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4D Pharmacy Managed Formulary Updates January, 2008 Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2008 ELESTRIN estradiol ADD TO FORMULARY Non-Formulary 01/01/2008 ELESTRIN estradiol ADD UM: GENDER Female 01/01/2014 nicotine gum nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2014 nicorelief nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2014 quit 2 nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2014 nicotine gum nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2014 nicorelief nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2014 quit 4 nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2014 nicotine patch nicotine ADD TO FORMULARY Preventative 01/01/2014 nicotine patch nicotine ADD TO FORMULARY Preventative 01/01/2014 nicotine patch nicotine ADD TO FORMULARY Preventative 01/01/2014 nicotine patch nicotine ADD TO FORMULARY Preventative 01/01/2014 nts nicotine ADD TO FORMULARY Preventative 01/01/2014 nicotine patch nicotine ADD TO FORMULARY Preventative 01/01/2014 nicotine patch nicotine ADD TO FORMULARY Preventative 01/01/2014 bupropion hcl sr bupropion hcl ADD TO FORMULARY Preventative 01/01/2014 bupropion hcl sr bupropion hcl ADD UM: AGE 60 to 30 yrs old 01/01/2014 ZYBAN bupropion hcl ADD TO FORMULARY Non-Formulary 01/01/2014 ZYBAN bupropion hcl ADD UM: AGE 60 to 30 yrs old 01/01/2014 buproban bupropion hcl ADD TO FORMULARY Preventative 01/01/2014 buproban bupropion hcl ADD UM: AGE 60 to 30 yrs old 01/01/2014 8-MOP methoxsalen ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 1 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ABILIFY,ABILIFY aripiprazole MAINTENA,ABILI FY DISCMELT ADD TO FORMULARY Preferred Brands 01/01/2014 ACTIMMUNE ADD TO FORMULARY Preferred Brands 01/01/2014 ACTONEL,ATEL risedronate sodium VIA ADD TO FORMULARY Preferred Brands 01/01/2014 pioglitazonepioglitazone hcl/metformin metformin,actopl hcl us met,actoplus met xr ADD TO FORMULARY Preferred Brands 01/01/2014 ADVAIR fluticasone DISKUS,ADVAIR propionate/salmeterol HFA xinafoate ADD TO FORMULARY Preferred Brands 01/01/2014 ADVATE,ADVAT E L,ADVATE M,ADVATE H,ADVATE SH,ADVATE UH,XYNTHA,XY NTHA SOLOFUSE antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor (factor viii) recomb,b-domain deleted ADD TO FORMULARY Preferred Brands 01/01/2014 AGGRENOX aspirin/dipyridamole ADD TO FORMULARY Preferred Brands 01/01/2014 AGRYLIN anagrelide hcl ADD TO FORMULARY Preferred Brands 01/01/2014 AKNE-MYCIN erythromycin base ADD TO FORMULARY Preferred Brands 01/01/2014 ALDURAZYME laronidase ADD TO FORMULARY Preferred Brands 01/01/2014 ALINIA nitazoxanide ADD TO FORMULARY Preferred Brands 01/01/2014 ALINIA nitazoxanide ADD TO FORMULARY Preferred Brands 01/01/2014 ALKERAN melphalan hcl ADD TO FORMULARY Preferred Brands 01/01/2014 ALKERAN melphalan ADD TO FORMULARY Preferred Brands 01/01/2014 ALOCRIL nedocromil sodium ADD TO FORMULARY Preventative interferon gamma1b,recomb. BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 2 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ALOMIDE lodoxamide tromethamine ADD TO FORMULARY Preferred Brands 01/01/2014 ALPHAGAN P brimonidine tartrate ADD TO FORMULARY Preferred Brands 01/01/2014 ALPHAGAN P brimonidine tartrate ADD TO FORMULARY Preferred Brands 01/01/2014 onsolis,fentanyl fentanyl citrate citrate,abstral,laz anda,actiq,fentor a CHANGE TIER Non-Formulary 01/01/2014 benzaclin,duac,cli clindamycin ndamycinphosphate/benzoyl peroxide benzoyl peroxide,acanya, clindamycin phos-benzoyl perox CHANGE TIER Non-Formulary 01/01/2014 ACCOLATE zafirlukast ADD TO FORMULARY Non-Formulary 01/01/2014 ACCOLATE zafirlukast ADD TO FORMULARY Non-Formulary 01/01/2014 ADVANCED DNA lidocaine hcl/glycerin MEDICATED COLLECT 01/01/2014 DYSPORT abobotulinumtoxina 01/01/2014 FORTESTA testosterone CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 GELNIQUE oxybutynin chloride CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 GELNIQUE oxybutynin CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 GELX povidone/taurine/zinc gluconate/peg-40 castor oil CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 GILTUSS TR guaifenesin/dextromethorph an hbr/phenylephrine CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 HEPSERA adefovir dipivoxil CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 HYLATOPICPLU emollient combination no.53 S CHANGE TIER Preferred Brands Non-Formulary CHANGE TIER Preferred Brands ADD TO FORMULARY Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 3 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 HYLATOPICPLU emollient combination no.53 S CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 HYPERTENSA caffeine/choline bitartrate/aa comb11/herbal complex no. 130 CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ISTALOL timolol maleate CHANGE TIER 01/01/2014 JETREA ocriplasmin/pf CHANGE TIER 01/01/2014 KAPVAY clonidine hcl CHANGE TIER Non-Formulary 01/01/2014 KAPVAY clonidine hcl ADD TO FORMULARY Non-Formulary 01/01/2014 KLARON sulfacetamide sodium ADD TO FORMULARY Non-Formulary 01/01/2014 KOATE-DVI antihemophilic factor, human CHANGE TIER 01/01/2014 KOATE-DVI antihemophilic factor, human ADD TO FORMULARY 01/01/2014 KOATE-DVI antihemophilic factor, human CHANGE TIER 01/01/2014 KOATE-DVI antihemophilic factor, human ADD TO FORMULARY 01/01/2014 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) CHANGE TIER Preferred Brands Non-Formulary Non-Formulary Preferred Brands Preferred Brands Non-Formulary Non-Formulary Non-Formulary Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 4 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) ADD TO FORMULARY Non-Formulary 01/01/2014 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) ADD TO FORMULARY Non-Formulary 01/01/2014 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) ADD TO FORMULARY Non-Formulary 01/01/2014 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) ADD TO FORMULARY Non-Formulary 01/01/2014 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) ADD TO FORMULARY Non-Formulary 01/01/2014 LIDODERM lidocaine CHANGE TIER Non-Formulary 01/01/2014 ANDRODERM testosterone ADD TO FORMULARY Non-Formulary 01/01/2014 ANDRODERM testosterone ADD TO FORMULARY Non-Formulary 01/01/2014 LIPOFEN fenofibrate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LIPOFEN fenofibrate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LITHOBID lithium carbonate 01/01/2014 LIVALO 01/01/2014 ADD TO FORMULARY Non-Formulary pitavastatin calcium CHANGE TIER Non-Formulary LIVALO pitavastatin calcium CHANGE TIER Non-Formulary 01/01/2014 LUPANETA PACK leuprolide acetate/norethindrone acetate CHANGE TIER 01/01/2014 LYSTEDA tranexamic acid CHANGE TIER 01/01/2014 MACUGEN pegaptanib sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 MAKENA hydroxyprogesterone caproate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 MENOSTAR estradiol CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 MENTAX butenafine hcl 01/01/2014 METHYLIN methylphenidate hcl Preferred Brands Non-Formulary ADD TO FORMULARY CHANGE TIER Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 5 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Preferred Brands Non-Formulary 01/01/2014 METHYLIN methylphenidate hcl CHANGE TIER 01/01/2014 METHYLIN methylphenidate hcl ADD TO FORMULARY Non-Formulary 01/01/2014 METHYLIN methylphenidate hcl ADD TO FORMULARY Non-Formulary 01/01/2014 MONONINE factor ix ADD TO FORMULARY Non-Formulary 01/01/2014 mononessa norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 mononessa norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 MORGIDOX doxycycline hyclate/skin cleanser comb no.19 CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 MORGIDOX doxycycline hyclate/skin cleanser comb no.19 CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NATA KOMPLETE prenatal vitamin #50/iron fumarate,bisglycinate/folic acid ADD TO FORMULARY Non-Formulary 01/01/2014 NATA KOMPLETE prenatal vitamin #50/iron fumarate,bisglycinate/folic acid ADD UM: GENDER Female 01/01/2014 NEEVODHA prenatal no.64/iron fum/lmefolate ca/algal oil/soy lecithin CHANGE TIER 01/01/2014 NEEVO DHA prenatal vitamin comb no.79/iron fumarat/fa/lmefolate ca/dha ADD TO FORMULARY Non-Formulary 01/01/2014 NEUPRO rotigotine ADD TO FORMULARY Non-Formulary 01/01/2014 NEUPRO rotigotine ADD TO FORMULARY Non-Formulary 01/01/2014 NEUPRO rotigotine ADD TO FORMULARY Non-Formulary 01/01/2014 NEUPRO rotigotine CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NEUPRO rotigotine CHANGE TIER Preferred Brands Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 6 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 NEUPRO rotigotine CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NICAZEL FORTE niacinamide/azelaic ac/quercet/turmer/fa/b6/zinc ox/copper CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NICAZEL niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NIRAVAM alprazolam ADD TO FORMULARY Non-Formulary 01/01/2014 NIRAVAM alprazolam ADD TO FORMULARY Non-Formulary 01/01/2014 NIRAVAM alprazolam ADD TO FORMULARY Non-Formulary 01/01/2014 NIRAVAM alprazolam ADD TO FORMULARY Non-Formulary 01/01/2014 normlgel ag silver carbonate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NUEDEXTA dextromethorphan hbr/quinidine sulfate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NUOX benzoyl peroxide/sulfur CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NUVAIL poly-ureaurethane CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NUVARING etonogestrel/ethinyl estradiol CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NUVARING etonogestrel/ethinyl estradiol ADD UM: GENDER Female 01/01/2014 nuzole miconazole nitrate ADD TO FORMULARY Non-Formulary 01/01/2014 onetouch ultra test strips blood sugar diagnostic CHANGE TIER Non-Formulary 01/01/2014 onetouch verio blood sugar diagnostic CHANGE TIER Non-Formulary 01/01/2014 ORAFATE sucralfate malate, polymerized CHANGE TIER 01/01/2014 OXYTROL oxybutynin CHANGE TIER Non-Formulary 01/01/2014 OXYTROL FOR WOMEN oxybutynin ADD TO FORMULARY Generics Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 7 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 PEDIATEX TD triprolidine hcl/pseudoephedrine hcl ADD TO FORMULARY Not Covered 01/01/2014 PENLAC ciclopirox ADD TO FORMULARY Non-Formulary 01/01/2014 precision xtra blood sugar diagnostic CHANGE TIER 01/01/2014 precision xtra blood ketone test,strips ADD TO FORMULARY 01/01/2014 precision q-i-d blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 precision pcx blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 precision pcx plus blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 precision point of blood sugar diagnostic care CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 PROVENTIL HFA CHANGE TIER 01/01/2014 RECOMBINATE antihemophilic factor viii, human recombinant CHANGE TIER 01/01/2014 RECOMBINATE antihemophilic factor viii, human recombinant ADD TO FORMULARY 01/01/2014 RECOMBINATE antihemophilic factor viii, human recombinant CHANGE TIER 01/01/2014 RECOMBINATE antihemophilic factor viii, human recombinant ADD TO FORMULARY 01/01/2014 RECOMBINATE antihemophilic factor viii, human recombinant CHANGE TIER 01/01/2014 REMESENSE potassium oxalate 01/01/2014 REMICADE infliximab 01/01/2014 RILUTEK riluzole ADD TO FORMULARY Non-Formulary 01/01/2014 SALAGEN pilocarpine hcl ADD TO FORMULARY Non-Formulary 01/01/2014 SALAGEN pilocarpine hcl ADD TO FORMULARY Non-Formulary albuterol sulfate Preferred Brands Non-Formulary Non-Formulary Preferred Brands Non-Formulary Non-Formulary Preferred Brands Non-Formulary Non-Formulary Preferred Brands ADD TO FORMULARY CHANGE TIER Non-Formulary Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 8 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Preferred Brands Non-Formulary 01/01/2014 SANCTURA trospium chloride CHANGE TIER 01/01/2014 SANCTURA XR trospium chloride ADD TO FORMULARY 01/01/2014 SAPHRIS asenapine maleate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 SAPHRIS asenapine maleate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 SAPHRIS asenapine maleate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 SAPHRIS asenapine maleate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 se bpo benzoyl peroxide microspheres ADD TO FORMULARY Non-Formulary 01/01/2014 se bpo benzoyl peroxide microspheres ADD TO FORMULARY Non-Formulary 01/01/2014 SEMPREX-D pseudoephedrine hcl/acrivastine ADD TO FORMULARY Non-Formulary 01/01/2014 SENTRA AM aa comb.no9/acetylcarnitine hcl/dextrose/cocoa/hrb cb127 ADD TO FORMULARY Non-Formulary 01/01/2014 SENTRA PM aa comb.no9/acetylcarnitine hcl/dextrose/cocoa/hrb cb128 CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur/urea CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 SOLARAZE diclofenac sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 stagesic hydrocodone bitartrate/acetaminophen ADD TO FORMULARY Non-Formulary 01/01/2014 symbyax,olanzap olanzapine/fluoxetine hcl ine-fluoxetine hcl ADD TO FORMULARY Non-Formulary 01/01/2014 TESTOPEL testosterone CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 TEV-TROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 THALITONE chlorthalidone Non-Formulary ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 9 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 THERAMINE choline bitartrate/aa comb10/g-aminobuty acid/hrb cb129 CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 TINDAMAX tinidazole CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 TINDAMAX tinidazole ADD TO FORMULARY Non-Formulary 01/01/2014 TRELSTAR triptorelin pamoate ADD TO FORMULARY Non-Formulary 01/01/2014 TRELSTAR triptorelin pamoate ADD TO FORMULARY Non-Formulary 01/01/2014 TRELSTAR triptorelin pamoate ADD TO FORMULARY Non-Formulary 01/01/2014 TRELSTAR triptorelin pamoate ADD TO FORMULARY Non-Formulary 01/01/2014 TRELSTAR triptorelin pamoate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 TRELSTAR triptorelin pamoate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 TRETIN-X tretinoin CHANGE TIER 01/01/2014 TRETIN-X tretinoin CHANGE TIER 01/01/2014 TRICODE AR chlorpheniramine maleate/pseudoephedrine hcl/codeine ADD TO FORMULARY Non-Formulary 01/01/2014 TRICODE GF pseudoephedrine hcl/codeine phosphate/guaifenesin ADD TO FORMULARY Preferred Brands 01/01/2014 truetrack test strip blood sugar diagnostic CHANGE TIER Non-Formulary 01/01/2014 truetest test strips blood sugar diagnostic CHANGE TIER Non-Formulary 01/01/2014 TUSSIONEX hydrocodone polistirex/chlorpheniramine polistirex CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 VANOS fluocinonide CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 VELTIN clindamycin phosphate/tretinoin Non-Formulary Preferred Brands ADD TO FORMULARY Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 10 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Preferred Brands Non-Formulary 01/01/2014 VIRAMUNE XR nevirapine CHANGE TIER 01/01/2014 VIRAMUNE XR nevirapine ADD TO FORMULARY 01/01/2014 VOSPIRE ER albuterol sulfate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 VOSPIRE ER albuterol sulfate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 VPRIV velaglucerase alfa CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XOPENEX levalbuterol hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XOPENEX levalbuterol hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XOPENEX levalbuterol hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XOPENEX levalbuterol hcl CONCENTRATE CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XOPENEX HFA levalbuterol tartrate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ZUTRIPRO hydrocodone bitart/chlorpheniramine maleate/pseudoephedrine CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 aspirin aspirin ADD TO FORMULARY Preventative 01/01/2014 aspirin aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 aspirin aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 aspirin ec aspirin ADD TO FORMULARY Preventative 01/01/2014 aspirin ec aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 aspirin ec aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 aspir-trin aspirin ADD TO FORMULARY Preventative 01/01/2014 aspir-trin aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 aspir-trin aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 ecpirin aspirin ADD TO FORMULARY Preventative 01/01/2014 ecpirin aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 ecpirin aspirin ADD UM: AGE 45 to 79 yrs old Not Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 11 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 lite coat aspirin aspirin ADD TO FORMULARY Preventative 01/01/2014 lite coat aspirin aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 lite coat aspirin aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 low dose aspirin ec aspirin ADD TO FORMULARY Preventative 01/01/2014 low dose aspirin ec aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 low dose aspirin ec aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 aspir-low aspirin ADD TO FORMULARY Preventative 01/01/2014 aspir-low aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 aspir-low aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 aspirin ec aspirin ADD TO FORMULARY Preventative 01/01/2014 aspirin ec aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 aspirin ec aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 aspir 81 aspirin ADD TO FORMULARY Preventative 01/01/2014 aspir 81 aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 aspir 81 aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 aspirin ec aspirin ADD TO FORMULARY Preventative 01/01/2014 aspirin ec aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 aspirin ec aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 aspirin ec,lo-dose aspirin aspirin ec ADD TO FORMULARY Preventative 01/01/2014 aspirin ec,lo-dose aspirin aspirin ec ADD UM: QUANTITY 30 / 30 days 01/01/2014 aspirin ec,lo-dose aspirin aspirin ec ADD UM: AGE 45 to 79 yrs old BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 12 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 adult low dose aspirin ec aspirin ADD TO FORMULARY Preventative 01/01/2014 adult low dose aspirin ec aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 adult low dose aspirin ec aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 miniprin aspirin ADD TO FORMULARY Preventative 01/01/2014 miniprin aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 miniprin aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 folic acid folic acid ADD TO FORMULARY Preventative 01/01/2014 folic acid folic acid ADD UM: QUANTITY 30 / 30 days 01/01/2014 folic acid folic acid ADD UM: AGE 12 to 60 yrs old 01/01/2014 folic acid folic acid ADD UM: GENDER Female 01/01/2014 folic acid folic acid ADD TO FORMULARY Preventative 01/01/2014 folic acid folic acid ADD UM: QUANTITY 30 / 30 days 01/01/2014 folic acid folic acid ADD UM: AGE 12 to 60 yrs old 01/01/2014 folic acid folic acid ADD UM: GENDER Female 01/01/2014 ferrous ferrous sulfate sulfate,children's ferrous sulfate ADD TO FORMULARY Preventative 01/01/2014 ferrous ferrous sulfate sulfate,children's ferrous sulfate ADD UM: QUANTITY 50 / 30 days 01/01/2014 ferrous ferrous sulfate sulfate,children's ferrous sulfate ADD UM: AGE 0.6 to 1 yrs old 01/01/2014 fer-iron ferrous sulfate ADD TO FORMULARY Preventative 01/01/2014 fer-iron ferrous sulfate ADD UM: QUANTITY 50 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 13 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 fer-iron ferrous sulfate ADD UM: AGE 0.6 to 1 yrs old 01/01/2014 children's iron ferrous sulfate ADD TO FORMULARY Preventative 01/01/2014 children's iron ferrous sulfate ADD UM: QUANTITY 50 / 30 days 01/01/2014 children's iron ferrous sulfate ADD UM: AGE 0.6 to 1 yrs old 01/01/2014 sodium fluoride sodium fluoride ADD TO FORMULARY Preventative 01/01/2014 sodium fluoride sodium fluoride ADD UM: QUANTITY 50 / 30 days 01/01/2014 sodium fluoride sodium fluoride ADD UM: AGE 0.6 to 2 yrs old 01/01/2014 sodium fluoride sodium fluoride ADD TO FORMULARY Preventative 01/01/2014 sodium fluoride sodium fluoride ADD UM: QUANTITY 30 / 30 days 01/01/2014 sodium fluoride sodium fluoride ADD UM: AGE 0.6 to 2 yrs old 01/01/2014 fluoride,sodium fluoride sodium fluoride ADD TO FORMULARY Preventative 01/01/2014 fluoride,sodium fluoride sodium fluoride ADD UM: QUANTITY 30 / 30 days 01/01/2014 fluoride,sodium fluoride sodium fluoride ADD UM: AGE 0.6 to 2 yrs old 01/01/2014 ludent fluoride sodium fluoride ADD TO FORMULARY Preventative 01/01/2014 ludent fluoride sodium fluoride ADD UM: QUANTITY 30 / 30 days 01/01/2014 ludent fluoride sodium fluoride ADD UM: AGE 0.6 to 2 yrs old 01/01/2014 fluoride sodium fluoride ADD TO FORMULARY Preventative 01/01/2014 fluoride sodium fluoride ADD UM: QUANTITY 30 / 30 days 01/01/2014 fluoride sodium fluoride ADD UM: AGE 0.6 to 2 yrs old 01/01/2014 ludent fluoride sodium fluoride ADD TO FORMULARY Preventative 01/01/2014 ludent fluoride sodium fluoride ADD UM: QUANTITY 30 / 30 days 01/01/2014 ludent fluoride sodium fluoride ADD UM: AGE 0.6 to 2 yrs old 01/01/2014 fluoritab sodium fluoride ADD TO FORMULARY Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 14 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 fluoritab sodium fluoride ADD UM: QUANTITY 30 / 30 days 01/01/2014 fluoritab sodium fluoride ADD UM: AGE 0.6 to 2 yrs old 01/01/2014 sodium fluoride,fluoride sodium fluoride ADD TO FORMULARY Preventative 01/01/2014 sodium fluoride,fluoride sodium fluoride ADD UM: QUANTITY 30 / 30 days 01/01/2014 sodium fluoride,fluoride sodium fluoride ADD UM: AGE 0.6 to 2 yrs old 01/01/2014 ludent fluoride sodium fluoride ADD TO FORMULARY Preventative 01/01/2014 ludent fluoride sodium fluoride ADD UM: QUANTITY 30 / 30 days 01/01/2014 ludent fluoride sodium fluoride ADD UM: AGE 0.6 to 2 yrs old 01/01/2014 revatio,viagra,sild sildenafil citrate enafil,sildenafil citrate ADD UM: QUANTITY 6 / 30 days 01/01/2014 CIALIS,ADCIRC A ADD UM: QUANTITY 6 / 30 days 01/01/2014 LEVITRA,STAXY vardenafil hcl N ADD UM: QUANTITY 6 / 30 days 01/01/2014 prostin vr alprostadil pediatric,caverjec t,muse,alprostadil ,edex,prostaglan din e1 ADD UM: QUANTITY 6 / 30 days 01/01/2014 CAVERJECT alprostadil CHANGE TIER Non-Formulary 01/01/2014 CAVERJECT alprostadil ADD UM: GENDER Male 01/01/2014 prostin vr alprostadil pediatric,caverjec t,muse,alprostadil ,edex,prostaglan din e1 ADD UM: GENDER Male tadalafil BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 15 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Preferred Brands Non-Formulary 01/01/2014 CAVERJECT alprostadil CHANGE TIER 01/01/2014 alprostadil alprostadil ADD TO FORMULARY Not Covered 01/01/2014 prostaglandin e1 alprostadil ADD TO FORMULARY Not Covered 01/01/2014 PROSTIN VR PEDIATRIC alprostadil ADD TO FORMULARY Not Covered 01/01/2014 STENDRA avanafil ADD UM: GENDER Female 01/01/2014 minitran nitroglycerin ADD TO FORMULARY Non-Formulary 01/01/2014 minitran nitroglycerin ADD TO FORMULARY Non-Formulary 01/01/2014 minitran nitroglycerin ADD TO FORMULARY Non-Formulary 01/01/2014 NITRO-BID nitroglycerin ADD TO FORMULARY Non-Formulary 01/01/2014 minitran nitroglycerin ADD TO FORMULARY Non-Formulary 01/01/2014 STENDRA avanafil ADD UM: QUANTITY 6 / 30 days 01/01/2014 STENDRA avanafil ADD UM: GENDER Male 01/01/2014 STENDRA avanafil ADD UM: QUANTITY 6 / 30 days 01/01/2014 STENDRA avanafil ADD UM: QUANTITY 6 / 30 days 01/01/2014 STENDRA avanafil ADD UM: GENDER Male 01/01/2014 isoxsuprine hcl isoxsuprine hcl ADD TO FORMULARY Generics 01/01/2014 isosorbide isosorbide dinitrate dinitrate,isochron, isoditrate,dilatrate -sr,isordil titradose,isordil ADD TO FORMULARY Generics 01/01/2014 ISORDIL TITRADOSE ADD TO FORMULARY Non-Formulary 01/01/2014 caduet,amlodipin amlodipine e-atorvastatin besylate/atorvastatin calcium CHANGE TIER Non-Formulary isosorbide dinitrate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 16 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 amlodipineatorvastatin amlodipine besylate/atorvastatin calcium ADD TO FORMULARY Generics 01/01/2014 amlodipineatorvastatin amlodipine besylate/atorvastatin calcium ADD TO FORMULARY Generics 01/01/2014 amlodipineatorvastatin amlodipine besylate/atorvastatin calcium ADD TO FORMULARY Generics 01/01/2014 amlodipineatorvastatin amlodipine besylate/atorvastatin calcium ADD TO FORMULARY Generics 01/01/2014 amlodipineatorvastatin amlodipine besylate/atorvastatin calcium ADD TO FORMULARY Generics 01/01/2014 amlodipineatorvastatin amlodipine besylate/atorvastatin calcium ADD TO FORMULARY Generics 01/01/2014 amlodipineatorvastatin amlodipine besylate/atorvastatin calcium ADD TO FORMULARY Generics 01/01/2014 caduet,amlodipin amlodipine e-atorvastatin besylate/atorvastatin calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 amlodipineatorvastatin amlodipine besylate/atorvastatin calcium 01/01/2014 PLAN B ONESTEP levonorgestrel ADD TO FORMULARY Non-Formulary ADD UM: QUANTITY Generics 12 / 365 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 17 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 provera,depomedroxyprogesterone provera,depoacetate subq provera 104,medroxyprog esterone acetate ADD UM: QUANTITY 1 / 75 days 01/01/2014 provera,depomedroxyprogesterone provera,depoacetate subq provera 104,medroxyprog esterone acetate ADD UM: GENDER Female 01/01/2014 DEPOPROVERA 01/01/2014 medroxyprogeste medroxyprogesterone rone acetate acetate 01/01/2014 DEPOPROVERA 01/01/2014 medroxyprogeste medroxyprogesterone rone acetate acetate ADD TO FORMULARY Preventative 01/01/2014 clopidogrel clopidogrel bisulfate ADD TO FORMULARY Generics 01/01/2014 clopidogrel clopidogrel bisulfate ADD UM: QUANTITY 1 / 30 days 01/01/2014 clopidogrel clopidogrel bisulfate ADD TO FORMULARY Generics 01/01/2014 surestep pro blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 freestyle test strips blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 optium blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 accu-chek active blood sugar diagnostic 01/01/2014 evencare medroxyprogesterone acetate medroxyprogesterone acetate blood sugar diagnostic CHANGE TIER Preferred Brands ADD TO FORMULARY CHANGE TIER Preventative Preferred Brands ADD TO FORMULARY CHANGE TIER Non-Formulary Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 18 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 blood glucose blood sugar diagnostic test,glucose test strip,premium blood glucose test,blood glucose test strip 01/01/2014 accu-chek comfort curve 01/01/2014 Type of Change Previous Value New Value CHANGE TIER Non-Formulary blood sugar diagnostic ADD TO FORMULARY Non-Formulary ultima blood sugar diagnostic CHANGE TIER Non-Formulary 01/01/2014 easygluco test strips blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ez smart blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 control ast test strip,control blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 accu-chek aviva blood sugar diagnostic ADD TO FORMULARY 01/01/2014 ez smart plus blood sugar diagnostic CHANGE TIER 01/01/2014 contour blood sugar diagnostic ADD TO FORMULARY Preferred Brands 01/01/2014 smartest test blood sugar diagnostic ADD TO FORMULARY Non-Formulary 01/01/2014 rightest gs300 test strips blood sugar diagnostic ADD TO FORMULARY Non-Formulary 01/01/2014 nova max glucose test strips blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 freestyle lite strips,freestyle lite test strips blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 advocate test strip blood sugar diagnostic ADD TO FORMULARY Non-Formulary 01/01/2014 assure pro blood sugar diagnostic ADD TO FORMULARY Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 19 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 easygluco test blood sugar diagnostic strips,easy gluco g2 CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 g-4 blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 clever choice voice+ tst strip blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 surechek test strips blood sugar diagnostic ADD TO FORMULARY Non-Formulary 01/01/2014 microdot blood sugar diagnostic ADD TO FORMULARY Non-Formulary 01/01/2014 easy check test strip blood sugar diagnostic ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 20 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date 01/01/2014 Brand Name Generic Name contour,contour blood sugar diagnostic next,bgstar,assure pro,assure platinum,assure 4,glucocard expression,relion prime test strips,micro,relion confirmmicro,glucocard 01 sensor plus,glucocard vital,glucocard vital sensor,evencare g2,evencare,eve ncare g3,easygluco test strips,easy gluco g2,control g3,control ast test strip,control,g4,maxima,infinity test strips,acura test strips,easygluco plus,prodigy no coding,easy touch test strip,eclipse,envis ion,evolution test strips,element test strips,smartdiabet es xpres,element plus,glucolab,sm artest test,glucocom Type of Change Previous Value CHANGE TIER New Value Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 21 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value glucose,rightest gs300 test strips,rightest gs100 test strips,rightest gs550 test strips,ge100 blood glucose test strip,nova max glucose test strips,keynote,wa vesense jazz,wavesense presto,agamatrix amp,blood glucose test,liberty test strips,ultratrak,ult ratrak ultimate,solus v2 test strips,caresens n,smart caresens n,reveal test strip,glucose test strip,truetest test strips,truetrack test strip,premium blood glucose test,foracare gd20,fora v10,choicedm g20,fora g20,fora test strip,fora g71a,foracare gd40,premium v10,fora v12,refuah BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 22 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value plus,surechek test strips,sure edge test strips,vocal point,truetrack smart system,easymax, easymax 15,myglucohealth ,accu-chek comfort curve,accu-chek active,microdot,m icrodot xtra,ez smart,ez smart plus,onetouch ultra test strips,onetouch verio,surestep pro,precision pcx plus,precision point of care,optium ez,precision q-id,precision pcx,optium,precis ion xtra,neutek 2tek test strips,telcare,sure -test easyplus mini,accu-chek aviva,accutrend glucose,accuchek aviva plus,accu-chek smartview,ultima, on call plus test strip,on call vivid test strip,gmate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 23 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value test strips,gluco navii,choicedm clarus test strips,quintet,quin tet ac,easy step,easy plus,easy trak,easy talk,easy plus ii,easy check test strip,fifty50 test strip,embrace,vict ory,advocate test strip,advocate redicode,advocate redi-code+,clever choice test strips,clever choice voice+ tst strip,clever choice pro,pharmacist choice,clever choice micro test strip,clever choice talk,fora d10,fora d15c,fora d15z,fora v20,fora v22,fora g30a,fora d15g,fora d20,fora g90,fora v30a,freestyle test strips,freestyle lite strips,freestyle BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 24 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lite test strips,freestyle insulinx test strips,freestyle insulinx,test n'go,optumrx,ele ment compact,blood glucose test strip,diatrue plus,td gold test strip,rightest gs260 test strips,rightest gs250s test strips,smart sense test strips,genstrip,uni strip1,embrace evo,embrace pro,on call express test strip,healthpro test strips BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 25 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date 01/01/2014 Brand Name Generic Name contour,contour blood sugar diagnostic next,bgstar,assure pro,assure platinum,assure 4,glucocard expression,relion prime test strips,micro,relion confirmmicro,glucocard 01 sensor plus,glucocard vital,glucocard vital sensor,evencare g2,evencare,eve ncare g3,easygluco test strips,easy gluco g2,control g3,control ast test strip,control,g4,maxima,infinity test strips,acura test strips,easygluco plus,prodigy no coding,easy touch test strip,eclipse,envis ion,evolution test strips,element test strips,smartdiabet es xpres,element plus,glucolab,sm artest test,glucocom Type of Change Previous Value ADD UM: QUANTITY New Value 100 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 26 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value glucose,rightest gs300 test strips,rightest gs100 test strips,rightest gs550 test strips,ge100 blood glucose test strip,nova max glucose test strips,keynote,wa vesense jazz,wavesense presto,agamatrix amp,blood glucose test,liberty test strips,ultratrak,ult ratrak ultimate,solus v2 test strips,caresens n,smart caresens n,reveal test strip,glucose test strip,truetest test strips,truetrack test strip,premium blood glucose test,foracare gd20,fora v10,choicedm g20,fora g20,fora test strip,fora g71a,foracare gd40,premium v10,fora v12,refuah BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 27 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value plus,surechek test strips,sure edge test strips,vocal point,truetrack smart system,easymax, easymax 15,myglucohealth ,accu-chek comfort curve,accu-chek active,microdot,m icrodot xtra,ez smart,ez smart plus,onetouch ultra test strips,onetouch verio,surestep pro,precision pcx plus,precision point of care,optium ez,precision q-id,precision pcx,optium,precis ion xtra,neutek 2tek test strips,telcare,sure -test easyplus mini,accu-chek aviva,accutrend glucose,accuchek aviva plus,accu-chek smartview,ultima, on