFY MAINTENA [INJ] [QLL] ABRAXANE [INJ] [SP]ABSORICA [SP]acamprosate delayed-release ACANYA acarboseacebutololacetaminophen/codeine acetaminophen/phenyltoloxamine citrate acetazolamide acetazolamide [INJ]acetazolamide ext-releaseacetic acid ear solutionacetic acid irrigation solutionacetic acid/aluminum acetate ear solutionacetic acid/hydrocortisone ear solution acetic acid/oxyquinoline acetylcysteine [INJ] acetylcysteine inhalation solution acitretinACTEMRA [INJ] [SP] [PA] [ST] ACTHAR H.P. [INJ] [SP] [PA] ACTHIB [INJ]ACTHREL [INJ] ACTIMMUNE [INJ] [SP] ACTIVASE [INJ]ACTOPLUS MET XR [QLL] acycloviracyclovir[INJ]acyclovirointmentADACEL [INJ]ADAGEN [INJ] [SP] [PA] adapaleneADCETRIS [INJ] [SP] [PA]ADCIRCA [QLL] [SP] [PA] ADDAMEL N [INJ]adefovirADEMPAS[QLL][SP][PA]

adenosine[INJ] ADVAIR DISKUS [QLL][ST] ADVAIR HFA [QLL][ST] advancedam/pm ADVATE[INJ][SP]AFINITOR [QLL][SP][PA] AFINITOR DISPERZ[QLL][SP][PA] AFLURIA [INJ]AGGRASTAT [INJ] AKYNZEO [PA] ALBENZAalbuminhuman [INJ]albuterolalbuterolext-release albuterol nebulization solution alclometasone ALDURAZYME [INJ][SP][PA] alendronatesodiumalfentanil [INJ]ALFERONN [INJ][SP] alfuzosinext-releaseALIMTA [INJ][SP]ALINIA[ QLL] ALKERAN TABLETS [SP] allopurinolallopurinol sodium [INJ]ALOXI [INJ][QLL][PA] ALPHAGANP 0.1% ALPHANATE [INJ][SP] ALPHANINESD [INJ][SP] alphaquinhpalprazolamalprazolam ext-release alprazolam orally disintegrating tabletsALPROLIX[INJ][SP] alprostadil[INJ] ALREXaltavera aluminum chloride20% topical solution alyacenamantadineAMBISOME [INJ] amcinonideamethia

amethia loamethystamifostine [INJ]amikacin [INJ]amilorideamiloride/hydrochlorothiazide amino acids [INJ] aminocaproic acid aminocaproic acid [INJ] aminophylline [INJ]AMINOSYN [INJ]amiodaroneamiodarone [INJ]AMITIZA [QLL]amitriptylineamitriptyline/chlordiazepoxide amlodipineamlodipine/atorvastatin amlodipine/benazepril amlodipine/valsartan AMMONIUM CHLORIDE [INJ] ammonium lactate 12% topical ammonium molybdate [INJ] AMMONUL [INJ]amoxapineamoxicillinamoxicillin/potassium clavulanate amoxicillin/potassium clavulanate ext-releaseamphotericin [INJ] ampicillinampicillin [INJ] ampicillin/sulbactam[INJ]AMPYRA [QLL] [SP] [PA] AMYTAL [INJ] anagrelideANALPRAM 2.5% LOTION ANALPRAM ADVANCED CREAM KIT ANALPRAM HC 1% CREAM SINGLES anastrozoleANDROGEL [ST]anectine [INJ]ANGIOMAX [INJ] ANORO ELLIPTA [QLL] anthralinantipyrine/benzocaine ear solution APLISOL [INJ]

APOKYN [ INJ] [SP] apraclonidineeyesolutionapriAPTIVUS [ QLL] [SP]AQUASOL A [INJ]ARALAST NP [INJ] [SP] [PA] aranelle ARANESP [INJ] [SP] [PA] [ST] arbinoxaARCALYST [INJ] [SP] [PA] ARCAPTA [QLL]ARGATROBAN [INJ]aripiprazole [QLL]ARISTOSPAN [INJ]ARMOUR THYROIDARRANON [INJ] [SP]ARZERRA [INJ] [SP]ASACOL HD [QLL]ascorbic acid [INJ]ASMANEX [QLL] [ST]aspirin delayed-release 975 mg aspirin/dipyridamole [QLL] ASTEPRO [QLL]ATELVIA [QLL]atenololatenolol/chlorthalidoneATGAM [INJ]atorvastatinatovaquoneatovaquone/proguanilATRALINATRIPLA [QLL] [SP]atropine sulfate [INJ]atropine sulfate eye ointment atropine sulfate eye solution ATROVENT HFA [QLL]ATRYN [INJ] [SP]aubraAUGMENTIN 125-31.25 MG/5 ML AUVI-Q [INJ] [ST]

1

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2015 All Rights Reserved Page 00 Preferred Universal Formulary Comp8109bp-15 (11/01/15)

AVASTIN [INJ] [SP]AVELOX IV [INJ]avianeavocreamAVONEX [INJ] [QLL] [SP] [PA] [ST] AXIRON AXIRON [ST]azacitidine [INJ]AZACTAM-ISO-OSMOTIC DEXTROSE [INJ] AZASANazathioprineazathioprine sodium [ INJ]azelastine eye solutionazelastine nasal sprayAZILECT [QLL]azithromycinazithromycin [INJ]AZOR [QLL] [ST]aztreonam [ INJ]azurettB

bacitracin [INJ]bacitracin eye ointmentbacitracin/polymyxin eye ointment baclofenBAL IN OIL [INJ]balanced salt eye irrigation solution bal-care dha prenatal vitamins balsalazidebalzivaBANZEL [QLL]b-complex [INJ]BEBULIN [INJ] [SP]benazeprilbenazepril/hydrochlorothiazide BENEFIX [INJ] [SP]BENICAR [QLL] [ST]BENICAR HCT [QLL] [ST]BENLYSTA [INJ] [SP] [PA]benoxinate/f uorescein eye solution benzocaine ear solutionbenzonatatebenzoyl peroxidebenzphetaminebenztropinebenztropine [INJ]BEPREVEBESIVANCE [ST]betamethasone acetate/betamethasone sodium phosphate [INJ] betamethasone dipropionate betamethasone dipropionate augmented betamethasone valerateBETASERON [INJ] [QLL] [SP] [PA] [ST] betaxololbetaxolol eye solutionbethanecholBETHKIS [SP] [PA]BEYAZbicalutamideBICILLIN C-R [INJ]BICILLIN L-A [INJ]BICNU [INJ] [SP]BIOTHRAX [INJ]bisoprololbisoprolol/hydrochlorothiazide bleomycin [INJ] [SP]BLOXIVERZ [INJ]BOOSTRIX [INJ]

BOSULIF [QLL] [SP] [PA]BOTOX [INJ] [SP] [PA]bp folinatal plus b prenatal vitaminsbp vit 3BRAVELLE [INJ] [SP] [ST]BREO ELLIPTA [QLL] [ST]BREVITAL [INJ]briellynBRILINTA [QLL]brimonidine eye solutionBRISDELLE [ST]bromfenac eye solutionbromocriptinebrompheniramine/phenylephrine/ dextromethorphan brompheniramine/pseudoephedrine/ codeinebrompheniramine/pseudoephedrine/ dextromethorphanbudesonide delayed-release budesonide nasal spraybudesonide nebulization suspension bumetanidebumetanide [INJ]BUPHENYL TABLETSbupivacaine [INJ]bupivacaine/dextrose [INJ] bupivacaine/epinephrine [INJ] buprenorphinebuprenorphine [INJ]buprenorphine/naloxonebupropion [ST]bupropion ext-release (12 hour) [ST] bupropion ext-release (12 hour) smoking deterrentbupropion ext-release (24 hour) [ST] buspironeBUSULFEX [INJ] [SP]butalbital/acetaminophenbutalbital/acetaminophen/caffeine butalbital/acetaminophen/caffeine/ codeinebutalbital/aspirin/caffeinebutalbital/aspirin/caffeine/codeine butorphanol [INJ]butorphanol nasalBUTRANS [QLL] [PA]BYDUREON [INJ] [QLL] [PA] [ST] BYDUREON PEN [QLL] [PA] [ST] BYETTA [INJ] [QLL] [PA] [ST] BYSTOLIC [QLL]

C

cabergolinecaffeine citratedcaffeine citrated [INJ]caffeine/sodium benzoate [INJ] calcipotrienecalcipotriene/betamethasone dipropionate calcitonin salmon nasalcalcitriolcalcitriol [INJ]calcitriol ointmentcalcium acetatecalcium chloride [INJ]CALCIUM DISODIUM VERSENATE [INJ] calcium gluconate [INJ]calcium-folic acid plus dcalcium-pnv 28-1-250 prenatal vitamins