call plus test strip,on call vivid test strip,gmate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 28 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value test strips,gluco navii,choicedm clarus test strips,quintet,quin tet ac,easy step,easy plus,easy trak,easy talk,easy plus ii,easy check test strip,fifty50 test strip,embrace,vict ory,advocate test strip,advocate redicode,advocate redi-code+,clever choice test strips,clever choice voice+ tst strip,clever choice pro,pharmacist choice,clever choice micro test strip,clever choice talk,fora d10,fora d15c,fora d15z,fora v20,fora v22,fora g30a,fora d15g,fora d20,fora g90,fora v30a,freestyle test strips,freestyle lite strips,freestyle BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 29 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lite test strips,freestyle insulinx test strips,freestyle insulinx,test n'go,optumrx,ele ment compact,blood glucose test strip,diatrue plus,td gold test strip,rightest gs260 test strips,rightest gs250s test strips,smart sense test strips,genstrip,uni strip1,embrace evo,embrace pro,on call express test strip,healthpro test strips 01/01/2014 contour blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2014 contour next blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2014 breeze 2 blood sugar diagnostic, disctype ADD TO FORMULARY Preferred Brands 01/01/2014 breeze 2 blood sugar diagnostic, disctype ADD UM: QUANTITY 100 / 30 days 01/01/2014 sumatriptan succinate sumatriptan succinate ADD TO FORMULARY Generics 01/01/2014 sumatriptan succinate sumatriptan succinate ADD UM: QUANTITY 18 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 30 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 sumatriptan succinate sumatriptan succinate ADD TO FORMULARY Generics 01/01/2014 sumatriptan succinate sumatriptan succinate ADD UM: QUANTITY 18 / 30 days 01/01/2014 sumatriptan succinate sumatriptan succinate ADD TO FORMULARY Generics 01/01/2014 sumatriptan succinate sumatriptan succinate ADD UM: QUANTITY 1 / 30 days 01/01/2014 sumatriptan succinate sumatriptan succinate ADD TO FORMULARY Generics 01/01/2014 sumatriptan succinate sumatriptan succinate ADD UM: QUANTITY 18 / 30 days 01/01/2014 sumatriptan succinate sumatriptan succinate ADD TO FORMULARY Generics 01/01/2014 sumatriptan succinate sumatriptan succinate ADD UM: QUANTITY 1 / 30 days 01/01/2014 sumatriptan succinate sumatriptan succinate ADD TO FORMULARY Generics 01/01/2014 sumatriptan succinate sumatriptan succinate ADD UM: QUANTITY 1 / 30 days 01/01/2014 sumatriptan succinate sumatriptan succinate ADD TO FORMULARY Generics 01/01/2014 sumatriptan succinate sumatriptan succinate ADD UM: QUANTITY 1 / 30 days 01/01/2014 sumatriptan sumatriptan ADD TO FORMULARY Generics 01/01/2014 sumatriptan sumatriptan ADD UM: QUANTITY 6 / 30 days 01/01/2014 sumatriptan sumatriptan ADD TO FORMULARY Generics 01/01/2014 sumatriptan sumatriptan ADD UM: QUANTITY 6 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 31 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 kariva desogestrel-ethinyl estradiol/ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 kariva desogestrel-ethinyl estradiol/ethinyl estradiol ADD UM: GENDER Female 01/01/2014 kariva,mircette,az desogestrel-ethinyl urette,viorele,pim estradiol/ethinyl estradiol trea CHANGE TIER Preventative 01/01/2014 kariva,mircette,az desogestrel-ethinyl urette,viorele,pim estradiol/ethinyl estradiol trea ADD UM: GENDER Female 01/01/2014 MIRCETTE 01/01/2014 desogen,apri,em desogestrel-ethinyl estradiol oquette,orthocept,reclipsen,en skyce,desogestre l-ethinyl estradiol CHANGE TIER Preventative 01/01/2014 desogen,apri,em desogestrel-ethinyl estradiol oquette,orthocept,reclipsen,en skyce,desogestre l-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 DESOGEN desogestrel-ethinyl estradiol CHANGE TIER 01/01/2014 ORTHO-CEPT desogestrel-ethinyl estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 cyclessa,velivet,c desogestrel-ethinyl estradiol aziant CHANGE TIER Preventative 01/01/2014 cyclessa,velivet,c desogestrel-ethinyl estradiol aziant ADD UM: GENDER Female desogestrel-ethinyl estradiol/ethinyl estradiol CHANGE TIER Preferred Brands Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 32 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ocella,syeda,yas ethinyl min estradiol/drospirenone 28,zarah,drospire none-ethinyl estradiol CHANGE TIER Non-Formulary 01/01/2014 ocella,syeda,yas ethinyl min estradiol/drospirenone 28,zarah,drospire none-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 NATAZIA estradiol valerate/dienogest CHANGE TIER 01/01/2014 NATAZIA estradiol valerate/dienogest ADD UM: GENDER Female 01/01/2014 BEYAZ drospirenone/ethinyl estradiol/levomefolate calcium ADD UM: GENDER Female 01/01/2014 YAZ ethinyl estradiol/drospirenone CHANGE TIER 01/01/2014 YAZ ethinyl estradiol/drospirenone ADD UM: GENDER 01/01/2014 ocella ethinyl estradiol/drospirenone ADD TO FORMULARY 01/01/2014 gianvi ethinyl estradiol/drospirenone ADD TO FORMULARY Generics 01/01/2014 gianvi ethinyl estradiol/drospirenone ADD UM: GENDER Female 01/01/2014 loryna ethinyl estradiol/drospirenone ADD TO FORMULARY Preventative 01/01/2014 loryna ethinyl estradiol/drospirenone ADD UM: GENDER Female 01/01/2014 kelnor 1-35,zovia ethynodiol diacetate-ethinyl 1-35e estradiol ADD TO FORMULARY Preventative Preferred Brands Preferred Brands Non-Formulary Non-Formulary Female Non-Formulary Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 33 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 kelnor 1-35,zovia ethynodiol diacetate-ethinyl 1-35e estradiol 01/01/2014 zovia 1-50e 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female ethynodiol diacetate-ethinyl estradiol ADD TO FORMULARY Preventative zovia 1-50e ethynodiol diacetate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 SAFYRAL drospirenone/ethinyl estradiol/levomefolate calcium CHANGE TIER 01/01/2014 SAFYRAL drospirenone/ethinyl estradiol/levomefolate calcium ADD UM: GENDER Female 01/01/2014 vestura ethinyl estradiol/drospirenone ADD TO FORMULARY Preventative 01/01/2014 vestura ethinyl estradiol/drospirenone ADD UM: GENDER Female 01/01/2014 SEASONIQUE levonorgestrel/ethinyl estradiol and ethinyl estradiol CHANGE TIER 01/01/2014 SEASONIQUE levonorgestrel/ethinyl estradiol and ethinyl estradiol ADD UM: GENDER Female 01/01/2014 levonorg-eth levonorgestrel/ethinyl estrad eth estrad estradiol and ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 levonorg-eth levonorgestrel/ethinyl estrad eth estrad estradiol and ethinyl estradiol ADD UM: GENDER Female 01/01/2014 LOSEASONIQU levonorgestrel/ethinyl E estradiol and ethinyl estradiol ADD TO FORMULARY Non-Formulary Preferred Brands Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 34 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 LOSEASONIQU levonorgestrel/ethinyl E estradiol and ethinyl estradiol 01/01/2014 amethia 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female levonorgestrel/ethinyl estradiol and ethinyl estradiol ADD TO FORMULARY Preventative amethia levonorgestrel/ethinyl estradiol and ethinyl estradiol ADD UM: GENDER Female 01/01/2014 camrese levonorgestrel/ethinyl estradiol and ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 camrese levonorgestrel/ethinyl estradiol and ethinyl estradiol ADD UM: GENDER Female 01/01/2014 daysee levonorgestrel/ethinyl estradiol and ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 daysee levonorgestrel/ethinyl estradiol and ethinyl estradiol ADD UM: GENDER Female 01/01/2014 QUARTETTE levonorgestrel/ethinyl estradiol and ethinyl estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 QUARTETTE levonorgestrel/ethinyl estradiol and ethinyl estradiol ADD UM: GENDER Female 01/01/2014 lessina,aviane,or levonorgestrel-ethinyl sythia,falmina,lut estradiol era,sronyx,levono rgestrel-eth estradiol,aubra ADD TO FORMULARY Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 35 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 lessina,aviane,or levonorgestrel-ethinyl sythia,falmina,lut estradiol era,sronyx,levono rgestrel-eth estradiol,aubra ADD UM: GENDER Female 01/01/2014 camrese levonorgestrel/ethinyl lo,loseasonique,a estradiol and ethinyl methia estradiol lo,levonorg-eth estrad eth estrad ADD TO FORMULARY Preventative 01/01/2014 camrese levonorgestrel/ethinyl lo,loseasonique,a estradiol and ethinyl methia estradiol lo,levonorg-eth estrad eth estrad ADD UM: GENDER Female 01/01/2014 NORDETTE-28 levonorgestrel-ethinyl estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 NORDETTE-28 levonorgestrel-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 levora-28 levonorgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 levora-28 levonorgestrel-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 portia levonorgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 portia levonorgestrel-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 enpresse levonorgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 enpresse levonorgestrel-ethinyl estradiol ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 36 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 jolessa,introvale, levonorgestrel-ethinyl quasense,levonor estradiol gestrel-eth estradiol ADD TO FORMULARY Preventative 01/01/2014 jolessa,introvale, levonorgestrel-ethinyl quasense,levonor estradiol gestrel-eth estradiol ADD UM: GENDER Female 01/01/2014 levonorgestrellevonorgestrel-ethinyl eth estradiol estradiol,portia,alt avera,chateal,nor dette-28,levora28,kurvelo,marlis sa ADD TO FORMULARY Preventative 01/01/2014 levonorgestrellevonorgestrel-ethinyl eth estradiol estradiol,portia,alt avera,chateal,nor dette-28,levora28,kurvelo,marlis sa ADD UM: GENDER Female 01/01/2014 next levonorgestrel choice,levonorge strel ADD TO FORMULARY Preventative 01/01/2014 next levonorgestrel choice,levonorge strel ADD UM: GENDER Female 01/01/2014 SKYLA levonorgestrel CHANGE TIER 01/01/2014 SKYLA levonorgestrel ADD UM: GENDER Female 01/01/2014 ORTHO EVRA norelgestromin/ethinyl estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ORTHO EVRA norelgestromin/ethinyl estradiol ADD UM: GENDER Female Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 37 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 xulane norelgestromin/ethinyl estradiol ADD TO FORMULARY Generics 01/01/2014 xulane norelgestromin/ethinyl estradiol ADD UM: GENDER Female 01/01/2014 PLAN B ONESTEP levonorgestrel ADD TO FORMULARY Non-Formulary 01/01/2014 next choice one dose levonorgestrel ADD TO FORMULARY Generics 01/01/2014 next choice one dose levonorgestrel ADD UM: GENDER Female 01/01/2014 junel fe,gildess fe,loestrin fe,microgestin fe,larin fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 01/01/2014 junel fe,gildess fe,loestrin fe,microgestin fe,larin fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/01/2014 estrostep fe,trilegest fe,tilia fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 01/01/2014 estrostep fe,trilegest fe,tilia fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/01/2014 loestrin 24 fe,lomedia 24 fe norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE TIER Preventative 01/01/2014 loestrin 24 fe,lomedia 24 fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/01/2014 gianvi ethinyl estradiol/drospirenone CHANGE TIER Generics Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 38 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 trivora-28 levonorgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 trivora-28 levonorgestrel-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 amethyst levonorgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 amethyst levonorgestrel-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 levonest levonorgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 levonest levonorgestrel-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 levonorgestrel levonorgestrel ADD TO FORMULARY Preventative 01/01/2014 levonorgestrel levonorgestrel ADD UM: GENDER Female 01/01/2014 LOESTRIN FE norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Non-Formulary 01/01/2014 LOESTRIN FE norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/01/2014 microgestin fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 01/01/2014 microgestin fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/01/2014 junel fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 39 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 junel fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/01/2014 LO LOESTRIN FE norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE TIER 01/01/2014 LO LOESTRIN FE norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER 01/01/2014 MINASTRIN 24 FE norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE TIER 01/01/2014 MINASTRIN 24 FE norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/01/2014 LO MINASTRIN FE norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Non-Formulary 01/01/2014 LO MINASTRIN FE norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/01/2014 LOESTRIN norethindrone acetateethinyl estradiol CHANGE TIER 01/01/2014 LOESTRIN norethindrone acetateethinyl estradiol ADD UM: GENDER 01/01/2014 LOESTRIN norethindrone acetateethinyl estradiol CHANGE TIER 01/01/2014 LOESTRIN norethindrone acetateethinyl estradiol ADD UM: GENDER Female 01/01/2014 microgestin norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative Preferred Brands Non-Formulary Female Preferred Brands Preferred Brands Non-Formulary Non-Formulary Female Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 40 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 microgestin norethindrone acetateethinyl estradiol ADD UM: GENDER Female 01/01/2014 microgestin norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 microgestin norethindrone acetateethinyl estradiol ADD UM: GENDER Female 01/01/2014 gildess norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 gildess norethindrone acetateethinyl estradiol ADD UM: GENDER Female 01/01/2014 larin norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 larin norethindrone acetateethinyl estradiol ADD UM: GENDER Female 01/01/2014 FEMCON FE norethindrone-ethinyl estradiol/ferrous fumarate CHANGE TIER 01/01/2014 FEMCON FE norethindrone-ethinyl estradiol/ferrous fumarate ADD UM: GENDER 01/01/2014 zeosa norethindrone-ethinyl estradiol/ferrous fumarate CHANGE TIER 01/01/2014 zeosa norethindrone-ethinyl estradiol/ferrous fumarate ADD UM: GENDER 01/01/2014 GENERESS FE norethindrone-ethinyl estradiol/ferrous fumarate CHANGE TIER 01/01/2014 GENERESS FE norethindrone-ethinyl estradiol/ferrous fumarate ADD UM: GENDER 01/01/2014 wymzya fe norethindrone-ethinyl estradiol/ferrous fumarate CHANGE TIER 01/01/2014 wymzya fe norethindrone-ethinyl estradiol/ferrous fumarate ADD UM: GENDER Preferred Brands Non-Formulary Female Preferred Brands Preventative Female Preferred Brands Non-Formulary Female Preferred Brands Non-Formulary Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 41 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ORTHO-NOVUM norethindrone-ethinyl estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ORTHO-NOVUM norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 PLAN B ONESTEP levonorgestrel ADD UM: GENDER Female 01/01/2014 gildess fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 01/01/2014 gildess fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/01/2014 junel norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 junel norethindrone acetateethinyl estradiol ADD UM: GENDER Female 01/01/2014 junel norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 junel norethindrone acetateethinyl estradiol ADD UM: GENDER Female 01/01/2014 gildess norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 gildess norethindrone acetateethinyl estradiol ADD UM: GENDER Female 01/01/2014 zenchent fe norethindrone-ethinyl estradiol/ferrous fumarate CHANGE TIER Preventative 01/01/2014 zenchent fe norethindrone-ethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/01/2014 MODICON norethindrone-ethinyl estradiol ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 42 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 MODICON norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 NORINYL 1+35 norethindrone-ethinyl estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 NORINYL 1+35 norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 BREVICON norethindrone-ethinyl estradiol CHANGE TIER 01/01/2014 BREVICON norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 TRI-NORINYL norethindrone-ethinyl estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 TRI-NORINYL norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 necon norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 necon norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 nortrel norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 nortrel norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 necon norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 necon norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 myzilra levonorgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 myzilra levonorgestrel-ethinyl estradiol ADD UM: GENDER Female Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 43 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 LOESTRIN FE norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE TIER Preventative Non-Formulary 01/01/2014 ESTROSTEP FE norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE TIER Preventative Non-Formulary 01/01/2014 larin fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 01/01/2014 larin fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/01/2014 ORTHO-NOVUM norethindrone-ethinyl estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ORTHO-NOVUM norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 OVCON-35 norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 nortrel norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 nortrel norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 necon norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 necon norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 necon norethindrone-ethinyl estradiol CHANGE TIER 01/01/2014 necon norethindrone-ethinyl estradiol ADD UM: GENDER Preferred Brands Preventative Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 44 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 nortrel norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 nortrel norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 aranelle norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 aranelle norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 balziva norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 balziva norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 leena norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 leena norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 zenchent norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 zenchent norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 briellyn norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 briellyn norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 alyacen norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 alyacen norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 alyacen norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 45 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 alyacen norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 philith norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 philith norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 wera norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 wera norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 my way,plan b levonorgestrel one-step,next choice one dose,levonorgest rel CHANGE UM: GENDER Female 01/01/2014 my way,plan b levonorgestrel one-step,next choice one dose,levonorgest rel CHANGE UM: QUANTITY 23 / 365 days 01/01/2014 my way levonorgestrel ADD TO FORMULARY Generics 01/01/2014 nortrel norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 nortrel norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 cyclafem norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 cyclafem norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 cyclafem norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 46 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 cyclafem norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 dasetta norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 dasetta norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 dasetta norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 dasetta norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 gildagia norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 gildagia norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 pirmella norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 pirmella norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 NORINYL 1+50 norethindrone-mestranol CHANGE TIER 01/01/2014 NORINYL 1+50 norethindrone-mestranol ADD UM: GENDER 01/01/2014 necon norethindrone-mestranol CHANGE TIER 01/01/2014 necon norethindrone-mestranol ADD UM: GENDER Female 01/01/2014 NOR-Q-D norethindrone ADD TO FORMULARY Non-Formulary 01/01/2014 NOR-Q-D norethindrone ADD UM: GENDER Female 01/01/2014 necon norethindrone-mestranol 01/01/2014 ORTHO MICRONOR norethindrone ADD TO FORMULARY Preventative 01/01/2014 ORTHO MICRONOR norethindrone ADD UM: GENDER Female CHANGE TIER Preferred Brands Non-Formulary Female Preferred Brands Preferred Brands Preventative Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 47 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 camila norethindrone ADD TO FORMULARY Preventative 01/01/2014 camila norethindrone ADD UM: GENDER Female 01/01/2014 pirmella norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 pirmella norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 vyfemla norethindrone-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 vyfemla norethindrone-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 nora-be norethindrone ADD TO FORMULARY Preventative 01/01/2014 nora-be norethindrone ADD UM: GENDER Female 01/01/2014 jolivette norethindrone ADD TO FORMULARY Preventative 01/01/2014 jolivette norethindrone ADD UM: GENDER Female 01/01/2014 heather norethindrone ADD TO FORMULARY Preventative 01/01/2014 heather norethindrone ADD UM: GENDER Female 01/01/2014 ORTHO TRICYCLEN norgestimate-ethinyl estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ORTHO TRICYCLEN norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 ELLA ulipristal acetate CHANGE TIER Non-Formulary 01/01/2014 ELLA ulipristal acetate ADD UM: GENDER Female 01/01/2014 ampicillin trihydrate ampicillin trihydrate ADD TO FORMULARY Generics 01/01/2014 ampicillin trihydrate ampicillin trihydrate ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 48 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 AVIDOXY DK doxycycline monohydrate/salicylic acid/octinoxate/zinc oxide ADD TO FORMULARY Non-Formulary 01/01/2014 amantadine amantadine hcl ADD TO FORMULARY Generics 01/01/2014 amoxicillin amoxicillin ADD TO FORMULARY Generics 01/01/2014 amoxicillin amoxicillin ADD TO FORMULARY Generics 01/01/2014 ALODOX doxycycline hyclate/eyelid cleanser no2/eyelid cleanser no3 ADD TO FORMULARY Non-Formulary 01/01/2014 albuterol sulfate albuterol sulfate ADD TO FORMULARY Generics 01/01/2014 aminocaproic acid aminocaproic acid ADD TO FORMULARY Generics 01/01/2014 aminocaproic acid aminocaproic acid ADD TO FORMULARY Generics 01/01/2014 aminocaproic acid aminocaproic acid ADD TO FORMULARY Generics 01/01/2014 anagrelide hcl anagrelide hcl ADD TO FORMULARY Generics 01/01/2014 advanced am/pm omega-3 fatty acids/calcium carb/vitamin d3/fa/mv cmb 13 ADD TO FORMULARY Generics 01/01/2014 acetaminophencodeine acetaminophen with codeine phosphate ADD TO FORMULARY Generics 01/01/2014 alprostadil alprostadil ADD TO FORMULARY Generics 01/01/2014 aspirin ec aspirin ADD TO FORMULARY Generics 01/01/2014 acetaminophcaffdihydrocodein acetaminophen/caffeine/dihy drocodeine bitartrate ADD TO FORMULARY Generics 01/01/2014 AVITENE microfibrillar collagen ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 49 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value acetaminophen with codeine phosphate ADD TO FORMULARY Generics 01/01/2014 acetaminophencodeine 01/01/2014 dextroamphetami dextroamphetamine sulfne-amphetamine saccharate/amphetamine sulf-aspartate ADD TO FORMULARY Generics 01/01/2014 alprazolam intensol alprazolam ADD TO FORMULARY Generics 01/01/2014 alagesic lq butalbital/acetaminophen/caf feine ADD TO FORMULARY Generics 01/01/2014 amoxapine amoxapine ADD TO FORMULARY Generics 01/01/2014 amoxapine amoxapine ADD TO FORMULARY Generics 01/01/2014 amoxapine amoxapine ADD TO FORMULARY Generics 01/01/2014 amoxapine amoxapine ADD TO FORMULARY Generics 01/01/2014 acetic acidaluminum acetic acid/aluminum acetate ADD TO FORMULARY Generics 01/01/2014 acetazolamide acetazolamide ADD TO FORMULARY Generics 01/01/2014 antipyrinebenzocaine antipyrine/benzocaine ADD TO FORMULARY Generics 01/01/2014 atropine sulfate atropine sulfate ADD TO FORMULARY Generics 01/01/2014 androxy fluoxymesterone ADD TO FORMULARY Generics 01/01/2014 ANDROGEL testosterone ADD TO FORMULARY Preferred Brands 01/01/2014 ANDROGEL testosterone ADD UM: GENDER Male 01/01/2014 ANDROGEL testosterone ADD TO FORMULARY Preferred Brands 01/01/2014 ANDROGEL testosterone ADD UM: GENDER Male 01/01/2014 ANDROGEL testosterone ADD TO FORMULARY Preferred Brands 01/01/2014 ANDROGEL testosterone ADD UM: GENDER Male 01/01/2014 AXIRON testosterone ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 50 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 AXIRON testosterone CHANGE UM: GENDER Male 01/01/2014 ANDROGEL testosterone ADD TO FORMULARY Preferred Brands 01/01/2014 ANDROGEL testosterone ADD UM: GENDER Male 01/01/2014 ANDROGEL testosterone ADD TO FORMULARY Non-Formulary 01/01/2014 ANDROGEL testosterone ADD UM: GENDER Male 01/01/2014 ANDROGEL testosterone ADD TO FORMULARY Non-Formulary 01/01/2014 ANDROGEL testosterone ADD UM: GENDER Male 01/01/2014 ALORA estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ALORA estradiol CHANGE UM: GENDER Female 01/01/2014 ALORA estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ALORA estradiol CHANGE UM: GENDER Female 01/01/2014 ALORA estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ALORA estradiol CHANGE UM: GENDER Male 01/01/2014 ALORA estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ALORA estradiol CHANGE UM: GENDER Male 01/01/2014 alendronate sodium alendronate sodium ADD TO FORMULARY Generics 01/01/2014 AVONEX interferon beta-1a/albumin human ADD TO FORMULARY Preferred Brands 01/01/2014 AVONEX interferon beta-1a/albumin human ADD UM: AUTHORIZATION PA applies 01/01/2014 AVONEX interferon beta-1a ADD TO FORMULARY Preferred Brands 01/01/2014 AVONEX interferon beta-1a ADD UM: AUTHORIZATION PA applies 01/01/2014 AVONEX PEN interferon beta-1a ADD TO FORMULARY Preferred Brands 01/01/2014 AVONEX PEN interferon beta-1a ADD UM: AUTHORIZATION PA applies 01/01/2014 AVC sulfanilamide ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 51 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 AVC sulfanilamide 01/01/2014 amcinonide 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female amcinonide ADD TO FORMULARY Generics amcinonide amcinonide ADD TO FORMULARY Generics 01/01/2014 apexicon e diflorasone diacetate/emollient base ADD TO FORMULARY Generics 01/01/2014 BEBULIN VH IMMUNO factor ix complex, prothrombin complex conc. (pcc) comb. 6 ADD TO FORMULARY Preferred Brands 01/01/2014 BEBULIN factor ix complex, prothrombin cplx conc(pcc) no.6, 3-factor ADD TO FORMULARY Preferred Brands 01/01/2014 BENEFIX factor ix human recombinant ADD TO FORMULARY Preferred Brands 01/01/2014 belladonnaopium opium/belladonna alkaloids ADD TO FORMULARY Generics 01/01/2014 belladonnaopium opium/belladonna alkaloids ADD TO FORMULARY Generics 01/01/2014 butalbacetaminophcaff-codein butalbital/acetaminophen/caf feine/codeine phosphate ADD TO FORMULARY Generics 01/01/2014 butalbital-aspirin- butalbital/aspirin/caffeine caffeine ADD TO FORMULARY Generics 01/01/2014 bacitracin bacitracin ADD TO FORMULARY Generics 01/01/2014 BUCALSEP benzocaine/zinc chloride/pine tar/cetylpyridinium chloride ADD TO FORMULARY Preferred Brands 01/01/2014 BUCALSEP benzocaine/zinc chloride/pine tar/cetylpyridinium chloride ADD TO FORMULARY Preferred Brands 01/01/2014 bensal hp benzoic acid/salicylic acid ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 52 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 betamethasone dipropionate betamethasone dipropionate ADD TO FORMULARY Generics 01/01/2014 bpo benzoyl peroxide ADD TO FORMULARY Generics 01/01/2014 bpo benzoyl peroxide ADD TO FORMULARY Generics 01/01/2014 bpo benzoyl peroxide ADD TO FORMULARY Generics 01/01/2014 bpo benzoyl peroxide ADD TO FORMULARY Generics 01/01/2014 bpo benzoyl peroxide ADD TO FORMULARY Generics 01/01/2014 bensal hp salicylic acid ADD TO FORMULARY Generics 01/01/2014 bp 10-1 sulfacetamide sodium/sulfur ADD TO FORMULARY Generics 01/01/2014 b-plex plus multivits,therap w-fe,hematin ADD TO FORMULARY Generics 01/01/2014 b-plex folic acid/vitamin b comp and c ADD TO FORMULARY Generics 01/01/2014 vit 3 omega-3/dha/epa/b12/folic acid/pyridoxine hcl/phytosterols ADD TO FORMULARY Generics 01/01/2014 cefaclor cefaclor ADD TO FORMULARY Generics 01/01/2014 cefaclor er cefaclor ADD TO FORMULARY Generics 01/01/2014 cefaclor cefaclor ADD TO FORMULARY Generics 01/01/2014 cefaclor cefaclor ADD TO FORMULARY Generics 01/01/2014 cefditoren pivoxil cefditoren pivoxil ADD TO FORMULARY Generics 01/01/2014 cefditoren pivoxil cefditoren pivoxil ADD TO FORMULARY Generics 01/01/2014 cephalexin cephalexin ADD TO FORMULARY Generics 01/01/2014 cephalexin cephalexin ADD TO FORMULARY Generics 01/01/2014 ciprofloxacin hcl ciprofloxacin hcl ADD TO FORMULARY Generics 01/01/2014 cycloserine cycloserine ADD TO FORMULARY Generics 01/01/2014 cyproheptadine hcl cyproheptadine hcl ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 53 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 captoprilcaptopril/hydrochlorothiazide hydrochlorothiazi de ADD TO FORMULARY Generics 01/01/2014 captoprilcaptopril/hydrochlorothiazide hydrochlorothiazi de ADD TO FORMULARY Generics 01/01/2014 captoprilcaptopril/hydrochlorothiazide hydrochlorothiazi de ADD TO FORMULARY Generics 01/01/2014 captoprilcaptopril/hydrochlorothiazide hydrochlorothiazi de ADD TO FORMULARY Generics 01/01/2014 choline mag trisalicylate ADD TO FORMULARY Generics 01/01/2014 chlordiazepoxide- amitriptyline amitriptyline hcl/chlordiazepoxide ADD TO FORMULARY Generics 01/01/2014 chlordiazepoxide- amitriptyline amitriptyline hcl/chlordiazepoxide ADD TO FORMULARY Generics 01/01/2014 cytra-k potassium citrate/citric acid ADD TO FORMULARY Generics 01/01/2014 chlorothiazide chlorothiazide ADD TO FORMULARY Generics 01/01/2014 chlorthalidone chlorthalidone ADD TO FORMULARY Generics 01/01/2014 cascara sagrada aromatic cascara fluid extract ADD TO FORMULARY Generics 01/01/2014 chlorpropamide chlorpropamide ADD TO FORMULARY Generics 01/01/2014 chlorpropamide chlorpropamide ADD TO FORMULARY Generics 01/01/2014 COMBIPATCH estradiol/norethindrone acetate ADD TO FORMULARY Preferred Brands 01/01/2014 COMBIPATCH estradiol/norethindrone acetate ADD UM: GENDER Female choline salicylate/magnesium salicylate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 54 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 COMBIPATCH estradiol/norethindrone acetate ADD TO FORMULARY Preferred Brands 01/01/2014 COMBIPATCH estradiol/norethindrone acetate ADD UM: GENDER Female 01/01/2014 CLINPRO 5000 sodium fluoride ADD TO FORMULARY Preferred Brands 01/01/2014 cyclophosphamid cyclophosphamide e ADD TO FORMULARY Generics 01/01/2014 cyclophosphamid cyclophosphamide e ADD TO FORMULARY Generics 01/01/2014 cyclosporine modified ADD TO FORMULARY Generics 01/01/2014 cromolyn sodium cromolyn sodium ADD TO FORMULARY Generics 01/01/2014 clemastine fumarate clemastine fumarate ADD TO FORMULARY Generics 01/01/2014 codeine sulfate codeine sulfate ADD TO FORMULARY Generics 01/01/2014 codeine sulfate codeine sulfate ADD TO FORMULARY Generics 01/01/2014 codeine sulfate codeine sulfate ADD TO FORMULARY Generics 01/01/2014 codeine sulfate codeine sulfate ADD TO FORMULARY Generics 01/01/2014 clindamycin phosphate clindamycin phosphate ADD TO FORMULARY Generics 01/01/2014 clindamycin phosphate clindamycin phosphate ADD UM: GENDER Female 01/01/2014 clotrimazole clotrimazole ADD TO FORMULARY Generics 01/01/2014 cyclophene cyclobenzaprine hcl ADD TO FORMULARY Generics 01/01/2014 complete-rf prenatal prenatal vitamin no.17/iron,carbonyl/folic acid/docusate sod ADD TO FORMULARY Generics cyclosporine, modified BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 55 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 complete-rf prenatal prenatal vitamin no.17/iron,carbonyl/folic acid/docusate sod 01/01/2014 cavan-alpha kit 01/01/2014 cavan-alpha kit 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female prenatal vit no.67/sodium feredetate-iron ps/folic acid/omg3 ADD TO FORMULARY Generics prenatal vit no.67/sodium feredetate-iron ps/folic acid/omg3 ADD UM: GENDER Female cavan-ec sod dha prenatal vitamins comb no.48/iron na feredetate/fa/omega-3 ADD TO FORMULARY Generics 01/01/2014 