CALDOLOR [INJ]camilacamresecamrese loCANASACANCIDAS [INJ]candesartan [ST]candesartan/hydrochlorothiazide [ST] CAPASTAT SULFATE [INJ] capecitabine [SP] [PA]CAPRELSA [QLL] [SP] [PA]captoprilcaptopril/hydrochlorothiazideCARACcarafate suspensioncarbachol [INJ]CARBAGLU [SP] [PA]carbamazepinecarbamazepine ext-releasecarbidopacarbidopa/levodopacarbidopa/levodopa ext-release carbidopa/levodopa orally disintegrating tabletscarbidopa/levodopa/entacapone carbinoxamineCARBOCAINE 2% [INJ]carboplatin [INJ]carteolol eye solutioncarvedilolCATHFLO ACTIVASE [INJ]cavan-ec sod dha prenatal vitamins CAVERJECT [INJ]CAYSTON [QLL] [SP] [PA]caziantcefaclorcefaclor ext-releasecefadroxilcefazolin [INJ]cefazolin/dextrose [INJ]cefdinircefditorencefepime [INJ]cefepime/dextrose [INJ]cefotaxime [INJ]cefotetan [INJ]cefoxitin [INJ]cefoxitin/dextrose [INJ]cefpodoximecefprozilceftazidime [INJ]CEFTAZIDIME/DEXTROSE [INJ] ceftibutenceftriaxone [INJ]ceftriaxone/dextrose [INJ]cefuroxime axetilcefuroxime sodium [INJ]celecoxib [PA][QLL][ST]CELLCEPT [INJ]CELLCEPT SUSPENSIONCELONTINCENESTINCENOLATE [INJ]centratexcephalexinCEPROTIN [INJ]CEREZYME [INJ]CERVARIX [INJ]cetirizine syrupCETROTIDE [INJ][PA][SP]

cevimelineCHANTIX [QLL]chatealCHEMETCHENODALchloramphenicol [INJ]chlorcyclizine/codeinechlorcyclizine/pseudoephedrine/codeinechlordiazepoxidechlordiazepoxide/clidiniumchlorhexidine gluconatechloroprocaine [INJ]chloroquine phosphatechlorothiazidechlorothiazide sodium [INJ]chlorpheniramine tannatechlorpheniramine/codeinechlorpromazinechlorpromazine [INJ]chlorthalidonechlorzoxazonechoice-ob + dha prenatal vitaminschoice-tabscholestryraminecholestryramine lightcholine salicylate/magnesium salicylate

liquidchorionic gonadotropin [INJ] [SP] chromium chloride [INJ] CIALIS [QLL] [ST]ciclopiroxciclopirox shampoocidofovir [INJ]cilostazolcimetidineCINRYZE [INJ] [SP] [PA] CIPRODEXciprofloxacinciprofloxacin ear solution ciprofloxacin ext-release ciprofloxacin eye solution ciprofloxacin lactate [INJ]ciprofloxacin/dextrose [INJ]cisplatin [INJ] [SP]citalopram [QLL] [ST]citric acid/sodium citratecladribine [INJ]clarithromycinclarithromycinext-releaseclemastineCLEVIPREX [INJ]clindamycinhclclindamycin palmitateclindamycin phosphate [INJ] clindamycin phosphate topical clindamycin phosphate vaginal clindamycin phosphate/benzoyl peroxide clindamycin phosphate/dextrose [INJ] CLINIMIX [INJ]CLINIMIX E [INJ]clobetasol propionateclobetasol propionate shampoo clobetasol propionate/emollient CLOLAR [INJ] [SP]clomiphene citrateclomipramineclonazepamclonazepam orally disintegrating tablets clonidineclonidine [INJ]

2

Created 11/1/2015. Please note this document is subject to change. Any changes/updates to this document can be viewed at emhp.welldynerx.com.

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2015 All Rights Reserved Page 00 Preferred Universal Formulary Comp8109bp-15 (11/01/15)

clonidine ext-releaseclonidine patchesclonidine/chlorthalidoneclopidogrelclorazepateclotrimazole topicalclotrimazole trocheclotrimazole/betamethasone dipropionate clozapineclozapine orally disintegrating tablets c-nate dha prenatal vitamins COARTEMcocaine topical solutioncodeine sulfatecolchicine/probenecidCOLCRYS [QLL]colestipolcolistimethate [INJ]COMBIGANCOMBIPATCHCOMBIVENT RESPIMAT [QLL] COMPLERA [QLL] [SP]complete natal dha prenatal vitamins completenate prenatal vitamins COMVAX [INJ]CONCEPTION KITCONDYLOX GELCOPAXONE [INJ] [QLL] [SP] [PA] [ST] copper chloride [INJ]COREG CR [QLL]CORIFACT [INJ] [SP]CORLANOR [PA][QLL]CORTIFOAMcortisone acetatecorvitacorvita 150cosyntropin [INJ]COUMADIN [INJ]CREON [ST[CRESTOR [QLL]CRINONE 4%CRINONE 8%CRIXIVAN [QLL] [SP]CROFAB [INJ]cromolyn sodium eye solution cromolyn sodium nebulization solution cromolyn sodium oral solutioncryselleCUBICIN [INJ]CUPRIC SULFATE [INJ]CUPRIMINEcyanocobalamin [INJ]cyclafemcyclobenzaprinecyclopentolate eye solution cyclophosphamide [INJ] [SP] CYCLOPHOSPHAMIDE CAPSULES [SP] cyclophosphamide tablets [SP] cyclosporinecyclosporine [INJ]cyclosporine modif edcyproheptadineCYRAMZA [INJ] [SP]CYSTADANECYSTAGON [SP] [PA]CYSTARAN [QLL] [SP] [PA]cytarabine [INJ] [SP]CYTOGAM [INJ] [SP]cytra-3

D

dacarbazine [INJ]dactinomycin [INJ]dailyvite with zincDALIRESP [QLL] [PA]DALVANCE [INJ]danazoldantrolenedantrolene [INJ]DAPSONEDAPTACEL DTAP [INJ]DARAPRIMdasettadaunorubicin [INJ]DAUNOXOME [INJ] [SP]dayseeDAYTRANA [QLL]deblitanedecitabine [INJ]deferoxamine [INJ]delf ex with dextrose [INJ]delylaDELZICOL [QLL]demeclocyclineDEMSERDEPOCYT [INJ] [SP]DEPO-ESTRADIOL [INJ]DEPO-MEDROL 20 MG/ML [INJ] DEPO-PROVERA 400 MG/ML [INJ] [QLL] desipraminedesloratadinedesloratadine orally disintegrating tablets desmopressin acetatedesmopressin acetate [INJ] desmopressin acetate nasaldesonidedesoximetasonedexamethasonedexamethasone sodium phosphate [INJ] dexamethasone sodium phosphate eye solutiondexchlorpheniramine ext-release DEXCOM G4 SENSORdexferrum [INJ]dexmedetomidine [INJ] dexmethylphenidate dexmethylphenidate ext-release dexpanthenol [INJ]dexrazoxane [INJ]dextroamphetamine dextroamphetamine ext-release dextroamphetamine/amphetamine dextroamphetamine/amphetamine ext-releasedextrose/lactated ringers [INJ] dextrose/sodium chloride [INJ] dextrose/water [INJ]dialyvitedialyvite/zincdiazepamdiazepam[INJ]diazepamrectalgelDIBENZYLINEdiclofenac eye solutiondiclofenac potassium [ST]diclofenac sodium delayed-release [ST] diclofenac sodium delayed-release/ misoprostoldiclofenac sodium ext-release [ST] diclofenac sodium gel

diclofenacsodiumtopicalsolution dicloxacillindicyclomine hcldidanosine delayed-release [QLL] [SP] diethylpropion [PA]diethylpropion ext-release [PA] DIFFERIN 0.1% LOTIONdiflorasone diacetatediflorasone diacetate/emollientdiflunisaldigoxindigoxin [INJ]dihydrocodeine/acetaminophen/caffeine dihydrocodeine/aspirin/caffeine dihydroergotamine [INJ] [ QLL] dihydroergotamine nasal [QLL] DILANTIN30MGCAPSULES DILATRATE-SRDILAUDID-HP 250 MG [INJ]diltiazemdiltiazem [INJ]diltiazem ext-release (12 hour) diltiazem ext-release (24 hour) dimenhydrinate [INJ] diphenhydraminediphenhydramine [INJ]diphenoxylate/atropinedipyridamoledipyridamole [INJ]disulfiramdivalproex sodiumdivalproex sodium delayed-release divalproex sodium ext-release DIVIGELdobutamine [INJ]dobutamine/dextrose [INJ] DOCEFREZ [INJ]docetaxel [INJ]donepezildonepezil orally disintegrating tablets dopamine [INJ]dopamine/dextrose [INJ]DORIBAX [INJ]dorzolamide eye solution dorzolamide/ timolol eye solution doxazosindoxepindoxepin creamdoxercalciferoldoxercalciferol [INJ]doxorubicin [INJ]doxorubicin/liposomal [INJ] doxycycline hyclatedoxycycline hyclate [INJ]doxycycline hyclate delayed-release doxycycline monohydratedronabinoldroperidol [INJ]DROXIADUAVEE [QLL]DULERA [QLL] [ST]duloxetine delayed-release [QLL] [ST] DYMISTA [QLL]dyphylline

E

econazoleEDARBI [QL] [ST] EDARBYCLOR [QLL] [ST]EDECRIN SODIUM [INJ]

edrophonium [INJ]EDURANT [QLL] [ SP]EFFIENT [QLL]EGRIFTA [INJ] [QLL] [ SP] [PA] ELAPRASE [INJ] [SP] [PA] electrolyte-48 solution/dextrose [INJ] ELELYSO [INJ]eletoneELIDEL [PA]ELIGARD [INJ] [QLL] [SP] [PA] elinesteliphosELIQUIS[QLL]ELITEK [INJ]elite-ob prenatal vitamins ELMIRONELOCTATE [INJ] [SP]ELSPAR [INJ] [SP]EMCYTEMEND [QLL] [PA]EMEND [INJ] [QLL] [PA] emoquetteEMTRIVA [QLL] [SP]emulsion sbenalaprilenalapril/hydrochlorothiazide enalaprilat [INJ]ENBREL [INJ] [QLL] [SP] [ PA] [ST] ENDOMETRINENGERIX-B [INJ]ENJUVIAenoxaparin [ INJ]enpresseenskyceentacaponeentecavir [QLL] [SP ] [PA] ENTRESTO [PA][QLL]ENTYVIOENTYVIO [INJ] [SP] [ PA]EOVIST [INJ]ephedrine [INJ]EPIDUOepinastine eye solution epinephrine [INJ] [QLL]epinephrine auto-injector [INJ] [ QLL] EPIPEN [INJ] [QLL] [ST]EPIPEN JR [INJ ] [QLL] [ST] epirubicin [INJ] [SP]EPIVIR HBV SOLUTION [QLL] [SP] EPIVIR SOLUTION [QLL] [SP] eplerenoneepoprostenol [INJ]epoprostenol diluent [INJ] eprosartan [QLL ] [ST]EPZICOM [QLL] [ ST]ERAXIS [INJ]ERBITUX [INJ] [SP] [ PA] ergocalciferolergoloid mesylatesergotamine tartrate/caffeine suppositoriesERIVEDGE [QLL] [SP] [PA]errinERYTHROCIN [INJ]erythromycinerythromycin delayed-release erythromycin ethylsuccinate erythromycin eye ointment erythromycin stearate erythromycin topical

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Created 11/1/2015. Please note this document is subject to change. Any changes/updates to this document can be viewed at emhp.welldynerx.com.