cavan-ec sod dha prenatal vitamins comb no.48/iron na feredetate/fa/omega-3 ADD UM: GENDER Female 01/01/2014 completenate prenatal vitamins combo no.14/ferrous fumarate/folic acid ADD TO FORMULARY Generics 01/01/2014 completenate prenatal vitamins combo no.14/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 dapsone dapsone ADD TO FORMULARY Generics 01/01/2014 dapsone dapsone ADD TO FORMULARY Generics 01/01/2014 dexchlorphenira mine maleate dexchlorpheniramine maleate ADD TO FORMULARY Generics 01/01/2014 doxytex doxylamine succinate ADD TO FORMULARY Generics 01/01/2014 dicyclomine hcl dicyclomine hcl CHANGE TIER Generics 01/01/2014 diphenoxylateatropine diphenoxylate hcl/atropine sulfate ADD TO FORMULARY Generics 01/01/2014 digoxin digoxin ADD TO FORMULARY Generics 01/01/2014 diazepam diazepam ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 56 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 diazepam diazepam ADD TO FORMULARY Generics 01/01/2014 diazepam diazepam ADD TO FORMULARY Generics 01/01/2014 desvenlafaxine fumarate er desvenlafaxine fumarate ADD TO FORMULARY Generics 01/01/2014 desvenlafaxine fumarate er desvenlafaxine fumarate ADD TO FORMULARY Generics 01/01/2014 desvenlafaxine er desvenlafaxine ADD TO FORMULARY Non-Formulary 01/01/2014 desvenlafaxine er desvenlafaxine ADD TO FORMULARY Non-Formulary 01/01/2014 doxepin hcl doxepin hcl ADD TO FORMULARY Generics 01/01/2014 doxepin hcl doxepin hcl ADD TO FORMULARY Generics 01/01/2014 dexamethasone dexamethasone ADD TO FORMULARY Generics 01/01/2014 dexamethasone dexamethasone ADD TO FORMULARY Generics 01/01/2014 dexamethasone dexamethasone ADD TO FORMULARY Generics 01/01/2014 dexamethasone intensol dexamethasone ADD TO FORMULARY Generics 01/01/2014 denta 5000 plus sodium fluoride ADD TO FORMULARY Generics 01/01/2014 dentagel sodium fluoride ADD TO FORMULARY Generics 01/01/2014 DYSPORT abobotulinumtoxina ADD TO FORMULARY Non-Formulary 01/01/2014 DYSPORT abobotulinumtoxina ADD UM: AUTHORIZATION PA applies 01/01/2014 difil-g 400 guaifenesin/dyphylline ADD TO FORMULARY Generics 01/01/2014 desoximetasone desoximetasone ADD TO FORMULARY Generics 01/01/2014 desoximetasone desoximetasone ADD TO FORMULARY Generics 01/01/2014 diflorasone diacetate diflorasone diacetate ADD TO FORMULARY Generics 01/01/2014 diflorasone diacetate diflorasone diacetate ADD TO FORMULARY Preventative 01/01/2014 erythromycin erythromycin base ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 57 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 erythromycin erythromycin base ADD TO FORMULARY Generics 01/01/2014 erythromycin erythromycin base ADD TO FORMULARY Generics 01/01/2014 erythromycinsulfisoxazole erythromycin ethylsuccinate/sulfisoxazole acetyl ADD TO FORMULARY Generics 01/01/2014 erythromycin ethylsuccinate erythromycin ethylsuccinate ADD TO FORMULARY Generics 01/01/2014 etoposide etoposide ADD TO FORMULARY Generics 01/01/2014 EXELON rivastigmine ADD TO FORMULARY Non-Formulary 01/01/2014 EXELON rivastigmine ADD TO FORMULARY Non-Formulary 01/01/2014 ergoloid mesylates ergoloid mesylates ADD TO FORMULARY Generics 01/01/2014 EMSAM selegiline ADD TO FORMULARY Preferred Brands 01/01/2014 EMSAM selegiline ADD TO FORMULARY Preferred Brands 01/01/2014 EMSAM selegiline ADD TO FORMULARY Preferred Brands 01/01/2014 ESTRING estradiol ADD TO FORMULARY Preferred Brands 01/01/2014 ESTRING estradiol ADD UM: GENDER Female 01/01/2014 ESTRACE estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ESTRACE estradiol ADD UM: GENDER Female 01/01/2014 estradiol estradiol ADD TO FORMULARY Generics 01/01/2014 estradiol estradiol ADD UM: GENDER Female 01/01/2014 estradiol estradiol ADD TO FORMULARY Generics 01/01/2014 estradiol estradiol ADD UM: GENDER Female 01/01/2014 estradiol estradiol ADD TO FORMULARY Generics 01/01/2014 estradiol estradiol ADD UM: GENDER Female 01/01/2014 estradiol estradiol ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 58 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 estradiol estradiol ADD UM: GENDER Female 01/01/2014 estradiol estradiol ADD TO FORMULARY Generics 01/01/2014 estradiol estradiol ADD UM: GENDER Female 01/01/2014 estropipate estropipate ADD TO FORMULARY Generics 01/01/2014 estropipate estropipate ADD UM: GENDER Female 01/01/2014 estropipate estropipate ADD TO FORMULARY Generics 01/01/2014 estropipate estropipate ADD UM: GENDER Female 01/01/2014 ENDOMETRIN progesterone,micronized ADD TO FORMULARY Preferred Brands 01/01/2014 ENDOMETRIN progesterone,micronized ADD UM: GENDER Female 01/01/2014 etidronate disodium etidronate disodium ADD TO FORMULARY Generics 01/01/2014 etidronate disodium etidronate disodium ADD TO FORMULARY Generics 01/01/2014 exoderm sodium thiosulfate/salicylic acid ADD TO FORMULARY Generics 01/01/2014 elite ob dha prenatal vitamin no.7-ferrous fumarate-folic acid-dha ADD TO FORMULARY Generics 01/01/2014 elite ob dha prenatal vitamin no.7-ferrous fumarate-folic acid-dha ADD UM: GENDER Female 01/01/2014 ferrex 150 forte plus iron asp,gly,ps/ascorb.calcium/b 12/folic/calcium/succ.acid ADD TO FORMULARY Generics 01/01/2014 ferrex 28 iron asp.gly,fum/vit c/folic acid/m-vit no.11/calcium threon ADD TO FORMULARY Generics 01/01/2014 ferraplus 90 iron,carbonyl/folic acid/vitamin b12/vitamin c/docusate na ADD TO FORMULARY Generics 01/01/2014 furosemide furosemide ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 59 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 FLECTOR diclofenac epolamine ADD TO FORMULARY Preferred Brands 01/01/2014 fenoprofen calcium fenoprofen calcium ADD TO FORMULARY Generics 01/01/2014 fluoxetine hcl fluoxetine hcl ADD TO FORMULARY Generics 01/01/2014 fluoxetine hcl fluoxetine hcl ADD UM: QUANTITY 4 / 30 days 01/01/2014 fluphenazine decanoate fluphenazine decanoate ADD TO FORMULARY Generics 01/01/2014 fluphenazine hcl fluphenazine hcl ADD TO FORMULARY Generics 01/01/2014 fluphenazine hcl fluphenazine hcl ADD TO FORMULARY Generics 01/01/2014 fluphenazine hcl fluphenazine hcl ADD TO FORMULARY Generics 01/01/2014 femcap cervical cap ADD TO FORMULARY Preferred Brands 01/01/2014 femcap cervical cap ADD TO FORMULARY Preferred Brands 01/01/2014 femcap cervical cap ADD TO FORMULARY Preferred Brands 01/01/2014 flunisolide flunisolide ADD TO FORMULARY Generics 01/01/2014 fluoresceinproparacaine proparacaine hcl/fluorescein sodium ADD TO FORMULARY Generics 01/01/2014 FEMRING estradiol acetate ADD TO FORMULARY Preferred Brands 01/01/2014 FEMRING estradiol acetate ADD UM: GENDER Female 01/01/2014 FEMRING estradiol acetate ADD TO FORMULARY Preferred Brands 01/01/2014 FEMRING estradiol acetate ADD UM: GENDER Female 01/01/2014 FIRSTprogesterone PROGESTERON E VGS 50 ADD TO FORMULARY Preferred Brands 01/01/2014 FIRSTprogesterone PROGESTERON E VGS 50 ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 60 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 FIRSTprogesterone PROGESTERON E VGS 100 ADD TO FORMULARY Preferred Brands 01/01/2014 FIRSTprogesterone PROGESTERON E VGS 100 ADD UM: GENDER Female 01/01/2014 FIRSTprogesterone PROGESTERON E VGS 200 ADD TO FORMULARY Preferred Brands 01/01/2014 FIRSTprogesterone PROGESTERON E VGS 200 ADD UM: GENDER Female 01/01/2014 flanax naproxen sodium ADD TO FORMULARY Generics 01/01/2014 fluoritab sodium fluoride ADD TO FORMULARY Preventative 01/01/2014 fluoritab sodium fluoride ADD UM: AGE 0.6 to 2 yrs old 01/01/2014 FEM PH acetic acid/oxyquinoline sulfate ADD TO FORMULARY Preferred Brands 01/01/2014 FEM PH acetic acid/oxyquinoline sulfate ADD UM: GENDER Female 01/01/2014 focalgin-b prenatal vit/folic acid/b6/calcium phosph di,tribasic/ginger ADD TO FORMULARY Generics 01/01/2014 focalgin-b prenatal vit/folic acid/b6/calcium phosph di,tribasic/ginger ADD UM: GENDER Female 01/01/2014 folbee plus cz folic acid/vitamin b comp and c/copper/zinc oxide ADD TO FORMULARY Generics 01/01/2014 folbee plus folic acid/vitamin b comp and c ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 61 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 gastrinex nf hyoscyamine sulfate/phenyltoloxamine citrate ADD TO FORMULARY Generics 01/01/2014 nicotine lozenge nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2014 nicotine lozenge nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2014 guanidine hcl guanidine hcl ADD TO FORMULARY Generics 01/01/2014 GELFOAM gelatin sponge,absorbable ADD TO FORMULARY Preferred Brands 01/01/2014 gabapentin gabapentin ADD TO FORMULARY Generics 01/01/2014 gabapentin gabapentin ADD TO FORMULARY Generics 01/01/2014 GELCLAIR potassium sorbate/hydroxyethylcellulos e/povidone/hyalur ac ADD TO FORMULARY Preferred Brands 01/01/2014 green glo lissamine green ADD TO FORMULARY Generics 01/01/2014 glutaraldehyde glutaraldehyde ADD TO FORMULARY Generics 01/01/2014 gelfilm gelatin ADD TO FORMULARY Preferred Brands 01/01/2014 gentamicin sulfate gentamicin sulfate ADD TO FORMULARY Generics 01/01/2014 gentamicin sulfate gentamicin sulfate ADD TO FORMULARY Generics 01/01/2014 silver nitrate applicator silver nitrate/potassium nitrate ADD TO FORMULARY Generics 01/01/2014 HUMATE-P antihemophilic factor, human/von willebrand factor,human ADD TO FORMULARY Preferred Brands 01/01/2014 HUMATE-P antihemophilic factor, human/von willebrand factor,human ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 62 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 HUMATE-P antihemophilic factor, human/von willebrand factor,human ADD TO FORMULARY Preferred Brands 01/01/2014 HEMOFIL M antihemophilic factor, human ADD TO FORMULARY Preferred Brands 01/01/2014 HEMOFIL M antihemophilic factor, human ADD TO FORMULARY Preferred Brands 01/01/2014 HEMOFIL M antihemophilic factor, human ADD TO FORMULARY Preferred Brands 01/01/2014 HEMOFIL M antihemophilic factor, human ADD TO FORMULARY Preferred Brands 01/01/2014 aspirin aspirin ADD TO FORMULARY Preventative 01/01/2014 aspirin aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 aspirin aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 halfprin aspirin ADD TO FORMULARY Preventative 01/01/2014 halfprin aspirin ADD UM: QUANTITY 30 / 30 days 01/01/2014 halfprin aspirin ADD UM: AGE 45 to 79 yrs old 01/01/2014 heparin sodium in heparin sodium,porcine in 0.45% nacl 0.45 % sodium chloride ADD TO FORMULARY Generics 01/01/2014 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD TO FORMULARY Generics 01/01/2014 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD TO FORMULARY Generics 01/01/2014 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD TO FORMULARY Generics 01/01/2014 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD TO FORMULARY Generics 01/01/2014 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 63 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD TO FORMULARY Generics 01/01/2014 hydrocodoneacetaminophen hydrocodone bitartrate/acetaminophen ADD TO FORMULARY Generics 01/01/2014 hydromorphone hcl hydromorphone hcl ADD TO FORMULARY Generics 01/01/2014 hydromorphone hcl hydromorphone hcl ADD TO FORMULARY Generics 01/01/2014 hydromorphone hcl hydromorphone hcl ADD TO FORMULARY Generics 01/01/2014 hydromorphone hcl hydromorphone hcl ADD TO FORMULARY Generics 01/01/2014 hydromorphone hcl hydromorphone hcl ADD TO FORMULARY Generics 01/01/2014 hydroxyzine pamoate hydroxyzine pamoate ADD TO FORMULARY Generics 01/01/2014 hollihesive skin barrier ostomy supply ADD TO FORMULARY Generics 01/01/2014 hydrofera blue polyvinyl alcohol/gentian violet/methylene blue ADD TO FORMULARY Preferred Brands 01/01/2014 hydrocodonehydrocodone homatropine mbr bitartrate/homatropine methylbromide ADD TO FORMULARY Generics 01/01/2014 halonate halobetasol propionate/ammonium lactate ADD TO FORMULARY Generics 01/01/2014 halonate pac halobetasol propionate/ammonium lactate ADD TO FORMULARY Generics 01/01/2014 hydrocortisone acetate hydrocortisone acetate/aloe vera ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 64 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 hydrocortisone valerate hydrocortisone valerate ADD TO FORMULARY Generics 01/01/2014 hydrocortisone hydrocortisone/mineral oil/petrolatum,white ADD TO FORMULARY Generics 01/01/2014 hydrocortisonelidocaine hydrocortisone acetate/lidocaine hcl/aloe vera ADD TO FORMULARY Generics 01/01/2014 hydroquinone hydroquinone microspheres ADD TO FORMULARY Generics 01/01/2014 hematogen fa ferrous fumarate/ascorbic acid/cyanocobalamin/folic acid ADD TO FORMULARY Generics 01/01/2014 LUPRON DEPOT-PED leuprolide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 LUPRON DEPOT-PED leuprolide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 LUPRON DEPOT-PED leuprolide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 LUPRON DEPOT leuprolide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 LUPRON DEPOT-PED leuprolide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 levorphanol tartrate levorphanol tartrate ADD TO FORMULARY Generics 01/01/2014 lithium lithium citrate ADD TO FORMULARY Generics 01/01/2014 lorazepam lorazepam ADD TO FORMULARY Generics 01/01/2014 lorazepam lorazepam ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 65 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 01/01/2014 insulin syringe,easytouch insulin syringe,monoject insulin syringe,ulticare,in tegra syringe,eclipse syringe,safetyglid e syringe,ultilet insulin syringe,ultra comfort,ultracomf ort,orsini insulin syringe,prodigy insulin syringe,easy touch insulin syringe,easy touch,terumo insulin syringe,thinpro insulin syringe,vanishpoi nt,trueplus insulin syringe,lite touch,topcare ultra comfort,glucopro, sure-ject insulin syringe,sure comfort,maxicomfort,ultra-thin ii,easy comfort insulin syringe,advocate syringes,comfort ez,freestyle precision,easy Generic Name syringe with needle,disposable,insulin 1 ml,syringe with needle, insulin, safety, 1 ml Type of Change Previous Value ADD TO FORMULARY New Value Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 66 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value touch insulin safety 01/01/2014 leucovorin calcium leucovorin calcium ADD TO FORMULARY Generics 01/01/2014 leucovorin calcium leucovorin calcium ADD TO FORMULARY Generics 01/01/2014 loratadine loratadine ADD TO FORMULARY Generics 01/01/2014 loratadine loratadine ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 loratadine-d loratadine/pseudoephedrine sulfate ADD TO FORMULARY Generics 01/01/2014 loratadine-d loratadine/pseudoephedrine sulfate ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 loratadine d,loratadine-d loratadine/pseudoephedrine sulfate ADD TO FORMULARY Generics 01/01/2014 loratadine d,loratadine-d loratadine/pseudoephedrine sulfate ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 loratadine,childre loratadine n's loratadine,loratad ine hives relief,loratadine allergy ADD TO FORMULARY Generics 01/01/2014 loratadine,childre loratadine n's loratadine,loratad ine hives relief,loratadine allergy ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 loratadine loratadine ADD TO FORMULARY Generics 01/01/2014 loratadine loratadine ADD UM: CUSTOM OTC Benefit Rider REQUIRED BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 67 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 loradamed loratadine ADD TO FORMULARY Generics 01/01/2014 loradamed loratadine ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 lusair guaifenesin/phenylephrine hcl ADD TO FORMULARY Generics 01/01/2014 lidocainehydrocortisone hydrocortisone acetate/lidocaine hcl/aloe vera ADD TO FORMULARY Generics 01/01/2014 lidocainehydrocortisone hydrocortisone acetate/lidocaine hcl/aloe vera ADD TO FORMULARY Generics 01/01/2014 lidocainehydrocortisone lidocaine hcl/hydrocortisone acetate ADD TO FORMULARY Generics 01/01/2014 lidocainehydrocortisone lidocaine hcl/hydrocortisone acetate ADD TO FORMULARY Generics 01/01/2014 lidocaine hcl lidocaine hcl ADD TO FORMULARY Generics 01/01/2014 lidocaineprilocaine lidocaine/prilocaine ADD TO FORMULARY Generics 01/01/2014 LUPRON DEPOT leuprolide acetate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LUPRON DEPOT leuprolide acetate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LUPRON DEPOT-PED leuprolide acetate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LUPRON DEPOT leuprolide acetate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LUPRON DEPOT leuprolide acetate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 levalbuterol hcl levalbuterol hcl CHANGE TIER Preferred Brands Generics 01/01/2014 levalbuterol hcl levalbuterol hcl CHANGE TIER Preferred Brands Generics 01/01/2014 LOVENOX enoxaparin sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOVENOX enoxaparin sodium CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 68 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 LOVENOX enoxaparin sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOVENOX enoxaparin sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOVENOX enoxaparin sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOVENOX enoxaparin sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOVENOX enoxaparin sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOVENOX enoxaparin sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LIPITOR atorvastatin calcium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LIPITOR atorvastatin calcium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LIPITOR atorvastatin calcium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 lofibra fenofibrate,micronized CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 lofibra fenofibrate,micronized CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LESCOL XL fluvastatin sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LESCOL fluvastatin sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOVAZA omega-3 acid ethyl esters CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOTREL amlodipine besylate/benazepril hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOTREL amlodipine besylate/benazepril hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOTREL amlodipine besylate/benazepril hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOTREL amlodipine besylate/benazepril hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LOTREL amlodipine besylate/benazepril hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LEXAPRO escitalopram oxalate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LEXAPRO escitalopram oxalate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 LEXAPRO escitalopram oxalate CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 69 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 LUVOX CR fluvoxamine maleate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 lindane lindane CHANGE TIER Preferred Brands Generics 01/01/2014 lindane lindane CHANGE TIER Preferred Brands Generics 01/01/2014 lidocainehydrocortisone lidocaine hcl/hydrocortisone acetate CHANGE TIER Preferred Brands Generics 01/01/2014 l-methylfolate calcium levomefolate calcium CHANGE TIER 01/01/2014 l-methylfolate levomefolate calcium CHANGE TIER Preferred Brands Generics 01/01/2014 l-methyl-b6-b12 mecobalamin/levomefolate calcium/pyridoxal phosphate CHANGE TIER Preferred Brands Generics 01/01/2014 levomefolate dha prenatal vitamin comb no.79/iron fumarat/fa/lmefolate ca/dha CHANGE TIER Preferred Brands Generics 01/01/2014 MINOCIN minocycline hcl/skin cleanser combination no.4 ADD TO FORMULARY Non-Formulary 01/01/2014 MINOCIN minocycline hcl/skin cleanser combination no.4 ADD TO FORMULARY Non-Formulary 01/01/2014 MYOBLOC rimabotulinumtoxinb ADD TO FORMULARY Preferred Brands 01/01/2014 MYOBLOC rimabotulinumtoxinb ADD UM: AUTHORIZATION PA applies 01/01/2014 MYOBLOC rimabotulinumtoxinb ADD TO FORMULARY Preferred Brands 01/01/2014 MYOBLOC rimabotulinumtoxinb ADD UM: AUTHORIZATION PA applies 01/01/2014 methyldopamethyldopa/hydrochlorothia hydrochlorothiazi zide de ADD TO FORMULARY Generics 01/01/2014 methyldopamethyldopa/hydrochlorothia hydrochlorothiazi zide de ADD TO FORMULARY Generics Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 70 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 multigen folic iron asp gly/ascorb.cal/vit b12/fa/ca-threonte/succinic acid ADD TO FORMULARY Generics 01/01/2014 multigen iron aspgly/ascorb.cal/vit b12/calcium thr/succ.acid/stomach ADD TO FORMULARY Generics 01/01/2014 multigen plus iron fum,ag/ascorb.calcium/b12/f olic acid/calcium/succ.acid ADD TO FORMULARY Generics 01/01/2014 multi-vitamin w- pediatric multivitamin combo fluorideno.45/fluoride/ferrous sulfate iron,multi-vitaminfluor-iron ADD TO FORMULARY Generics 01/01/2014 multi-vitamin w- pediatric multivitamin combo fluorideno.45/fluoride/ferrous sulfate iron,multi-vitaminfluor-iron ADD UM: AGE 0.6 to 2 yrs old 01/01/2014 mexiletine hcl mexiletine hcl ADD TO FORMULARY Generics 01/01/2014 mexiletine hcl mexiletine hcl ADD TO FORMULARY Generics 01/01/2014 mexiletine hcl mexiletine hcl ADD TO FORMULARY Generics 01/01/2014 meclofenamate sodium meclofenamate sodium ADD TO FORMULARY Generics 01/01/2014 meclofenamate sodium meclofenamate sodium ADD TO FORMULARY Generics 01/01/2014 morphine sulfate morphine sulfate ADD TO FORMULARY Generics 01/01/2014 morphine sulfate morphine sulfate ADD TO FORMULARY Generics 01/01/2014 morphine sulfate morphine sulfate ADD TO FORMULARY Generics 01/01/2014 morphine sulfate morphine sulfate ADD TO FORMULARY Generics 01/01/2014 morphine sulfate morphine sulfate ADD TO FORMULARY Generics 01/01/2014 morphine sulfate morphine sulfate ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 71 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 methylphenidate methylphenidate hcl er ADD TO FORMULARY Generics 01/01/2014 migergot ergotamine tartrate/caffeine ADD TO FORMULARY Generics 01/01/2014 maprotiline hcl maprotiline hcl ADD TO FORMULARY Generics 01/01/2014 maprotiline hcl maprotiline hcl ADD TO FORMULARY Generics 01/01/2014 maprotiline hcl maprotiline hcl ADD TO FORMULARY Generics 01/01/2014 medi-lance lancets ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 72 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date 01/01/2014 Brand Name Generic Name fingerstix,microlet lancets,lancing ,singledevice/lancets let,lancets,careon e,kinney brand lancets,thin lancets,ultra thin lancets,incontrol ultra thin lancets,unilet lancets,alternate site lancets,super thin lancets,advanced travel lancets,comfort lancets,aurora super thin lancets,incontrol super thin lancets,healthy accents unilet lancet,ulticare,lan cets thin,lancets ultra thin,fine 30 universal lancets,medlance plus,glucosource, bd ultra-fine,bd ultra-fine ii,bd microtainer lancets,techlite lancets,assure haemolance plus,assure lance,ultilet safety,ultilet classic,ultilet lancets,ultilet basic,safety Type of Change Previous Value ADD TO FORMULARY New Value Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 73 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lancets,pressure activated lancets,unilet lancet,unilet gp lancet,unilet comfortouch,unile t excelite,unilet excelite ii,unistik 3,unistik czt,unistik 3 extra,prodigy twist top lancet,prodigy lancets,actilance,droplet lancets,easy touch,1st choice lancets,1st tier unilet comfortouch,fifty5 0 safety seal lancets,smartdiab etes vantage,smartest lancet,glucocom lancets,glucocom ,rightest gl300 lancets,nova sureflex,nova safety lancets,sterilance tl,ultralance,solus v2 lancets,solus v2,invacare lancets,monolet lancets,monolet thin lancets,color lancets,e-zject lancets,micro thin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 74 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lancets,trueplus lancets,medilance,lite touch,universal 1,smart sense lancets,topcare universal1 thin lancet,e-z ject lancets,ultra thin plus,smart sense,ultra thin plus lancets,renew advanced microlancets,bullseye mini safety lancets,safetylet,safety seal lancets,easy twist & cap lancets,reliamed,r eliamed safety seal lancets,myglucoh ealth lancets,coaguche k,accu-chek safet-pro plus,accuchek,soft touch,accu-chek safe-t-pro,accuchek softclix,ez smart lancets,onetouch finepoint lancets,onetouch suresoft,onetouc h delica,onetouch lancets,medisens BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 75 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value e thin lancets,telcare,su re-lance,suretouch,softclix,acc u-chek fastclix,on call plus lancet,on call lancet,sure comfort lancets,ultra-thin ii,inject ease lancets,easy comfort,easy touch lancets,ultratlc lancets,advocate lancet,advocate lancets,clever chek lancets,foracare lancets,freestyle lancets,freestyle unistik 2,gmate,on-thego,relion thin,comfort ez,embrace BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 76 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date 01/01/2014 Brand Name Generic Name fingerstix,microlet lancets,lancing ,singledevice/lancets let,lancets,careon e,kinney brand lancets,thin lancets,ultra thin lancets,incontrol ultra thin lancets,unilet lancets,alternate site lancets,super thin lancets,advanced travel lancets,comfort lancets,aurora super thin lancets,incontrol super thin lancets,healthy accents unilet lancet,ulticare,lan cets thin,lancets ultra thin,fine 30 universal lancets,medlance plus,glucosource, bd ultra-fine,bd ultra-fine ii,bd microtainer lancets,techlite lancets,assure haemolance plus,assure lance,ultilet safety,ultilet classic,ultilet lancets,ultilet basic,safety Type of Change Previous Value ADD UM: CUSTOM New Value History of Blood Glucose Strips REQUIRED BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 77 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lancets,pressure activated lancets,unilet lancet,unilet gp lancet,unilet comfortouch,unile t excelite,unilet excelite ii,unistik 3,unistik czt,unistik 3 extra,prodigy twist top lancet,prodigy lancets,actilance,droplet lancets,easy touch,1st choice lancets,1st tier unilet comfortouch,fifty5 0 safety seal lancets,smartdiab etes vantage,smartest lancet,glucocom lancets,glucocom ,rightest gl300 lancets,nova sureflex,nova safety lancets,sterilance tl,ultralance,solus v2 lancets,solus v2,invacare lancets,monolet lancets,monolet thin lancets,color lancets,e-zject lancets,micro thin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 78 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lancets,trueplus lancets,medilance,lite touch,universal 1,smart sense lancets,topcare universal1 thin lancet,e-z ject lancets,ultra thin plus,smart sense,ultra thin plus lancets,renew advanced microlancets,bullseye mini safety lancets,safetylet,safety seal lancets,easy twist & cap lancets,reliamed,r eliamed safety seal lancets,myglucoh ealth lancets,coaguche k,accu-chek safet-pro plus,accuchek,soft touch,accu-chek safe-t-pro,accuchek softclix,ez smart lancets,onetouch finepoint lancets,onetouch suresoft,onetouc h delica,onetouch lancets,medisens BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 79 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value e thin lancets,telcare,su re-lance,suretouch,softclix,acc u-chek fastclix,on call plus lancet,on call lancet,sure comfort lancets,ultra-thin ii,inject ease lancets,easy comfort,easy touch lancets,ultratlc lancets,advocate lancet,advocate lancets,clever chek lancets,foracare lancets,freestyle lancets,freestyle unistik 2,gmate,on-thego,relion thin,comfort ez,embrace BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 80 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 01/01/2014 novofine 32,novofine,novot wist,unifine pentips,pen needle,incontrol pen needle,pen needles,unifine pentips plus,healthy accents unifine pentip,ulticare pen needle,insupen,in sulin pen needle,bd ultrafine pen needle,ultilet pen needle,clickfine,r elion pen needles,ultracomf ort,prodigy pen needle,easy touch pen needle,1st tier unifine pentips,1st tier unifine pentips plus,lite touch,needles,top care clickfine,sure-fine pen needles,sure comfort,ultra-thin ii,mini ultra-thin ii,advocate pen needles,comfort ez,easy comfort pen needles Generic Name pen needle, diabetic,needles, insulin disposable,syringe with needle,disposable,insulin 1 ml Type of Change Previous Value ADD TO FORMULARY New Value Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 81 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe with needle, insulin, safety, 0.3 ml ADD TO FORMULARY Generics 01/01/2014 magellan insulin safety syrng,magellan insulin syringe 01/01/2014 methyclothiazide methyclothiazide ADD TO FORMULARY Generics 01/01/2014 MINIVELLE estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 MINIVELLE estradiol ADD UM: GENDER Female 01/01/2014 MINIVELLE estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 MINIVELLE estradiol ADD UM: GENDER Female 01/01/2014 MINIVELLE estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 MINIVELLE estradiol ADD UM: GENDER Female 01/01/2014 MINIVELLE estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 MINIVELLE estradiol ADD UM: GENDER Female 01/01/2014 multi-vitamin wfluoride pediatric multivitamin combination no.2/sodium fluoride ADD TO FORMULARY Generics 01/01/2014 multi-vitamin wfluoride pediatric multivitamin combination no.2/sodium fluoride ADD UM: AGE 0.6 to 1 yrs old 01/01/2014 multi-vitamin wfluoride pediatric multivitamin combination no.2/sodium fluoride ADD TO FORMULARY Generics 01/01/2014 multi-vitamin wfluoride pediatric multivitamin combination no.2/sodium fluoride ADD UM: AGE 0.6 to 1 yrs old 01/01/2014 multivitamin with pediatric multivitamins no.17 fluoride,multivita with sodium mins with fluoride fluoride,pediatric multivitamins no.16 with sodium fluoride ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 82 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 multivitamin with pediatric multivitamins no.17 fluoride,multivita with sodium mins with fluoride fluoride,pediatric multivitamins no.16 with sodium fluoride ADD TO FORMULARY Generics 01/01/2014 multivitamins with pediatric multivitamins no.16 fluoride with sodium fluoride ADD TO FORMULARY Generics 01/01/2014 metaproterenol sulfate metaproterenol sulfate ADD TO FORMULARY Generics 01/01/2014 metaproterenol sulfate metaproterenol sulfate ADD TO FORMULARY Generics 01/01/2014 metaproterenol sulfate metaproterenol sulfate ADD TO FORMULARY Generics 01/01/2014 metronidazole metronidazole ADD TO FORMULARY Generics 01/01/2014 metronidazole metronidazole ADD UM: GENDER Female 01/01/2014 METROGELVAGINAL metronidazole ADD TO FORMULARY Non-Formulary 01/01/2014 METROGELVAGINAL metronidazole ADD UM: GENDER Female 01/01/2014 miconazole 3 miconazole nitrate ADD TO FORMULARY Generics 01/01/2014 miconazole 3 miconazole nitrate ADD UM: GENDER Female 01/01/2014 melpaque hp hydroquinone/ferric oxide ADD UM: CUSTOM Agents for Cosmetic Use are Not Covered 01/01/2014 methenamine mandelate methenamine mandelate ADD TO FORMULARY Generics 01/01/2014 nystatin nystatin ADD TO FORMULARY Generics 01/01/2014 nystatin nystatin ADD TO FORMULARY Generics 01/01/2014 nystatin nystatin ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 83 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 non-drowsy allergy loratadine ADD TO FORMULARY Generics 01/01/2014 non-drowsy allergy loratadine ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 niacor niacin ADD TO FORMULARY Generics 01/01/2014 nisoldipine nisoldipine ADD TO FORMULARY Generics 01/01/2014 nisoldipine nisoldipine ADD TO FORMULARY Generics 01/01/2014 nisoldipine nisoldipine ADD TO FORMULARY Generics 01/01/2014 nisoldipine nisoldipine ADD TO FORMULARY Generics 01/01/2014 nitroglycerin patch nitroglycerin ADD TO FORMULARY Generics 01/01/2014 nitroglycerin patch nitroglycerin ADD TO FORMULARY Generics 01/01/2014 nitroglycerin nitroglycerin ADD TO FORMULARY Generics 01/01/2014 nitroglycerin patch nitroglycerin ADD TO FORMULARY Generics 01/01/2014 NITRO-DUR nitroglycerin ADD TO FORMULARY Non-Formulary 01/01/2014 NITRO-DUR nitroglycerin ADD TO FORMULARY Non-Formulary 01/01/2014 nitroglycerin nitroglycerin ADD TO FORMULARY Generics 01/01/2014 NITRO-DUR nitroglycerin ADD TO FORMULARY Non-Formulary 01/01/2014 NITRO-DUR nitroglycerin ADD TO FORMULARY Non-Formulary 01/01/2014 NITROLINGUAL nitroglycerin ADD TO FORMULARY Non-Formulary 01/01/2014 nefazodone hcl nefazodone hcl ADD TO FORMULARY Generics 01/01/2014 nefazodone hcl nefazodone hcl ADD TO FORMULARY Generics 01/01/2014 nefazodone hcl nefazodone hcl ADD TO FORMULARY Generics 01/01/2014 nefazodone hcl nefazodone hcl ADD TO FORMULARY Generics 01/01/2014 nefazodone hcl nefazodone hcl ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 84 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 nortriptyline hcl nortriptyline hcl ADD TO FORMULARY Generics 01/01/2014 NUMOISYN flaxseed ADD TO FORMULARY Non-Formulary 01/01/2014 neomycinpolymyxin-hc neomycin sulfate/polymyxin b sulfate/hydrocortisone ADD TO FORMULARY Generics 01/01/2014 naphazoline hcl naphazoline hcl ADD TO FORMULARY Generics 01/01/2014 naphazoline hcl naphazoline hcl ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 NOVOLIN R insulin regular, human ADD TO FORMULARY Preferred Brands 01/01/2014 NOVOLIN 70-30 insulin nph human isophane/insulin regular, human ADD TO FORMULARY Preferred Brands 01/01/2014 NOVOLIN N insulin nph human isophane ADD TO FORMULARY Preferred Brands 01/01/2014 sodium fluoride sodium fluoride ADD TO FORMULARY Generics 01/01/2014 NAFRINSE sodium fluoride DAILY-NEUTRAL ADD TO FORMULARY Preferred Brands 01/01/2014 naproderm naproxen ADD TO FORMULARY Preferred Brands 01/01/2014 napro naproxen ADD TO FORMULARY Preferred Brands 01/01/2014 ofloxacin ofloxacin ADD TO FORMULARY Generics 01/01/2014 ofloxacin