2015 All Rights Reserved Page 00 Preferred Universal Formulary Comp8109bp-15 (11/01/15)

erythromycin/benzoyl peroxide erythromycin/sulfioxazole escitalopram [ST] esomeprazole sodium [INJ] esomeprazole magnesium

delayed-release[QLL][ST]estaryllaestazolamesterified estrogens/methyltestosterone ESTRACE CREAM [ST]estradiolestradiol patchesestradiol valerate [INJ]estradiol/norethindrone acetate estropipateeszopiclone [QLL] [ST]ethambutolETHAMOLIN [INJ]ethosuximideethyl alcohol [INJ]ethylchloridesprayetidronateetodolac [ST]etodolac ext-release [ST]etomidate [INJ]ETOPOPHOS [INJ] [SP]etoposide [SP]etoposide [INJ] [SP]EXELON PATCHES [ QLL]EXELONSOLUTIONexemestaneEXJADE [SP] [PA]EXTRANEAL ICODEXTRIN DIALYSIS SOLUTION EYLEA [INJ] [SP]

F

fabbFABRAZYME [INJ] [SP] [PA]falminafamciclovirfamotidinefamotidine [INJ]famotidine/sodium chloride [INJ]FARESTONFARXIGA [QLL]FASLODEX [INJ] [SP]fe 90 plusfe c plusFEIBA NF [INJ] [SP]felbamatefelodipine ext-releasefenof brate [QLL]fenof brate micronized [QLL]fenof bric acid [QLL]fenof bric acid delayed-release [QLL]fenoprofen 600 mg [ST]fentanyl [INJ] [QLL] [PA]fentanyl citrate lozenges [QLL] [PA]fentanyl patches [QLL] [PA]FENTORA [QLL] [PA]FERAHEME [INJ]feroconferotrinsicferraplus 90ferrex 150 forteferrex 150 forte plusferrex 28

FERRIPROXferrocite plusferrogels forteFETZIMA [QLL]FINACEAfinasterideFIRAZYR [INJ] [ SP] [PA]FIRST-BXNFIRST-LANSOPRAZOLEFIRST-MOUTHWASH BLMFIRST-OMEPRAZOLEflavoxateflecainideFLOVENT DISKUS [QLL] [ PA] FLOVENT HFA [QLL] [ PA] floxuridine [INJ] [SPFLUARIX [INJ]FLUARIX QUAD [INJ]fluconazolefluconazole/dextrose [INJ] fluconazole/no mal saline [INJ]flucytosinefludarabine [INJ] [SP]fludrocortisone acetateFLULAVAL INJ]FLULAVAL QUAD [INJ]flumazenil [INJ]FLUMISTQUADflunisolide nasalsprayfluocinolonefluocinolone acetonide oil ear solution fluocinonidefluocinonide/emollientfluorescein eye strips fluorometholone eye suspensionfluorouracil[INJ]fluorouraciltopicalfluoxetine[ST]fluoxetine delayed-release[ST]fluoxymesteronefluphenazine decanoate[INJ]fluphenazinehclfluphenazinehcl[INJ]flurazepamflurbiprofen[ST]flurbiprofen eyesolutionflutamidefluticasone nasalspray[ST]fluticasonetopicalfluvastatinFLUVIRIN [INJ]f uvoxamine [ST]fluvoxamineext-release[QLL][ST FLUZONE [INJ]FLUZONEQUAD [INJ]FMLS.O.P.FOCALIN XR 5 MG, 10 MG, 20 MG 25 MG, 35 MG [QLL]folbecal prenatal vitaminsfolbeefolbee plusfolbee plus czfolbicfolcal dha prenatal vitamins folcaps omega-3 prenatal vitamins folic acidfolic acid [INJ]folic acid/cyanocobalamin/pyridoxine folivane-ffolivane-ob prenatal vitamins

folivane-plusfolivane-prx dha nf prenatal vitaminsFOLLISTIM AQ [INJ] [SP] [ST]FOLOTYN [INJ] [SP]folplex 2.2foltanxfomepizole [INJ]fondaparinux [INJ]FORA LANCING DEVICE [OTC]FORACARE 30G LANCETS [OTC]FORADIL [QLL]FORTAZ-ISO-OSMOTIC DEXTROSE [INJ]FORTEO [INJ] [SP] [PA]foscarnet [INJ]fosinoprilfosinopril/hydrochlorothiazidefosphenytoin [INJ]FOSRENOLFRAGMIN [INJ] [QLL]FREAMINE HBC [INJ]freamine III [INJ]FREESTYLE FREEDOM KIT [OTC]FREESTYLE FREEDOM LITE METER [OTC]FREESTYLE INSULINX GLUCOSE SYSTEM [OTC]FREESTYLE INSULINX TEST STRIPS [OTC]FREESTYLE LITE METER [OTC]FREESTYLE LITE TEST STRIPS [OTC]FREESTYLE TEST STRIPS [OTC]furosemidefurosemide [INJ]FUSILEV [INJ]FUZEON [INJ] [QLL] [SP] [PA]FYCOMPA [QLL]

G

gabapentinGABITRIL 12 MG, 16 MG GABLOFEN [INJ] [SP]galantaminegalantamine ext-release GAMASTAN S-D [INJ] [SP] [PA] GAMMAGARD LIQUID [INJ] [SP] [PA] GAMMAGARD S-D [INJ] [SP] [PA] GAMUNEX-C [INJ] [SP] [PA] ganciclovir [INJ]GARDASIL [INJ]gatif oxacin eye solutionGAZYVA [INJ] [SP]GELNIQUE [ST]gemcitabine [INJ] [SP]gemf brozilGENOTROPIN [INJ] [SP] [PA] [ST] gentamicin [INJ]gentamicin eye ointment gentamicin eye solution gentamicin topicalgentamicin/normal saline [INJ] GENTAMICIN/NORMAL SALINE 100 MG/50 ML [INJ]gianvigildagiagildessgildess feGILENYA [QLL] [SP] [PA] [ST] GILOTRIF [QLL] [SP] [PA] GLEEVEC [QLL] [SP] [PA] glimepiride

glipizideglipizide ext-release glipizide/metformin GLUCAGEN [INJ] [QLL] GLUCAGON [INJ] [QLL] glyburideglyburide micronized glyburide/metformin glycine irrigation solution GLYCOPHOS [INJ] glycopyrrolate glycopyrrolate [INJ] GLYXAMBI [QLL]GRALISE [QLL] granisetron [PA] granisetron [INJ] [PA] GRASTEK [QLL] griseofulvin microsize griseofulvin ultramicrosize guaifenesin/codeine guanfacineguanidine

H

HALAVEN [INJ] [SP]halobetasolhalobetasol + ammonium lactate combo

packhaloperidolhaloperidol decanoate [INJ] haloperidol lactatehaloperidol lactate [INJ]HARVONI [QLL][PA][SP] HAVRIX [INJ] heatherHECTOROL 2 MCG/ML [INJ] HELIXATE FS [INJ] [SP]HEMABATE [INJ] hematinic plushematinic with folic acid hematinic-vitamin-mineral hematogenhematogen fahematogen forte hemenatal ob + dha prenatal vitamins hemenatal ob prenatal vitamins hemetabHEMOFIL M [INJ] [SP]HEPAGAM B [INJ]heparin lock flush [INJ]heparin sodium [INJ]heparin sodium/dextrose [INJ] heparin sodium/sodium chloride [INJ] HEPATAMINE [INJ]HEPATASOL [INJ]HERCEPTIN [INJ] [SP] [PA] hetastarch/ normal saline [INJ] HEXALEN HEXTEND LACTATED ELECTROLYE [INJ] HIZENTRA [INJ] [SP] [PA] homatropine eye solutionhpr emollient foamhpr plusHUMALOG [INJ] [ST]HUMATE-P [INJ] [SP]HUMATROPE [INJ] [SP] [PA] [ST] HUMIRA [INJ] [SP] [PA] [ST]HUMULIN [INJ] [OTC] [ST]HUMULIN R 500 UNITS [INJ] [ST]

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HYCAMTINCAPSULES[SP]hydralazinehydralazine[INJ]hydrochlorothiazidehydrocodone/acetaminophen hydrocodone/chlorpheniramine/ polistirex hydrocodone/chlorpheniramine/ pseudoephedrine hydrocodone/homatropine hydrocodone/ibuprofen hydrocortisone hydrocortisone acetate suppositories hydrocortisone acetate topical hydrocortisone acetate/lidocaine hydrocortisone acetate/pramoxine hydrocortisone butyrate hydrocortisone butyrate/emollient hydrocortisone enema hydrocortisone sodium succinate [INJ] hydrocortisone topical hydrocortisone valerate hydrocortisone/iodoquinol hydrocortisone/pramoxine hydrocortisone/pramoxine/ chloroxylenol ear solution hydromorphonehydromorphone [INJ] hydromorphone ext-release hydromorphone suppositories hydroquinonehydroquinone ext-release hydroxocobalamin [INJ] hydroxychloroquine sulfate hydroxyurea hydroxyzine hcl hydroxyzine hcl [INJ]hydroxyzine pamoatehyophenhyoscyaminehyoscyamine ext-release hyoscyamine orally disintegrating tablets HYPERHEP B S-D [INJ]HYPERRAB S-D [INJ] HYPERRHO S-D [INJ] [SP] HYPERTET S-D [INJ]HYSINGLA ER [QLL]

I

ibandronate [QLL] [ST] ibandronate [INJ] [QLL] [SP] [PA] ibuprofen [ST]ibutilide [INJ]ICLUSIG [QLL] [SP] [PA] idarubicin [INJ]iferex 150 forteifosfamide [INJ] [SP] ifosfamide/mesna [INJ] [SP] ILARIS [INJ] [SP] [PA]ILEVROIMBRUVICA [QLL] [SP] [PA] imipenem/cilastatin [INJ] imipramine hclimipramine pamoate imiquimodIMOGAM RABIES-HT [INJ] IMOVAX RABIES VACCINE [INJ] inatal advance prenatal vitamins inatal gt prenatal vitamins inatal ultra prenatal vitamins

INCRELEX [INJ] [SP] [PA] indapamideindomethacin [ST]indomethacin ext-release [ST] indomethacin sodium [INJ] [ST] infanate plus prenatal vitamins INFANRIX [INJ]infed [INJ]INFERGEN [INJ] [QLL] [SP] [PA] INFUMORPH [INJ]INFUVITE [INJ]INLYTA [QLL] [SP] [PA]INTEGRILIN [INJ]INTELENCE [QLL] [SP]intralipid 20% [INJ]INTRON A [INJ] [SP]introvaleINTUNIV [QLL] [PA]INVANZ [INJ]INVIRASE [QLL] [SP]INVOKAMET [QLL]INVOKANA [QLL]IODOPEN [INJ]IONOSOL [INJ]IPOL [INJ]ipratropium bromide nasal spray ipratropium bromide nebulization solution ipratropium/albuterol sulfate nebulization solutionirbesartan [ST]irbesartan/hydrochlorothiazide [ST] irinotecan [INJ]ISENTRESS [QLL] [SP]ISOLYTE [INJ]isometheptene/caffeine/acetaminophen isometheptene/dichloralphenazone/ acetaminophenisoniazidisoniazid [INJ]isosorbide dinitrateisosorbide dinitrate ext-release isosorbide mononitrateisosorbide mononitrate ext-release isotretinoin [PA]ISOVUE [INJ]ISOVUE-M [INJ]isoxsuprineisradipineISTODAX [INJ] [SP]itraconazoleIXEMPRA [INJ] [SP]IXIARO [INJ]

J

JAKAFI [QLL] [SP] [PA] JANUMET [QLL] [ST] JANUMET XR [QLL] [ST] JANUVIA [QLL] [ST] JARDIANCE [QLL]jencyclaJENTADUETO [QLL] [ST] JETREA [INJ] [SP] JEVTANA [INJ] [SP] [PA] jinteli [QLL] jolessajolivettejuneljunel feJUXTAPID [QLL] [SP] [PA]

K

KADCYLA [INJ] [SP] [PA] KALBITOR [INJ] [SP] [PA] KALETRA [QLL] [SP] KALYDECO [QLL] [SP] [PA] karivakelnorKENALOG 10 MG/ML [INJ] KEPTIVANCE [INJ] [SP] ketamine [INJ] ketoconazole ketoconazole shampoo ketoconazole topical ketoprofen ketoprofen ext-release ketorolac [QLL] [ST] ketorolac [INJ]ketorolac eye solution KINEVAC [INJ]KOATE-DVI [INJ] [SP] k-phos neutralK-PHOS ORIGINAL KRYSTEXXA [INJ] [SP] [PA] kurveloKUVAN [SP] [PA] KYPROLIS [INJ] [SP] [PA]

L

labetalollabetalol [INJ]lactic acid 10% topicallactuloseLAMICTAL XR STARTER KITS LAMISIL GRANULESlamivudine [QLL] [SP]lamivudine hbv [QLL] [SP] lamivudine/zidovudine [QLL] [SP] lamotriginelamotrigine orally disintegrating tablet [QLL]lamotrigine ext-release LANOXIN PEDIATRIC [INJ] lansoprazole delayed-release [ST] lansoprazole delayed-release

+amoxicillin+clarithromycin [QLL] LANTUS [INJ] larinlarin felatanoprost eye solution [ST] LATUDA [QLL]l-cysteine [INJ]leenaleflunomidelessinaLETAIRIS [QLL] [SP] [PA] [ST] letrozoleleucovorinleucovorin [INJ]LEUKERANLEUKINE [INJ] [QLL] [SP] [PA] leuprolide [INJ]levalbuterolLEVEMIR [INJ]levetiracetamlevetiracetam [INJ]levetiracetam ext-release levobunolol eye solution

levocarnitinelevocarnitine [INJ]levocetirizinelevofloxacinlevofloxacin [INJ]levofloxacin eye solutionlevof oxacin/dextrose [INJ]levonestlevonorgestrellevoralevorphanollevothyroxine sodiumlevothyroxine sodium [INJ] LEVOTHYROXINE SODIUM 100 MCG [INJ] LEVSIN [INJ]LEXISCAN [INJ]LEXIVA [QLL] [SP]LIALDAlidocaine [INJ]lidocaine jellylidocaine patch [PA]lidocaine topicallidocaine viscouslidocaine/dextrose [INJ]lidocaine/epinephrine [INJ]lidocaine/prilocainelindanelindane shampoolinezolid linezolid [INJ]LINZESS [QLL]LIORESAL [INJ] [SP]liothyronineliothyronine [INJ]LIPOFEN [QLL]liposyn III [INJ]LIPTRUZET [QLL]lisinoprillisinopril/hydrochlorothiazidelithium carbonatelithium carbonate ext-releaselithium citratel-methylfolate calciumLO LOESTRIN FELO MINASTRIN FElomedia 24 feLOMUSTINEloperamidelorazepamlorazepam [INJ]lorynalosartan [ST]losartan/hydrochlorothiazide [ST] LOTEMAXLOTRONEX [QLL]lovastatinlow-ogestrelloxapineLUCENTIS [INJ] [SP]LUMIGAN [ST]LUMIZYME [INJ] [SP]LUPRON DEPOT 3.75 MG, 11.25 MG [INJ] [QLL] [SP] [PA] LUPRON DEPOT-PED [INJ] [QLL] [SP] [PA] lustra-ultraluteraLYRICA [QLL] [PA]LYSODRENlyza

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2015 All Rights Reserved Page 00 Preferred Universal Formulary Comp8109bp-15 (11/01/15)

M

m.v.i. adult [INJ]M.V.I. PEDIATRIC [INJ]M.V.I.-12 [INJ]macnatal cn dha prenatal vitaminsmafenidemagnesium chloride [INJ] magnesium sulfate [INJ] MAGNESIUM-D5W 1GM/100 ML [INJ] MAGNEVIST [INJ]MAKENA [INJ] [SP]malathionmanganese chloride [INJ] manganese sulfate [INJ]mannitol [INJ]maprotilinemarlissaMARQIBO KIT [INJ] [SP]MATULANE [ST]mb hydrogelmd-gastroviewmeclizine hclmeclofenamate [ST] medroxyprogesterone medroxyprogesterone