ofloxacin ADD TO FORMULARY Generics 01/01/2014 ofloxacin ofloxacin ADD TO FORMULARY Generics 01/01/2014 orphenadrine compound forte orphenadrine citrate/aspirin/caffeine ADD TO FORMULARY Generics 01/01/2014 orphenadrine compound orphenadrine citrate/aspirin/caffeine ADD TO FORMULARY Generics 01/01/2014 ortho all-flex diaphragms, arc-spring ADD TO FORMULARY Preferred Brands 01/01/2014 ortho all-flex diaphragms, arc-spring ADD UM: GENDER Female 01/01/2014 ortho all-flex diaphragms, arc-spring ADD TO FORMULARY Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 85 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 ortho all-flex diaphragms, arc-spring 01/01/2014 ortho all-flex 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female diaphragm fitting set,arcspring ADD TO FORMULARY Preventative ortho all-flex diaphragm fitting set,arcspring ADD UM: GENDER Female 01/01/2014 ORTHOVISC hyaluronate sodium ADD TO FORMULARY Preferred Brands 01/01/2014 wound matrix porcine submucosa, fenestrated ADD TO FORMULARY Preferred Brands 01/01/2014 otozin antipyrine/benzocaine/glycer in/zinc acetate ADD TO FORMULARY Generics 01/01/2014 ORASEP benzocaine/tannic acid/menthol/cetylpyridinium chloride ADD TO FORMULARY Preferred Brands 01/01/2014 oticin chloroxylenol/pramoxine hcl ADD TO FORMULARY Generics 01/01/2014 ondansetron hcl ondansetron hcl ADD TO FORMULARY Generics 01/01/2014 ondansetron hcl ondansetron hcl/pf ADD TO FORMULARY Generics 01/01/2014 ogestrel norgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 ogestrel norgestrel-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 ORAVIG miconazole ADD TO FORMULARY Preferred Brands 01/01/2014 oralone triamcinolone acetonide ADD TO FORMULARY Generics 01/01/2014 primaquine primaquine phosphate ADD TO FORMULARY Generics 01/01/2014 promethegan promethazine hcl ADD TO FORMULARY Generics 01/01/2014 promethazine vc phenylephrine hcl/promethazine hcl ADD TO FORMULARY Generics 01/01/2014 propantheline bromide ADD TO FORMULARY Generics 01/01/2014 stop smoking aid nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2014 stop smoking aid nicotine polacrilex ADD TO FORMULARY Preventative propantheline bromide BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 86 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 propranololpropranolol hydrochlorothiazi hcl/hydrochlorothiazide d ADD TO FORMULARY Generics 01/01/2014 propranololpropranolol hydrochlorothiazi hcl/hydrochlorothiazide d ADD TO FORMULARY Generics 01/01/2014 propranolol hcl propranolol hcl ADD TO FORMULARY Generics 01/01/2014 primlev oxycodone hcl/acetaminophen ADD TO FORMULARY Generics 01/01/2014 pentazocineacetaminophen pentazocine hcl/acetaminophen ADD TO FORMULARY Generics 01/01/2014 phendimetrazine phendimetrazine tartrate tartrate ADD TO FORMULARY Generics 01/01/2014 phendimetrazine phendimetrazine tartrate tartrate ADD UM: CUSTOM Benefit Rider REQUIRED 01/01/2014 phenobarbital phenobarbital ADD TO FORMULARY Generics 01/01/2014 phenobarbital phenobarbital ADD TO FORMULARY Generics 01/01/2014 phenobarbital phenobarbital ADD TO FORMULARY Generics 01/01/2014 phenobarbital phenobarbital ADD TO FORMULARY Generics 01/01/2014 phenobarbital phenobarbital ADD TO FORMULARY Generics 01/01/2014 phenytoin phenytoin ADD TO FORMULARY Generics 01/01/2014 perphenazineamitriptyline perphenazine/amitriptyline hcl ADD TO FORMULARY Generics 01/01/2014 perphenazineamitriptyline perphenazine/amitriptyline hcl ADD TO FORMULARY Generics 01/01/2014 perphenazineamitriptyline perphenazine/amitriptyline hcl ADD TO FORMULARY Generics 01/01/2014 perphenazineamitriptyline perphenazine/amitriptyline hcl ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 87 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 perphenazineamitriptyline perphenazine/amitriptyline hcl ADD TO FORMULARY Generics 01/01/2014 prumyx emollient combination no.35 ADD TO FORMULARY Generics 01/01/2014 potassium chloride potassium chloride/potassium bicarbonate/citric acid ADD TO FORMULARY Generics 01/01/2014 PERIDEX chlorhexidine gluconate ADD TO FORMULARY Non-Formulary 01/01/2014 periogard chlorhexidine gluconate ADD TO FORMULARY Generics 01/01/2014 prednisolone sodium phosphate prednisolone sod phosphate ADD TO FORMULARY Generics 01/01/2014 paregoric paregoric ADD TO FORMULARY Generics 01/01/2014 prednisone prednisone ADD TO FORMULARY Generics 01/01/2014 prednisone prednisone ADD TO FORMULARY Generics 01/01/2014 prednisone prednisone ADD TO FORMULARY Generics 01/01/2014 prednisone intensol prednisone ADD TO FORMULARY Generics 01/01/2014 prednisone prednisone ADD TO FORMULARY Generics 01/01/2014 PREMARIN estrogens, conjugated ADD TO FORMULARY Preferred Brands 01/01/2014 PREMARIN estrogens, conjugated ADD UM: GENDER Female 01/01/2014 PREVIDENT sodium fluoride/potassium 5000 SENSITIVE nitrate ADD TO FORMULARY Non-Formulary 01/01/2014 PREVIDENT 5000 ENAMEL PROTECT sodium fluoride/potassium nitrate ADD TO FORMULARY Non-Formulary 01/01/2014 phos-flur sodium fluoride ADD TO FORMULARY Generics 01/01/2014 PREVIDENT sodium fluoride ADD TO FORMULARY Non-Formulary 01/01/2014 prevident sodium fluoride ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 88 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 PREVIDENT 5000 PLUS sodium fluoride ADD TO FORMULARY Non-Formulary 01/01/2014 PREVIDENT 5000 sodium fluoride ADD TO FORMULARY Non-Formulary 01/01/2014 PROSTIN E2 VAGINAL SUPPOSITORY dinoprostone ADD TO FORMULARY Preferred Brands 01/01/2014 PREPIDIL dinoprostone ADD TO FORMULARY Non-Formulary 01/01/2014 promethazine vc- promethazine/phenylephrine codeine hcl/codeine ADD TO FORMULARY Generics 01/01/2014 phenazopyridine phenazopyridine plus hcl/hyoscyamine/butabarbita l ADD TO FORMULARY Generics 01/01/2014 potassium hydroxide potassium hydroxide ADD TO FORMULARY Generics 01/01/2014 podocon-25 podophyllum resin ADD TO FORMULARY Generics 01/01/2014 promar multivits w-iron,hematinic ADD TO FORMULARY Generics 01/01/2014 promar multivits w-iron,hematinic ADD UM: CUSTOM Vitamin Benefit Rider REQUIRED 01/01/2014 pr natal 430 ec prenatal vit #55/iron bisgly hcl,suc-prot/folic acid/omega-3 ADD TO FORMULARY Generics 01/01/2014 pr natal 430 ec prenatal vit #55/iron bisgly hcl,suc-prot/folic acid/omega-3 ADD UM: GENDER Female 01/01/2014 prenaissance dha prenatal vitamin no.105/iron harmony edta &polysaccha/fa/om3/dha/ep a ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 89 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 prenaissance dha prenatal vitamin no.105/iron harmony edta &polysaccha/fa/om3/dha/ep a 01/01/2014 quinidine sulfate 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female quinidine sulfate ADD TO FORMULARY Generics ribasphere ribavirin ADD TO FORMULARY Generics 01/01/2014 ribasphere ribavirin ADD UM: AUTHORIZATION PA applies 01/01/2014 ribasphere ribavirin ADD TO FORMULARY Generics 01/01/2014 ribasphere ribavirin ADD UM: AUTHORIZATION PA applies 01/01/2014 cetiri-d cetirizine hcl/pseudoephedrine hcl ADD TO FORMULARY Generics 01/01/2014 cetiri-d cetirizine hcl/pseudoephedrine hcl ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 cetirizine hcl cetirizine hcl ADD TO FORMULARY Generics 01/01/2014 cetirizine hcl cetirizine hcl ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 allergy relief,allergy cetirizine hcl,loratadine ADD TO FORMULARY Generics 01/01/2014 allergy relief,allergy cetirizine hcl,loratadine ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 children's allergy cetirizine hcl relief ADD TO FORMULARY Generics 01/01/2014 children's allergy cetirizine hcl relief ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 allergy relief-d fexofenadine hcl/pseudoephedrine hcl ADD TO FORMULARY Generics 01/01/2014 allergy relief-d fexofenadine hcl/pseudoephedrine hcl ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 allergy relief fexofenadine hcl ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 90 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 allergy relief fexofenadine hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 allergy relief fexofenadine hcl ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 lorata-d loratadine/pseudoephedrine sulfate ADD TO FORMULARY Generics 01/01/2014 lorata-d loratadine/pseudoephedrine sulfate ADD UM: QUANTITY 30 / 30 days 01/01/2014 lorata-d loratadine/pseudoephedrine sulfate ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 allergycongestion relief,allergycongestion loratadine/pseudoephedrine sulfate ADD TO FORMULARY Generics 01/01/2014 allergycongestion relief,allergycongestion loratadine/pseudoephedrine sulfate ADD UM: QUANTITY 30 / 30 days 01/01/2014 allergycongestion relief,allergycongestion loratadine/pseudoephedrine sulfate ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 reserpine reserpine ADD TO FORMULARY Generics 01/01/2014 reserpine reserpine ADD TO FORMULARY Generics 01/01/2014 REVATIO sildenafil citrate ADD TO FORMULARY Non-Formulary 01/01/2014 restore silver sulfate/foam bandage ADD TO FORMULARY Non-Formulary 01/01/2014 restore silver sulfate/foam bandage ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 91 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change 01/01/2014 ultra comfort,monoject ,insulin syringe,ulticare,e xel insulin syringe,safetyglid e insulin syringe,ultilet insulin syringe,ultracomf ort,orsini insulin syringe,prodigy insulin syringe,easy touch insulin syringe,easy touch,monoject insulin syringe,terumo insulin syringe,thinpro insulin syringe,vanishpoi nt,trueplus insulin syringe,lite touch,topcare ultra comfort,glucopro, sure-ject insulin syringe,sure comfort,maxicomfort,ultra-thin ii,easy comfort insulin syringe,advocate syringes,comfort ez,freestyle precision syringe with needle,insulin,0.5 ml,syringe with needle,insulin disposable,0.5 ml,syringeneedle,insulin,0.5 ml/container,empty ADD TO FORMULARY Previous Value New Value Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 92 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 radiagel emollient base ADD TO FORMULARY Preferred Brands 01/01/2014 restore contact layer silver silver sulfate/non-adherent bandage ADD TO FORMULARY Non-Formulary 01/01/2014 restore calcium alginate silver/calcium alginate ADD TO FORMULARY Non-Formulary 01/01/2014 restore silver/calcium alginate ADD TO FORMULARY Non-Formulary 01/01/2014 relagard acetic acid/oxyquinoline sulfate ADD TO FORMULARY Generics 01/01/2014 relagard acetic acid/oxyquinoline sulfate ADD UM: GENDER Female 01/01/2014 refissa tretinoin/emollient base ADD TO FORMULARY Preferred Brands 01/01/2014 sulfadiazine sulfadiazine ADD TO FORMULARY Generics 01/01/2014 sulfamethoxazole sulfamethoxazole/trimethopr -trimethoprim im ADD TO FORMULARY Generics 01/01/2014 SYNAGIS palivizumab ADD TO FORMULARY Preferred Brands 01/01/2014 SYNAGIS palivizumab ADD TO FORMULARY Preferred Brands 01/01/2014 se-tan dha prenatal vit no.10/iron fum,polysac comp/folic acid/omega-3 ADD TO FORMULARY Generics 01/01/2014 se-tan dha prenatal vit no.10/iron fum,polysac comp/folic acid/omega-3 ADD UM: GENDER Female 01/01/2014 sulfacetamide sodium sulfacetamide sodium ADD TO FORMULARY Generics 01/01/2014 SANCUSO granisetron ADD TO FORMULARY Non-Formulary 01/01/2014 STRIANT testosterone ADD TO FORMULARY Preferred Brands 01/01/2014 STRIANT testosterone ADD UM: GENDER Male 01/01/2014 sski potassium iodide ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 93 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 sodium polystyrene sulfonate sodium polystyrene sulfonate ADD TO FORMULARY Generics 01/01/2014 sf sodium fluoride ADD TO FORMULARY Generics 01/01/2014 sf 5000 plus sodium fluoride ADD TO FORMULARY Generics 01/01/2014 stannous fluoride stannous fluoride ADD TO FORMULARY Generics 01/01/2014 SIMPONI ARIA golimumab ADD TO FORMULARY Non-Formulary 01/01/2014 SIMPONI ARIA golimumab ADD UM: AUTHORIZATION PA applies 01/01/2014 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur ADD TO FORMULARY Generics 01/01/2014 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur ADD TO FORMULARY Generics 01/01/2014 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur ADD TO FORMULARY Generics 01/01/2014 sss 10-4 sulfacetamide sodium/sulfur ADD TO FORMULARY Generics 01/01/2014 sodium sulfacetamide sulfacetamide sodium/urea ADD TO FORMULARY Generics 01/01/2014 salicylic acid salicylic acid ADD TO FORMULARY Generics 01/01/2014 salicylic acid salicylic acid ADD TO FORMULARY Generics 01/01/2014 salicylic acid salicylic acid ADD TO FORMULARY Generics 01/01/2014 silver nitrate silver nitrate ADD TO FORMULARY Generics 01/01/2014 terbutaline sulfate terbutaline sulfate ADD TO FORMULARY Generics 01/01/2014 timolol maleate timolol maleate ADD TO FORMULARY Generics 01/01/2014 timolol maleate timolol maleate ADD TO FORMULARY Generics 01/01/2014 timolol maleate timolol maleate ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 94 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 taron forte iron bisgly,pscmplx/ascorbate calc/b12/folic acid/calc-threo ADD TO FORMULARY Generics 01/01/2014 therapeutic hematinic multivits,therap iron,hematin ADD TO FORMULARY Generics 01/01/2014 therapeutic hematinic multivits,therap iron,hematin ADD UM: CUSTOM Vitamin Benefit Rider May Be Required 01/01/2014 triveen-ten prenatal vitamins no.18/iron,carbonyl/fa/ubide carenone/dha ADD TO FORMULARY Generics 01/01/2014 triveen-ten prenatal vitamins no.18/iron,carbonyl/fa/ubide carenone/dha ADD UM: GENDER Female 01/01/2014 triveen-one prenatal vits with calcium #62/ferrous fumarate/fa/dha ADD TO FORMULARY Generics 01/01/2014 triveen-one prenatal vits with calcium #62/ferrous fumarate/fa/dha ADD UM: GENDER Female 01/01/2014 theophylline theophylline anhydrous ADD TO FORMULARY Generics 01/01/2014 triamterenetriamterene/hydrochlorothiaz hydrochlorothiazi ide d ADD TO FORMULARY Generics 01/01/2014 tencon butalbital/acetaminophen ADD TO FORMULARY Generics 01/01/2014 trezix acetaminophen/caffeine/dihy drocodeine bitartrate ADD TO FORMULARY Generics 01/01/2014 tolmetin sodium tolmetin sodium ADD TO FORMULARY Generics 01/01/2014 tolmetin sodium tolmetin sodium ADD TO FORMULARY Generics 01/01/2014 tramadol hcl er tramadol hcl ADD TO FORMULARY Generics 01/01/2014 triamcinolone acetonide triamcinolone acetonide ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 95 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 travoprost travoprost (benzalkonium) ADD TO FORMULARY Generics 01/01/2014 treagan otic acetic acid/antipyrine/benzocaine/p olicosanol no.1/al acetat ADD TO FORMULARY Generics 01/01/2014 tetracaine hcl tetracaine hcl/pf ADD TO FORMULARY Generics 01/01/2014 TRANSDERMSCOP scopolamine ADD TO FORMULARY Preferred Brands 01/01/2014 TIGAN trimethobenzamide hcl ADD TO FORMULARY Non-Formulary 01/01/2014 taron-prex prenatal prenatal vit with calcium no.39/iron fum/folic acid/dss/dha ADD TO FORMULARY Generics 01/01/2014 taron-prex prenatal prenatal vit with calcium no.39/iron fum/folic acid/dss/dha ADD UM: GENDER Female 01/01/2014 tolazamide tolazamide ADD TO FORMULARY Generics 01/01/2014 tolbutamide tolbutamide ADD TO FORMULARY Generics 01/01/2014 TESTIM testosterone ADD TO FORMULARY Non-Formulary 01/01/2014 TESTIM testosterone ADD UM: GENDER Male 01/01/2014 THYROSAFE potassium iodide ADD TO FORMULARY Preferred Brands 01/01/2014 thyroshield potassium iodide ADD TO FORMULARY Generics 01/01/2014 tri-vit with fluoride-iron fluoride/iron/vitamins a,c,and d ADD TO FORMULARY Generics 01/01/2014 TYSABRI natalizumab ADD TO FORMULARY Preferred Brands 01/01/2014 TYSABRI natalizumab ADD UM: AUTHORIZATION PA applies 01/01/2014 terconazole terconazole ADD TO FORMULARY Generics 01/01/2014 terconazole terconazole ADD UM: GENDER Female 01/01/2014 TERAZOL 3 terconazole ADD TO FORMULARY Non-Formulary 01/01/2014 TERAZOL 3 terconazole ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 96 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 terconazole terconazole ADD TO FORMULARY Generics 01/01/2014 terconazole terconazole ADD UM: GENDER Female 01/01/2014 terconazole terconazole ADD TO FORMULARY Generics 01/01/2014 terconazole terconazole ADD UM: GENDER Female 01/01/2014 TERAZOL 7 terconazole ADD TO FORMULARY Non-Formulary 01/01/2014 TERAZOL 7 terconazole ADD UM: GENDER Female 01/01/2014 tretinoin tretinoin/emollient base ADD TO FORMULARY Generics 01/01/2014 tretinoin tretinoin/emollient base ADD UM: AGE Age Limit 01/01/2014 trichloroacetic acid trichloroacetic acid ADD TO FORMULARY Generics 01/01/2014 trichloroacetic acid trichloroacetic acid ADD TO FORMULARY Generics 01/01/2014 ultra comfort syringe with needle,insulin 0.3 ml (half unit mark) ADD TO FORMULARY Generics 01/01/2014 ultra comfort syringe with needle,insulin 0.3 ml (half unit mark) ADD TO FORMULARY Generics 01/01/2014 ultra comfort syringe with needle,insulin 0.3 ml (half unit mark) ADD TO FORMULARY Generics 01/01/2014 ulticare,ultracomf syringe with needle, ort,careone insulin,1 ml and sharps container ADD TO FORMULARY Generics 01/01/2014 ULTRAFOAM microfibrillar collagen ADD TO FORMULARY Generics 01/01/2014 ULTRAFOAM microfibrillar collagen ADD TO FORMULARY Generics 01/01/2014 ULTRAFOAM microfibrillar collagen ADD TO FORMULARY Generics 01/01/2014 ULTRAFOAM microfibrillar collagen ADD TO FORMULARY Generics 01/01/2014 u-cort hydrocortisone acetate/urea ADD TO FORMULARY Generics 01/01/2014 urea urea/hyaluronate sodium ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 97 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ultimatecare one prenatal vit,calcium nf no.35/iron/folic acid/docusate/omega-3 ADD TO FORMULARY Generics 01/01/2014 ultimatecare one prenatal vit,calcium nf no.35/iron/folic acid/docusate/omega-3 ADD UM: GENDER Female 01/01/2014 venatal complete prenatal vitamin dha no.77/sodium feredetateiron poly/fa/omega3 ADD TO FORMULARY Generics 01/01/2014 venatal complete prenatal vitamin dha no.77/sodium feredetateiron poly/fa/omega3 ADD UM: GENDER Female 01/01/2014 vp-era ob plus prenatal vit no.8/iron polysach,heme polypeptide/folic acid ADD TO FORMULARY Generics 01/01/2014 vp-era ob plus prenatal vit no.8/iron polysach,heme polypeptide/folic acid ADD UM: GENDER Female 01/01/2014 vinate ii prenatal vitamins with calcium/iron bg/folic acid ADD TO FORMULARY Generics 01/01/2014 vinate ii prenatal vitamins with calcium/iron bg/folic acid ADD UM: GENDER Female 01/01/2014 vinate az prenatal vitamins with calcium/fe bisgly/folic acid ADD TO FORMULARY Generics 01/01/2014 vinate az prenatal vitamins with calcium/fe bisgly/folic acid ADD UM: GENDER Female 01/01/2014 verapamil hcl verapamil hcl ADD TO FORMULARY Generics 01/01/2014 added strength pain reliever aspirin/acetaminophen/caffei ne ADD TO FORMULARY Not Covered 01/01/2014 vp-ch plus prenatal vitamins combo no.59/iron,carb/folic acid/dss/dha ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 98 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 vp-ch plus prenatal vitamins combo no.59/iron,carb/folic acid/dss/dha 01/01/2014 VIVELLE-DOT 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female estradiol ADD TO FORMULARY Non-Formulary VIVELLE-DOT estradiol ADD UM: GENDER Female 01/01/2014 VIVELLE-DOT estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 VIVELLE-DOT estradiol ADD UM: GENDER Female 01/01/2014 VIVELLE-DOT estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 VIVELLE-DOT estradiol ADD UM: GENDER Female 01/01/2014 VIVELLE-DOT estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 VIVELLE-DOT estradiol ADD UM: GENDER Female 01/01/2014 VIVELLE-DOT estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 VIVELLE-DOT estradiol ADD UM: GENDER Female 01/01/2014 VAGIFEM estradiol ADD TO FORMULARY Preferred Brands 01/01/2014 VAGIFEM estradiol ADD UM: GENDER Female 01/01/2014 VANTAS histrelin acetate ADD TO FORMULARY Preferred Brands 01/01/2014 VANDAZOLE metronidazole ADD TO FORMULARY Preferred Brands 01/01/2014 VANDAZOLE metronidazole ADD UM: GENDER Female 01/01/2014 vasolex trypsin/balsam peru/castor oil ADD TO FORMULARY Generics 01/01/2014 vecamyl mecamylamine hcl ADD TO FORMULARY Generics 01/01/2014 vinate ic prenatal vits cmb w-o ca no.2 ADD TO FORMULARY Generics 01/01/2014 vinate ic prenatal vits cmb w-o ca no.2 ADD UM: GENDER Female 01/01/2014 vitaspire prenatal vits with calcium #44/iron,carbonyl/folic acid ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 99 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 vitaspire prenatal vits with calcium #44/iron,carbonyl/folic acid ADD UM: GENDER Female 01/01/2014 vinate pn care prenatal vits with calcium #7/fe asp gly/docusate/folic acid ADD TO FORMULARY Generics 01/01/2014 vinate pn care prenatal vits with calcium #7/fe asp gly/docusate/folic acid ADD UM: GENDER Female 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD TO FORMULARY Preventative 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD UM: GENDER Female 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD TO FORMULARY Preventative 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD UM: GENDER Female 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD TO FORMULARY Preventative 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD UM: GENDER Female 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD TO FORMULARY Preventative 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD UM: GENDER Female 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD TO FORMULARY Preventative 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD UM: GENDER Female 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD TO FORMULARY Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 100 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD UM: GENDER Female 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD TO FORMULARY Preventative 01/01/2014 wide seal diaphragm diaphragms, wide seal ADD UM: GENDER Female 01/01/2014 wal-dram dimenhydrinate ADD TO FORMULARY Generics 01/01/2014 xeroform petrolatum dressing bismuth tribromophenate/petrolatum, white ADD TO FORMULARY Preferred Brands 01/01/2014 xeroform bismuth tribromophenate/petrolatum, white ADD TO FORMULARY Preferred Brands 01/01/2014 xeroform petrolatum dressing bismuth tribromophenate/petrolatum, white ADD TO FORMULARY Preferred Brands 01/01/2014 XYLOCAINE lidocaine hcl ADD TO FORMULARY Non-Formulary 01/01/2014 x-viate urea ADD TO FORMULARY Generics 01/01/2014 yohimbine hcl yohimbine hcl ADD TO FORMULARY Generics 01/01/2014 yohimbine hcl yohimbine hcl ADD UM: GENDER Male 01/01/2014 zgesic acetaminophen/phenyltoloxa mine citrate ADD TO FORMULARY Generics 01/01/2014 zflex acetaminophen/phenyltoloxa mine citrate ADD TO FORMULARY Generics 01/01/2014 zatean-ch prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha ADD TO FORMULARY Generics 01/01/2014 zatean-ch prenatal vit with calcium #69/iron,carbon/folic acid/dss/dha ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 101 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 accolate,zafirluka zafirlukast st ADD UM: QUANTITY 60 / 30 days 01/01/2014 accuretic,quinapri quinapril lhcl/hydrochlorothiazide hydrochlorothiazi de ADD UM: QUANTITY 30 / 30 days 01/01/2014 accupril,quinapril quinapril hcl hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 ACIPHEX rabeprazole sodium CHANGE TIER Non-Formulary 01/01/2014 ACIPHEX SPRINKLE rabeprazole sodium ADD TO FORMULARY Non-Formulary 01/01/2014 ACIPHEX SPRINKLE rabeprazole sodium ADD TO FORMULARY Non-Formulary 01/01/2014 aciphex,aciphex rabeprazole sodium sprinkle,rabepraz ole sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 ACTEMRA ADD TO FORMULARY Non-Formulary 01/01/2014 onsolis,fentanyl fentanyl citrate citrate,abstral,laz anda,actiq,fentor a ADD UM: QUANTITY 13 / 30 days 01/01/2014 ACTONEL risedronate sodium ADD UM: QUANTITY 1 / 30 days 01/01/2014 ACTONEL risedronate sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 ACTONEL risedronate sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 ACTONEL risedronate sodium ADD UM: QUANTITY 4 / 30 days 01/01/2014 pioglitazone hcl,actos pioglitazone hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 adalat cc,nifedipine er,afeditab cr nifedipine ADD UM: QUANTITY 90 / 30 days tocilizumab BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 102 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 adalat cc,nifediac nifedipine cc,nifedipine er ADD UM: QUANTITY 90 / 30 days 01/01/2014 adalat cc,nifedipine er,afeditab cr nifedipine ADD UM: QUANTITY 90 / 30 days 01/01/2014 ADALAT CC nifedipine ADD TO FORMULARY Non-Formulary 01/01/2014 ADALAT CC nifedipine ADD TO FORMULARY Non-Formulary 01/01/2014 ADALAT CC nifedipine ADD TO FORMULARY Non-Formulary 01/01/2014 ADVAIR DISKUS fluticasone propionate/salmeterol xinafoate ADD UM: QUANTITY 60 / 30 days 01/01/2014 ADVAIR DISKUS fluticasone propionate/salmeterol xinafoate ADD UM: QUANTITY 60 / 30 days 01/01/2014 ADVAIR DISKUS fluticasone propionate/salmeterol xinafoate ADD UM: QUANTITY 60 / 30 days 01/01/2014 ADVAIR HFA fluticasone propionate/salmeterol xinafoate ADD UM: QUANTITY 12 / 30 days 01/01/2014 ADVAIR HFA fluticasone propionate/salmeterol xinafoate ADD UM: QUANTITY 12 / 30 days 01/01/2014 ADVAIR HFA fluticasone propionate/salmeterol xinafoate ADD UM: QUANTITY 12 / 30 days 01/01/2014 ADVICOR niacin/lovastatin CHANGE TIER 01/01/2014 ADVICOR niacin/lovastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 imiquimod,aldara imiquimod ADD TO FORMULARY Preferred Brands 01/01/2014 imiquimod,aldara imiquimod ADD UM: QUANTITY 15 / 30 days Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 103 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ALINIA nitazoxanide ADD UM: QUANTITY 7 / 30 days 01/01/2014 allergy reliefd,allegra-d 12 hour fexofenadine hcl/pseudoephedrine hcl ADD UM: QUANTITY 60 / 30 days 01/01/2014 allegra-d 24 fexofenadine hour,wal-fex d 24 hcl/pseudoephedrine hcl hour,allergy relief d,fexofenadinepse er ADD UM: QUANTITY 30 / 30 days 01/01/2014 ALLEGRA fexofenadine hcl ODT,CHILDREN' S ALLEGRA ALLERGY ADD UM: QUANTITY 60 / 30 days 01/01/2014 fexofenadine hcl,wal-fex allergy,allergy relief,allerease,allegra allergy,aller-fex CHANGE UM: QUANTITY 30 / 30 days 01/01/2014 allerfexofenadine hcl ease,fexofenadin e hcl,wal-fex allergy,allegra allergy,allergy relief ADD UM: QUANTITY 60 / 30 days 01/01/2014 ALLEGRA-D 24 HOUR fexofenadine hcl/pseudoephedrine hcl ADD TO FORMULARY Non-Formulary 01/01/2014 ALLEGRA ODT fexofenadine hcl ADD TO FORMULARY Non-Formulary 01/01/2014 ALOCRIL nedocromil sodium ADD UM: QUANTITY 5 / 30 days 01/01/2014 ALOMIDE lodoxamide tromethamine ADD UM: QUANTITY 10 / 30 days 01/01/2014 VIVELLEestradiol DOT,ALORA,MIN IVELLE ADD UM: QUANTITY 8 / 30 days fexofenadine hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 104 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 VIVELLEestradiol DOT,ALORA,MIN IVELLE ADD UM: QUANTITY 8 / 30 days 01/01/2014 VIVELLEestradiol DOT,ALORA,MIN IVELLE ADD UM: QUANTITY 8 / 30 days 01/01/2014 VIVELLEDOT,ALORA estradiol ADD UM: QUANTITY 8 / 30 days 01/01/2014 ALTOPREV lovastatin CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALTOPREV lovastatin CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALTOPREV lovastatin CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 mevacor,lovastati lovastatin n,altoprev ADD UM: QUANTITY 30 / 30 days 01/01/2014 ALVESCO ciclesonide ADD UM: QUANTITY 6.1 / 30 days 01/01/2014 ALVESCO ciclesonide ADD UM: QUANTITY 12.2 / 30 days 01/01/2014 ambien,zolpidem zolpidem tartrate tartrate ADD UM: QUANTITY 30 / 30 days 01/01/2014 ambien,ambien zolpidem tartrate cr,edluar,zolpide m tartrate,zolpimist, zolpidem tartrate er,intermezzo ADD UM: QUANTITY 30 / 30 days 01/01/2014 AMBIEN zolpidem tartrate ADD TO FORMULARY Non-Formulary 01/01/2014 AMBIEN zolpidem tartrate ADD TO FORMULARY Non-Formulary 01/01/2014 AMBIEN CR zolpidem tartrate ADD TO FORMULARY Non-Formulary 01/01/2014 AMBIEN CR zolpidem tartrate ADD TO FORMULARY Non-Formulary 01/01/2014 AMITIZA lubiprostone ADD UM: QUANTITY 60 / 30 days 01/01/2014 ANDRODERM testosterone ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 105 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ANDRODERM testosterone ADD UM: GENDER Male 01/01/2014 ANDRODERM testosterone ADD UM: QUANTITY 30 / 30 days 01/01/2014 ANDRODERM testosterone ADD UM: GENDER Male 01/01/2014 ANDROGEL testosterone ADD UM: QUANTITY 75 / 30 days 01/01/2014 ANDROGEL testosterone ADD UM: QUANTITY 75 / 30 days 01/01/2014 ANDROGEL testosterone ADD UM: QUANTITY 75 / 30 days 01/01/2014 ANDROGEL testosterone ADD UM: QUANTITY 75 / 30 days 01/01/2014 ANDROGEL testosterone ADD UM: QUANTITY 75 / 30 days 01/01/2014 ANDROGEL testosterone ADD UM: QUANTITY 75 / 30 days 01/01/2014 ANDROGEL testosterone CHANGE UM: QUANTITY 75 / 30 days 90 / 30 days 01/01/2014 ANDROGEL testosterone CHANGE UM: QUANTITY 75 / 30 days 60 / 30 days 01/01/2014 ANDROGEL testosterone CHANGE UM: QUANTITY 75 / 30 days 60 / 30 days 01/01/2014 ANZEMET dolasetron mesylate ADD TO FORMULARY Preferred Brands 01/01/2014 ANZEMET dolasetron mesylate ADD UM: QUANTITY 12 / 30 days 01/01/2014 ANZEMET dolasetron mesylate ADD TO FORMULARY Preferred Brands 01/01/2014 ANZEMET dolasetron mesylate ADD UM: QUANTITY 12 / 30 days 01/01/2014 ASMANEX mometasone furoate ADD TO FORMULARY Preferred Brands 01/01/2014 ASMANEX mometasone furoate ADD UM: QUANTITY 1 / 30 days 01/01/2014 ASMANEX mometasone furoate ADD TO FORMULARY Preferred Brands 01/01/2014 ASMANEX mometasone furoate ADD UM: QUANTITY 1 / 30 days 01/01/2014 ASMANEX mometasone furoate ADD TO FORMULARY Preferred Brands 01/01/2014 ASMANEX mometasone furoate ADD UM: QUANTITY 1 / 30 days 01/01/2014 ASMANEX mometasone furoate ADD TO FORMULARY Preferred Brands 01/01/2014 ASMANEX mometasone furoate ADD UM: QUANTITY 1 / 30 days 01/01/2014 ASMANEX mometasone furoate ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 106 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ASMANEX mometasone furoate ADD UM: QUANTITY 1 / 30 days 01/01/2014 ASMANEX mometasone furoate ADD TO FORMULARY Preferred Brands 01/01/2014 ASMANEX mometasone furoate ADD UM: QUANTITY 1 / 30 days 01/01/2014 ASTELIN azelastine hcl ADD TO FORMULARY Non-Formulary 01/01/2014 ASTELIN azelastine hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 azelastine hcl azelastine hcl ADD TO FORMULARY Generics 01/01/2014 azelastine hcl azelastine hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 atacand candesartan hct,candesartan- cilexetil/hydrochlorothiazide hydrochlorothiazi d ADD UM: QUANTITY 30 / 30 days 01/01/2014 atacand,candesa candesartan cilexetil rtan cilexetil ADD UM: QUANTITY 30 / 30 days 01/01/2014 atacand candesartan hct,candesartan- cilexetil/hydrochlorothiazide hydrochlorothiazi d CHANGE TIER Non-Formulary 01/01/2014 atacand candesartan hct,candesartan- cilexetil/hydrochlorothiazide hydrochlorothiazi d CHANGE TIER Non-Formulary 01/01/2014 atacand candesartan hct,candesartan- cilexetil/hydrochlorothiazide hydrochlorothiazi d CHANGE TIER Non-Formulary 01/01/2014 atacand,candesa candesartan cilexetil rtan cilexetil CHANGE TIER 01/01/2014 atacand,candesa candesartan cilexetil rtan cilexetil CHANGE TIER 01/01/2014 atacand,candesa candesartan cilexetil rtan cilexetil CHANGE TIER Preferred Brands Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 107 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 01/01/2014 ATACAND 01/01/2014 Generic Name candesartan cilexetil Type of Change Previous Value New Value CHANGE TIER Non-Formulary ipratropium ipratropium bromide bromide,atrovent ADD TO FORMULARY Preferred Brands 01/01/2014 ATROVENT HFA ipratropium bromide ADD TO FORMULARY Preferred Brands 01/01/2014 ipratropium ipratropium bromide bromide,atrovent ADD TO FORMULARY Preferred Brands 01/01/2014 avalide,irbesartan irbesartan/hydrochlorothiazi de hydrochlorothiazi de ADD TO FORMULARY Non-Formulary 01/01/2014 avalide,irbesartan irbesartan/hydrochlorothiazi de hydrochlorothiazi de ADD UM: QUANTITY 30 / 30 days 01/01/2014 avalide,irbesartan irbesartan/hydrochlorothiazi de hydrochlorothiazi de REMOVE UM: AGE 01/01/2014 avalide,irbesartan irbesartan/hydrochlorothiazi de hydrochlorothiazi de ADD TO FORMULARY Non-Formulary 01/01/2014 avalide,irbesartan irbesartan/hydrochlorothiazi de hydrochlorothiazi de ADD UM: QUANTITY 30 / 30 days 01/01/2014 avapro,irbesartan irbesartan ADD TO FORMULARY Non-Formulary 01/01/2014 avapro,irbesartan irbesartan ADD UM: QUANTITY 30 / 30 days 01/01/2014 avapro,irbesartan irbesartan REMOVE UM: AGE 01/01/2014 avapro,irbesartan irbesartan ADD TO FORMULARY Non-Formulary 01/01/2014 avapro,irbesartan irbesartan ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 108 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 avapro,irbesartan irbesartan REMOVE UM: AGE 01/01/2014 avapro,irbesartan irbesartan ADD TO FORMULARY Non-Formulary 01/01/2014 avapro,irbesartan irbesartan ADD UM: QUANTITY 30 / 30 days 01/01/2014 avapro,irbesartan irbesartan REMOVE UM: AGE 01/01/2014 candesartancandesartan hydrochlorothiazi cilexetil/hydrochlorothiazide d CHANGE TIER Generics 01/01/2014 candesartancandesartan hydrochlorothiazi cilexetil/hydrochlorothiazide d CHANGE TIER Generics 01/01/2014 candesartancandesartan hydrochlorothiazi cilexetil/hydrochlorothiazide d CHANGE TIER Generics 01/01/2014 candesartan cilexetil candesartan cilexetil CHANGE TIER Preferred Brands Generics 01/01/2014 candesartan cilexetil candesartan cilexetil CHANGE TIER Preferred Brands Generics 01/01/2014 candesartan cilexetil candesartan cilexetil CHANGE TIER Preferred Brands Generics 01/01/2014 candesartan cilexetil candesartan cilexetil CHANGE TIER Preferred Brands Generics 