(contraceptive)[INJ][QLL]mefenamicacid[ST]mefoquinemegestrolMEKINIST[QLL][SP][PA]meloxicam[ST]melpaquehpmelphalan[INJ]memantine[QLL]MENACTRA[INJ]MENOMUNE-A-C-Y-W-135[INJ]MENOPUR[INJ][SP]meperidine[INJ]MEPHYTONmepivacaine[INJ]mercaptopurinemeropenem[INJ]mesalaminemesna[INJ][SP] MESNEX TABLETS [SP] MESTINON SYRUP MESTINONTIMESPAN metafolbicmetafolbic plus metaproterenolmetaxalonemetforminmetforminext-release[QLL] methadonemethadone[INJ] methamphetamine methazolamide methenaminehippurate methenaminemandelate methimazoleMETHITESTmethocarbamolmethotrexatemethotrexate [INJ] methoxsalen methyclothiazidemethyldopamethyldopa/hydrochlorothiazide

methyldopate [INJ] methylergonovinemethylergonovine [INJ ] methylphenidate [QLL] methylphenidate ext-release [QLL] methylprednisolone methylprednisolone acetate [INJ] methylprednisolone sodium succinate [INJ]metipranolol eye solution metoclopramide metoclopramide [INJ] metolazonemetoprolol succinate ext-release metoprolol tartrate metoprolol tartrate [INJ] metoprolol/hydrochlorothiazide metronidazolemetronidazole [INJ] metronidazole topical metronidazole vaginal metronidazole/sodium chloride [INJ] mexiletineMIACALCIN [INJ] miconazole vaginal microgestin microgestin fe midazolammidazolam [INJ] midodrinemilrinone [INJ] milrinone/dextrose [INJ] mimveymimvey lo MINASTRIN 24 FE MINIMED INFUSION SET MINIMED RESERVOIR MINIVELLEMINOCIN [INJ] minocyclineminocycline ext-release minoxidil MIRENA mirtazapine mirtazapine orally disintegrating tablets MIRVASOmisoprostolmitomycin [INJ] [SP] mitoxantrone [INJ] [SP] [PA] M-M-R II [INJ] modafi nil [QLL] [PA moexiprilmoexipril/hydrochlorothiazide mometasone MONOCLATE-P [INJ] [SP] mono-linyahmononessaMONONINE [INJ] [SP]MONOVISC [INJ] [QLL] [SP] [PA] montelukastmorphine sulfatemorphine sulfate [INJ]morphine sulfate ext-release [QLL] [PA] [ST] morphine sulfate suppositories MOVANTIK MOXEZA [ST]moxifloxacinMOZOBIL [INJ] [QLL] [SP] [PA]

multigenmultigen folicmultigen plusmultitrace-4 [INJ]MULTITRACE-4 [INJ]MULTITRACE-5 [INJ]multivitamins/fluoridemultivitamins/fluoride/iron mupirocin MUSE [QLL]MUSTARGEN [INJ] [SP] MYALEPT [INJ] [SP] [PA] MYCAMINE [INJ]mycophenolate mofetil mycophenolic acid delayed-release myferon-150 forteMYLERANmynatal advance prenatal vitamins mynatal plus prenatal vitamins mynatal prenatal vitamins mynatal ultracaplet prenatal vitamins mynatal-z prenatal vitamins mynate 90 plus prenatal vitamins mynephrocaps MYOBLOC [INJ] [SP] [PA] MYOZYME [INJ] [SP] MYRBETRIQ [QLL] [ST]myzilra

N

nabumetone [ST] nadololnadolol/bendrof umethiazide nafcillin [INJ]nafcillin/dextrose [INJ] NAGLAZYME [INJ] [SP] [PA] nalbuphine [INJ] naloxone [INJ] naltrexoneNAMENDA XR [QLL] NAMZARIC [QLL] naphazoline eye solution naproxen [ST] naproxen delayed-release [ST] naproxen sodium [ST] naratriptan [QLL] [ST] NAROPIN 0.2%, 0.75%, 1% [INJ] NASCOBALNASONEX [QLL] [ST] NATACYNnatal-v rx prenatal vitamins natalvirt 90 dha prenatal vitamins natalvirt ca prenatal vitamins natalvirt fltNATAZIAnateglinideNATRECOR [INJ] NEBUPENTneconNEMBUTAL [INJ] neomycinneomycin/bacitracin/polymyxin eye ointmentneomycin/bacitracin/polymyxin/ hydrocortisone eye ointment neomycin/polymyxin irrigation solution neomycin/polymyxin/dexamethasone eye ointmentneomycin/polymyxin/dexamethasone eye suspension

neomycin/polymyxin/gramicidin eye solutionneomycin/polymyxin/hydrocortisone ear solutionneomycin/polymyxin/hydrocortisone ear suspensionneomycin/polymyxin/hydrocortisone eye suspensionNEOPROFEN [INJ]neostigmine [INJ]nephplex rxNEPHRAMINE [INJ]nephro-vite rxNESACAINE 1% [INJ]NEULASTA [INJ] [QLL] [SP] [PA] NEUMEGA [INJ] SP] [PA]NEUPOGEN [INJ] [QLL] [SP] [PA]NEUT [INJ]NEVANACnevirapinenevirapine ext-releasenewgen prenatal vitaminsNEXAVAR [QLL] [SP] [PA]NEXPLANONNEXTERONE [INJ]niacin ext-release [QLL]nicardipine nicardipine [INJ]nifedipine ext-releasenikkiNILANDRONnimodipinenisoldipine ext-releasenitrofurantoinnitrofurantoin macrocrystal nitrofurantoin monohydrate/macrocrystals nitroglycerin [INJ]nitroglycerin ext-releasenitroglycerin ointmentnitroglycerin patchesnitroglycerin translingual spray nitroglycerin/dextrose [INJ] NITROSTATnivatopic plusnizatidinenora-beNORDITROPIN [INJ] [SP] [PA] [ST] norepinephrine [INJ]norethindronenorethindrone acetatenorlyrocNORMOSOL-M AND DEXTROSE [INJ] NORMOSOL-R PH 7.4 [INJ] NORMOSOL- R-DEXTROSE [INJ]nortrelnortriptylineNORVIR [QLL] [SP]NOVOFINE 30G, 32G NEEDLES [OTC] NOVOFINE AUTOCOVER [OTC] NOVOLOG [INJ] [ST]NOVOLOG FLEXPEN [ST]NOVOLOG MIX 70-30 [ST] NOVOSEVEN RT [INJ] [SP]NOXAFIL [PA]NOXAFIL [INJ] [PA]NPLATE [INJ] [SP] [PA]NUCYNTA [QLL]NUCYNTA ER [QLL] [ST]NUEDEXTA [QLL]NULOJIX [INJ]

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nuquin hpnutrilyte [INJ]nutrilyte II [INJ] NUVARING [QLL] NUVIGIL [QLL] [PA] nystatinnystatin topical nystatin/triamcinolone

O

obstretrix dha prenatal vitamins ocellaoctreotide [INJ] [QLL] [SP] [PA] ocudox kitOFIRMEV [INJ]of oxacinof oxacin ear solutionof oxacin eye solutionogestrelolanzapineolanzapine [INJ]olanzapine orally disintegrating tablets olanzapine/fluoxetine [QLL] omega-3 ethyl esters capsules [QLL] omeprazole delayed-release [ST] omeprazole/sodium bicarbonate [ST] OMNIPAQUE [INJ] ONCASPAR [INJ] ondansetron [SP] ondansetron [INJ] [PA] ondansetron orally disintegrating tablets [PA]ONETOUCH ULTRA 2 METER [OTC] ONETOUCH ULTRA SYSTEM [OTC] ONETOUCH ULTRA TEST STRIPS [OTC] ONETOUCH ULTRAMINI METER [OTC] ONETOUCH VERIO IQ METER [OTC] ONETOUCH VERIO SYNC SYSTEM [OTC] ONETOUCH VERIO TEST STRIPS [OTC] ONEXTONONFIOPANA ER [QLL] [PA] [ST] opiumtinctureopium/belladona alkaloids suppositories OPSUMIT [QLL] [SP] [PA] OPTIUMOPTIUM EZ ORACEA [QLL] ORBACTIV [INJ] ORENCIA [INJ] [SP] [PA] [ST] ORFADIN [SP] orphenadrine [INJ] orphenadrine ext-release orphenadrine/ aspirin/caffeineorsythiaORTHOVISC [INJ] [QLL] [SP] [PA] OTEZLA [QLL] [SP] [PA] oxacillin [INJ]oxacillin/dextrose [INJ] oxaliplatin [INJ] oxandroloneoxaprozin [ST] oxazepamoxcarbazepineOXSORALEN 1% LOTION OXTELLAR XRoxybutynin [ST] oxybutynin ext-release [ST] oxycodoneoxycodone/acetaminophen

oxycodone/aspirinoxycodone/ibuprofen [QLL]OXYCONTIN [QLL] [PA] [ST]oxymorphone [QLL] [PA]oxymorphone ext-release [QLL] [PA] [ST]oxytocin [INJ]

P

paclitaxel [INJ] [SP]pamidronate [INJ] [SP]pancrelipase delayed-release 5000 units [ST] PANHEMATIN [INJ] pantoprazole [INJ]pantoprazole delayed-release [ST] papaverine [INJ]papaverine ext-release PARADIGM INFUSION SETS PARADIGM RESERVOIRSPARADIGM SILHOUETTE SETS paregoricparicalcitolparomomycin paroxetine [ST]paroxetine ext-release [ST] PATADAYPATANOLPEDIARIX [INJ] PEDITRACE [INJ]PEDVAXHIB [INJ] peg 3350/electrolytes powder for 4000 mL solutionPEGANONEPEGASYS [INJ] [QLL] [SP] [PA] [ST] penicillin g potassium [INJ]penicillin g procaine [INJ] penicillin g sodium [INJ] PENICILLIN GK/DEXTROSE [INJ]penicillin v potassium PENTASApentoxifylline ext-release PERFOROMIST perindoprilPERJETA [INJ] [SP] permethrinperphenazineperphenazine/amitriptyline phenazopyridinephendimetrazinephendimetrazine ext-release phenelzinephenobarbitalphenobarbital sodium [INJ] phenobarbital/hyoscyamine/atropine/ scopolamine phentermine [PA]phentolamine mesylate [INJ] phenylbutyratephenylephrine [INJ]phenylephrine eye solutionphenytoinphenytoin sodium [INJ]phenytoin sodium extendedphilithphospha 250 neutralphosphasalPHOSPHOLINE IODIDEPHOTOFRIN [INJ] [SP]physostigmine [INJ]

phytonadione [INJ]PHYTONADIONE 1 MG/0.5 ML SYRINGE [INJ]pilocarpinepilocarpineeyesolutionpimtreapindololpioglitazonepioglitazone/glimepiridepioglitazone/metforminpiperacillin/tazobactam [INJ] pirmellapiroxicam [ST] PLASMA-LYTE [INJ] plasmanate [INJ] PNEUMOVAX 23 [INJ] pnv 29-1 prenatal vitamins pnv ob+dha prenatal vitamins pnv prenatal plus multivit prenatal vitaminspnv-dha + docusate prenatal vitamins pnv-dha prenatal vitamins pnv-ferrous fumarate-docu-fa prenatal vitaminspnv-f rst prenatal vitamins pnv-omega prenatal vitamins pnv-select prenatal vitaminspnv-total prenatal vitamins podof lox polyethylene glycol 3350POLYFIN QR INFUSION SET poly-iron150fortepolymyxin [INJ]polymyxin/trimethoprim eye solution polysaccharide iron forte POMALYST [QLL] [SP] [PA] portiapotassium acetate [INJ] potassium bicarbonate/citric acid effervescent tabletspotassium chloride [INJ] potassium chloride ext-release potassium chloride oral solution potassium chloride powder packets for solutionpotassium chloride/dextrose [INJ] potassium chloride/lactated ringers/ dextrose [INJ]potassium chloride/sodium chloride [INJ] potassium citrate ext-release potassium citrate/citric acid potassium phosphate [INJ]POTIGApr creampr natal 400 ec prenatal vitaminspr natal 400 prenatal vitaminspr natal 430 ec prenatal vitaminspr natal 430 prenatal vitamins PRADAXA [QLL]pramipexolepramipexole ext-release [QLL] PRANDIMET [QLL]pravastatinprazosinPRECISION PCXPRECISION PCX PLUSPRECISION POINT OF CARE PRECISION Q-I-DPRECISION XTRA B-KETONE STRIPS [OTC]

PRECISION XTRA MONITOR [OTC] PRECISION XTRA TEST STRIPS [OTC] PRED MILDprednicarbateprednisoloneprednisolone acetate eye suspension prednisolone sodium phosphate prednisolone sodium phosphate eye solutionprednisoneprefol-dha prenatal vitamins PREMARIN [INJ] PREMARIN CREAM PREMARIN TABLETS [QLL] premasol [INJ] PREMASOL 6% [INJ] PREMPHASE [QLL] PREMPRO [QLL]prena1 chew prenatal vitamins prena1 pearl prenatal vitamins prena1 plus prenatal vitamins prena1 prenatal vitamins prenaissance 90 dha prenatal vitamins prenaissance balance prenatal vitamins prenaissance dha prenatal vitamins prenaissance harmony dha prenatal vitaminsprenaissance next prenatal vitamins prenaissance plus prenatal vitamins prenaissance prenatal vitamins prenaissance promise prenatal vitamins prenaplus prenatal vitamins prenatabs fa prenatal vitamins prenatabs rx prenatal vitamins prenatal ad prenatal vitamins prenatal low iron prenatal vitamins prenatal plus iron prenatal vitamins prenatal plus multivitamin prenatal vitaminsprenatal plus prenatal vitaminsprenatal-u prenatal vitaminspreplus prenatal vitaminsPREPOPIK pretab 29-1 prenatal vitaminsprevifemPREVNAR 13 [INJ]PREZISTA [QLL] [SP]PRIALT [INJ] [SP]PRIFTINPRIMAQUINEprimidonePRISTIQ [QLL] [ST]PRIVIGEN [INJ] [SP] [PA]PROAIR HFA [QLL] [ST]PROAIR RESPICLICK [QLL][ST] probenecidprocainamide [INJ]PROCALAMINE [INJ]prochlorperazine edisylate [INJ] prochlorperazine maleate prochlorperazine maleate suppositories PROCRIT [INJ] [QLL] [SP] [PA] [ST] PROCTOFOAM-HCPRODIGY INSULIN SYRINGES [OTC] PROFILNINE SD UNITS [INJ] progesterone in oil [INJ]progesterone; micronizedPROGLYCEMPROGRAF [INJ]

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PROHANCE [INJ]PROLASTIN C [INJ] [SP] PROLENSAPROLEUKIN [INJ] [SP]PROMACTA [QLL] [SP] [PA] promethazinepromethazine [INJ]promethazine suppositories promethazine/codeine promethazine/dextromethorphan promethazine/phenylephrine promethazine/phenylephrine/codeine propafenonepropafenone ext-release proparacaine eye solution proparacaine/f uorescein eye solution propofol [INJ]propranololpropranolol [INJ]propranolol ext-release propranolol/hydrochlorothiazide propylthiouracilPROQUAD [INJ]PROSOL [INJ]PROSTIGMINprotamine [INJ]PROTOPAM CHLORIDE [INJ] PROTOPIC [SP]protriptylinePROVENGE [INJ] [SP] [PA]pruclair prumyx prutectpseudoephedrine/codeine/ chlorpheniramine pseudoephedrine/codeine/ guaifenesin PULMICORT FLEXHALER [QLL] [ST] PULMICORT RESPULES 1 MG/2 ML PULMOZYME [QLL] [SP] purevit dualfe plus PURIXAN [SP]PYLERA [QLL]pyrazinamidepyridostigminepyridostigmine [INJ]pyridoxine [INJ]

Q

QUADRAMET [INJ]quasensequazepamquetiapineQUICK RELEASE TEFLON CANNULAQUILLIVANT XRquinaprilquinapril/hydrochlorothiazidequinidine gluconate [INJ]quinidine gluconate ext-releasequinidine sulfatequinidine sulfate ext-releasequinine sulfateQVAR [QLL] [ST]

R

RABAVERT [INJ]rabeprazole delayed-release [QLL] [ST]

RAGWITEK [QLL]raloxifene [QLL]ramiprilRANEXA [QLL]ranitidineranitidine [INJ]RAPAFLO [QLL]RAPAMUNE 1 MG, 2 MG TABLETS RAPAMUNE SOLUTIONRAVICTI [QLL] [SP] [PA]REBIF [INJ] [QLL] [SP] [PA] [ST] reclipsenRECOMBINATE [INJ] [SP] RECOMBIVAX HB [INJ]RECTIVREFLUDAN [INJ] REGRANEX [PA] RELENZA [QLL]RELISTOR [INJ] [QLL]relnate dha prenatal vitamins RELPAX [QLL] [ST]REMICADE [INJ] [SP] [PA] [ST] REMODULIN [INJ] [SP] [PA] RENACIDIN renal capsrena-vite rx reno caps RENVELAREOPRO [INJ] repaglinide [QLL]RESCRIPTOR [QLL] [SP] RESECTISOLreserpineRESTASIS [QLL] RETAVASE [INJ] RETROVIR [INJ] [QLL] [SP] REVATIO [INJ] [QLL] [SP] [PA] REVLIMID [QLL] [SP] [PA] REYATAZ [QLL] [SP] [PA] R-GENE 10 [INJ] RIASTAP [INJ] [SP] ribavirin [QLL] [SP] [PA] RIDAURA rifabutinrifampinrifampin [INJ] riluzolerimantadineringers irrigation solution ringers lactated irrigation solution ringers solution [INJ]ringers solution lactated [INJ] RIOMET [QLL]risedronate sodium [QLL] [ST] RISPERDAL CONSTA [INJ] risperidonerisperidone orally disintegrating tablets RITUXAN [INJ] [SP] [ST] rivastigmine [QLL]rizatriptan [QLL] [ST]rizatriptan orally disintegrating tablets [QLL] [ST]ROBAXIN [INJ]ropiniroleropinirole ext-release [QLL] ropivacaine [INJ]ROTATEQROZEREM [QLL] [ST]

S

SABRILSAFYRALsalicylic acid shampoosalicylic acid topical salsalateSAMSCA [SP]SANCUSO [QLL] [PA] SANDIMMUNE SOLUTION SANDOSTATIN LAR [INJ] [QLL] [SP] [PA] SANTYLSAVELLA [QLL] SCOPOLAMINE [INJ] secobarbitalselegilineselenium [INJ] selenium sulfidSELZENTRY [QLL] [SP]se-natal 19 prenatal vitamins SENSIPARSENSORCAINE-EPI 0.75%-0.0005% [INJ] SEREVENT DISKUS [QLL]SEROQUEL XRSEROSTIM [INJ] [SP] [PA] sertraline [ST]se-tan dha prenatal vitamins se-tan plussetonet prenatal vitaminssetonet-ec prenatal vitaminssevelamer carbonatesharobelSIGNIFOR [INJ] [QLL] [SP] [PA]sildenaf l [QLL] [SP] [PA]SILHOUETTE COMBO SETS SILHOUETTE INFUSION SETSsilver sulfadiazineSIMCOR [QLL]SIMPONI 100MG [INJ][SP][PA] SIMULECT [INJ]simvastatinsirolimusSIRTUROSIVEXTRO [INJ]sodium acetate [INJ]sodium bicarbonate [INJ]sodium chloride [INJ]sodium chloride 0.45% [INJ]sodium chloride 0.9% [INJ] sodium chloride 3% [INJ]sodium chloride 5% [INJ]sodium chloride irrigation solution sodium chloride nebulization solution sodium chloride; bacteriostatic [INJ] sodium ferric gluconate complex [INJ] sodium fluoridesodium fluoride dental cream, gel sodiumfluoride dental rinsesodium lactate [INJ]sodium morrhuate [INJ]sodium phosphate [INJ]sodium polystyrene sulfonate sodium polystyrene sulfonate rectal sodium thiosulfate [INJ]SOF-SET MICRO INFUSION SET SOF-SET ULTIMATE QR SET SOFT TOUCH LANCETS [OTC] SOLIRIS [INJ] [SP] [PA]