01/01/2014 irbesartanirbesartan/hydrochlorothiazi hydrochlorothiazi de de ADD TO FORMULARY Generics 01/01/2014 irbesartanirbesartan/hydrochlorothiazi hydrochlorothiazi de de ADD TO FORMULARY Generics 01/01/2014 irbesartan irbesartan ADD TO FORMULARY Generics 01/01/2014 irbesartan irbesartan ADD TO FORMULARY Generics 01/01/2014 irbesartan irbesartan ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 109 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 avinza,morphine morphine sulfate sulfate er CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 avinza,morphine morphine sulfate sulfate er CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 avinza,morphine morphine sulfate sulfate er CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 avinza,morphine morphine sulfate sulfate er CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 avinza,morphine morphine sulfate sulfate er ADD TO FORMULARY Non-Formulary 01/01/2014 avinza,morphine morphine sulfate sulfate er ADD TO FORMULARY Non-Formulary 01/01/2014 OPTIVAR azelastine hcl ADD TO FORMULARY Non-Formulary 01/01/2014 azelastine hcl azelastine hcl ADD TO FORMULARY Generics 01/01/2014 optivar,azelastine azelastine hcl hcl ADD UM: QUANTITY 6 / 30 days 01/01/2014 AZOR amlodipine besylate/olmesartan medoxomil ADD TO FORMULARY Preferred Brands 01/01/2014 AZOR amlodipine besylate/olmesartan medoxomil ADD TO FORMULARY Preferred Brands 01/01/2014 AZOR amlodipine besylate/olmesartan medoxomil ADD UM: QUANTITY 30 / 30 days 01/01/2014 AZOR amlodipine besylate/olmesartan medoxomil ADD UM: QUANTITY 30 / 30 days 01/01/2014 AZOR amlodipine besylate/olmesartan medoxomil ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 110 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 AZOR amlodipine besylate/olmesartan medoxomil ADD UM: QUANTITY 30 / 30 days 01/01/2014 AZOR amlodipine besylate/olmesartan medoxomil ADD TO FORMULARY Preferred Brands 01/01/2014 AZOR amlodipine besylate/olmesartan medoxomil ADD UM: QUANTITY 30 / 30 days 01/01/2014 BECONASE AQ beclomethasone dipropionate ADD UM: QUANTITY 25 / 30 days 01/01/2014 BENICAR HCT olmesartan medoxomil/hydrochlorothiazi de ADD TO FORMULARY Preferred Brands 01/01/2014 BENICAR HCT olmesartan medoxomil/hydrochlorothiazi de ADD TO FORMULARY Preferred Brands 01/01/2014 BENICAR HCT olmesartan medoxomil/hydrochlorothiazi de ADD TO FORMULARY Preferred Brands 01/01/2014 BENICAR olmesartan medoxomil ADD TO FORMULARY Preferred Brands 01/01/2014 BENICAR olmesartan medoxomil ADD TO FORMULARY Preferred Brands 01/01/2014 BENICAR olmesartan medoxomil ADD TO FORMULARY Preferred Brands 01/01/2014 BENICAR HCT olmesartan medoxomil/hydrochlorothiazi de ADD UM: QUANTITY 30 / 30 days 01/01/2014 BENICAR olmesartan medoxomil ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 111 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change 01/01/2014 ADVATE,ADVAT E L,ADVATE M,ADVATE H,ADVATE SH,ADVATE UH,XYNTHA,XY NTHA SOLOFUSE antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (albfree),antihemophilic factor (factor viii) recomb,b-domain deleted 01/01/2014 ALOCRIL nedocromil sodium 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human ADD TO FORMULARY Preferred Brands 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human ADD UM: AUTHORIZATION PA applies 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human ADD TO FORMULARY Preferred Brands 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human ADD UM: AUTHORIZATION PA applies 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human ADD TO FORMULARY Preferred Brands 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human ADD UM: AUTHORIZATION PA applies 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human ADD TO FORMULARY Preferred Brands 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human ADD UM: AUTHORIZATION PA applies CHANGE TIER Previous Value New Value PA applies Preventative Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 112 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ALPHANINE SD factor ix ADD TO FORMULARY Preferred Brands 01/01/2014 ALPHANINE SD factor ix ADD UM: AUTHORIZATION PA applies 01/01/2014 ALPHANINE SD factor ix ADD TO FORMULARY Preferred Brands 01/01/2014 ALPHANINE SD factor ix ADD UM: AUTHORIZATION PA applies 01/01/2014 ALPHANINE SD factor ix ADD TO FORMULARY Preferred Brands 01/01/2014 ALPHANINE SD factor ix ADD UM: AUTHORIZATION PA applies 01/01/2014 ALVESCO ciclesonide ADD TO FORMULARY Preferred Brands 01/01/2014 ALVESCO ciclesonide ADD TO FORMULARY Preferred Brands 01/01/2014 amnesteem,clara isotretinoin vis,absorica,zena tane,myorisan ADD TO FORMULARY Preferred Brands 01/01/2014 amnesteem,clara isotretinoin vis,absorica,zena tane,myorisan ADD TO FORMULARY Preferred Brands 01/01/2014 amnesteem,clara isotretinoin vis,absorica,zena tane,myorisan ADD TO FORMULARY Preferred Brands 01/01/2014 AMTURNIDE aliskiren hemifumarate/amlodipine/hy drochlorothiazide ADD TO FORMULARY Preferred Brands 01/01/2014 ANADROL-50 oxymetholone ADD TO FORMULARY Preferred Brands 01/01/2014 APOKYN apomorphine hcl ADD TO FORMULARY Preferred Brands 01/01/2014 APOKYN apomorphine hcl ADD UM: AUTHORIZATION PA applies 01/01/2014 APTIVUS tipranavir/vitamin e tpgs ADD TO FORMULARY Preferred Brands 01/01/2014 APTIVUS tipranavir ADD TO FORMULARY Preferred Brands 01/01/2014 ARANESP darbepoetin alfa in polysorbate 80 ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 113 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ARMOUR THYROID thyroid,pork ADD TO FORMULARY Preferred Brands 01/01/2014 ARMOUR THYROID thyroid,pork ADD TO FORMULARY Preferred Brands 01/01/2014 ARMOUR THYROID thyroid,pork ADD TO FORMULARY Preferred Brands 01/01/2014 ARMOUR THYROID thyroid,pork ADD TO FORMULARY Preferred Brands 01/01/2014 ARMOUR THYROID thyroid,pork ADD TO FORMULARY Preferred Brands 01/01/2014 ARMOUR THYROID thyroid,pork ADD TO FORMULARY Preferred Brands 01/01/2014 ARMOUR THYROID thyroid,pork ADD TO FORMULARY Preferred Brands 01/01/2014 ARMOUR THYROID thyroid,pork ADD TO FORMULARY Preferred Brands 01/01/2014 ASACOL mesalamine ADD TO FORMULARY Preferred Brands 01/01/2014 ASACOL HD mesalamine ADD TO FORMULARY Preferred Brands 01/01/2014 ATRALIN tretinoin ADD TO FORMULARY Preferred Brands 01/01/2014 ATRIPLA efavirenz/emtricitabine/tenof ovir disoproxil fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 AUVI-Q epinephrine ADD TO FORMULARY Preferred Brands 01/01/2014 AUVI-Q epinephrine ADD TO FORMULARY Preferred Brands 01/01/2014 AVANDAMET rosiglitazone maleate/metformin hcl ADD TO FORMULARY Preferred Brands 01/01/2014 AVANDARYL rosiglitazone maleate/glimepiride ADD TO FORMULARY Preferred Brands 01/01/2014 AVANDIA rosiglitazone maleate ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 114 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 moxeza,vigamox, moxifloxacin hcl avelox,avelox abc pack,moxifloxacin hcl ADD TO FORMULARY Preferred Brands 01/01/2014 AVODART dutasteride ADD TO FORMULARY Preferred Brands 01/01/2014 AVONEX PEN interferon beta-1a ADD TO FORMULARY Preferred Brands 01/01/2014 AVONEX PEN interferon beta-1a ADD UM: AUTHORIZATION PA applies 01/01/2014 AVONEX interferon beta-1a ADD TO FORMULARY Preferred Brands 01/01/2014 AVONEX interferon beta-1a ADD UM: AUTHORIZATION PA applies 01/01/2014 AZASAN azathioprine ADD TO FORMULARY Preferred Brands 01/01/2014 AZASAN azathioprine ADD TO FORMULARY Preferred Brands 01/01/2014 AZELEX azelaic acid ADD TO FORMULARY Preferred Brands 01/01/2014 AZOPT brinzolamide ADD TO FORMULARY Preferred Brands 01/01/2014 BARACLUDE entecavir ADD TO FORMULARY Preferred Brands 01/01/2014 BARACLUDE entecavir ADD TO FORMULARY Preferred Brands 01/01/2014 BARACLUDE entecavir ADD TO FORMULARY Preferred Brands 01/01/2014 pen needle needles, insulin disposable, safety ADD TO FORMULARY Preferred Brands 01/01/2014 autoshield pen needle pen needle, diabetic, safety ADD TO FORMULARY Preferred Brands 01/01/2014 autoshield pen needle pen needle, diabetic, safety ADD TO FORMULARY Preferred Brands 01/01/2014 autoshield duo pen needle pen needle, diabetic disposable, safety ADD TO FORMULARY Preferred Brands 01/01/2014 BETHKIS tobramycin ADD TO FORMULARY Preferred Brands 01/01/2014 BETIMOL timolol ADD TO FORMULARY Preferred Brands 01/01/2014 BETIMOL timolol ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 115 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 BETOPTIC S betaxolol hcl ADD TO FORMULARY Preferred Brands 01/01/2014 BIDIL isosorbide dinitrate/hydralazine hcl ADD TO FORMULARY Preferred Brands 01/01/2014 BLEPHAMIDE sulfacetamide sodium/prednisolone acetate ADD TO FORMULARY Preferred Brands 01/01/2014 BLEPHAMIDE S.O.P. sulfacetamide sodium/prednisolone acetate ADD TO FORMULARY Preferred Brands 01/01/2014 BRAVELLE urofollitropin ADD UM: CUSTOM Fertility Rider REQUIRED 01/01/2014 breeze 2 blood-glucose meter, disctype ADD UM: CUSTOM Provide Free of Charge 01/01/2014 BRILINTA ticagrelor ADD TO FORMULARY Preferred Brands 01/01/2014 BUPHENYL sodium phenylbutyrate ADD TO FORMULARY Preferred Brands 01/01/2014 BYETTA exenatide ADD TO FORMULARY Preferred Brands 01/01/2014 BYETTA exenatide ADD TO FORMULARY Preferred Brands 01/01/2014 levocarnitine,carn levocarnitine (with sugar) itor ADD TO FORMULARY Preferred Brands 01/01/2014 levocarnitine,llevocarnitine,levocarnitine carnitine,gtartrate levocarnitine,bioc arnitine sf,carnitor,carnito r sf ADD TO FORMULARY Preferred Brands 01/01/2014 CELEBREX celecoxib ADD TO FORMULARY Preferred Brands 01/01/2014 CELEBREX celecoxib ADD TO FORMULARY Preferred Brands 01/01/2014 CELEBREX celecoxib ADD TO FORMULARY Preferred Brands 01/01/2014 CELEBREX celecoxib ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 116 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 CELONTIN methsuximide ADD TO FORMULARY Preferred Brands 01/01/2014 CHANTIX varenicline tartrate ADD TO FORMULARY Preferred Brands 01/01/2014 CIALIS,ADCIRC A tadalafil CHANGE TIER Preferred Brands 01/01/2014 CIALIS tadalafil ADD UM: CUSTOM PA required for QL = 30 01/01/2014 CIALIS tadalafil ADD UM: AUTHORIZATION PA applies 01/01/2014 CIALIS tadalafil ADD UM: CUSTOM PA required for QL = 30 01/01/2014 CIALIS tadalafil ADD UM: AUTHORIZATION PA applies 01/01/2014 CIPRO ciprofloxacin hcl ADD TO FORMULARY Non-Formulary 01/01/2014 CIPRODEX ciprofloxacin hcl/dexamethasone ADD TO FORMULARY Preferred Brands 01/01/2014 CIPRO HC ciprofloxacin hcl/hydrocortisone ADD TO FORMULARY Preferred Brands 01/01/2014 ciprofloxacin hcl ciprofloxacin hcl ADD TO FORMULARY Generics 01/01/2014 ciprofloxacin hcl ciprofloxacin hcl ADD TO FORMULARY Generics 01/01/2014 CLARIFOAM EF sulfacetamide sodium/sulfur ADD TO FORMULARY Preferred Brands 01/01/2014 CLOBEX clobetasol propionate ADD TO FORMULARY Preferred Brands 01/01/2014 COARTEM artemether/lumefantrine ADD TO FORMULARY Preferred Brands 01/01/2014 COLCRYS colchicine ADD TO FORMULARY Preferred Brands 01/01/2014 COLY-MYCIN M colistin (as colistimethate PARENTERAL sodium) ADD TO FORMULARY Preferred Brands 01/01/2014 COMBIGAN brimonidine tartrate/timolol maleate ADD TO FORMULARY Preferred Brands 01/01/2014 COMBIVENT ipratropium bromide/albuterol sulfate ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 117 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 COMBIVENT RESPIMAT ipratropium bromide/albuterol sulfate ADD TO FORMULARY Preferred Brands 01/01/2014 COMPLERA emtricitabine/rilpivirine hcl/tenofovir disoproxil fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 CONCERTA methylphenidate hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 CONCERTA methylphenidate hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 CONCERTA methylphenidate hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 CONCERTA methylphenidate hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 contour next ez blood-glucose meter ADD UM: CUSTOM Provided Free of Charge 01/01/2014 COPAXONE glatiramer acetate ADD TO FORMULARY Preferred Brands 01/01/2014 COPAXONE glatiramer acetate ADD UM: AUTHORIZATION PA applies 01/01/2014 COPAXONE glatiramer acetate ADD TO FORMULARY Preferred Brands 01/01/2014 CORDRAN flurandrenolide ADD TO FORMULARY Preferred Brands 01/01/2014 CORTIFOAM hydrocortisone acetate ADD TO FORMULARY Preferred Brands 01/01/2014 creon,pancrelipas lipase/protease/amylase e 5,000,tri-pase 8,tri-pase 16,zenpep,pancr eaze,ultresa,viok ace,pertzye ADD TO FORMULARY Non-Formulary 01/01/2014 CRESTOR rosuvastatin calcium ADD TO FORMULARY Preferred Brands 01/01/2014 CRIXIVAN indinavir sulfate ADD TO FORMULARY Preferred Brands 01/01/2014 CYSTADANE betaine ADD TO FORMULARY Preferred Brands 01/01/2014 CYSTAGON cysteamine bitartrate ADD TO FORMULARY Preferred Brands 01/01/2014 CYSTAGON cysteamine bitartrate ADD TO FORMULARY Preferred Brands 01/01/2014 DARAPRIM pyrimethamine ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 118 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 DETROL tolterodine tartrate ADD TO FORMULARY Non-Formulary 01/01/2014 DETROL LA tolterodine tartrate ADD TO FORMULARY Non-Formulary 01/01/2014 DETROL tolterodine tartrate ADD TO FORMULARY Non-Formulary 01/01/2014 DETROL LA tolterodine tartrate ADD TO FORMULARY Non-Formulary 01/01/2014 detrol,detrol tolterodine tartrate la,tolterodine tartrate,tolterodin e tartrate er ADD TO FORMULARY Preferred Brands 01/01/2014 DEXILANT dexlansoprazole ADD TO FORMULARY Preferred Brands 01/01/2014 DIBENZYLINE phenoxybenzamine hcl ADD TO FORMULARY Preferred Brands 01/01/2014 DIPENTUM olsalazine sodium ADD TO FORMULARY Preferred Brands 01/01/2014 DORAL quazepam ADD TO FORMULARY Non-Formulary 01/01/2014 DULERA mometasone furoate/formoterol fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 DULERA mometasone furoate/formoterol fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 DYRENIUM triamterene ADD TO FORMULARY Preferred Brands 01/01/2014 DYRENIUM triamterene ADD TO FORMULARY Preferred Brands 01/01/2014 EDURANT rilpivirine hcl ADD TO FORMULARY Preferred Brands 01/01/2014 EFFIENT prasugrel hcl ADD TO FORMULARY Preferred Brands 01/01/2014 ELDEPRYL selegiline hcl ADD TO FORMULARY Non-Formulary 01/01/2014 ELIDEL pimecrolimus ADD TO FORMULARY Preferred Brands 01/01/2014 ELMIRON pentosan polysulfate sodium ADD TO FORMULARY Non-Formulary 01/01/2014 ELIQUIS apixaban ADD TO FORMULARY Preferred Brands 01/01/2014 EMCYT estramustine phosphate sodium ADD TO FORMULARY Preferred Brands 01/01/2014 EMTRIVA emtricitabine ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 119 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ENBREL etanercept ADD TO FORMULARY Preferred Brands 01/01/2014 ENBREL etanercept ADD UM: AUTHORIZATION PA applies 01/01/2014 EPIPEN JR 2PAK epinephrine ADD TO FORMULARY Preferred Brands 01/01/2014 EPIPEN 2-PAK epinephrine ADD TO FORMULARY Preferred Brands 01/01/2014 EPIVIR HBV lamivudine ADD TO FORMULARY Non-Formulary 01/01/2014 EPIVIR HBV lamivudine ADD TO FORMULARY Preferred Brands 01/01/2014 EPIVIR lamivudine ADD TO FORMULARY Preferred Brands 01/01/2014 EPIVIR lamivudine CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 EPIVIR lamivudine CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 EPIVIR HBV lamivudine ADD UM: AUTHORIZATION PA applies 01/01/2014 EPOGEN epoetin alfa ADD TO FORMULARY Preferred Brands 01/01/2014 EPOGEN epoetin alfa ADD TO FORMULARY Preferred Brands 01/01/2014 EPOGEN,PROC epoetin alfa RIT ADD TO FORMULARY Preferred Brands 01/01/2014 EPZICOM abacavir sulfate/lamivudine ADD TO FORMULARY Preferred Brands 01/01/2014 ESTRACE estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ESTRACE estradiol ADD UM: GENDER Female 01/01/2014 ESTRACE estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ESTRACE estradiol ADD UM: GENDER Female 01/01/2014 ESTRACE estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ESTRACE estradiol ADD UM: GENDER Female 01/01/2014 ESTRACE estradiol ADD TO FORMULARY 01/01/2014 ESTROGEL estradiol ADD UM: GENDER Female 01/01/2014 EVISTA raloxifene hcl ADD TO FORMULARY Preferred Brands Non-Formulary Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 120 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 FABRAZYME agalsidase beta ADD TO FORMULARY Preferred Brands 01/01/2014 FABRAZYME agalsidase beta ADD TO FORMULARY Preferred Brands 01/01/2014 FASLODEX fulvestrant ADD TO FORMULARY Preferred Brands 01/01/2014 FEIBA NF anti-inhibitor coagulant complex ADD TO FORMULARY Preferred Brands 01/01/2014 FEIBA NF anti-inhibitor coagulant complex ADD TO FORMULARY Preferred Brands 01/01/2014 FEIBA NF anti-inhibitor coagulant complex ADD TO FORMULARY Preferred Brands 01/01/2014 felbamate felbamate ADD TO FORMULARY Generics 01/01/2014 felbamate felbamate ADD TO FORMULARY Generics 01/01/2014 FELBATOL felbamate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 FELBATOL felbamate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 felbamate felbamate ADD TO FORMULARY Non-Formulary 01/01/2014 FIRMAGON degarelix acetate ADD TO FORMULARY Preferred Brands 01/01/2014 FLOVENT HFA fluticasone propionate ADD TO FORMULARY Preferred Brands 01/01/2014 FLOVENT HFA fluticasone propionate ADD TO FORMULARY Preferred Brands 01/01/2014 FLOVENT HFA fluticasone propionate ADD TO FORMULARY Preferred Brands 01/01/2014 FLOVENT DISKUS fluticasone propionate ADD TO FORMULARY Preferred Brands 01/01/2014 FLOVENT DISKUS fluticasone propionate ADD TO FORMULARY Preferred Brands 01/01/2014 FLOVENT DISKUS fluticasone propionate ADD TO FORMULARY Preferred Brands 01/01/2014 FML fluorometholone CHANGE TIER Preferred Brands 01/01/2014 FML S.O.P. fluorometholone ADD TO FORMULARY Preferred Brands 01/01/2014 FOCALIN XR dexmethylphenidate hcl ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 121 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 FOCALIN XR dexmethylphenidate hcl ADD TO FORMULARY Preferred Brands 01/01/2014 FOCALIN XR dexmethylphenidate hcl ADD TO FORMULARY Preferred Brands 01/01/2014 focalin,focalin dexmethylphenidate hcl xr,dexmethylphen idate hcl,dexmethylphe nidate hcl er CHANGE TIER Preferred Brands 01/01/2014 arixtra,fondaparin fondaparinux sodium ux sodium ADD TO FORMULARY Preferred Brands 01/01/2014 FORADIL formoterol fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 FOSRENOL lanthanum carbonate ADD TO FORMULARY Preferred Brands 01/01/2014 FRAGMIN dalteparin sodium,porcine ADD TO FORMULARY Preferred Brands 01/01/2014 FUZEON enfuvirtide ADD TO FORMULARY Preferred Brands 01/01/2014 FUZEON enfuvirtide ADD UM: AUTHORIZATION PA applies 01/01/2014 FUZEON enfuvirtide ADD TO FORMULARY Preferred Brands 01/01/2014 FUZEON enfuvirtide ADD UM: AUTHORIZATION PA applies 01/01/2014 GASTROCROM cromolyn sodium ADD TO FORMULARY Preferred Brands 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 122 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands 01/01/2014 GENOTROPIN somatropin ADD TO FORMULARY Preferred Brands 01/01/2014 GLEEVEC imatinib mesylate ADD TO FORMULARY Preferred Brands 01/01/2014 GLEEVEC imatinib mesylate ADD UM: AUTHORIZATION PA applies 01/01/2014 GONAL-F follitropin alfa, recomb RFF,GONALF,GONAL-F RFF REDI-JECT ADD TO FORMULARY Preferred Brands 01/01/2014 GONAL-F follitropin alfa, recomb RFF,GONALF,GONAL-F RFF REDI-JECT ADD UM: CUSTOM Fertility Benefit Rider REQUIRED 01/01/2014 GRIFULVIN V griseofulvin, microsize ADD TO FORMULARY Preferred Brands 01/01/2014 GRIS-PEG griseofulvin ultramicrosize ADD TO FORMULARY Preferred Brands 01/01/2014 GRIS-PEG griseofulvin ultramicrosize ADD TO FORMULARY Preferred Brands 01/01/2014 griseofulvin ultramicrosize griseofulvin ultramicrosize ADD TO FORMULARY Preferred Brands 01/01/2014 HALFLYTELYBISACODYL bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3350 ADD TO FORMULARY Preferred Brands 01/01/2014 HECTOROL doxercalciferol ADD TO FORMULARY Preferred Brands 01/01/2014 HECTOROL doxercalciferol ADD TO FORMULARY Preferred Brands 01/01/2014 HECTOROL doxercalciferol ADD TO FORMULARY Preferred Brands 01/01/2014 HECTOROL doxercalciferol ADD TO FORMULARY Preferred Brands 01/01/2014 HEXALEN altretamine ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 123 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 HUMALOG MIX insulin lispro protamine and 75-25,HUMALOG insulin lispro MIX 5050,HUMALOG MIX 75-25 KWIKPEN,HUMA LOG MIX 50-50 KWIKPEN ADD TO FORMULARY Preferred Brands 01/01/2014 HUMALOG,HUM insulin lispro ALOG KWIKPEN U-100 ADD TO FORMULARY Preferred Brands 01/01/2014 HUMIRA,HUMIR adalimumab A PEN,HUMIRA PEN CROHNUC-HS STARTER,HUMI RA PEN PSORIASISUVEITIS ADD TO FORMULARY Preferred Brands 01/01/2014 HUMIRA,HUMIR adalimumab A PEN,HUMIRA PEN CROHNUC-HS STARTER,HUMI RA PEN PSORIASISUVEITIS ADD UM: AUTHORIZATION PA applies 01/01/2014 HUMULIN R U500 ADD TO FORMULARY Preferred Brands 01/01/2014 HUMULIN 70insulin nph human 30,NOVOLIN 70- isophane/insulin regular, 30,HUMULIN human 70/30 KWIKPEN CHANGE TIER Preferred Brands insulin regular, human BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 124 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE TIER Preferred Brands 01/01/2014 HUMULIN N,NOVOLIN N,HUMULIN N KWIKPEN insulin nph human isophane 01/01/2014 IMURAN azathioprine ADD TO FORMULARY Preferred Brands 01/01/2014 INCIVEK telaprevir ADD TO FORMULARY Preferred Brands 01/01/2014 INCIVEK telaprevir ADD UM: AUTHORIZATION PA applies 01/01/2014 INSPRA eplerenone ADD TO FORMULARY Preferred Brands 01/01/2014 INSPRA eplerenone ADD TO FORMULARY Preferred Brands 01/01/2014 INTELENCE etravirine ADD TO FORMULARY Preferred Brands 01/01/2014 INTRON A interferon alfa-2b,recomb. ADD TO FORMULARY Preferred Brands 01/01/2014 INTRON A interferon alfa-2b,recomb. ADD UM: AUTHORIZATION PA applies 01/01/2014 INVIRASE saquinavir mesylate ADD TO FORMULARY Preferred Brands 01/01/2014 ISENTRESS raltegravir potassium ADD TO FORMULARY Preferred Brands 01/01/2014 ISOPTO CARBACHOL carbachol ADD TO FORMULARY Preferred Brands 01/01/2014 ISOPTO CARBACHOL carbachol ADD TO FORMULARY Preferred Brands 01/01/2014 ISOPTO CARPINE pilocarpine hcl ADD TO FORMULARY Non-Formulary 01/01/2014 ISOPTO CARPINE pilocarpine hcl ADD TO FORMULARY Preferred Brands 01/01/2014 ISOPTO CARPINE pilocarpine hcl ADD TO FORMULARY Preferred Brands 01/01/2014 JALYN dutasteride/tamsulosin hcl ADD TO FORMULARY Preferred Brands 01/01/2014 JANUMET XR,JANUMET sitagliptin phosphate/metformin hcl ADD TO FORMULARY Preferred Brands 01/01/2014 JANUVIA sitagliptin phosphate ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 125 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 KADIAN morphine sulfate ADD TO FORMULARY Preferred Brands 01/01/2014 KADIAN morphine sulfate ADD TO FORMULARY Non-Formulary 01/01/2014 KADIAN morphine sulfate ADD TO FORMULARY Non-Formulary 01/01/2014 KADIAN morphine sulfate ADD TO FORMULARY Non-Formulary 01/01/2014 KADIAN morphine sulfate ADD TO FORMULARY Non-Formulary 01/01/2014 KADIAN morphine sulfate ADD TO FORMULARY Non-Formulary 01/01/2014 KADIAN morphine sulfate ADD TO FORMULARY Non-Formulary 01/01/2014 KADIAN morphine sulfate ADD TO FORMULARY Non-Formulary 01/01/2014 KALETRA lopinavir/ritonavir ADD TO FORMULARY Preferred Brands 01/01/2014 KOMBIGLYZE XR saxagliptin hcl/metformin hcl ADD TO FORMULARY Preferred Brands 01/01/2014 LANTUS insulin glargine,human SOLOSTAR,LAN recombinant analog TUS ADD TO FORMULARY Preferred Brands 01/01/2014 LETAIRIS ambrisentan ADD TO FORMULARY Preferred Brands 01/01/2014 LETAIRIS ambrisentan ADD UM: AUTHORIZATION PA applies 01/01/2014 LEUKERAN chlorambucil ADD TO FORMULARY Preferred Brands 01/01/2014 LEUKINE sargramostim ADD TO FORMULARY Preferred Brands 01/01/2014 LEVEMIR,LEVE MIR FLEXPEN insulin detemir ADD TO FORMULARY Preferred Brands 01/01/2014 LEXIVA fosamprenavir calcium ADD TO FORMULARY Preferred Brands 01/01/2014 LIDOVIR acyclovir/lidocaine hcl ADD TO FORMULARY Preferred Brands 01/01/2014 LIPITOR atorvastatin calcium CHANGE TIER Non-Formulary 01/01/2014 LODOSYN carbidopa ADD TO FORMULARY Non-Formulary 01/01/2014 ALREX,LOTEMA loteprednol etabonate X CHANGE TIER Preferred Brands 01/01/2014 LOTRONEX ADD TO FORMULARY Preferred Brands alosetron hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 126 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 lyrica,pregabalin pregabalin ADD TO FORMULARY Preferred Brands 01/01/2014 MACROBID nitrofurantoin monohydrate/macrocrystals ADD TO FORMULARY Preferred Brands 01/01/2014 MALARONE atovaquone/proguanil hcl ADD TO FORMULARY Preferred Brands 01/01/2014 MALARONE atovaquone/proguanil hcl ADD TO FORMULARY Preferred Brands 01/01/2014 MARPLAN isocarboxazid ADD TO FORMULARY Preferred Brands 01/01/2014 MATULANE procarbazine hcl ADD TO FORMULARY Preferred Brands 01/01/2014 MEPRON atovaquone ADD TO FORMULARY Non-Formulary 01/01/2014 MESNEX mesna ADD TO FORMULARY Non-Formulary 01/01/2014 MESNEX mesna ADD TO FORMULARY Preferred Brands 01/01/2014 pyridostigmine pyridostigmine bromide bromide,mestino n,regonol ADD TO FORMULARY Preferred Brands 01/01/2014 METHITEST methyltestosterone ADD TO FORMULARY Preferred Brands 01/01/2014 MIGRANAL dihydroergotamine mesylate ADD TO FORMULARY Preferred Brands 01/01/2014 MONOCLATEP,HEMOFIL M,KOATE-DVI antihemophilic factor, human CHANGE TIER Preferred Brands 01/01/2014 MUGARD glycerin/carbomer homopolymer type a/potassium hydroxide ADD TO FORMULARY Preferred Brands 01/01/2014 MYAMBUTOL ethambutol hcl ADD TO FORMULARY Preferred Brands 01/01/2014 MYFORTIC mycophenolate sodium ADD TO FORMULARY Preferred Brands 01/01/2014 MYFORTIC mycophenolate sodium ADD TO FORMULARY Preferred Brands 01/01/2014 MYLERAN busulfan ADD TO FORMULARY Preferred Brands 01/01/2014 MYOZYME alglucosidase alfa ADD TO FORMULARY Preferred Brands 01/01/2014 NAMENDA,NAM memantine hcl ENDA XR ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 127 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 NATROBA spinosad 01/01/2014 armour thyroid,pork,thyroid thyroid,thyroid,np thyroid,naturethroid,westhroid, wp thyroid 01/01/2014 NEULASTA 01/01/2014 Type of Change Previous Value New Value ADD TO FORMULARY Preferred Brands CHANGE TIER Preferred Brands pegfilgrastim ADD TO FORMULARY Preferred Brands NEVANAC nepafenac ADD TO FORMULARY Preferred Brands 01/01/2014 NEXAVAR sorafenib tosylate ADD TO FORMULARY Preferred Brands 01/01/2014 NIASPAN niacin ADD TO FORMULARY Preferred Brands 01/01/2014 NIASPAN niacin ADD TO FORMULARY Preferred Brands 01/01/2014 NIASPAN niacin ADD TO FORMULARY Preferred Brands 01/01/2014 NILANDRON nilutamide ADD TO FORMULARY Preferred Brands 01/01/2014 NITROLINGUAL nitroglycerin ADD TO FORMULARY 01/01/2014 NITROSTAT nitroglycerin ADD TO FORMULARY Preferred Brands 01/01/2014 NITROSTAT nitroglycerin ADD TO FORMULARY Preferred Brands 01/01/2014 NITROSTAT nitroglycerin ADD TO FORMULARY Preferred Brands 01/01/2014 NORITATE metronidazole ADD TO FORMULARY Preferred Brands 01/01/2014 novofine pen needle, diabetic CHANGE TIER Generics Preferred Brands 01/01/2014 novofine 32 pen needle, diabetic CHANGE TIER Generics Preferred Brands 01/01/2014 NOVOLOG MIX insulin aspart protamine 70-30,NOVOLOG human/insulin aspart MIX 70-30 FLEXPEN ADD TO FORMULARY Preferred Brands 01/01/2014 NOVOLOG,NOV insulin aspart OLOG FLEXPEN ADD TO FORMULARY Preferred Brands 01/01/2014 NOVOSEVEN RT ADD TO FORMULARY Preferred Brands coagulation factor viia (recombinant) Non-Formulary Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 128 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 novotwist pen needle, diabetic CHANGE TIER Generics Preferred Brands 01/01/2014 novotwist pen needle, diabetic CHANGE TIER Generics Preferred Brands 01/01/2014 HUMATROPE,G somatropin ENOTROPIN,NO RDITROPIN NORDIFLEX,NO RDITROPIN FLEXPRO,OMNI TROPE,SEROST IM,SAIZEN,ZOR BTIVE,NUTROPI N,NUTROPIN AQ,NUTROPIN AQ NUSPIN,TEVTROPIN 01/01/2014 NUVIGIL 01/01/2014 CHANGE TIER Preferred Brands armodafinil ADD TO FORMULARY Preferred Brands ONGLYZA saxagliptin hcl ADD TO FORMULARY Preferred Brands 01/01/2014 ORAP pimozide ADD TO FORMULARY Preferred Brands 01/01/2014 ORFADIN nitisinone ADD TO FORMULARY Preferred Brands 01/01/2014 ORTHO TRICYCLEN LO norgestimate-ethinyl estradiol ADD TO FORMULARY Preferred Brands 01/01/2014 ORTHO TRICYCLEN LO norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 OSMOPREP sodium phosphate,m-basic m-hyd/sodium phosphate,dibasic ADD TO FORMULARY Preferred Brands 01/01/2014 OXSORALENULTRA methoxsalen, rapid ADD TO FORMULARY Preferred Brands 01/01/2014 oxsoralen,8methoxsalen mop,methoxsalen ,uvadex CHANGE TIER Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 129 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value CHANGE TIER New Value 01/01/2014 oxycodone oxycodone hcl hcl,oxycodone hydrochloride,roxi codone,oxycontin ,oxecta Preferred Brands 01/01/2014 PANCREAZE lipase/protease/amylase ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2014 PANCREAZE lipase/protease/amylase ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2014 PANCREAZE lipase/protease/amylase ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2014 PANCREAZE lipase/protease/amylase ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2014 pancrelipase 5,000 lipase/protease/amylase ADD TO FORMULARY Non-Formulary Generics 01/01/2014 PARCOPA carbidopa/levodopa ADD TO FORMULARY Preferred Brands 01/01/2014 PARCOPA carbidopa/levodopa ADD TO FORMULARY Preferred Brands 01/01/2014 PARCOPA carbidopa/levodopa ADD TO FORMULARY Preferred Brands 01/01/2014 PATADAY olopatadine hcl ADD TO FORMULARY Preferred Brands 01/01/2014 PEGASYS,PEGA peginterferon alfa-2a SYS PROCLICK ADD TO FORMULARY Preferred Brands 01/01/2014 PEGASYS,PEGA peginterferon alfa-2a SYS PROCLICK ADD UM: AUTHORIZATION PA applies 01/01/2014 PEGINTRON,SY peginterferon alfa-2b LATRON,SYLAT RON 4PACK,PEGINTR ON REDIPEN CHANGE TIER Preferred Brands 01/01/2014 PEGINTRON,SY peginterferon alfa-2b LATRON,SYLAT RON 4PACK,PEGINTR ON REDIPEN ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 130 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value CHANGE TIER New Value 01/01/2014 asacol,delzicol,as mesalamine acol hd,5aminosalicylic acid,mesalamine, pentasa,lialda,ca nasa,apriso,sfrow asa Preferred Brands 01/01/2014 creon,pancrelipas lipase/protease/amylase e 5,000,tri-pase 8,tri-pase 16,zenpep,pancr eaze,ultresa,viok ace,pertzye ADD TO FORMULARY 01/01/2014 PHOSLO calcium acetate ADD TO FORMULARY Preferred Brands 01/01/2014 PHOSPHOLINE IODIDE echothiophate iodide ADD TO FORMULARY Preferred Brands 01/01/2014 PILOPINE HS pilocarpine hcl ADD TO FORMULARY Preferred Brands 01/01/2014 PLAVIX clopidogrel bisulfate CHANGE TIER Non-Formulary 01/01/2014 PLAVIX clopidogrel bisulfate ADD TO FORMULARY Non-Formulary 01/01/2014 PLETAL cilostazol ADD TO FORMULARY Preferred Brands 01/01/2014 PLETAL cilostazol ADD TO FORMULARY Preferred Brands 01/01/2014 PRADAXA dabigatran etexilate mesylate ADD TO FORMULARY Preferred Brands 01/01/2014 PRED-G gentamicin sulfate/prednisolone acetate ADD TO FORMULARY Preferred Brands 01/01/2014 PRED-G gentamicin sulfate/prednisolone acetate ADD TO FORMULARY Preferred Brands 01/01/2014 PREMARIN estrogens, conjugated CHANGE TIER Preferred Brands 01/01/2014 PREMARIN estrogens, conjugated CHANGE UM: GENDER Female Non-Formulary Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 131 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 PREMPRO,PRE estrogens, MPHASE conjugated/medroxyprogest erone acetate ADD TO FORMULARY Preferred Brands 01/01/2014 PREMPRO,PRE estrogens, MPHASE conjugated/medroxyprogest erone acetate ADD UM: GENDER Female 01/01/2014 PREVPAC lansoprazole/amoxicillin trihydrate/clarithromycin ADD TO FORMULARY Preferred Brands 01/01/2014 PREVACID lansoprazole ADD TO FORMULARY Non-Formulary 01/01/2014 PREVACID lansoprazole CHANGE TIER 01/01/2014 PREZISTA darunavir ethanolate ADD TO FORMULARY Preferred Brands 01/01/2014 PRISTIQ ER desvenlafaxine succinate ADD TO FORMULARY Preferred Brands 01/01/2014 PRISTIQ ER desvenlafaxine succinate ADD TO FORMULARY Preferred Brands 01/01/2014 PROAIR HFA albuterol sulfate ADD TO FORMULARY Preferred Brands 01/01/2014 BEBULIN VH factor ix complex, IMMUNO,BEBUL prothrombin complex conc. IN,PROFILNINE (pcc) comb. 6,factor ix complex, prothrombin cplx conc(pcc) no.6, 3factor,factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor CHANGE TIER Preferred Brands 01/01/2014 progesterone progesterone,micronized ADD TO FORMULARY Generics 01/01/2014 progesterone progesterone,micronized ADD TO FORMULARY Generics 01/01/2014 PROMETRIUM progesterone,micronized ADD TO FORMULARY Preferred Brands 01/01/2014 PROMETRIUM progesterone,micronized ADD TO FORMULARY Preferred Brands 01/01/2014 PROMISEB COMPLETE emollient combination no.43/skin cleanser combination #27 ADD TO FORMULARY Preferred Brands 01/01/2014 PROVIGIL modafinil ADD TO FORMULARY Preferred Brands Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 132 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 PROVIGIL modafinil ADD TO FORMULARY Preferred Brands 01/01/2014 PULMICORT FLEXHALER budesonide ADD TO FORMULARY Preferred Brands 01/01/2014 PULMICORT FLEXHALER budesonide ADD TO FORMULARY Preferred Brands 01/01/2014 PULMICORT budesonide ADD TO FORMULARY Preferred Brands 01/01/2014 PULMICORT budesonide ADD TO FORMULARY Non-Formulary 01/01/2014 PULMICORT budesonide ADD TO FORMULARY Non-Formulary 01/01/2014 PULMOZYME dornase alfa ADD TO FORMULARY Preferred Brands 01/01/2014 PULMOZYME dornase alfa ADD UM: AUTHORIZATION PA applies 01/01/2014 PURINETHOL mercaptopurine ADD TO FORMULARY Preferred Brands 01/01/2014 beconase beclomethasone aq,beclomethaso dipropionate ne dipropionate,qvar ,qnasl CHANGE TIER Preferred Brands 01/01/2014 REBIF,REBIF interferon beta-1a/albumin REBIDOSE,AVO human NEX CHANGE TIER Preferred Brands 01/01/2014 REBIF,REBIF interferon beta-1a/albumin REBIDOSE,AVO human NEX CHANGE UM: AUTHORIZATION PA applies 01/01/2014 RELPAX eletriptan hbr ADD TO FORMULARY Preferred Brands 01/01/2014 RELPAX eletriptan hbr ADD UM: QUANTITY 18 / 30 days 01/01/2014 RENAGEL sevelamer hcl ADD TO FORMULARY Preferred Brands 01/01/2014 RENAGEL sevelamer hcl ADD TO FORMULARY Preferred Brands 01/01/2014 REQUIP ropinirole hcl ADD TO FORMULARY Preferred Brands 01/01/2014 REQUIP ropinirole hcl ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 133 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 REQUIP ropinirole hcl ADD TO FORMULARY Preferred Brands 01/01/2014 REQUIP ropinirole hcl ADD TO FORMULARY Preferred Brands 01/01/2014 REQUIP ropinirole hcl ADD TO FORMULARY Preferred Brands 01/01/2014 REQUIP ropinirole hcl ADD TO FORMULARY Preferred Brands 01/01/2014 REQUIP ropinirole hcl ADD TO FORMULARY Preferred Brands 01/01/2014 REQUIP XL ropinirole hcl ADD TO FORMULARY Preferred Brands 01/01/2014 REQUIP XL ropinirole hcl ADD TO FORMULARY Preferred Brands 01/01/2014 REQUIP XL ropinirole hcl ADD TO FORMULARY Preferred Brands 01/01/2014 REQUIP XL ropinirole hcl ADD TO FORMULARY Preferred Brands 01/01/2014 REQUIP XL ropinirole hcl ADD TO FORMULARY Preferred Brands 01/01/2014 RESCRIPTOR delavirdine mesylate ADD TO FORMULARY Preferred Brands 01/01/2014 RESCRIPTOR delavirdine mesylate ADD TO FORMULARY Preferred Brands 01/01/2014 RESTASIS cyclosporine ADD TO FORMULARY Preferred Brands 01/01/2014 REVLIMID lenalidomide ADD TO FORMULARY Preferred Brands 01/01/2014 REYATAZ atazanavir sulfate ADD TO FORMULARY Preferred Brands 01/01/2014 RHEUMATREX methotrexate sodium ADD TO FORMULARY Preferred Brands 01/01/2014 RIDAURA auranofin ADD TO FORMULARY Preferred Brands 01/01/2014 RIMSO-50 dimethyl sulfoxide ADD TO FORMULARY Preferred Brands 01/01/2014 RISPERDAL CONSTA risperidone microspheres ADD TO FORMULARY Preferred Brands 01/01/2014 RISPERDAL risperidone ADD TO FORMULARY Non-Formulary 01/01/2014 RISPERDAL risperidone ADD TO FORMULARY Generics 01/01/2014 RISPERDAL risperidone ADD TO FORMULARY Generics 01/01/2014 RISPERDAL risperidone ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 134 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 RISPERDAL MTAB risperidone ADD TO FORMULARY Non-Formulary 01/01/2014 RISPERDAL risperidone ADD TO FORMULARY Non-Formulary 01/01/2014 RISPERDAL risperidone ADD TO FORMULARY Non-Formulary 01/01/2014 RISPERDAL risperidone ADD TO FORMULARY Non-Formulary 01/01/2014 RISPERDAL MTAB risperidone ADD TO FORMULARY Non-Formulary 01/01/2014 RISPERDAL MTAB risperidone ADD TO FORMULARY Non-Formulary 01/01/2014 RISPERDAL MTAB risperidone ADD TO FORMULARY Non-Formulary 01/01/2014 RISPERDAL MTAB risperidone ADD TO FORMULARY Non-Formulary 01/01/2014 ROWASA mesalamine with cleansing wipes ADD TO FORMULARY Preferred Brands 01/01/2014 SECONAL SODIUM secobarbital sodium ADD TO FORMULARY Preferred Brands 01/01/2014 SELZENTRY maraviroc ADD TO FORMULARY Preferred Brands 01/01/2014 SENSIPAR cinacalcet hcl ADD TO FORMULARY Preferred Brands 01/01/2014 SEREVENT DISKUS salmeterol xinafoate ADD TO FORMULARY Preferred Brands 01/01/2014 SEROQUEL quetiapine fumarate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 SEROQUEL quetiapine fumarate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 SEROQUEL quetiapine fumarate CHANGE TIER Non-Formulary 01/01/2014 SEROQUEL quetiapine fumarate CHANGE TIER Non-Formulary 01/01/2014 SEROQUEL XR quetiapine fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 SEROQUEL XR quetiapine fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 SEROQUEL XR quetiapine fumarate ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 135 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 SEROQUEL XR quetiapine fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 SEROQUEL XR quetiapine fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 SIMPONI,SIMPO golimumab NI ARIA ADD TO FORMULARY Preferred Brands 01/01/2014 SIMPONI,SIMPO golimumab NI ARIA CHANGE UM: AUTHORIZATION PA applies 01/01/2014 SINGULAIR montelukast sodium CHANGE TIER Non-Formulary 01/01/2014 SINGULAIR montelukast sodium CHANGE TIER Non-Formulary 01/01/2014 SINGULAIR montelukast sodium CHANGE TIER Non-Formulary 01/01/2014 SINGULAIR montelukast sodium CHANGE TIER 01/01/2014 spectracef,cefdito cefditoren pivoxil ren pivoxil 01/01/2014 SPIRIVA 01/01/2014 Preferred Brands Non-Formulary CHANGE TIER Preferred Brands tiotropium bromide ADD TO FORMULARY Preferred Brands SPRYCEL dasatinib ADD TO FORMULARY Preferred Brands 01/01/2014 stavudine stavudine ADD TO FORMULARY Generics 01/01/2014 stavudine stavudine ADD TO FORMULARY Generics 01/01/2014 stavudine stavudine ADD TO FORMULARY Generics 01/01/2014 stavudine stavudine ADD TO FORMULARY Generics 01/01/2014 stavudine stavudine ADD TO FORMULARY Generics 01/01/2014 STALEVO 50 carbidopa/levodopa/entacap one ADD TO FORMULARY Preferred Brands 01/01/2014 STALEVO 100 carbidopa/levodopa/entacap one ADD TO FORMULARY Preferred Brands 01/01/2014 STALEVO 150 carbidopa/levodopa/entacap one ADD TO FORMULARY Preferred Brands 01/01/2014 STALEVO 200 carbidopa/levodopa/entacap one ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 136 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 STALEVO 75 carbidopa/levodopa/entacap one ADD TO FORMULARY Preferred Brands 01/01/2014 STALEVO 125 carbidopa/levodopa/entacap one ADD TO FORMULARY Preferred Brands 01/01/2014 STIMATE desmopressin acetate ADD TO FORMULARY Preferred Brands 01/01/2014 SUBOXONE buprenorphine hcl/naloxone hcl ADD TO FORMULARY Preferred Brands 01/01/2014 SUBOXONE buprenorphine hcl/naloxone hcl ADD TO FORMULARY Non-Formulary 01/01/2014 SUBOXONE buprenorphine hcl/naloxone hcl ADD TO FORMULARY Non-Formulary 01/01/2014 SUBOXONE buprenorphine hcl/naloxone hcl ADD TO FORMULARY Non-Formulary 01/01/2014 SUCRAID sacrosidase ADD TO FORMULARY Preferred Brands 01/01/2014 SUSTIVA efavirenz ADD TO FORMULARY Preferred Brands 01/01/2014 SUTENT sunitinib malate ADD TO FORMULARY Preferred Brands 01/01/2014 SYMBICORT budesonide/formoterol fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 SYNAGIS palivizumab ADD UM: AUTHORIZATION PA applies 01/01/2014 TAMBOCOR flecainide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 TAMBOCOR flecainide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 TAMBOCOR flecainide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 TAPAZOLE methimazole ADD TO FORMULARY Non-Formulary 01/01/2014 TAPAZOLE methimazole ADD TO FORMULARY Non-Formulary 01/01/2014 TARCEVA erlotinib hcl ADD TO FORMULARY Preferred Brands 01/01/2014 TARGRETIN bexarotene CHANGE TIER Preferred Brands 01/01/2014 TASIGNA nilotinib hcl ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 137 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 TASIGNA nilotinib hcl 01/01/2014 TASMAR tolcapone 01/01/2014 tazorac,avage,fa tazarotene bior,tazarotene 01/01/2014 TEKAMLO 01/01/2014 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies ADD TO FORMULARY Preferred Brands CHANGE TIER Preferred Brands ADD TO FORMULARY Preferred Brands TEKTURNA HCT aliskiren hemifumarate/hydrochlorothi azide ADD TO FORMULARY Preferred Brands 01/01/2014 TEKTURNA ADD TO FORMULARY Preferred Brands 01/01/2014 temodar,temozol temozolomide omide ADD TO FORMULARY Preferred Brands 01/01/2014 THALOMID thalidomide ADD TO FORMULARY Preferred Brands 01/01/2014 TOBRADEX tobramycin/dexamethasone ADD TO FORMULARY Preferred Brands 01/01/2014 TOBRADEX tobramycin/dexamethasone ADD TO FORMULARY Non-Formulary 01/01/2014 TOBRADEX ST tobramycin/dexamethasone ADD TO FORMULARY Preferred Brands 01/01/2014 TOVIAZ fesoterodine fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 TRACLEER bosentan ADD TO FORMULARY Preferred Brands 01/01/2014 TRACLEER bosentan ADD UM: AUTHORIZATION PA applies 01/01/2014 TRAVATAN Z travoprost ADD TO FORMULARY Preferred Brands 01/01/2014 TREXALL methotrexate sodium ADD TO FORMULARY Preferred Brands 01/01/2014 TREXALL methotrexate sodium ADD TO FORMULARY Preferred Brands 01/01/2014 TREXALL methotrexate sodium ADD TO FORMULARY Preferred Brands 01/01/2014 TREXALL methotrexate sodium ADD TO FORMULARY Preferred Brands 01/01/2014 TRIBENZOR olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide ADD TO FORMULARY Preferred Brands aliskiren hemifumarate/amlodipine besylate aliskiren hemifumarate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 138 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 TRIZIVIR abacavir sulfate/lamivudine/zidovudin e ADD TO FORMULARY Non-Formulary 01/01/2014 TRUVADA emtricitabine/tenofovir disoproxil fumarate ADD TO FORMULARY Non-Formulary 01/01/2014 TYKERB lapatinib ditosylate ADD TO FORMULARY Preferred Brands 01/01/2014 ULESFIA benzyl alcohol ADD TO FORMULARY Preferred Brands 01/01/2014 ULORIC febuxostat ADD TO FORMULARY Preferred Brands 01/01/2014 UROCIT-K potassium citrate ADD TO FORMULARY Non-Formulary 01/01/2014 UROCIT-K potassium citrate ADD TO FORMULARY Non-Formulary 01/01/2014 UROCIT-K potassium citrate ADD TO FORMULARY Non-Formulary 01/01/2014 UROGESICBLUE methenamine/sodium phosphate,monobasic/meth blue/hyosc sul ADD TO FORMULARY Preferred Brands 01/01/2014 VENTOLIN HFA albuterol sulfate ADD TO FORMULARY Preferred Brands 01/01/2014 VEXOL rimexolone ADD TO FORMULARY Preferred Brands 01/01/2014 VIAGRA sildenafil citrate ADD TO FORMULARY Preferred Brands 01/01/2014 VIAGRA sildenafil citrate ADD TO FORMULARY Preferred Brands 01/01/2014 VIAGRA sildenafil citrate ADD TO FORMULARY Preferred Brands 01/01/2014 VIRACEPT nelfinavir mesylate ADD TO FORMULARY Preferred Brands 01/01/2014 VIRAMUNE XR nevirapine CHANGE TIER 01/01/2014 VIRAMUNE nevirapine ADD TO FORMULARY Non-Formulary 01/01/2014 VIRAMUNE nevirapine ADD TO FORMULARY Non-Formulary 01/01/2014 VIRAZOLE ribavirin ADD TO FORMULARY Preferred Brands 01/01/2014 VIRAZOLE ribavirin ADD UM: AUTHORIZATION PA applies 01/01/2014 VIREAD tenofovir disoproxil fumarate ADD TO FORMULARY Preferred Brands 01/01/2014 VIVELLE-DOT estradiol ADD TO FORMULARY Not Covered Non-Formulary Preferred Brands Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 139 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 VIVELLE-DOT estradiol ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2014 VIVELLE-DOT estradiol ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2014 VIVELLE-DOT estradiol ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2014 VIVELLE-DOT estradiol ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2014 vol-tab rx prenatal vits with calcium #76/iron,carbonyl/folic acid ADD TO FORMULARY Non-Formulary 01/01/2014 VOLTAREN diclofenac sodium CHANGE TIER Preferred Brands 01/01/2014 VUSION miconazole nitrate/zinc oxide/petrolatum,white ADD TO FORMULARY Preferred Brands 01/01/2014 VYVANSE lisdexamfetamine dimesylate ADD TO FORMULARY Preferred Brands 01/01/2014 WELCHOL colesevelam hcl ADD TO FORMULARY Preferred Brands 01/01/2014 WELCHOL colesevelam hcl ADD TO FORMULARY Preferred Brands 01/01/2014 XALATAN latanoprost CHANGE TIER 01/01/2014 XARELTO rivaroxaban ADD TO FORMULARY Preferred Brands 01/01/2014 XELODA capecitabine ADD TO FORMULARY Preferred Brands 01/01/2014 XELODA capecitabine ADD UM: AUTHORIZATION PA applies 01/01/2014 XELODA capecitabine ADD TO FORMULARY Preferred Brands 01/01/2014 XELODA capecitabine ADD UM: AUTHORIZATION PA applies 01/01/2014 XOLEGEL ketoconazole ADD TO FORMULARY Preferred Brands 01/01/2014 zemplar,paricalcit paricalcitol ol ADD TO FORMULARY Preferred Brands 01/01/2014 ZERIT stavudine ADD TO FORMULARY Non-Formulary 01/01/2014 ZERIT stavudine ADD TO FORMULARY Non-Formulary 01/01/2014 ZERIT stavudine ADD TO FORMULARY Non-Formulary 01/01/2014 ZERIT stavudine ADD TO FORMULARY Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 140 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ZERIT stavudine ADD TO FORMULARY Non-Formulary 01/01/2014 ZETIA ezetimibe ADD TO FORMULARY Preferred Brands 01/01/2014 ZIAGEN abacavir sulfate ADD TO FORMULARY Non-Formulary 01/01/2014 ZIAGEN abacavir sulfate ADD TO FORMULARY Non-Formulary 01/01/2014 ZOLINZA vorinostat ADD TO FORMULARY Preferred Brands 01/01/2014 ZOLVIT hydrocodone bitartrate/acetaminophen ADD TO FORMULARY Preferred Brands 01/01/2014 ZOVIRAX acyclovir CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ZOVIRAX acyclovir CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ZOVIRAX acyclovir ADD TO FORMULARY Preferred Brands 01/01/2014 ZOVIRAX acyclovir ADD TO FORMULARY Preferred Brands 01/01/2014 ZOVIRAX acyclovir ADD TO FORMULARY Non-Formulary 01/01/2014 ZOVIRAX acyclovir CHANGE TIER 01/01/2014 ZYPREXA olanzapine CHANGE TIER Preferred Brands 01/01/2014 ZYPREXA olanzapine CHANGE TIER Preferred Brands 01/01/2014 ZYPREXA olanzapine CHANGE TIER Preferred Brands 01/01/2014 ZYPREXA olanzapine CHANGE TIER Preferred Brands 01/01/2014 ZYTAZE zinc citrate/phytase ADD TO FORMULARY Preferred Brands 01/01/2014 BIAXIN clarithromycin ADD TO FORMULARY Non-Formulary 01/01/2014 BIAXIN XL clarithromycin CHANGE TIER 01/01/2014 BIAXIN clarithromycin ADD TO FORMULARY Non-Formulary 01/01/2014 BIAXIN clarithromycin ADD TO FORMULARY Non-Formulary 01/01/2014 TEVETEN HCT eprosartan mesylate/hydrochlorothiazid e CHANGE TIER Preferred Brands Preferred Brands Preferred Brands Non-Formulary Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 141 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 teveten,eprosarta eprosartan mesylate n mesylate 01/01/2014 ARICEPT 01/01/2014 Type of Change Previous Value New Value CHANGE TIER Non-Formulary donepezil hcl ADD TO FORMULARY Non-Formulary ALPROLIX factor ix recombinant, fc fusion protein ADD TO FORMULARY Preferred Brands 01/01/2014 ALPROLIX factor ix recombinant, fc fusion protein ADD TO FORMULARY Preferred Brands 01/01/2014 ALPROLIX factor ix recombinant, fc fusion protein ADD TO FORMULARY Preferred Brands 01/01/2014 ADEMPAS riociguat 01/01/2014 IMPLANON,NEX etonogestrel PLANON ADD UM: GENDER Female 01/01/2014 MIRENA levonorgestrel ADD UM: GENDER Female 01/01/2014 errin norethindrone ADD TO FORMULARY Preventative 01/01/2014 errin norethindrone ADD UM: GENDER Female 01/01/2014 jencycla norethindrone ADD TO FORMULARY Preventative 01/01/2014 jencycla norethindrone ADD UM: GENDER Female 01/01/2014 lyza norethindrone ADD TO FORMULARY Preventative 01/01/2014 lyza norethindrone ADD UM: GENDER Female 01/01/2014 estarylla norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 estarylla norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 norethindrone norethindrone ADD TO FORMULARY Preventative 01/01/2014 norethindrone norethindrone ADD UM: GENDER Female 01/01/2014 mono-linyah norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative REMOVE UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 142 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 mono-linyah norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 ORTHOCYCLEN norgestimate-ethinyl estradiol ADD TO FORMULARY Non-Formulary 01/01/2014 ORTHOCYCLEN norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 previfem norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 previfem norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 sprintec norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 sprintec norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 cryselle norgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 cryselle norgestrel-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 elinest norgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 elinest norgestrel-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 low-ogestrel norgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 low-ogestrel norgestrel-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 norgestimateethinyl estradiol norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 norgestimateethinyl estradiol norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 norgestimateethinyl estradiol norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 norgestimateethinyl estradiol norgestimate-ethinyl estradiol ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 143 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 tri-estarylla norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 tri-estarylla norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 tri-linyah norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 tri-linyah norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 tri-previfem norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 tri-previfem norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 tri-sprintec norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 tri-sprintec norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 trinessa norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/01/2014 trinessa norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/01/2014 PRENATE ESSENTIAL pnv no.35/iron fumarate/folate comb. #6/dha ADD UM: GENDER Female 01/01/2014 PRENATE ENHANCE prenatal vitamin combo no.68/iron fumarate/fa combo no.6/dha ADD UM: GENDER Female 01/01/2014 PRENATE MINI prenatal vitamins #44/iron,carbonyl/folic acid/dha ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 144 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 PRENATE ELITE prenatal vitamins combo #36/ferrous fumarate/folate combo #6,prenatal vitamins no.79/ferrous aspart glycinate/folate no.1 ADD UM: GENDER Female 01/01/2014 PRENATE RESTORE prenatal vitamins combo no.69/iron fumarate/fa comb no.6/dha ADD UM: GENDER Female 01/01/2014 PRENATE DHA prenatal vitamins no.38/iron fumarate/folate comb no.6/dha,prenatal vitamins no.78/iron asparto glycin/folate no.1/dha ADD UM: GENDER Female 01/01/2014 PRENATE CHEWABLE prenatal vitamins no.112/methyltetrahydrofolat e glucosami,fa ADD UM: GENDER Female 01/01/2014 PRENATE AM prenatal vitamins no.114/methyltetrahydfolate gluc,fa/ginger ADD UM: GENDER Female 01/01/2014 PREQUE 10 prenatal vitamins no.18/fe,carbonyl/fa/docusat e/ubidecar/dha ADD UM: GENDER Female 01/01/2014 vitapearl,prena1 pearl prenatal vit no.71/iron fumsodium feredetate/folic acid/dha ADD UM: GENDER Female 01/01/2014 LATISSE bimatoprost ADD UM: CUSTOM Lifestyle Drugs are Excluded 01/01/2014 morphine sulfate morphine sulfate er ADD TO FORMULARY Non-Formulary Generics 01/01/2014 morphine sulfate morphine sulfate er ADD TO FORMULARY Non-Formulary Generics 01/01/2014 morphine sulfate morphine sulfate er ADD TO FORMULARY Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 145 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Preferred Brands Not Covered 01/01/2014 BOTOX COSMETIC onabotulinumtoxina CHANGE TIER 01/01/2014 BOTOX COSMETIC onabotulinumtoxina ADD UM: CUSTOM 01/01/2014 NOVOLIN R insulin regular, human CHANGE TIER 01/01/2014 NOVOLIN R insulin regular, human ADD UM: CUSTOM Non Covered Manufacturer 01/01/2014 HUMULIN R insulin regular, human ADD UM: CUSTOM Non Covered Manufacturer 01/01/2014 NOVOLIN 70-30 insulin nph human isophane/insulin regular, human ADD UM: CUSTOM Non Covered Manufacturer 01/01/2014 HUMULIN 70-30 insulin nph human isophane/insulin regular, human CHANGE TIER 01/01/2014 HUMULIN 70-30 insulin nph human isophane/insulin regular, human ADD UM: CUSTOM 01/01/2014 NOVOLIN N insulin nph human isophane CHANGE TIER 01/01/2014 NOVOLIN N insulin nph human isophane ADD UM: CUSTOM 01/01/2014 HUMULIN N insulin nph human isophane CHANGE TIER 01/01/2014 HUMULIN N insulin nph human isophane ADD UM: CUSTOM Non Covered Manufacturer 01/01/2014 tamoxifen citrate tamoxifen citrate ADD TO FORMULARY Generics 01/01/2014 tamoxifen citrate tamoxifen citrate ADD TO FORMULARY Generics 01/01/2014 raloxifene hcl ADD TO FORMULARY Generics 01/01/2014 lescol,fluvastatin fluvastatin sodium sodium ADD UM: QUANTITY 30 / 30 days raloxifene hcl Lifestyle Drugs are Excluded Preferred Brands Preferred Brands Not Covered Not Covered Non Covered Manufacturer Preferred Brands Not Covered Non Covered Manufacturer Preferred Brands Not Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 146 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 lescol,fluvastatin fluvastatin sodium sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 prevacid lansoprazole 24hr,lansoprazol e,heartburn treatment 24 hour,heartburn relief 24 hour,prevacid ADD UM: QUANTITY 30 / 30 days 01/01/2014 lansoprazole,prev lansoprazole acid ADD UM: QUANTITY 30 / 30 days 01/01/2014 CARDENE SR nicardipine hcl ADD UM: QUANTITY 60 / 30 days 01/01/2014 CARDENE SR nicardipine hcl ADD UM: QUANTITY 60 / 30 days 01/01/2014 CARDENE SR nicardipine hcl ADD UM: QUANTITY 60 / 30 days 01/01/2014 procardia xl,nifedical xl,nifedipine er nifedipine ADD UM: QUANTITY 30 / 30 days 01/01/2014 procardia xl,nifedical xl,nifedipine er nifedipine ADD UM: QUANTITY 30 / 30 days 01/01/2014 procardia xl,nifedipine er nifedipine ADD UM: QUANTITY 30 / 30 days 01/01/2014 adalat cc,nifedipine er,afeditab cr nifedipine CHANGE UM: QUANTITY 90 / 30 days 30 / 30 days 01/01/2014 adalat cc,nifedipine er,afeditab cr nifedipine CHANGE UM: QUANTITY 90 / 30 days 30 / 30 days 01/01/2014 adalat cc,nifediac nifedipine cc,nifedipine er CHANGE UM: QUANTITY 90 / 30 days 30 / 30 days 01/01/2014 diltiazem 12hr er diltiazem hcl ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 147 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 diltiazem 12hr er diltiazem hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 diltiazem 24hr diltiazem hcl er,cardizem cd,diltiazem 24hr cd,dilt-cd,cartia xt ADD UM: QUANTITY 30 / 30 days 01/01/2014 diltiazem 24hr diltiazem hcl er,cardizem cd,diltiazem 24hr cd,dilt-cd,cartia xt ADD UM: QUANTITY 60 / 30 days 01/01/2014 diltiazem 24hr diltiazem hcl er,cardizem cd,diltiazem 24hr cd,dilt-cd,cartia xt ADD UM: QUANTITY 30 / 30 days 01/01/2014 diltiazem 24hr diltiazem hcl er,cardizem cd,diltiazem 24hr cd,dilt-cd,cartia xt ADD UM: QUANTITY 30 / 30 days 01/01/2014 diltiazem er,tiazac,diltzac er,taztia xt diltiazem hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 diltiazem er,tiazac,diltzac er,taztia xt diltiazem hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 diltiazem er,tiazac,diltzac er,taztia xt diltiazem hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 diltiazem er,tiazac,diltzac er,taztia xt diltiazem hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 diltiazem er,tiazac,diltzac er,taztia xt diltiazem hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 TESTOPEL testosterone ADD UM: GENDER Male BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 148 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 amlodipine amlodipine besylate besylate,norvasc ADD UM: QUANTITY 30 / 30 days 01/01/2014 amlodipine amlodipine besylate besylate,norvasc ADD UM: QUANTITY 30 / 30 days 01/01/2014 amlodipine amlodipine besylate besylate,norvasc ADD UM: QUANTITY 30 / 30 days 01/01/2014 prilosec,omepraz omeprazole ole ADD UM: QUANTITY 30 / 30 days 01/01/2014 sumatriptan sumatriptan succinate succinate,imitrex CHANGE UM: QUANTITY 18 / 30 days 01/01/2014 sumatriptan sumatriptan succinate succinate,imitrex CHANGE UM: QUANTITY 18 / 30 days 01/01/2014 sumatriptan sumatriptan succinate succinate,imitrex CHANGE UM: QUANTITY 18 / 30 days 01/01/2014 BYSTOLIC nebivolol hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 cardizem diltiazem hcl cd,diltiazem 24hr er,diltiazem 24hr cd ADD UM: QUANTITY 30 / 30 days 01/01/2014 diovan valsartan/hydrochlorothiazid hct,valsartane hydrochlorothiazi de ADD UM: QUANTITY 30 / 30 days 01/01/2014 diovan valsartan/hydrochlorothiazid hct,valsartane hydrochlorothiazi de ADD UM: QUANTITY 30 / 30 days 01/01/2014 TESTRED,ANDR methyltestosterone OID ADD UM: GENDER Male 01/01/2014 androxy fluoxymesterone ADD UM: GENDER Male 01/01/2014 ANADROL-50 oxymetholone ADD UM: GENDER Male BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 149 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 estradiol,estrace estradiol CHANGE UM: GENDER Female 01/01/2014 estradiol,estrace estradiol CHANGE UM: GENDER Female 01/01/2014 estradiol,estrace estradiol CHANGE UM: GENDER Female 01/01/2014 MENEST estrogens,esterified ADD UM: GENDER Female 01/01/2014 MENEST estrogens,esterified ADD UM: GENDER Female 01/01/2014 MENEST estrogens,esterified ADD UM: GENDER Female 01/01/2014 MENEST estrogens,esterified ADD UM: GENDER Female 01/01/2014 ogen,estropipate estropipate ADD UM: GENDER Female 01/01/2014 vynatalfa,mynatalz,mynatal plus prenatal vitamins with calcium/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 MYNATAL prenatal vitamins with calcium/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 O-CAL FA prenatal vitamins with calcium/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 MAKENA hydroxyprogesterone caproate ADD UM: GENDER Female 01/01/2014 norethindrone norethindrone acetate acetate,aygestin ADD UM: GENDER Female 01/01/2014 oxytocin,pitocin ADD UM: GENDER Female 01/01/2014 micardis telmisartan/hydrochlorothiazi hct,telmisartan- de hydrochlorothiazi d ADD UM: QUANTITY 30 / 30 days 01/01/2014 micardis telmisartan/hydrochlorothiazi hct,telmisartan- de hydrochlorothiazi d ADD UM: QUANTITY 30 / 30 days oxytocin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 150 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 alendronate sodium alendronate sodium ADD UM: QUANTITY 4 / 30 days 01/01/2014 AXERT almotriptan malate ADD UM: QUANTITY 18 / 30 days 01/01/2014 CENESTIN estrogens,conj.,synthetic a ADD UM: GENDER Female 01/01/2014 clarinex,deslorata desloratadine dine ADD UM: QUANTITY 30 / 30 days 01/01/2014 setonet,pr natal 430 prenatal vitamins comb no.54/iron b-g hcl sucp/fa/omega-3 ADD UM: GENDER Female 01/01/2014 NEXIUM esomeprazole magnesium ADD UM: QUANTITY 30 / 30 days 01/01/2014 NEXIUM esomeprazole magnesium ADD UM: QUANTITY 30 / 30 days 01/01/2014 FOLLISTIM AQ follitropin beta,recomb ADD UM: GENDER Female 01/01/2014 FOLLISTIM AQ follitropin beta,recomb ADD UM: GENDER Female 01/01/2014 prozac fluoxetine hcl weekly,fluoxetine dr ADD UM: QUANTITY 4 / 30 days 01/01/2014 geodon,ziprasido ziprasidone hcl ne hcl ADD UM: GENDER Female 01/01/2014 NATALVIT prenatal vitamins with calcium/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 AXERT almotriptan malate ADD UM: QUANTITY 18 / 30 days 01/01/2014 DIOVAN valsartan ADD UM: QUANTITY 30 / 30 days 01/01/2014 DIOVAN valsartan ADD UM: QUANTITY 30 / 30 days 01/01/2014 DIOVAN valsartan ADD UM: QUANTITY 30 / 30 days 01/01/2014 gengraf,neoral,cy cyclosporine, modified closporine ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 151 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 c-nate dha,relnate dha,viva dha prenatal vitamins no.11/ferrous fumarate/folic acid/omega-3 01/01/2014 zomig zmt,zolmitriptan odt 01/01/2014 SANCUSO 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female zolmitriptan ADD UM: QUANTITY 18 / 30 days granisetron ADD UM: QUANTITY 6 / 30 days venlafaxine hcl er venlafaxine hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 venlafaxine hcl er venlafaxine hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 venlafaxine hcl er venlafaxine hcl ADD UM: QUANTITY 60 / 30 days 01/01/2014 VENLAFAXINE HCL ER venlafaxine hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 ultimatecare one,folcaps omega-3 prenatal vit with calcium no.37/iron,aspg/folic acid/omega-3 ADD UM: GENDER Female 01/01/2014 obstetrix dha,obtrex dha prenatal vitamins no.12/iron,carbonyl/fa/docus ate/omega-3 ADD UM: GENDER Female 01/01/2014 citranatal prenatal vitamin no.38/iron assure,natalvirt carb,gluc/folic ca,prenaissance acid/docusat/dha promise ADD UM: GENDER Female 01/01/2014 cozaar,losartan potassium losartan potassium ADD UM: QUANTITY 30 / 30 days 01/01/2014 cozaar,losartan potassium losartan potassium ADD UM: QUANTITY 30 / 30 days 01/01/2014 hyzaar,losartan- losartan hydrochlorothiazi potassium/hydrochlorothiazi de de ADD UM: QUANTITY 30 / 30 days 01/01/2014 cozaar,losartan potassium ADD UM: QUANTITY 30 / 30 days losartan potassium BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 152 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 hyzaar,losartan- losartan hydrochlorothiazi potassium/hydrochlorothiazi de de ADD UM: QUANTITY 30 / 30 days 01/01/2014 xyzal,levocetirizin levocetirizine e dihydrochloride dihydrochloride ADD UM: QUANTITY 30 / 30 days 01/01/2014 pravachol,pravast pravastatin sodium atin sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 FEMHRT norethindrone acetateethinyl estradiol ADD UM: GENDER Female 01/01/2014 REBIF interferon beta-1a/albumin human ADD UM: QUANTITY 12 / 28 days 01/01/2014 REBIF interferon beta-1a/albumin human ADD UM: QUANTITY 12 / 28 days 01/01/2014 zatean-pn,pnvselect,virt-pn prenatal vit with calcium no. 40/iron fumarate/fa cmb no.1 ADD UM: GENDER Female 01/01/2014 avinza,morphine morphine sulfate sulfate er ADD UM: QUANTITY 120 / 30 days 01/01/2014 avinza,morphine morphine sulfate sulfate er ADD UM: QUANTITY 120 / 30 days 01/01/2014 OXYCONTIN oxycodone hcl ADD UM: QUANTITY 240 / 30 days 01/01/2014 OXYCONTIN oxycodone hcl ADD UM: QUANTITY 240 / 30 days 01/01/2014 OXYCONTIN oxycodone hcl ADD UM: QUANTITY 240 / 30 days 01/01/2014 OXYCONTIN oxycodone hcl ADD UM: QUANTITY 240 / 30 days 01/01/2014 DEXILANT dexlansoprazole ADD UM: QUANTITY 30 / 30 days 01/01/2014 DEXILANT dexlansoprazole ADD UM: QUANTITY 30 / 30 days 01/01/2014 budeprion sr,wellbutrin sr,bupropion hcl sr bupropion hcl ADD UM: QUANTITY 60 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 153 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 01/01/2014 COPAXONE 01/01/2014 Generic Name glatiramer acetate Type of Change Previous Value New Value ADD UM: QUANTITY 30 / 30 days effexor venlafaxine hcl xr,venlafaxine hcl er ADD UM: QUANTITY 30 / 30 days 01/01/2014 effexor venlafaxine hcl xr,venlafaxine hcl er ADD UM: QUANTITY 30 / 30 days 01/01/2014 effexor venlafaxine hcl xr,venlafaxine hcl er ADD UM: QUANTITY 60 / 30 days 01/01/2014 avinza,morphine morphine sulfate sulfate er ADD UM: QUANTITY 180 / 30 days 01/01/2014 avinza,morphine morphine sulfate sulfate er ADD UM: QUANTITY 120 / 30 days 01/01/2014 avinza,morphine morphine sulfate sulfate er ADD UM: QUANTITY 120 / 30 days 01/01/2014 avinza,morphine morphine sulfate sulfate er ADD UM: QUANTITY 120 / 30 days 01/01/2014 diovan valsartan/hydrochlorothiazid hct,valsartane hydrochlorothiazi de ADD UM: QUANTITY 30 / 30 days 01/01/2014 retin-a micro,tretinoin microsphere tretinoin microspheres ADD UM: AGE Up to 25 yrs old 01/01/2014 AVONEX interferon beta-1a/albumin human ADD UM: QUANTITY 4 / 28 days 01/01/2014 CENESTIN estrogens,conj.,synthetic a ADD UM: GENDER Female 01/01/2014 SPIRIVA tiotropium bromide ADD UM: QUANTITY 30 / 30 days 01/01/2014 DIOVAN valsartan ADD UM: QUANTITY 30 / 30 days 01/01/2014 ZETIA ezetimibe ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 154 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 AVODART dutasteride ADD UM: GENDER Male 01/01/2014 BYSTOLIC nebivolol hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 singulair,montelu montelukast sodium kast sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 HUMIRA adalimumab ADD UM: QUANTITY 4 / 28 days 01/01/2014 ZOMIG zolmitriptan ADD UM: QUANTITY 18 / 30 days 01/01/2014 PREVACID lansoprazole ADD UM: QUANTITY 30 / 30 days 01/01/2014 PREVACID lansoprazole ADD UM: QUANTITY 30 / 30 days 01/01/2014 CIALIS tadalafil ADD UM: GENDER Male 01/01/2014 CIALIS tadalafil ADD UM: GENDER Male 01/01/2014 CRESTOR rosuvastatin calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 CRESTOR rosuvastatin calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 CRESTOR rosuvastatin calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 CARDIZEM LA diltiazem hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 cardizem la,matzim la,diltiazem er diltiazem hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 cardizem la,matzim la,diltiazem er diltiazem hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 cardizem la,matzim la,diltiazem er diltiazem hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 cardizem la,matzim la,diltiazem er diltiazem hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 cardizem la,matzim la,diltiazem er diltiazem hcl ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 155 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 fentanyl,duragesi fentanyl c ADD UM: QUANTITY 15 / 30 days 01/01/2014 fentanyl,duragesi fentanyl c ADD UM: QUANTITY 15 / 30 days 01/01/2014 fentanyl,duragesi fentanyl c ADD UM: QUANTITY 15 / 30 days 01/01/2014 fentanyl,duragesi fentanyl c ADD UM: QUANTITY 15 / 30 days 01/01/2014 RESTASIS cyclosporine ADD UM: QUANTITY 60 / 30 days 01/01/2014 LEVITRA vardenafil hcl ADD UM: GENDER Male 01/01/2014 LEVITRA vardenafil hcl ADD UM: GENDER Male 01/01/2014 LEVITRA vardenafil hcl ADD UM: GENDER Male 01/01/2014 maxalt,rizatriptan rizatriptan benzoate ADD UM: QUANTITY 18 / 30 days 01/01/2014 maxalt,rizatriptan rizatriptan benzoate ADD UM: QUANTITY 18 / 30 days 01/01/2014 maxalt mlt,rizatriptan rizatriptan benzoate ADD UM: QUANTITY 18 / 30 days 01/01/2014 maxalt mlt,rizatriptan rizatriptan benzoate ADD UM: QUANTITY 18 / 30 days 01/01/2014 FEMRING estradiol acetate ADD UM: QUANTITY 1 / 30 days 01/01/2014 FEMRING estradiol acetate ADD UM: QUANTITY 1 / 30 days 01/01/2014 clarinex,deslorata desloratadine dine ADD UM: QUANTITY 30 / 30 days 01/01/2014 OBTREX prenatal vitamin w-o calcium/iron,carbonyl/docus ate/fa ADD UM: GENDER Female 01/01/2014 EPIPEN JR 2PAK epinephrine ADD UM: QUANTITY 2 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 156 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 