SOLODYN 55 MG, 65 MG, 80 MG, 105 MG, 115 MG [QLL]SOLU-CORTEF[INJ]SOLU-MEDROL 2 G [INJ] SOMATULINE DEPOT [INJ] [QLL] [SP] [PA]SOMAVERT [INJ] [SP] [PA] sonafinesotalolSOTALOL [INJ]SOTRADECOL [INJ] SOVALDI [QLL] [SP] [PA] spinosadSPIRIVA [QLL]spironolactonespirononlactone/hydrochlorothiazide SPORONOX SOLUTIONsprintecSPRYCEL [QLL] [SP] [PA]sronyxstannous fluoride dental rinse stavudine [QLL] [SP]STELARA [INJ] [SP] [PA] [ST] STIMATE [SP]STIVARGA [QLL] [SP] [PA] STRATTERA [QLL] STREPTOMYCIN SULFATE [INJ] STRIBILD [QLL] [SP] STROMECTOLstrovite plusSUBOXONE SL FILM

SUCLEARSUCRAIDsucralfatesufentanil [INJ]sulfacetamide eye ointment sulfacetamideeyesolutionsulfacetamide sodium topical sulfacetamide sodium/sulfur sulfacetamide sodium/sulfur shampoo sulfacetamide/ prednisolone eye solution sulfadiazinesulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim [INJ] SULFAMYLON CREAM sulfasalazinesulfasalazine delayed-release sulindac [ST]sumatriptan [QLL] [ST] sumatriptan [INJ] [QLL] [ST] sumatriptan nasal [QLL] [ST] SUMAVEL DOSEPRO [INJ] [QLL] SUPREPSURE-T INFUSION SETSUSTIVA [QLL] [SP]SUTENT [QLL] [SP] [PA]syedaSYLATRON [INJ] [SP] [PA] SYLVANT [INJ] [SP] [PA] SYMBICORT [QLL] [ST] SYMLINPEN [INJ] [PA]SYNAGIS [INJ] [SP] [PA] SYNAREL [SP] [PA]SYNERCID [INJ]SYNRIBO [INJ] [SP] [PA]SYNVISC [INJ] [QLL] [SP] [PA] SYNVISC-ONE [INJ] [QLL] [SP] [PA]

8

Created 11/1/2015. Please note this document is subject to change. Any changes/updates to this document can be viewed at emhp.welldynerx.com. Created 11/1/2015. Please note this document is subject to change. Any changes/updates to this document can be viewed at emhp.welldynerx.com.

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(continued)

2015 All Rights Reserved Page 00 Preferred Universal Formulary Comp8109bp-15 (11/01/15)

T

TABLOIDTACLONEXSUSPENSIONtacrolimusTAFINLAR[QLL][SP][PA]TALWIN[INJ]TAMIFLU[QLL]tamoxifentamsulosin ext-releaseTARCEVA [QLL] [SP] [PA]TARGRETIN [SP]TARGRETIN GEL [SP]TARKAtaron fortetaron-bc prenatal vitaminstaron-c dha prenatal vitaminstaron-prex prenatal dha prenatalvitamins TASIGNA [QLL] [SP] [PA]TAZORACTECFIDERA [QLL] [SP] [PA] [ST]TEFLARO [INJ]TEGRETOL XR 100 MGTEKAMLO [QLL]TEKTURNA [QLL]TEKTURNA HCT [QLL]telmisartan [QLL] [ST]telmisartan/amlodipine [QLL] [ST]telmisartan/hydrochlorothiazide [QLL] [ST]temazepamTEMODAR [INJ] [SP] [PA]temozolomide [SP] [PA]TENIPOSIDE [INJ]terazosinterbinafineterbutalineterbutaline [INJ]terconazoletestosterone cypionate [INJ] testosterone enanthate [INJ]TETANUS DIPHTHERIA TOXOIDS [INJ] tetanus toxoid; absorbed [INJ] tetracaine eye solutiontetracyclinetetrazenabine [PA][QLL][SP] THALLOUS CHLORIDE TL-201 [INJ] THALOMID [SP] [PA]theophyllinetheophylline ext-releaseTHERACYS [INJ] [SP]thiamine [INJ]thioridazinethiotepa [INJ]thiothixeneTHROMBATE III [INJ] [SP] THYMOGLOBULIN [INJ]THYROGEN [INJ] [SP]thyroidtiagabineTICE BCG [INJ] [SP]TIKOSYN [SP]tilia feTIMENTIN [INJ]timolol maleatetimolol maleate eye solutiontinidazoleTIVICAY [QLL] [SP]tizanidinetlgardrx

tl g-fol os tl icontl-care dha prenatal vitamins tl-cermidetl-hem 150 tl-select prenatal vitamins TOBI PODHALER [SP] [PA] TOBRADEX OINTMENTTOBRADEX STtobramycin [INJ]tobramycin eye solutiontobramycin nebulization solutiontobramycin/dexamethasone eye suspensiontobramycin/sodium chloride [INJ]tolazamidetolbutamidetolmetintolterodine [ST]tolterodine ext-release [QLL] [ST]topiramatetopotecan [INJ]TORISEL [INJ]torsemidetorsemide [INJ]TOUJEO SOLOSTAR [INJ] TOVIAZ [QLL] [ST]TPN ELECTROLYTES II [INJ] TRACE ELEMENTS-4 [INJ] TRACLEER [QLL] [SP] [PA] [ST] TRADJENTA [QLL] [ST]tramadoltramadol ext-release [QLL]tramadol/acetaminophentrandolapriltranexamic acid [QLL]tranexamic acid [INJ] tranylcyprominetravasol [INJ]TRAVATAN Z [ST]travoprost eye solution [ST]trazodoneTREANDA [INJ] [SP]TRELSTAR [INJ] [QLL] [SP] [PA]TRELSTAR DEPOT [INJ] [QLL] [SP] [PA]TRELSTAR LA [INJ] [QLL] [SP] [PA]tretinointretinoin microspherestretinoin topicaltretinoin/emollientTRETTEN [INJ] [SP]TREXALLtriadvance prenatal vitaminstriamcinolone acetonide [INJ]triamcinolone acetonide dental pastetriamcinolone acetonide nasal spraytriamcinolone acetonide topicaltriamterene/hydrochlorothiazidetriazolamTRIBENZOR [QLL] [ST]tricitratestricontri-estaryllatrifluoperazinetrifluridinetrigels-f fortetrihexyphenidyltri-legest fetri-linyahtrimethobenzamide

trimethoprimtrinatal gt prenatal vitamins trinatal rx 1 prenatal vitaminstrinate prenatal vitamins trinessatriphrocapstri-previfemTRISENOX [INJ] [SP] tri-sprintectri-tabs dha prenatal vitamins triveen-duo dha prenatal vitamins triveen-prx rnf prenatal vitaminstri-vitamin/fluoridetri-vitamin/iron/fluoridetrivoratri-zelTROPHAMINE [INJ] tropicamide eye solution trospium [ST]trospium ext-release [QLL] [ST] TRUVADA [QLL] [SP]trypsin/balsam peru/castor oil ointment trypsin/balsam peru/castor oil spray TUBERSOL [INJ] TUDORZATUSSICAPS TWINRIX [INJ] TYGACIL [INJ]TYKERB [SP] [PA] TYPHIM VI [INJ]TYSABRI [INJ] [SP] [PA] TYVASO [SP] [PA] TYZEKA [SP] [PA]

U

UCERISULORIC [QLL]ultimatecare one nf prenatal vitamins ultimatecare one prenatal vitamins ULTIVA [INJ]ur n-cureaurea/hyaluronateurea/lactic acid/salicylic acid urea/lactic acid/zinc undecylenate uretron d-surimar-turin d.s.urogesic-blueursodiolurylustellutira-cUVADEX [INJ] [SP]V

VAGIFEMvalacyclovirVALCHLOR [SP]VALCYTEvalproate sodium [INJ]valproic acidvalsartan [ST]valsartan/hydrochlorothiazide [ST] VALSTAR [INJ] [SP] vancomycin [PA]vancomycin [INJ]

vancomycin/dextrose[INJ] VANTAS [SP] VAQTAVIALS [INJ] VARIVAX [INJ]VARIZIG [INJ] VASCEPA [QLL]vasopressin [INJ] v-c forteVECTIBIX [INJ] [SP] [PA] VELCADE [INJ] [SP]velivetvemavite-prx 2 prenatal vitamins vena-bal dha prenatal vitamins venatal-fa prenatal vitamins venlafaxine [ST]venlafaxine ext-release [ST] VENOFER [INJ]VENTAVIS [QLL] [SP] [PA] VENTOLIN HFA [QLL] [ST] VERAMYST [QLL] [ST] verapamilverapamil [INJ]verapamil ext-releaseveripredVESICARE [QLL] [ST]vesturaVGOVIAGRA [QLL] [ST]VIBATIV [INJ]vic-forteVICTOZA [INJ] [QLL] [PA] [ST]VICTRELIS [QLL] [SP] [PA]VIDEX SOLUTION [QLL] [SP]VIEKIRAVIEKIRA PAK [QLL][SP][PA] VIGAMOX [ST] VIIBRYD [QLL]VIMIZIM [INJ] [SP] [PA]VIMPAT [QLL]VIMPAT [INJ]vinate care prenatal vitaminsvinate dha prenatal vitaminsvinate gt prenatal vitaminsvinate II prenatal vitaminsvinate one prenatal vitaminsvinate ultra prenatal vitaminsvinate-m prenatal vitaminsvinblastine[INJ]vincristine[INJ]vinorelbine[INJ]VIOKACEvioreleVIRACEPT [QLL] [SP] VIRAMUNE XR 100 MG [QLL] [SP] VIREAD [QLL] [SP]virt nate prenatal vitaminsvirt-advance prenatal vitamins virt-phos 250 neutralvirt-pn dha prenatal vitamins virt-pn plus prenatal vitamins virt-pn prenatal vitaminsvirt-select prenatal vitamins virt-vitevirt-vite fortevirt-vite gt prenatal vitamins VISIPAQUE [INJ]VISUDYNE [INJ] [SP] [PA] vitafol-ob prenatal vitamins