auvi-q,epipen 2- epinephrine pak,adrenaclick,e pinephrine ADD UM: QUANTITY 2 / 30 days 01/01/2014 STRIANT testosterone ADD UM: QUANTITY 60 / 30 days 01/01/2014 estradiol,climara estradiol ADD UM: QUANTITY 8 / 28 days 01/01/2014 estradiol,climara estradiol CHANGE UM: GENDER Female 01/01/2014 estradiol,climara estradiol ADD UM: QUANTITY 8 / 28 days 01/01/2014 estradiol,climara estradiol CHANGE UM: GENDER Female 01/01/2014 AVONEX interferon beta-1a ADD UM: QUANTITY 4 / 28 days 01/01/2014 CRESTOR rosuvastatin calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 LEVITRA vardenafil hcl ADD UM: GENDER Male 01/01/2014 CLIMARA PRO estradiol/levonorgestrel ADD UM: QUANTITY 4 / 28 days 01/01/2014 CLIMARA PRO estradiol/levonorgestrel ADD UM: GENDER Female 01/01/2014 PEXEVA paroxetine mesylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 PEXEVA paroxetine mesylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 PEXEVA paroxetine mesylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 PEXEVA paroxetine mesylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 AVONEX interferon beta-1a ADD UM: QUANTITY 4 / 28 days 01/01/2014 elestat,epinastine epinastine hcl hcl ADD UM: QUANTITY 5 / 30 days 01/01/2014 strovite one,choice-tabs multivit with min#10/folic acid//vit d3/a lipoic acid/lutein ADD UM: GENDER Female 01/01/2014 folivaneob,concept ob prenatal vitamin no.15/iron fumarate,polysac comp/folic acid ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 157 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 taron-c prenatal vit no.16/iron dha,concept dha fum,ps complex/folic acid/omega-3 ADD UM: GENDER Female 01/01/2014 O-CAL PRENATAL prenatal vitamin with ca no.127/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 FACTIVE gemifloxacin mesylate ADD UM: QUANTITY 120 / 30 days 01/01/2014 alendronate sodium alendronate sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 alendronate sodium alendronate sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 alendronate sodium alendronate sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 CENESTIN estrogens,conj.,synthetic a ADD UM: GENDER Female 01/01/2014 ESTRASORB estradiol ADD UM: GENDER Female 01/01/2014 ESTROGEL estradiol ADD UM: QUANTITY 50 / 30 days 01/01/2014 EXFORGE HCT amlodipine besylate/valsartan/hydrochlo rothiazide ADD UM: QUANTITY 60 / 30 days 01/01/2014 EXFORGE HCT amlodipine besylate/valsartan/hydrochlo rothiazide ADD UM: QUANTITY 60 / 30 days 01/01/2014 EXFORGE HCT amlodipine besylate/valsartan/hydrochlo rothiazide ADD UM: QUANTITY 60 / 30 days 01/01/2014 EXFORGE HCT amlodipine besylate/valsartan/hydrochlo rothiazide ADD UM: QUANTITY 60 / 30 days 01/01/2014 EXFORGE HCT amlodipine besylate/valsartan/hydrochlo rothiazide ADD UM: QUANTITY 60 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 158 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 retin-a,tretinoin tretinoin ADD UM: AGE Up to 25 yrs old 01/01/2014 retina,avita,tretinoin tretinoin ADD UM: AGE Up to 25 yrs old 01/01/2014 ATRALIN tretinoin ADD UM: AGE Up to 25 yrs old 01/01/2014 retin-a micro,tretinoin microsphere tretinoin microspheres ADD UM: AGE Up to 25 yrs old 01/01/2014 retin-a,tretinoin tretinoin ADD UM: AGE Up to 25 yrs old 01/01/2014 retin-a,tretinoin tretinoin ADD UM: AGE Up to 25 yrs old 01/01/2014 retina,avita,tretinoin tretinoin ADD UM: AGE Up to 25 yrs old 01/01/2014 PROVENTIL HFA,VENTOLIN HFA,PROAIR HFA albuterol sulfate ADD UM: QUANTITY 18 / 30 days 01/01/2014 VYTORIN ezetimibe/simvastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 VYTORIN ezetimibe/simvastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 VYTORIN ezetimibe/simvastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 VYTORIN ezetimibe/simvastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 cymbalta,duloxeti duloxetine hcl ne hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 cymbalta,duloxeti duloxetine hcl ne hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 cymbalta,duloxeti duloxetine hcl ne hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 zatean-pn prenatal vits with calcium dha,pnv-dha,virt- #47/iron fum/fa cmb #1/dha pn dha ADD UM: GENDER Female 01/01/2014 ENBREL ADD UM: QUANTITY 4 / 28 days etanercept BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 159 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 elite-ob 400,pnv- pnv no17/iron,carb/iron total bisgly/fa/fish oil/dha/omega 3,6 #1 01/01/2014 TARCEVA 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female erlotinib hcl ADD UM: QUANTITY 30 / 30 days TARCEVA erlotinib hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 TARCEVA erlotinib hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 micardis,telmisart telmisartan an ADD UM: QUANTITY 30 / 30 days 01/01/2014 micardis,telmisart telmisartan an ADD UM: QUANTITY 30 / 30 days 01/01/2014 micardis,telmisart telmisartan an ADD UM: QUANTITY 30 / 30 days 01/01/2014 clonidine,catapre clonidine s-tts 1 ADD UM: QUANTITY 4 / 30 days 01/01/2014 clonidine,catapre clonidine s-tts 2 ADD UM: QUANTITY 4 / 30 days 01/01/2014 clonidine,catapre clonidine s-tts 3 ADD UM: QUANTITY 4 / 30 days 01/01/2014 CLINDESSE ADD UM: GENDER Female 01/01/2014 eszopiclone,lune eszopiclone sta ADD UM: QUANTITY 30 / 30 days 01/01/2014 lunesta,eszopiclo eszopiclone ne ADD UM: QUANTITY 30 / 30 days 01/01/2014 lunesta,eszopiclo eszopiclone ne ADD UM: QUANTITY 30 / 30 days 01/01/2014 ZOMIG ADD UM: QUANTITY 18 / 30 days 01/01/2014 OBSTETRIX EC prenatal vitamin w-o calcium/iron,carbonyl/docus ate/fa ADD UM: GENDER Female clindamycin phosphate zolmitriptan BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 160 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 REBIF interferon beta-1a/albumin human ADD UM: QUANTITY 1 / 180 days 01/01/2014 XOPENEX HFA levalbuterol tartrate ADD UM: QUANTITY 30 / 30 days 01/01/2014 CLARINEX-D 24 desloratadine/pseudoephedr HOUR ine sulfate ADD UM: QUANTITY 30 / 30 days 01/01/2014 boniva,ibandrona ibandronate sodium te sodium ADD UM: QUANTITY 1 / 30 days 01/01/2014 BYETTA exenatide ADD UM: QUANTITY 3 / 30 days 01/01/2014 BYETTA exenatide ADD UM: QUANTITY 3 / 30 days 01/01/2014 ATROVENT HFA ipratropium bromide ADD UM: QUANTITY 12.9 / 30 days 01/01/2014 fentanyl,duragesi fentanyl c ADD UM: QUANTITY 15 / 30 days 01/01/2014 imitrex,sumatripta sumatriptan succinate n succinate CHANGE UM: QUANTITY 2 / 30 days 01/01/2014 revatio,sildenafil sildenafil citrate CHANGE UM: QUANTITY 01/01/2014 elite-ob,ob complete iron,carbonyl/folic acid/multivitamin wminerals,iron,carbonyl/folic acid/multivitamin with minerals ADD UM: GENDER Female 01/01/2014 MAXINATE prenatal vitamin no.3/iron fumarate,gluconate/folic acid ADD UM: GENDER Female 01/01/2014 clarinex,deslorata desloratadine dine ADD UM: QUANTITY 30 / 30 days 01/01/2014 hyzaar,losartan- losartan hydrochlorothiazi potassium/hydrochlorothiazi de de ADD UM: QUANTITY 30 / 30 days 01/01/2014 clomiphene clomiphene citrate citrate,serophene ADD UM: GENDER Female 6 / 30 days 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 161 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 TRETIN-X tretinoin/emollient combination no. 9/skin cln1 ADD UM: AGE Up to 25 yrs old 01/01/2014 TRETIN-X tretinoin/emollient combination no. 9/skin cln1 ADD UM: AGE Up to 25 yrs old 01/01/2014 TRETIN-X tretinoin/emollient combination no. 9/skin cln1 ADD UM: AGE Up to 25 yrs old 01/01/2014 REVLIMID lenalidomide ADD UM: QUANTITY 30 / 30 days 01/01/2014 REVLIMID lenalidomide ADD UM: QUANTITY 30 / 30 days 01/01/2014 SUTENT sunitinib malate ADD UM: QUANTITY 30 / 30 days 01/01/2014 SUTENT sunitinib malate ADD UM: QUANTITY 30 / 30 days 01/01/2014 SUTENT sunitinib malate ADD UM: QUANTITY 30 / 30 days 01/01/2014 cerefolin nac,lmethylfolatemecobalaminnac,alznac,metafolbic plus,l-methyl-mc nac acetylcysteine/mecobalamin /levomefolate calcium ADD UM: GENDER Female 01/01/2014 kadian,morphine morphine sulfate sulfate er ADD UM: QUANTITY 120 / 30 days 01/01/2014 morphine sulfate morphine sulfate er,kadian ADD UM: QUANTITY 120 / 30 days 01/01/2014 morphine sulfate morphine sulfate er,kadian ADD UM: QUANTITY 120 / 30 days 01/01/2014 morphine sulfate morphine sulfate er,kadian ADD UM: QUANTITY 180 / 30 days 01/01/2014 zocor,simvastatin simvastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 zocor,simvastatin simvastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 zocor,simvastatin simvastatin ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 162 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 zocor,simvastatin simvastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 zocor,simvastatin simvastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 CLARINEX-D 12 desloratadine/pseudoephedr HOUR ine sulfate ADD UM: QUANTITY 60 / 30 days 01/01/2014 zegerid omeprazole/sodium otc,omeprazole- bicarbonate sodium bicarbonate,zege rid ADD UM: QUANTITY 30 / 30 days 01/01/2014 omeprazoleomeprazole/sodium sodium bicarbonate bicarbonate,zege rid ADD UM: QUANTITY 30 / 30 days 01/01/2014 ZEGERID omeprazole/sodium bicarbonate ADD UM: QUANTITY 30 / 30 days 01/01/2014 ZEGERID omeprazole/sodium bicarbonate ADD UM: QUANTITY 30 / 30 days 01/01/2014 imitrex,sumatripta sumatriptan succinate n succinate ADD UM: QUANTITY 2 / 30 days 01/01/2014 imitrex,sumatripta sumatriptan succinate n succinate ADD UM: QUANTITY 2 / 30 days 01/01/2014 ENJUVIA estrogens,conj.,synthetic b ADD UM: GENDER Female 01/01/2014 ENJUVIA estrogens,conj.,synthetic b ADD UM: GENDER Female 01/01/2014 ENJUVIA estrogens,conj.,synthetic b ADD UM: GENDER Female 01/01/2014 ENJUVIA estrogens,conj.,synthetic b ADD UM: GENDER Female 01/01/2014 se-tan plus,tandem plus,purevit dualfe plus iron fumarate-iron polysacch cplex/folic acid/multivit no.18 ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 163 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 diovan valsartan/hydrochlorothiazid hct,valsartane hydrochlorothiazi de ADD UM: QUANTITY 30 / 30 days 01/01/2014 diovan valsartan/hydrochlorothiazid hct,valsartane hydrochlorothiazi de ADD UM: QUANTITY 30 / 30 days 01/01/2014 triveenu,prenatal-u prenatal vits without calc no5/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 SPRYCEL dasatinib ADD UM: QUANTITY 30 / 30 days 01/01/2014 SPRYCEL dasatinib ADD UM: QUANTITY 30 / 30 days 01/01/2014 SPRYCEL dasatinib ADD UM: QUANTITY 30 / 30 days 01/01/2014 REVLIMID lenalidomide ADD UM: QUANTITY 30 / 30 days 01/01/2014 REVLIMID lenalidomide ADD UM: QUANTITY 30 / 30 days 01/01/2014 AVONEX PEN interferon beta-1a ADD UM: QUANTITY 4 / 28 days 01/01/2014 astepro,azelastin azelastine hcl e hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 BEPREVE ADD UM: QUANTITY 10 / 30 days 01/01/2014 twynsta,telmisart telmisartan/amlodipine an-amlodipine besylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 twynsta,telmisart telmisartan/amlodipine an-amlodipine besylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 twynsta,telmisart telmisartan/amlodipine an-amlodipine besylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 twynsta,telmisart telmisartan/amlodipine an-amlodipine besylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 buproban,zyban, bupropion hcl bupropion hcl sr ADD UM: QUANTITY 60 / 30 days bepotastine besilate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 164 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 auviepinephrine q,adrenaclick,epi nephrine ADD UM: QUANTITY 2 / 30 days 01/01/2014 SUMAVEL DOSEPRO ADD UM: QUANTITY 1 / 30 days 01/01/2014 citranatal 90 prenatal vit,calcium #64/iron dha,natalvirt 90 carb,gluc/folic acid/dss/dha dha,prenaissance 90 dha ADD UM: GENDER Female 01/01/2014 triveen-prx rnf,prefol-dha ADD UM: GENDER Female 01/01/2014 prefera-ob prenatal vitamin no.19/iron one,vp-heme one polysac,iron heme/folic acid/dha ADD UM: GENDER Female 01/01/2014 zatean-pn plus,pnvomega,virt-pn plus prenatal vit with ca no.68/iron fumarate/folic acid #1/dha ADD UM: GENDER Female 01/01/2014 paire ob plus dha,ultimate ob dha prenatal vitamin no.8/iron ps complex,asp gl/folic acid/dha ADD UM: GENDER Female 01/01/2014 ferralet 90,natalvirt flt,fe 90 plus iron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium ADD UM: GENDER Female 01/01/2014 PNV-IRON prenatal vit with calcium no8-iron ps cmplx,fa,lmefolate ca ADD UM: GENDER Female 01/01/2014 pnv-dha plus,lprenatal vit with calcium methylfolate pnv no42/iron fum/fa/l-mefolate dha ca/dha ADD UM: GENDER Female 01/01/2014 cleocin,clindamyc clindamycin phosphate in phosphate CHANGE UM: GENDER Female sumatriptan succinate prenatal vit with calcium no.66/iron fum/folic acid/dss/dha BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 165 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 LIVALO pitavastatin calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 LIVALO pitavastatin calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 LIVALO pitavastatin calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 prenexa,vemavite prenatal vit with calcium -prx 2,pnv-dha + no.66/iron fum/folic docusate,folcal acid/dss/dha dha ADD UM: GENDER Female 01/01/2014 NATELLE ONE prenatal vits with calcium #70/ferrous fumarate/fa/dha ADD UM: GENDER Female 01/01/2014 tricare prenatal dha one,tl-care dha pnv no.20/iron fumarate/fa/docusate na/fish oil conc/dha/epa ADD UM: GENDER Female 01/01/2014 volplus,prenaplus prenatal vits with calcium #74/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 prenatal vitamin plus low iron,prenatal plus,preplus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 prenatal low iron prenatal vits with calcium #74/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 TRETIN-X tretinoin ADD UM: AGE Up to 25 yrs old 01/01/2014 DULERA mometasone furoate/formoterol fumarate ADD UM: QUANTITY 13 / 30 days 01/01/2014 DULERA mometasone furoate/formoterol fumarate ADD UM: QUANTITY 13 / 30 days 01/01/2014 vol-tab rx,prenatabs rx,natal-v rx prenatal vits with calcium #76/iron,carbonyl/folic acid ADD UM: GENDER Female 01/01/2014 SIMCOR niacin/simvastatin ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 166 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 01/01/2014 SIMCOR 01/01/2014 Generic Name niacin/simvastatin Type of Change Previous Value New Value ADD UM: QUANTITY 30 / 30 days VIVELLEestradiol DOT,ALORA,MIN IVELLE CHANGE UM: GENDER Female 01/01/2014 VIVELLEDOT,ALORA estradiol CHANGE UM: GENDER Female 01/01/2014 estradiol,climara estradiol ADD UM: QUANTITY 8 / 28 days 01/01/2014 estradiol,climara estradiol CHANGE UM: GENDER Female 01/01/2014 estradiol,climara estradiol ADD UM: QUANTITY 8 / 28 days 01/01/2014 estradiol,climara estradiol CHANGE UM: GENDER Female 01/01/2014 VIVELLEestradiol DOT,MINIVELLE ADD UM: QUANTITY 8 / 28 days 01/01/2014 estradiol,climara estradiol ADD UM: QUANTITY 8 / 28 days 01/01/2014 estradiol,climara estradiol CHANGE UM: GENDER Female 01/01/2014 estradiol,climara estradiol ADD UM: QUANTITY 8 / 28 days 01/01/2014 estradiol,climara estradiol ADD UM: GENDER Female 01/01/2014 vol-nate,trinate prenatal vits with calcium #73/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 venatalfa,prenatabs fa prenatal vits with calcium #78/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 TEKAMLO aliskiren hemifumarate/amlodipine besylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 TEKAMLO aliskiren hemifumarate/amlodipine besylate ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 167 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 TEKAMLO aliskiren hemifumarate/amlodipine besylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 TEKAMLO aliskiren hemifumarate/amlodipine besylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 GILENYA fingolimod hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 prefera ob,hemenatal ob,vp-heme ob prenatal vit no.21/iron polysacch,heme polypep/folic acid ADD UM: GENDER Female 01/01/2014 neevo prenatal vitamin comb dha,levomefolate no.79/iron dha,vinate dha fumarat/fa/lmefolate ca/dha ADD UM: GENDER Female 01/01/2014 PREPOPIK sodium picosulfate/magnesium oxide/citric acid ADD UM: GENDER Female 01/01/2014 LAZANDA fentanyl citrate 01/01/2014 prefera-ob plus dha,hemenatal ob + dha,vpheme ob + dha prenatal vitamin combo no.22/iron/folic acid/omega3/dha 01/01/2014 CHANGE UM: QUANTITY 13 / 30 days 1 / 30 days ADD UM: GENDER Female vena-bal dha,bal- prenatal vit care dha no.81/sod.feredetate-iron ps/folic acid/omega-3 ADD UM: GENDER Female 01/01/2014 OB COMPLETE prenatal vits with calcium #84/iron,carbonyl/folic acid/dha ADD UM: GENDER Female 01/01/2014 OB COMPLETE PREMIER prenatal vitamins comb #83/iron,carbonyl/iron asparto gly/fa ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 168 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 OB COMPLETE ONE pnv no.85/iron carb,aspart.glycinate/folic acid/dha/fish oil ADD UM: GENDER Female 01/01/2014 CORVITE FE iron,carbonyl/ferrous asparto glycinate/folic acid/mvmin27 ADD UM: GENDER Female 01/01/2014 ZOLPIMIST zolpidem tartrate 01/01/2014 SPRYCEL dasatinib ADD UM: QUANTITY 30 / 30 days 01/01/2014 SPRYCEL dasatinib ADD UM: QUANTITY 30 / 30 days 01/01/2014 tlprenatal vit with calcium select,prenaissan no.80/iron fum/folic ce,virt-select acid/dss/dha ADD UM: GENDER Female 01/01/2014 nestabs,v-natal ADD UM: GENDER Female 01/01/2014 nestabs dha,vprenatal vitamins comb natal dha,tri-tabs no.87/iron bisgly/folic dha acid/dha ADD UM: GENDER Female 01/01/2014 prenaissance prenatal vit with calcium plus,macnatal cn #69/iron,carbon/folic dha acid/dss/dha ADD UM: GENDER Female 01/01/2014 EDARBI azilsartan medoxomil ADD UM: QUANTITY 30 / 30 days 01/01/2014 EDARBI azilsartan medoxomil ADD UM: QUANTITY 30 / 30 days 01/01/2014 SPRIX ketorolac tromethamine ADD UM: QUANTITY 30 / 30 days 01/01/2014 vitafol-one,pnvfirst prenatal vitamins no.26/iron polysaccharides/fa/dha ADD UM: GENDER Female 01/01/2014 OB COMPLETE 400 prenatal no.29/iron carb,asp.glycin/folic acid/dha/fish oil ADD UM: GENDER Female 01/01/2014 NATAFORT prenatal vitamin no.27/iron carbonyl and fumarate/folic acid ADD UM: GENDER Female prenatal vitamin no.86/iron bis-glycinate/folic acid CHANGE UM: QUANTITY 30 / 30 days 6 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 169 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 OB COMPLETE WITH DHA prenatal vit no.30/iron carbonyl,asp glyc/folic acid/omega-3 01/01/2014 AVONEX PEN interferon beta-1a 01/01/2014 PUREFE PLUS 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female ADD UM: QUANTITY 4 / 28 days prenatal vitamins no.4/ferrous fumarate/folic acid ADD UM: GENDER Female PUREFE OB PLUS prenatal vits #4/iron fumarate, polysacc complex/folic acid ADD UM: GENDER Female 01/01/2014 select-ob + dha,choice-ob + dha prenatal vitamins combo no.33/iron ps cmplx/folic acid/dha ADD UM: GENDER Female 01/01/2014 prenaissance prenatal vit #94/sodium harmony dha,virt- feredetate-iron ps/folic bal dha plus,virt- acid/omega3 bal dha ADD UM: GENDER Female 01/01/2014 prenaissance prenatal vit/folic next,zingiber,vp- acid/b6/calcium phosph ggr-b6 di,tribasic/ginger ADD UM: GENDER Female 01/01/2014 prenaissance balance,vp-chpnv prenatal vitamins combo no.34/iron,carb/folic acid/dss/dha ADD UM: GENDER Female 01/01/2014 EDARBYCLOR azilsartan medoxomil/chlorthalidone ADD UM: QUANTITY 30 / 30 days 01/01/2014 EDARBYCLOR azilsartan medoxomil/chlorthalidone ADD UM: QUANTITY 30 / 30 days 01/01/2014 PRENATA prenatal vitamins combo no.37/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 ZETONNA ciclesonide ADD UM: QUANTITY 6.1 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 170 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 vitamedmd plus rx,prena1 plus prenatal vitamins #39/iron amino acid chelate/fa combo#6/dha ADD UM: GENDER Female 01/01/2014 JANUMET XR sitagliptin phosphate/metformin hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 JANUMET XR sitagliptin phosphate/metformin hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 JANUMET XR sitagliptin phosphate/metformin hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 vitamedmd one rx,prena1 prenatal vitamins combo no.25/iron fumarate/fa combo#6/dha ADD UM: GENDER Female 01/01/2014 retin-a micro pump,tretinoin microsphere tretinoin microspheres ADD UM: AGE Up to 25 yrs old 01/01/2014 retin-a micro pump,tretinoin microsphere tretinoin microspheres ADD UM: AGE Up to 25 yrs old 01/01/2014 vitamedmd redichew rx,prena1 chew prenatal vitamins comb no.42/folic acid comb no.6 ADD UM: GENDER Female 01/01/2014 REVLIMID lenalidomide ADD UM: QUANTITY 30 / 30 days 01/01/2014 BAL-CARE DHA prenatal vit 100/iron sod ESSENTIAL edta,ps complex/folic acid/omega-3 ADD UM: GENDER Female 01/01/2014 DYMISTA azelastine hcl/fluticasone propionate ADD UM: QUANTITY 23 / 30 days 01/01/2014 citranatal bcalm,vinacal b prenatal vitamin no.48/iron,carbonyl,gluconat e/folic acid/b6 ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 171 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 TRICARE prenatal vits with calcium#103/ferrous fumarate/folic acid 01/01/2014 COMBIVENT RESPIMAT ipratropium bromide/albuterol sulfate 01/01/2014 ANGELIQ drospirenone/estradiol 01/01/2014 prenaissance dha prenatal vitamin no.105/iron harmony,duet edta dha balanced &polysaccha/fa/om3/dha/ep a 01/01/2014 QSYMIA 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female ADD UM: QUANTITY 4 / 30 days CHANGE UM: GENDER Female CHANGE UM: GENDER Female ADD UM: QUANTITY 30 / 30 days DUET prenatal vitamin no.106/sod DHA,DUET DHA ferede-iron 400 poly/fa/om3/dha/epa ADD UM: GENDER Female 01/01/2014 DUET DHA prenatal vitamin no.106/sod ferede-iron poly/fa/om3/dha/epa ADD UM: GENDER Female 01/01/2014 DUET DHA EC prenatal vitamin no.107/sod ferede-iron poly/fa/om3/dha/epa ADD UM: GENDER Female 01/01/2014 DUET DHA EC prenatal vitamin no.107/sod ferede-iron poly/fa/om3/dha/epa ADD UM: GENDER Female 01/01/2014 FLUMIST influenza virus vaccine tv live 2012-2013 (2 yrs-49 yrs) ADD UM: QUANTITY 1 / 270 days 01/01/2014 QSYMIA phentermine hcl/topiramate ADD UM: QUANTITY 30 / 30 days 01/01/2014 QSYMIA phentermine hcl/topiramate ADD UM: QUANTITY 30 / 30 days 01/01/2014 QSYMIA phentermine hcl/topiramate ADD UM: QUANTITY 30 / 30 days 01/01/2014 MYRBETRIQ mirabegron ADD UM: GENDER Male phentermine hcl/topiramate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 172 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 VP-PNV-DHA prenatal vitamins combo no.52/ferrous fumarate/fa/dha 01/01/2014 b-nexa,focalgin-b prenatal vit/folic acid/b6/calcium phos di & tribasic/ginger,prenatal vit/folic acid/b6/calcium phosph di,tribasic/ginger 01/01/2014 NEXIUM 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female CHANGE UM: GENDER Female esomeprazole magnesium ADD UM: QUANTITY 30 / 30 days NEXIUM esomeprazole magnesium ADD UM: QUANTITY 30 / 30 days 01/01/2014 KADIAN morphine sulfate ADD UM: QUANTITY 120 / 30 days 01/01/2014 KADIAN morphine sulfate ADD UM: QUANTITY 120 / 30 days 01/01/2014 KADIAN morphine sulfate ADD UM: QUANTITY 120 / 30 days 01/01/2014 KADIAN morphine sulfate ADD UM: QUANTITY 120 / 30 days 01/01/2014 AUBAGIO teriflunomide ADD UM: QUANTITY 30 / 30 days 01/01/2014 AUBAGIO teriflunomide ADD UM: QUANTITY 30 / 30 days 01/01/2014 VINATE CARE prenatal vits with calcium#109/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 NATACHEW prenatal vitamin no.55/iron fumarate,bisglycinate/folic acid ADD UM: GENDER Female 01/01/2014 OB COMPLETE PETITE prenatal no56/iron carbonyl,asparto glycinate/folic acid/dha ADD UM: GENDER Female 01/01/2014 ANZEMET dolasetron mesylate CHANGE UM: QUANTITY 01/01/2014 ANZEMET dolasetron mesylate ADD UM: AGE 01/01/2014 ANZEMET dolasetron mesylate CHANGE UM: QUANTITY 12 / 30 days 12 / 15 days At least 30 yrs old 12 / 30 days 12 / 15 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 173 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 ANZEMET dolasetron mesylate 01/01/2014 DUET DHA BALANCED 01/01/2014 Type of Change Previous Value New Value ADD UM: AGE At least 30 yrs old prenatal vitamin no.110/iron edta &polysaccha/fa/om3/dha/ep a ADD UM: GENDER Female prenatal plus prenatal vits with calcium #72/iron,carbonyl/folic acid ADD UM: GENDER Female 01/01/2014 citranatal harmony,vp-ch plus prenatal vitamins combo no.59/iron,carb/folic acid/dss/dha CHANGE UM: GENDER Female 01/01/2014 VIRT-VITE PLUS folic acid/vitamin b complex with vitamin c no.17 ADD UM: GENDER Female 01/01/2014 pnv folic acid + iron prenatal vitamins combo no.60/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 OSPHENA ospemifene ADD UM: GENDER Female 01/01/2014 TECFIDERA dimethyl fumarate ADD UM: QUANTITY 1 / 180 days 01/01/2014 TECFIDERA dimethyl fumarate ADD UM: QUANTITY 60 / 30 days 01/01/2014 TECFIDERA dimethyl fumarate ADD UM: QUANTITY 60 / 30 days 01/01/2014 TRICARE PRENATAL COMPLEAT prenatal vitamin no.103/iron fum/fa/dha/epa/other omega-3s ADD UM: GENDER Female 01/01/2014 desvenlafaxine er desvenlafaxine ADD UM: QUANTITY 30 / 30 days 01/01/2014 desvenlafaxine er desvenlafaxine ADD UM: QUANTITY 30 / 30 days 01/01/2014 PRESERA emollient combination no.80 ADD UM: GENDER Female 01/01/2014 cerefolin nac,lmethylfolatemecobalaminnac,metafolbic plus rf levomefolate ca/acetylcysteine/mecobala min/schiz. algal oil ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 174 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 FLUMIST influenza virus vaccine qval live 2013-2014 (2 yrs-49 yrs) ADD UM: QUANTITY 1 / 270 days 01/01/2014 REVLIMID lenalidomide ADD UM: QUANTITY 30 / 30 days 01/01/2014 NEEVODHA prenatal no.64/iron fum/lmefolate ca/algal oil/soy lecithin ADD UM: GENDER Female 01/01/2014 NESTABS ABC prenatal vitamin comb no.86/iron ps cmplx/folic acid/dha/epa ADD UM: GENDER Female 01/01/2014 active ob,r-natal ob prenatal vitamins combo no.66/iron,carbonyl/folic acid/dha CHANGE UM: GENDER Female 01/01/2014 prenatal 19,pnv- prenatal vitamins comb ferrous fumarate- no.115/iron fumarate/folic docu-fa acid/dss ADD UM: GENDER Female 01/01/2014 INFANATE BALANCE prenatal vitamins combo no.34/iron,carb/folic acid/dss/dha ADD UM: GENDER Female 01/01/2014 prenatal 19 prenatal vitamins comb no.115/iron fumarate/folic acid ADD UM: GENDER Female 01/01/2014 fioricet with codeine,butalbacetaminophcaff-codein butalbital/acetaminophen/caf feine/codeine phosphate ADD UM: QUANTITY 180 / 30 days 01/01/2014 DUET DHA BALANCED prenatal vitamin no.117/sod ferede-iron poly/fa/om3/dha/epa ADD UM: GENDER Female 01/01/2014 OXYTROL FOR WOMEN oxybutynin ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 175 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ADD UM: GENDER Female ADD UM: AGE Up to 25 yrs old 01/01/2014 CORVITE FE iron,carbonyl/methyltetrahyd rofolate gluc,fa/mv, min no.40 01/01/2014 TRETIN-X tretinoin 01/01/2014 se-natal 19,prenatal 19 prenatal vits with calcium#118/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 se-natal 19,prenatal 19 prenatal vitamins comb no.119/iron fumarate/folic acid/dss ADD UM: GENDER Female 01/01/2014 khedezla,desvenl desvenlafaxine afaxine er ADD UM: QUANTITY 30 / 30 days 01/01/2014 khedezla,desvenl desvenlafaxine afaxine er ADD UM: QUANTITY 30 / 30 days 01/01/2014 PRENAISSANCE prenatal vit/folic NEXT-B acid/b6/calcium carb/ginger ADD UM: GENDER Female 01/01/2014 STENDRA avanafil 01/01/2014 ANORO ELLIPTA umeclidinium bromide/vilanterol trifenatate 01/01/2014 DUAVEE estrogens, conjugated/bazedoxifene acetate 01/01/2014 COPAXONE glatiramer acetate 01/01/2014 CITRANATAL HARMONY prenatal vitamin no.59/iron carb,fum/folic acid/docusate/dha 01/01/2014 VINATE DHA RF prenatal no.64/iron fum/lmefolate ca/algal oil/soy lecithin 01/01/2014 desvenlafaxine fumarate er desvenlafaxine fumarate CHANGE UM: GENDER Female Male ADD UM: QUANTITY 60 / 30 days ADD UM: GENDER Female ADD UM: QUANTITY 12 / 28 days ADD UM: GENDER Female ADD UM: GENDER Female ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 176 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 01/01/2014 desvenlafaxine fumarate er 01/01/2014 Generic Name desvenlafaxine fumarate Type of Change Previous Value New Value ADD UM: QUANTITY 30 / 30 days CITRANATAL 90 prenatal vit no.72/iron DHA carbony,gluc/folic acid/docusate/dha ADD UM: GENDER Female 01/01/2014 multi-vitamin wfluoride pediatric multivitamin combination no.2/sodium fluoride CHANGE UM: AGE 0.6 to 1 yrs old 1 to 2 yrs old 01/01/2014 multi-vitamin wfluoride pediatric multivitamin combination no.2/sodium fluoride CHANGE UM: AGE 0.6 to 1 yrs old 1 to 2 yrs old 01/01/2014 multivitamins w- pediatric multivitamin combo fluorideno.45/fluoride/ferrous sulfate iron,multi-vitamin w-fluorideiron,multi-vitaminfluor-iron CHANGE UM: AGE 1 to 2 yrs old 01/01/2014 VITAMEDMD REDICHEW RX,PRENA1 CHEW prenatal vitamins combination no.42/folic acid ADD UM: GENDER Female 01/01/2014 FORADIL formoterol fumarate ADD UM: QUANTITY 60 / 30 days 01/01/2014 children's allegra fexofenadine hcl allergy,fexofenadi ne hcl ADD UM: QUANTITY 60 / 30 days 01/01/2014 pantoprazole sodium,protonix pantoprazole sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 ZYFLO zileuton ADD UM: QUANTITY 60 / 30 days 01/01/2014 zomig zmt,zolmitriptan odt zolmitriptan ADD UM: QUANTITY 18 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 177 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ipratropium ipratropium bromide bromide,atrovent ADD UM: QUANTITY 50 / 30 days 01/01/2014 ipratropium ipratropium bromide bromide,atrovent ADD UM: QUANTITY 50 / 30 days 01/01/2014 singulair,montelu montelukast sodium kast sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 PROSTIN E2 VAGINAL SUPPOSITORY ADD UM: GENDER Female 01/01/2014 lipitor,atorvastatin atorvastatin calcium calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 lipitor,atorvastatin atorvastatin calcium calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 lipitor,atorvastatin atorvastatin calcium calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 lipitor,atorvastatin atorvastatin calcium calcium ADD UM: QUANTITY 30 / 30 days 01/01/2014 zomig,zolmitripta zolmitriptan n ADD UM: QUANTITY 18 / 30 days 01/01/2014 zomig,zolmitripta zolmitriptan n ADD UM: QUANTITY 18 / 30 days 01/01/2014 terazol terconazole 7,terconazole,zaz ole CHANGE UM: GENDER Female 01/01/2014 terazol terconazole 3,terconazole,zaz ole CHANGE UM: GENDER Female 01/01/2014 tretinoin tretinoin ADD UM: AGE Up to 25 yrs old 01/01/2014 pravastatin sodium pravastatin sodium ADD UM: QUANTITY 30 / 30 days dinoprostone BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 178 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 pravachol,pravast pravastatin sodium atin sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 pravachol,pravast pravastatin sodium atin sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 all day cetirizine hcl,loratadine allergy,cetirizine hcl,walzyr,zyrtec,all day allergy relief,allergy relief,allergy,allertec ADD UM: QUANTITY 30 / 30 days 01/01/2014 trimesis rx,folinatal plus b,folbecal ADD UM: GENDER Female 01/01/2014 imitrex,sumatripta sumatriptan n CHANGE UM: QUANTITY 6 / 30 days 01/01/2014 imitrex,sumatripta sumatriptan succinate n succinate,alsuma CHANGE UM: QUANTITY 1 / 30 days 01/01/2014 sumatriptan sumatriptan succinate succinate,imitrex CHANGE UM: QUANTITY 1 / 30 days 01/01/2014 imitrex,sumatripta sumatriptan n CHANGE UM: QUANTITY 6 / 30 days 01/01/2014 prometrium,proge progesterone,micronized sterone ADD UM: GENDER Female 01/01/2014 prometrium,proge progesterone,micronized sterone ADD UM: GENDER Female 01/01/2014 accolate,zafirluka zafirlukast st CHANGE UM: QUANTITY 60 / 30 days 01/01/2014 ENBREL ADD UM: QUANTITY 4 / 28 days prenatal without iron/folic acid/calcium carb/pyridoxine/b12 etanercept BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 179 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 FLOVENT DISKUS fluticasone propionate ADD UM: QUANTITY 60 / 30 days 01/01/2014 FLOVENT DISKUS fluticasone propionate ADD UM: QUANTITY 60 / 30 days 01/01/2014 FLOVENT DISKUS fluticasone propionate ADD UM: QUANTITY 60 / 30 days 01/01/2014 FLOVENT HFA fluticasone propionate ADD UM: QUANTITY 12 / 30 days 01/01/2014 FLOVENT HFA fluticasone propionate ADD UM: QUANTITY 12 / 30 days 01/01/2014 FLOVENT HFA fluticasone propionate ADD UM: QUANTITY 24 / 30 days 01/01/2014 walloratadine itin,alavert,loratad ine,allergy relief,claritin ADD UM: QUANTITY 30 / 30 days 01/01/2014 astelin,azelastine azelastine hcl hcl CHANGE UM: QUANTITY 30 / 30 days 01/01/2014 walloratadine itin,loratadine,clar itin,children's claritin,allergy relief,children's loratadine,childre n's allergy relief,loratadine hives relief,loratadine allergy ADD UM: QUANTITY 300 / 30 days 01/01/2014 loratadine,allergy loratadine relief,walitin,allergy,nondrowsy allergy,claritin,lor adamed,allerclea r ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 180 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 NEPHRON FA ferrous fumarate/docusate/folic acid/vitamin b comp and c 01/01/2014 PULMICORT budesonide 01/01/2014 refissa,tretinoin tretinoin/emollient base 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female ADD UM: QUANTITY 120 / 30 days CHANGE UM: AGE Up to 25 yrs old allergyloratadine/pseudoephedrine congestion sulfate relief,wal-itin d 12 hour,alavert,lorat adine d,claritin-d 12 hour,allergycongestion,allerg y reliefd,loratadined,allergy relief d12,allerclear d12hr,allergy relief d CHANGE UM: QUANTITY 60 / 30 days 01/01/2014 allergyloratadine/pseudoephedrine congestion sulfate relief,wal-itin d,loratadined,lorata-dine d,allergy reliefnasal decongest,claritin -d 24 hour,loratad,allergy relief d24,allergy relief d,allergycongestion