9

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2015 All Rights Reserved Page 00 Preferred Universal Formulary Comp8109bp-15 (11/01/15)

vitamins a,c,d/fluoride VIVELLE-DOT [QLL] VIVITROL [INJ] [SP] VIVOTIFBERNAvol-care rxvol-nate prenatal vitamins vol-plus prenatal vitamins vol-tab rx prenatal vitamins VOLTAREN GEL VOLUVEN [INJ] VORAXAZE [INJ] voriconazole voriconazole [INJ] VOTRIENT [QLL] [SP] [PA]vp-ch plus prenatal vitaminsvp-ch-pnv prenatal vitaminsvp-ggr-b6 prenatal vitaminsvp-heme ob + dha prenatal vitamins vp-heme ob prenatal vitaminsvp-heme one prenatal vitamins VPRIV [INJ] [SP] [PA]vp-zelvyfemlaVYTORIN [QLL]VYVANSE [QLL]

W

warfarinwater for injection, bacteriostatic [INJ]water for injection, sterile [INJ]water for irrigation; sterileWELCHOL [QLL]weraWILATE [INJ] [SP]wymzya fe

X

XALKORI [QLL] [SP] [PA] XARELTO [QLL] XGEVA [INJ] [SP] [PA] XIAFLEX [INJ] [SP] [PA] XIFAXAN [QLL] [PA] XIGDUO XR [QLL]XOFIGO [INJ] [SP] XOLAIR [INJ] [SP] [PA] XTANDI [QLL] [SP] [PA] [ST] xulane patchesXYNTHA [INJ] [SP] XYREM [QLL] [PA]

YERVOY [INJ] [SP] [PA]YF-VAX [INJ]yohimbine

Z

zafirlukastzaleplonZALTRAP [INJ] [ST] ZANOSAR [INJ] [SP] [PA] ZANTAC RX [INJ] [ST] zarahzatean-ch prenatal vitamins zatean-pn dha prenatal vitamins zatean-pn plus prenatal vitamins zatean-pn prenatal vitamins ZAVESCA [QLL] [SP] [PA] ZELBORAF [QLL] [SP] [PA] ZEMAIRA [INJ] [SP] [PA] ZEMPLAR [INJ] zenchentzenchent feZENPEP (EXCEPT 5000 UNITS) [ST] zeosaZETIA[QLL] ZEVALIN [INJ]ZIAGEN SOLUTION [QLL] [SP] ZIANAzidovudine [QLL] [SP] zinc chloride [INJ] zinc sulfate [INJ]zinc sulfate 220 mg ziprasidoneZOLADEX [QLL] [SP] zoledronic acid [INJ]zoledronic acid/mannitol [INJ] ZOLINZA [QLL] [SP] [PA] zolmitriptan [QLL] [ST] zolmitriptan orally disintegrating tablets [QLL] [ST] zolpidem [ST] zolpidemext-release[ST] ZOMETA 4 MG/100 ML [INJ] [SP] [PA] ZOMIG NASAL [QLL] [ST] zonisamideZONTIVITY [QLL] ZORTRESSZORVOLEX [QLL]ZOSTAVAX [INJ] ZOSYN GALAXY BAGS [INJ] zoviaZOVIRAXCREAMZUBSOLV [QLL] ZYDELIG [QLL] [SP] [PA] ZYKADIA [QLL] [SP] [PA] ZYLETZYTIGA [QLL] [SP] [PA] [ST] #

8-MOP

10

Y

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2015 All Rights Reserved Page 00 Preferred Universal Formulary Comp8109bp-15 (11/01/15)

Examples of Nonformulary Medications With Selected Formulary AlternativeThe following is a list of some nonformulary brand-name medications with examples of selected alternatives that are on the formulary.

Column 1 lists examples of nonformulary medications.Column 2 lists some alternatives that can be prescribed.

Nonformulary Medications Formulary Alternative(s)

ABSTRAL fentanyl citrate lozenges

ACCU-CHEK METERS/STRIPS FREESTYLE METERS/STRIPS, ONETOUCH METERS/STRIPS, OPTIUM STRIPS, PRECISION METERS/STRIPS

ALVESCO ASMANEX, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR

APIDRA HUMALOG, NOVOLOG

ARANESP PROCRIT

AXERT rizatriptan, sumatriptan, zolmitriptan, RELPAX

BECONASE AQ flunisolide, fluticasone, triamcinolone acetonide, NASONEX, VERAMYST

BENZACLIN GEL PUMP clindamycin phosphate/benzoyl peroxide, ACANYA, ZIANA

BREEZE, CONTOUR METERS/STRIPS FREESTYLE METERS/STRIPS, ONETOUCH METERS/STRIPS, OPTIUM STRIPS, PRECISION METERS/STRIPS

CETRAXAL ciprofloxacin ear solution, CIPRODEX

CIMZIA ENBREL, HUMIRA, STELARA

DUEXIS ibuprofen + famotidine

EPOGEN PROCRIT

EUFLEXXA MONOVISC, ORTHOVISC, SYNVISC, SYNVISC-ONE

EXTAVIA AVONEX, BETASERON, REBIF

FENTORA fentanyl citrate lozenges

FORTESTA ANDROGEL, AXIRON

FROVA rizatriptan, sumatriptan, zolmitriptan, RELPAX

GEL-ONE MONOVISC, ORTHOVISC, SYNVISC, SYNVISC-ONE

GONAL-F/GONAL-F RFF BRAVELLE, FOLLISTIM AQ

HYALGAN MONOVISC, ORTHOVISC, SYNVISC, SYNVISC-ONE

INCIVEK OLYSIO, VICTRELIS

KADIAN morphine sulfate ext-release, hydromorphone ext-release, oxymorphone ext-release, NUCYNTA ER, OPANA ER, OXYCONTIN

KAZANO JANUMET, JANUMET XR, JENTADUETO, KOMBIGLYZE XR

LEVITRA CIALIS, VIAGRA

NESINA JANUVIA, ONGLYZA, TRADJENTA

NOVOLIN HUMULIN

NUTROPIN/NUTROPIN AQ GENOTROPIN, HUMATROPE, NORDITROPIN

OMNARIS flunisolide, fluticasone, triamcinolone acetonide, NASONEX, VERAMYST

OMNITROPE GENOTROPIN, HUMATROPE, NORDITROPIN

PANCREAZE pancrelipase delayed-release, CREON, ZENPEP

PEGINTRON PEGASYS

PERTZYE pancrelipase delayed-release, CREON, ZENPEP

PROVENTIL HFA PROAIR HFA, VENTOLIN HFA

QNASL flunisolide, fluticasone, triamcinolone acetonide, NASONEX, VERAMYST

SAIZEN GENOTROPIN, HUMATROPE, NORDITROPIN

SIMPONI ENBREL, HUMIRA, STELARA

STAXYN CIALIS, VIAGRA

STENDRA CIALIS, VIAGRA

SUBSYS fentanyl citrate lozenges

SUPARTZ MONOVISC, ORTHOVISC, SYNVISC, SYNVISC-ONE

TANZEUM BYDUREON, BYETTA, VICTOZA

TESTIM ANDROGEL, AXIRON

TESTOSTERONE GEL ANDROGEL, AXIRON

11

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2015 All Rights Reserved Page 00 Preferred Universal Formulary Comp8109bp-15 (11/01/15)

Examples of Nonformulary Medications With Selected Formulary Alternatives (continued)

Nonformulary Medications Formulary Alternative(s)

TEVETEN HCT candesartan/hctz, irbesartan/hctz, losartan/hctz, telmisartan/hctz, valsartan/hctz, BENICAR/HCT, EDARBI/EDARBYCLOR

TEV-TROPIN GENOTROPIN, HUMATROPE, NORDITROPIN

TRUETEST, TRUETRACK METERS/STRIPS FREESTYLE METERS/STRIPS, ONETOUCH METERS/STRIPS, OPTIUM STRIPS, PRECISION METERS/STRIPS

ULTRESA pancrelipase delayed-release, CREON, ZENPEP

VELTIN clindamycin phosphate + tretinoin, ACANYA, ZIANA

VIMOVO omeprazole delayed-release + naproxen sodium

VOGELXO ANDROGEL, AXIRON

XELJANZ ENBREL, HUMIRA

XOPENEX HFA PROAIR HFA, VENTOLIN HFA

ZETONNA flunisolide, fluticasone, triamcinolone acetonide, NASONEX, VERAMYST

ZIOPTAN latanoprost, travoprost, LUMIGAN, TRAVATAN Z

ZOHYDRO ER morphine sulfate ext-release, hydromorphone ext-release, oxymorphone ext-release, NUCYNTA ER, OPANA ER, OXYCONTIN

12

Created 11/1/2015. Please note this document is subject to change. Any changes/updates to this document can be viewed at emhp.welldynerx.com.