reliefd,allerclear d24hr CHANGE UM: QUANTITY 30 / 30 days 01/01/2014 SEREVENT DISKUS ADD UM: QUANTITY 60 / 30 days salmeterol xinafoate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 181 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 covaryx h.s.,eemt estrogens,esterified/methylt h.s.,estrogen & estosterone methyltestosteron e,estrogenmethyltestosteron e ADD UM: GENDER Female 01/01/2014 covaryx,eemt,estr estrogens,esterified/methylt ogenestosterone methyltestosteron e ADD UM: GENDER Female 01/01/2014 COMBIPATCH estradiol/norethindrone acetate ADD UM: QUANTITY 4 / 28 days 01/01/2014 COMBIPATCH estradiol/norethindrone acetate ADD UM: QUANTITY 4 / 28 days 01/01/2014 butalbital codeine compoundphosphate/butalbital/aspirin/ codeine,ascomp caffeine with codeine,fiorinal with codeine #3 ADD UM: QUANTITY 180 / 30 days 01/01/2014 EXTAVIA,BETAS interferon beta-1b ERON ADD UM: QUANTITY 15 / 30 days 01/01/2014 butalb-caffacetaminophcodein,fioricet with codeine butalbital/acetaminophen/caf feine/codeine phosphate ADD UM: QUANTITY 180 / 30 days 01/01/2014 NASONEX mometasone furoate ADD UM: QUANTITY 17 / 30 days 01/01/2014 COMBIVENT ipratropium bromide/albuterol sulfate ADD UM: QUANTITY 4 / 30 days 01/01/2014 EMADINE emedastine difumarate ADD UM: QUANTITY 5 / 30 days 01/01/2014 QVAR beclomethasone dipropionate ADD UM: QUANTITY 8.7 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 182 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 01/01/2014 QVAR 01/01/2014 Generic Name beclomethasone dipropionate Type of Change Previous Value New Value ADD UM: QUANTITY 8.7 / 30 days naratriptan naratriptan hcl hcl,amerge,naratr iptan ADD UM: QUANTITY 18 / 30 days 01/01/2014 naratriptan naratriptan hcl hcl,amerge,naratr iptan ADD UM: QUANTITY 18 / 30 days 01/01/2014 fosamax,alendro alendronate sodium nate sodium ADD UM: QUANTITY 4 / 30 days 01/01/2014 LESCOL XL ADD UM: QUANTITY 30 / 30 days 01/01/2014 RENOVA,RENO tretinoin/emollient base VA PUMP ADD UM: AGE Up to 25 yrs old 01/01/2014 rhinocort budesonide aqua,budesonide ADD UM: QUANTITY 8.6 / 30 days 01/01/2014 PREFEST ADD UM: GENDER Female 01/01/2014 prilosec,omepraz omeprazole ole ADD UM: QUANTITY 30 / 30 days 01/01/2014 prilosec,omepraz omeprazole ole ADD UM: QUANTITY 30 / 30 days 01/01/2014 teveten,eprosarta eprosartan mesylate n mesylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 CENESTIN estrogens,conj.,synthetic a ADD UM: GENDER Female 01/01/2014 CENESTIN estrogens,conj.,synthetic a ADD UM: GENDER Female 01/01/2014 singulair,montelu montelukast sodium kast sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 singulair,montelu montelukast sodium kast sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 BRAVELLE ADD UM: GENDER Female fluvastatin sodium estradiol/norgestimate urofollitropin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 183 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 mimvey,activella, estradiol/norethindrone estradiolacetate norethindrone acetat ADD UM: GENDER Female 01/01/2014 maternity,vinate- prenatal vitamins with m calcium/ferrous fumarate/fa/selenium ADD UM: GENDER Female 01/01/2014 pantoprazole sodium,protonix pantoprazole sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 CRINONE progesterone,micronized ADD UM: GENDER Female 01/01/2014 HUMIRA adalimumab PEN,HUMIRA PEN CROHNUC-HS STARTER,HUMI RA PEN PSORIASISUVEITIS ADD UM: QUANTITY 4 / 28 days 01/01/2014 JANUVIA sitagliptin phosphate ADD UM: QUANTITY 30 / 30 days 01/01/2014 JANUVIA sitagliptin phosphate ADD UM: QUANTITY 30 / 30 days 01/01/2014 JANUVIA sitagliptin phosphate ADD UM: QUANTITY 30 / 30 days 01/01/2014 OMNARIS ciclesonide ADD UM: QUANTITY 12.5 / 30 days 01/01/2014 morphine sulfate morphine sulfate er,kadian ADD UM: QUANTITY 120 / 30 days 01/01/2014 morphine sulfate morphine sulfate er,kadian ADD UM: QUANTITY 120 / 30 days 01/01/2014 morphine sulfate morphine sulfate er,kadian ADD UM: QUANTITY 120 / 30 days 01/01/2014 VITAFOL-OB ADD UM: GENDER Female prenatal vitamins comb 10/ferrous fumarate/folic acid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 184 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 VITAFOL-PN prenatal vit with calcium cmb 11/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 vol-care rx,nephro-vite rx,rena-vite rx vitamin b complx no.3/folic acid/ascorbic acid/biotin ADD UM: GENDER Female 01/01/2014 ENBREL etanercept ADD UM: QUANTITY 4 / 28 days 01/01/2014 accu-chek compact,accuchek compact plus blood sugar diagnostic, drum-type ADD UM: QUANTITY 100 / 30 days 01/01/2014 xyzal,levocetirizin levocetirizine e dihydrochloride dihydrochloride ADD UM: QUANTITY 300 / 30 days 01/01/2014 EXFORGE amlodipine besylate/valsartan ADD UM: QUANTITY 60 / 30 days 01/01/2014 EXFORGE amlodipine besylate/valsartan ADD UM: QUANTITY 60 / 30 days 01/01/2014 vitafolob+dha,pnv-ob with dha prenatal vitamins comb 10/ferrous fumarate/folic acid/dha ADD UM: GENDER Female 01/01/2014 PULMICORT FLEXHALER budesonide ADD UM: QUANTITY 1 / 30 days 01/01/2014 PULMICORT FLEXHALER budesonide ADD UM: QUANTITY 1 / 30 days 01/01/2014 NEXIUM esomeprazole magnesium ADD UM: QUANTITY 30 / 30 days 01/01/2014 NEXIUM esomeprazole magnesium ADD UM: QUANTITY 30 / 30 days 01/01/2014 VYVANSE lisdexamfetamine dimesylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 VYVANSE lisdexamfetamine dimesylate ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 185 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 VYVANSE lisdexamfetamine dimesylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 TEKTURNA aliskiren hemifumarate ADD UM: QUANTITY 30 / 30 days 01/01/2014 TEKTURNA aliskiren hemifumarate ADD UM: QUANTITY 30 / 30 days 01/01/2014 KADIAN morphine sulfate ADD UM: QUANTITY 180 / 30 days 01/01/2014 JANUMET sitagliptin phosphate/metformin hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 JANUMET sitagliptin phosphate/metformin hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 activella,estradiol estradiol/norethindrone -norethindrone acetate acetat CHANGE UM: GENDER Female 01/01/2014 EXTAVIA,BETAS interferon beta-1b ERON ADD UM: QUANTITY 15 / 30 days 01/01/2014 ENBREL etanercept ADD UM: QUANTITY 4 / 28 days 01/01/2014 VERAMYST fluticasone furoate ADD UM: QUANTITY 10 / 30 days 01/01/2014 FOSAMAX PLUS alendronate D sodium/cholecalciferol (vitamin d3) ADD UM: QUANTITY 30 / 30 days 01/01/2014 SYMBICORT budesonide/formoterol fumarate ADD UM: QUANTITY 10.2 / 30 days 01/01/2014 SYMBICORT budesonide/formoterol fumarate ADD UM: QUANTITY 10.2 / 30 days 01/01/2014 EXFORGE amlodipine besylate/valsartan ADD UM: QUANTITY 60 / 30 days 01/01/2014 EXFORGE amlodipine besylate/valsartan ADD UM: QUANTITY 60 / 30 days 01/01/2014 doxycycline doxycycline monohydrate monohydrate,ado xa CHANGE UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 186 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 ZYFLO CR zileuton 01/01/2014 ENJUVIA estrogens,conj.,synthetic b 01/01/2014 Type of Change Previous Value New Value ADD UM: QUANTITY 60 / 30 days ADD UM: GENDER Female triadvance,mynat prenatal vitamin al no.15/iron,carbonyl/folic advance,prenatal acid/docusate sod ad,inatal advance ADD UM: GENDER Female 01/01/2014 trinatal gt,vinate gt prenatal vitamin no.16/iron,carbonyl/folic acid/docusate sod ADD UM: GENDER Female 01/01/2014 trinatal ultra,vinate ultra,inatal ultra prenatal vitamin no.18/iron,carbonyl/folic acid/docusate sod ADD UM: GENDER Female 01/01/2014 triveen-duo dha,pr natal 400 prenatal vitamins comb no.53/iron b-g hcl sucp/fa/omega-3 ADD UM: GENDER Female 01/01/2014 CORVITE FREE multivitamin with min no.6/folic acid/lutein/lycop/ubidecar ADD UM: GENDER Female 01/01/2014 citranatal rx,tri rx,vinacal prenatal vit no.22/iron cbn,gluc/folic acid/docusate sodium,prenatal vitamins no.22/iron cbn & gluc/folic acid/dss,prenatal vit no.81/iron carbonyl,gluc/folic acid/docusate ADD UM: GENDER Female 01/01/2014 BYSTOLIC nebivolol hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 BYSTOLIC nebivolol hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 OXYCONTIN oxycodone hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 OXYCONTIN oxycodone hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 OXYCONTIN oxycodone hcl ADD UM: QUANTITY 30 / 30 days 01/01/2014 clopidogrel,plavix clopidogrel bisulfate CHANGE UM: QUANTITY 1 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 187 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 TEKTURNA HCT aliskiren hemifumarate/hydrochlorothi azide ADD UM: QUANTITY 30 / 30 days 01/01/2014 TEKTURNA HCT aliskiren hemifumarate/hydrochlorothi azide ADD UM: QUANTITY 30 / 30 days 01/01/2014 TEKTURNA HCT aliskiren hemifumarate/hydrochlorothi azide ADD UM: QUANTITY 30 / 30 days 01/01/2014 TEKTURNA HCT aliskiren hemifumarate/hydrochlorothi azide ADD UM: QUANTITY 30 / 30 days 01/01/2014 VYVANSE lisdexamfetamine dimesylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 VYVANSE lisdexamfetamine dimesylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 VYVANSE lisdexamfetamine dimesylate ADD UM: QUANTITY 30 / 30 days 01/01/2014 NEXIUM esomeprazole magnesium ADD UM: QUANTITY 30 / 30 days 01/01/2014 SIMCOR niacin/simvastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 SIMCOR niacin/simvastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 SIMCOR niacin/simvastatin ADD UM: QUANTITY 30 / 30 days 01/01/2014 PROTONIX pantoprazole sodium ADD UM: QUANTITY 30 / 30 days 01/01/2014 HUMIRA adalimumab ADD UM: QUANTITY 4 / 28 days 01/01/2014 trinatal rx 1,vinate prenatal vitamin 27 with one calcium/ferrous fumarate/folic acid ADD UM: GENDER Female 01/01/2014 SPRYCEL ADD UM: QUANTITY 30 / 30 days dasatinib BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 188 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 citranatal dha,pnv prenatal vit no.22/iron ob+dha,prenaiss cbn,glucon/folic ance dha acid/docusate/dha,prenatal vit no.76/iron carbony,gluc/folic acid/docusate/dha 01/01/2014 INFERGEN 01/01/2014 copegus,rebetol,r ribavirin ibavirin,virazole,ri batab,ribasphere, ribasphere ribapak,moderiba 01/01/2014 TAMIFLU oseltamivir phosphate 01/01/2014 8-MOP 01/01/2014 Type of Change Previous Value New Value ADD UM: GENDER Female ADD UM: AUTHORIZATION PA applies CHANGE UM: AUTHORIZATION PA applies ADD UM: AUTHORIZATION PA applies methoxsalen ADD UM: CUSTOM Specialty Drug 8-MOP methoxsalen ADD UM: AUTHORIZATION PA applies 01/01/2014 ACTEMRA tocilizumab ADD UM: CUSTOM Specialty Drug 01/01/2014 ACTEMRA tocilizumab CHANGE UM: AUTHORIZATION PA applies 01/01/2014 ACTIMMUNE interferon gamma1b,recomb. ADD UM: CUSTOM Specialty Drug 01/01/2014 ACTIMMUNE interferon gamma1b,recomb. ADD UM: AUTHORIZATION PA applies 01/01/2014 ADCETRIS brentuximab vedotin ADD UM: CUSTOM Specialty Drug 01/01/2014 ADCIRCA tadalafil ADD UM: CUSTOM Specialty Drug 01/01/2014 ADCIRCA tadalafil ADD UM: AUTHORIZATION PA applies 01/01/2014 ADEMPAS riociguat ADD UM: CUSTOM Specialty Drug 01/01/2014 ADEMPAS riociguat ADD UM: AUTHORIZATION PA applies interferon alfacon-1 BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 189 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ADVATE,ADVAT E L,ADVATE M,ADVATE H,ADVATE SH,ADVATE UH,XYNTHA,XY NTHA SOLOFUSE antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor (factor viii) recomb,b-domain deleted ADD UM: CUSTOM Specialty Drug 01/01/2014 AFINITOR everolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 AFINITOR everolimus ADD UM: AUTHORIZATION PA applies 01/01/2014 AFINITOR everolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 AFINITOR everolimus ADD UM: AUTHORIZATION PA applies 01/01/2014 AFINITOR everolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 AFINITOR everolimus ADD UM: AUTHORIZATION PA applies 01/01/2014 AFINITOR DISPERZ everolimus ADD TO FORMULARY Non-Formulary 01/01/2014 AFINITOR DISPERZ everolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 AFINITOR DISPERZ everolimus ADD UM: AUTHORIZATION PA applies 01/01/2014 AFINITOR DISPERZ everolimus ADD TO FORMULARY Non-Formulary 01/01/2014 AFINITOR DISPERZ everolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 AFINITOR DISPERZ everolimus ADD UM: AUTHORIZATION PA applies 01/01/2014 AFINITOR DISPERZ everolimus ADD TO FORMULARY Non-Formulary 01/01/2014 AFINITOR DISPERZ everolimus ADD UM: CUSTOM Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 190 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 AFINITOR DISPERZ everolimus ADD UM: AUTHORIZATION PA applies 01/01/2014 AFINITOR everolimus ADD TO FORMULARY Preferred Brands 01/01/2014 AFINITOR everolimus ADD TO FORMULARY Preferred Brands 01/01/2014 AFINITOR everolimus ADD TO FORMULARY Preferred Brands 01/01/2014 AFINITOR everolimus ADD TO FORMULARY Preferred Brands 01/01/2014 AFINITOR everolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 ALDURAZYME laronidase ADD UM: CUSTOM Specialty Drug 01/01/2014 ALDURAZYME laronidase ADD UM: AUTHORIZATION PA applies 01/01/2014 ALFERON N interferon alfa-n3 ADD TO FORMULARY Preferred Brands 01/01/2014 ALFERON N interferon alfa-n3 ADD UM: CUSTOM Specialty Drug 01/01/2014 ALFERON N interferon alfa-n3 ADD UM: AUTHORIZATION PA applies 01/01/2014 HUMATEantihemophilic factor, P,WILATE,ALPH human/von willebrand ANATE factor,human ADD UM: CUSTOM Specialty Drug 01/01/2014 MONONINE,ALP factor ix HANINE SD ADD UM: CUSTOM Specialty Drug 01/01/2014 ALPROLIX factor ix recombinant, fc fusion protein ADD UM: CUSTOM Specialty Drug 01/01/2014 ARANESP darbepoetin alfa in polysorbate 80 ADD UM: CUSTOM Specialty Drug 01/01/2014 ARCALYST rilonacept ADD TO FORMULARY Preferred Brands 01/01/2014 ARCALYST rilonacept ADD UM: CUSTOM Specialty Drug 01/01/2014 ARCALYST rilonacept ADD UM: AUTHORIZATION PA applies 01/01/2014 AROMASIN exemestane ADD TO FORMULARY Non-Formulary 01/01/2014 AROMASIN exemestane ADD UM: CUSTOM Specialty Drug 01/01/2014 ARZERRA ofatumumab ADD UM: CUSTOM Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 191 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ASTAGRAF XL tacrolimus ADD TO FORMULARY Non-Formulary 01/01/2014 ASTAGRAF XL tacrolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 ASTAGRAF XL tacrolimus ADD TO FORMULARY Non-Formulary 01/01/2014 ASTAGRAF XL tacrolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 ASTAGRAF XL tacrolimus ADD TO FORMULARY Non-Formulary 01/01/2014 ASTAGRAF XL tacrolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 AUBAGIO teriflunomide ADD UM: CUSTOM Specialty Drug 01/01/2014 AUBAGIO teriflunomide ADD UM: STEP ST applies 01/01/2014 REBIF,REBIF interferon beta-1a/albumin REBIDOSE,AVO human NEX ADD UM: CUSTOM Specialty Drug 01/01/2014 AVONEX,AVON interferon beta-1a EX PEN ADD UM: CUSTOM Specialty Drug 01/01/2014 BARACLUDE entecavir ADD UM: CUSTOM Specialty Drug 01/01/2014 BARACLUDE entecavir ADD UM: AUTHORIZATION PA applies 01/01/2014 BARACLUDE entecavir ADD UM: CUSTOM Specialty Drug 01/01/2014 BARACLUDE entecavir ADD UM: CUSTOM Specialty Drug 01/01/2014 BEBULIN VH factor ix complex, IMMUNO,BEBUL prothrombin complex conc. IN,PROFILNINE (pcc) comb. 6,factor ix complex, prothrombin cplx conc(pcc) no.6, 3factor,factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor ADD UM: CUSTOM Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 192 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 BEBULIN VH factor ix complex, IMMUNO,BEBUL prothrombin complex conc. IN,PROFILNINE (pcc) comb. 6,factor ix complex, prothrombin cplx conc(pcc) no.6, 3factor,factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor 01/01/2014 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies bleomycin sulfate bleomycin sulfate ADD TO FORMULARY Generics 01/01/2014 bleomycin sulfate bleomycin sulfate ADD UM: CUSTOM Specialty Drug 01/01/2014 bleomycin sulfate bleomycin sulfate ADD TO FORMULARY Generics 01/01/2014 bleomycin sulfate bleomycin sulfate ADD UM: CUSTOM Specialty Drug 01/01/2014 BOSULIF bosutinib ADD TO FORMULARY Non-Formulary 01/01/2014 BOSULIF bosutinib ADD UM: CUSTOM Specialty Drug 01/01/2014 BOSULIF bosutinib ADD UM: AUTHORIZATION PA applies 01/01/2014 BOSULIF bosutinib ADD TO FORMULARY Non-Formulary 01/01/2014 BOSULIF bosutinib ADD UM: CUSTOM Specialty Drug 01/01/2014 BOSULIF bosutinib ADD UM: AUTHORIZATION PA applies 01/01/2014 BOTOX COSMETIC onabotulinumtoxina ADD TO FORMULARY Not Covered 01/01/2014 BOTOX COSMETIC onabotulinumtoxina ADD UM: CUSTOM Lifestyle Drugs are Excluded 01/01/2014 BOTOX onabotulinumtoxina ADD TO FORMULARY Non-Formulary 01/01/2014 BOTOX onabotulinumtoxina ADD UM: CUSTOM Specialty Drug 01/01/2014 BOTOX onabotulinumtoxina ADD UM: AUTHORIZATION PA applies 01/01/2014 BOTOX onabotulinumtoxina ADD TO FORMULARY Preferred Brands 01/01/2014 BOTOX,BOTOX onabotulinumtoxina COSMETIC CHANGE UM: CUSTOM Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 193 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 BOTOX,BOTOX onabotulinumtoxina COSMETIC 01/01/2014 CAPRELSA 01/01/2014 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies vandetanib ADD UM: CUSTOM Specialty Drug CAPRELSA vandetanib ADD UM: AUTHORIZATION PA applies 01/01/2014 CAPRELSA vandetanib ADD UM: CUSTOM Specialty Drug 01/01/2014 CAPRELSA vandetanib ADD UM: AUTHORIZATION PA applies 01/01/2014 bicalutamide,cas bicalutamide odex ADD TO FORMULARY Non-Formulary 01/01/2014 bicalutamide,cas bicalutamide odex ADD UM: CUSTOM Specialty Drug 01/01/2014 bicalutamide,cas bicalutamide odex ADD UM: AUTHORIZATION PA applies 01/01/2014 bicalutamide bicalutamide ADD TO FORMULARY Generics 01/01/2014 CAYSTON aztreonam lysine ADD UM: CUSTOM Specialty Drug 01/01/2014 CAYSTON aztreonam lysine ADD UM: AUTHORIZATION PA applies 01/01/2014 CHEMET succimer ADD TO FORMULARY Preferred Brands 01/01/2014 CHEMET succimer ADD UM: CUSTOM Specialty Drug 01/01/2014 CHEMET succimer ADD UM: AUTHORIZATION PA applies 01/01/2014 CIMZIA certolizumab pegol ADD UM: CUSTOM Specialty Drug 01/01/2014 CIMZIA certolizumab pegol ADD UM: AUTHORIZATION PA applies 01/01/2014 CIMZIA certolizumab pegol ADD TO FORMULARY Preferred Brands 01/01/2014 CIMZIA certolizumab pegol ADD UM: CUSTOM Specialty Drug 01/01/2014 CIMZIA certolizumab pegol ADD UM: AUTHORIZATION PA applies 01/01/2014 COMETRIQ cabozantinib s-malate ADD TO FORMULARY Non-Formulary 01/01/2014 COMETRIQ cabozantinib s-malate ADD UM: CUSTOM Specialty Drug 01/01/2014 COMETRIQ cabozantinib s-malate ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 194 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 COMETRIQ cabozantinib s-malate ADD TO FORMULARY Non-Formulary 01/01/2014 COMETRIQ cabozantinib s-malate ADD UM: CUSTOM Specialty Drug 01/01/2014 COMETRIQ cabozantinib s-malate ADD UM: AUTHORIZATION PA applies 01/01/2014 COMETRIQ cabozantinib s-malate ADD TO FORMULARY Non-Formulary 01/01/2014 COMETRIQ cabozantinib s-malate ADD UM: CUSTOM Specialty Drug 01/01/2014 COMETRIQ cabozantinib s-malate ADD UM: AUTHORIZATION PA applies 01/01/2014 COPAXONE glatiramer acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 COPAXONE glatiramer acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 COPAXONE glatiramer acetate ADD UM: AUTHORIZATION PA applies 01/01/2014 cortrosyn,cosyntr cosyntropin opin ADD TO FORMULARY Non-Formulary 01/01/2014 cortrosyn,cosyntr cosyntropin opin ADD UM: CUSTOM Specialty Drug 01/01/2014 cortrosyn,cosyntr cosyntropin opin ADD UM: AUTHORIZATION PA applies 01/01/2014 cosyntropin cosyntropin ADD TO FORMULARY Non-Formulary 01/01/2014 cosyntropin cosyntropin ADD UM: CUSTOM Specialty Drug 01/01/2014 cosyntropin cosyntropin ADD UM: AUTHORIZATION PA applies 01/01/2014 CUROSURF poractant alfa ADD TO FORMULARY Non-Formulary 01/01/2014 CUROSURF poractant alfa ADD UM: CUSTOM Specialty Drug 01/01/2014 CUROSURF poractant alfa ADD TO FORMULARY Non-Formulary 01/01/2014 CUROSURF poractant alfa ADD UM: CUSTOM Specialty Drug 01/01/2014 CUROSURF poractant alfa ADD UM: AUTHORIZATION PA applies 01/01/2014 desferal deferoxamine mesylate mesylate,deferox amine mesylate ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 195 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 desferal deferoxamine mesylate mesylate,deferox amine mesylate ADD UM: CUSTOM Specialty Drug 01/01/2014 desferal deferoxamine mesylate mesylate,deferox amine mesylate ADD UM: AUTHORIZATION PA applies 01/01/2014 desferal,deferoxa deferoxamine mesylate mine mesylate ADD TO FORMULARY Preferred Brands 01/01/2014 desferal,deferoxa deferoxamine mesylate mine mesylate ADD UM: CUSTOM Specialty Drug 01/01/2014 desferal,deferoxa deferoxamine mesylate mine mesylate ADD UM: AUTHORIZATION PA applies 01/01/2014 DYSPORT abobotulinumtoxina ADD UM: CUSTOM Specialty Drug 01/01/2014 DYSPORT abobotulinumtoxina ADD UM: AUTHORIZATION PA applies 01/01/2014 DYSPORT abobotulinumtoxina ADD UM: CUSTOM Specialty Drug 01/01/2014 EGRIFTA tesamorelin acetate ADD TO FORMULARY Preferred Brands 01/01/2014 EGRIFTA tesamorelin acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 EGRIFTA tesamorelin acetate ADD UM: AUTHORIZATION PA applies 01/01/2014 EGRIFTA tesamorelin acetate ADD TO FORMULARY Preferred Brands 01/01/2014 EGRIFTA tesamorelin acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 EGRIFTA tesamorelin acetate ADD UM: AUTHORIZATION PA applies 01/01/2014 ELSPAR asparaginase ADD TO FORMULARY Non-Formulary 01/01/2014 ELSPAR asparaginase ADD UM: CUSTOM Specialty Drug 01/01/2014 ELSPAR asparaginase ADD UM: AUTHORIZATION PA applies 01/01/2014 EMCYT estramustine phosphate sodium ADD UM: CUSTOM Specialty Drug 01/01/2014 EMCYT estramustine phosphate sodium ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 196 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ENBREL etanercept ADD UM: CUSTOM Specialty Drug 01/01/2014 ENTEREG alvimopan ADD TO FORMULARY Non-Formulary 01/01/2014 ENTEREG alvimopan ADD UM: CUSTOM Specialty Drug 01/01/2014 ENTEREG alvimopan ADD UM: AUTHORIZATION PA applies 01/01/2014 epivir hbv,lamivudine hbv lamivudine ADD TO FORMULARY Preferred Brands 01/01/2014 epivir hbv,lamivudine hbv lamivudine ADD UM: CUSTOM Specialty Drug 01/01/2014 epivir hbv,lamivudine hbv lamivudine ADD UM: AUTHORIZATION PA applies 01/01/2014 EPIVIR HBV lamivudine ADD UM: CUSTOM Specialty Drug 01/01/2014 ERIVEDGE vismodegib ADD UM: CUSTOM Specialty Drug 01/01/2014 ERIVEDGE vismodegib ADD UM: AUTHORIZATION PA applies 01/01/2014 ERWINAZE asparaginase (erwinia chrysanthemi) ADD TO FORMULARY Non-Formulary 01/01/2014 ERWINAZE asparaginase (erwinia chrysanthemi) ADD UM: CUSTOM Specialty Drug 01/01/2014 ERWINAZE asparaginase (erwinia chrysanthemi) ADD UM: AUTHORIZATION PA applies 01/01/2014 etoposide etoposide ADD UM: CUSTOM Specialty Drug 01/01/2014 etoposide etoposide ADD UM: AUTHORIZATION PA applies 01/01/2014 EXJADE deferasirox ADD TO FORMULARY Preferred Brands 01/01/2014 EXJADE deferasirox ADD UM: CUSTOM Specialty Drug 01/01/2014 EXJADE deferasirox ADD UM: AUTHORIZATION PA applies 01/01/2014 EXJADE deferasirox ADD TO FORMULARY Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 197 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 EXJADE deferasirox ADD UM: CUSTOM Specialty Drug 01/01/2014 EXJADE deferasirox ADD UM: AUTHORIZATION PA applies 01/01/2014 EXJADE deferasirox ADD TO FORMULARY Preferred Brands 01/01/2014 EXJADE deferasirox ADD UM: CUSTOM Specialty Drug 01/01/2014 EXJADE deferasirox ADD UM: AUTHORIZATION PA applies 01/01/2014 EXTAVIA,BETAS interferon beta-1b ERON ADD UM: CUSTOM Specialty Drug 01/01/2014 EXTAVIA,BETAS interferon beta-1b ERON ADD UM: AUTHORIZATION PA applies 01/01/2014 EXTAVIA,BETAS interferon beta-1b ERON ADD UM: CUSTOM Specialty Drug 01/01/2014 EXTAVIA,BETAS interferon beta-1b ERON ADD UM: AUTHORIZATION PA applies 01/01/2014 FARESTON toremifene citrate ADD TO FORMULARY Preferred Brands 01/01/2014 FARESTON toremifene citrate ADD UM: CUSTOM Specialty Drug 01/01/2014 FARESTON toremifene citrate ADD UM: AUTHORIZATION PA applies 01/01/2014 FASLODEX fulvestrant ADD UM: CUSTOM Specialty Drug 01/01/2014 FASLODEX fulvestrant ADD UM: AUTHORIZATION PA applies 01/01/2014 letrozole,femara letrozole ADD UM: CUSTOM Specialty Drug 01/01/2014 letrozole,femara letrozole ADD UM: AUTHORIZATION PA applies 01/01/2014 FERRIPROX deferiprone ADD UM: CUSTOM Specialty Drug 01/01/2014 FERRIPROX deferiprone ADD UM: AUTHORIZATION PA applies 01/01/2014 FIRAZYR icatibant acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 FIRAZYR icatibant acetate ADD UM: AUTHORIZATION PA applies 01/01/2014 FIRMAGON degarelix acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 FIRMAGON degarelix acetate ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 198 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 flutamide flutamide ADD TO FORMULARY Generics 01/01/2014 flutamide flutamide ADD UM: CUSTOM Specialty Drug 01/01/2014 FORTEO teriparatide ADD UM: CUSTOM Specialty Drug 01/01/2014 FORTEO teriparatide ADD UM: AUTHORIZATION PA applies 01/01/2014 GALZIN zinc acetate ADD TO FORMULARY Preferred Brands 01/01/2014 GALZIN zinc acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 GALZIN zinc acetate ADD TO FORMULARY Preferred Brands 01/01/2014 GALZIN zinc acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 gammagard sd,gammagard liquid,gamastan s-d,carimune nf nanofiltered,privig en,hizentra,biviga m,flebogamma dif,gammaplex immune globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml,immune globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml,immune globulin,gamma(igg)/glycine, immune globulin,gamm(igg)/sucrose/ iga greater than 50 mcg/ml,immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml,immune globulin,gamma (igg)/sorbitol/iga 0 to 50 mcg/ml,immune globul,gamma(igg)/sorbitol/i ga greater than 50 mcg/ml,immune globulin,gamm(igg)/sorbitol/ glycin/iga 0 to 50 mcg/ml ADD UM: CUSTOM Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 199 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value 01/01/2014 gammagard sd,gammagard liquid,gamastan s-d,carimune nf nanofiltered,privig en,hizentra,biviga m,flebogamma dif,gammaplex 01/01/2014 GAMASTAN S-D immune globulin,gamma(igg)/glycine ADD TO FORMULARY Preferred Brands 01/01/2014 GAMUNEX,GAM immune UNEXglobulin,gamm(igg)/glycine/i C,GAMMAKED ga greater than 50 mcg/ml ADD UM: CUSTOM Specialty Drug 01/01/2014 GAMUNEX,GAM immune ADD UM: AUTHORIZATION UNEXglobulin,gamm(igg)/glycine/i C,GAMMAKED ga greater than 50 mcg/ml 01/01/2014 GAMUNEX immune ADD UM: AUTHORIZATION globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml,immune globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml,immune globulin,gamma(igg)/glycine, immune globulin,gamm(igg)/sucrose/ iga greater than 50 mcg/ml,immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml,immune globulin,gamma (igg)/sorbitol/iga 0 to 50 mcg/ml,immune globul,gamma(igg)/sorbitol/i ga greater than 50 mcg/ml,immune globulin,gamm(igg)/sorbitol/ glycin/iga 0 to 50 mcg/ml immune globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml ADD TO FORMULARY New Value PA applies PA applies Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 200 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 GAMUNEXC,GAMMAKED immune globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml ADD TO FORMULARY Preferred Brands 01/01/2014 GAMUNEXC,GAMMAKED immune globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml ADD TO FORMULARY Preferred Brands 01/01/2014 GAMUNEXC,GAMMAKED immune globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml ADD TO FORMULARY Preferred Brands 01/01/2014 GAMUNEXC,GAMMAKED immune globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml ADD TO FORMULARY Preferred Brands 01/01/2014 GAMUNEXC,GAMMAKED immune globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml ADD TO FORMULARY Preferred Brands 01/01/2014 HUMATROPE,G somatropin ENOTROPIN,NO RDITROPIN NORDIFLEX,NO RDITROPIN FLEXPRO,OMNI TROPE,SEROST IM,SAIZEN,ZOR BTIVE,NUTROPI N,NUTROPIN AQ,NUTROPIN AQ NUSPIN,TEVTROPIN ADD UM: CUSTOM Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 201 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 HUMATROPE,G somatropin ENOTROPIN,NO RDITROPIN NORDIFLEX,NO RDITROPIN FLEXPRO,OMNI TROPE,SEROST IM,SAIZEN,ZOR BTIVE,NUTROPI N,NUTROPIN AQ,NUTROPIN AQ NUSPIN,TEVTROPIN 01/01/2014 GILENYA 01/01/2014 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies fingolimod hcl ADD TO FORMULARY Non-Formulary GILENYA fingolimod hcl ADD UM: CUSTOM Specialty Drug 01/01/2014 GILENYA fingolimod hcl ADD UM: AUTHORIZATION PA applies 01/01/2014 GILOTRIF afatinib dimaleate ADD UM: CUSTOM Specialty Drug 01/01/2014 GILOTRIF afatinib dimaleate ADD UM: AUTHORIZATION PA applies 01/01/2014 GRANIX tbo-filgrastim ADD UM: CUSTOM Specialty Drug 01/01/2014 GRANIX tbo-filgrastim ADD UM: AUTHORIZATION PA applies 01/01/2014 H.P. ACTHAR corticotropin ADD TO FORMULARY Preferred Brands 01/01/2014 H.P. ACTHAR corticotropin ADD UM: CUSTOM Specialty Drug 01/01/2014 H.P. ACTHAR corticotropin ADD UM: AUTHORIZATION PA applies 01/01/2014 hecoria,tacrolimu tacrolimus s,prograf ADD TO FORMULARY Generics 01/01/2014 tacrolimus tacrolimus ADD TO FORMULARY Generics 01/01/2014 PROGRAF tacrolimus ADD TO FORMULARY Non-Formulary 01/01/2014 PROGRAF tacrolimus ADD TO FORMULARY Non-Formulary 01/01/2014 PROGRAF tacrolimus ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 202 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 tacrolimus tacrolimus ADD TO FORMULARY Generics 01/01/2014 hecoria tacrolimus ADD TO FORMULARY Generics 01/01/2014 hecoria tacrolimus ADD TO FORMULARY Generics 01/01/2014 HEPAGAM B hepatitis b immune globulin/maltose ADD TO FORMULARY Preferred Brands 01/01/2014 HEPAGAM B hepatitis b immune globulin/maltose ADD UM: CUSTOM http://4d.adaptive rx.com/webSearc h/index?key=cnh mbGV4LnBsYW4 uUGxhblBkZlR5c GUtOTE= 01/01/2014 HEPAGAM B hepatitis b immune globulin/maltose ADD UM: AUTHORIZATION PA applies 01/01/2014 HUMIRA,HUMIR adalimumab A PEN,HUMIRA PEN CROHNUC-HS STARTER,HUMI RA PEN PSORIASISUVEITIS ADD UM: CUSTOM Specialty Drug 01/01/2014 HEPAGAM B hepatitis b immune globulin/maltose ADD TO FORMULARY Preferred Brands 01/01/2014 HEPAGAM B hepatitis b immune globulin/maltose ADD UM: CUSTOM Specialty Drug 01/01/2014 HEPAGAM B hepatitis b immune globulin/maltose ADD UM: AUTHORIZATION PA applies 01/01/2014 HEPAGAM B hepatitis b immune globulin/maltose CHANGE UM: CUSTOM http://4d.adaptive rx.com/webSearc h/index?key=cnh mbGV4LnBsYW4 uUGxhblBkZlR5c GUtOTE= Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 203 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 HYCAMTIN topotecan hcl ADD TO FORMULARY Preferred Brands 01/01/2014 HYCAMTIN topotecan hcl ADD UM: CUSTOM Specialty Drug 01/01/2014 HYCAMTIN topotecan hcl ADD UM: AUTHORIZATION PA applies 01/01/2014 HYCAMTIN topotecan hcl ADD TO FORMULARY Preferred Brands 01/01/2014 HYCAMTIN topotecan hcl ADD UM: CUSTOM Specialty Drug 01/01/2014 HYCAMTIN topotecan hcl ADD UM: AUTHORIZATION PA applies 01/01/2014 HYPERHEP B S- hepatitis b immune globulin D,NABI-HB ADD TO FORMULARY Preferred Brands 01/01/2014 HYPERHEP B S- hepatitis b immune globulin D,NABI-HB ADD UM: CUSTOM Specialty Drug 01/01/2014 HYPERHEP B S- hepatitis b immune globulin D,NABI-HB ADD UM: AUTHORIZATION PA applies 01/01/2014 ICLUSIG ponatinib hcl ADD TO FORMULARY Preferred Brands 01/01/2014 ICLUSIG ponatinib hcl ADD UM: CUSTOM Specialty Drug 01/01/2014 ICLUSIG ponatinib hcl ADD UM: AUTHORIZATION PA applies 01/01/2014 ICLUSIG ponatinib hcl ADD TO FORMULARY Preferred Brands 01/01/2014 ICLUSIG ponatinib hcl ADD UM: AUTHORIZATION PA applies 01/01/2014 ICLUSIG ponatinib hcl ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 ILARIS canakinumab/pf ADD UM: CUSTOM Specialty Drug 01/01/2014 ILARIS canakinumab/pf ADD UM: AUTHORIZATION PA applies 01/01/2014 IMBRUVICA ibrutinib ADD UM: CUSTOM Specialty Drug 01/01/2014 IMBRUVICA ibrutinib ADD UM: AUTHORIZATION PA applies 01/01/2014 imiquimod,aldara imiquimod ADD UM: CUSTOM Specialty Drug 01/01/2014 INFERGEN interferon alfacon-1 ADD UM: CUSTOM Specialty Drug 01/01/2014 INLYTA axitinib ADD UM: CUSTOM Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 204 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 INLYTA axitinib 01/01/2014 INTRON A interferon alfa-2b,recomb. 01/01/2014 IPRIVASK 01/01/2014 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies ADD UM: CUSTOM Specialty Drug desirudin ADD TO FORMULARY Preferred Brands IPRIVASK desirudin ADD UM: CUSTOM Specialty Drug 01/01/2014 IPRIVASK desirudin ADD UM: AUTHORIZATION PA applies 01/01/2014 JAKAFI ruxolitinib phosphate ADD UM: CUSTOM Specialty Drug 01/01/2014 JAKAFI ruxolitinib phosphate ADD UM: AUTHORIZATION PA applies 01/01/2014 JUXTAPID lomitapide mesylate ADD TO FORMULARY Non-Formulary 01/01/2014 JUXTAPID lomitapide mesylate ADD UM: CUSTOM Specialty Drug 01/01/2014 JUXTAPID lomitapide mesylate ADD UM: AUTHORIZATION PA applies 01/01/2014 KALBITOR ecallantide ADD UM: CUSTOM Specialty Drug 01/01/2014 KALBITOR ecallantide ADD UM: AUTHORIZATION PA applies 01/01/2014 KALYDECO ivacaftor ADD UM: CUSTOM Specialty Drug 01/01/2014 KALYDECO ivacaftor ADD UM: AUTHORIZATION PA applies 01/01/2014 KINERET anakinra ADD UM: CUSTOM Specialty Drug 01/01/2014 KINERET anakinra ADD UM: AUTHORIZATION PA applies 01/01/2014 MIFEPREX,KOR mifepristone LYM ADD UM: CUSTOM Specialty Drug 01/01/2014 MIFEPREX,KOR mifepristone LYM ADD UM: AUTHORIZATION PA applies 01/01/2014 kuvan,tetrahydro sapropterin dihydrochloride biopterin dihcl,tetrahydro-lbiopterin di-hcl ADD UM: CUSTOM Specialty Drug 01/01/2014 kuvan,tetrahydro sapropterin dihydrochloride biopterin dihcl,tetrahydro-lbiopterin di-hcl ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 205 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 KYNAMRO mipomersen sodium ADD UM: CUSTOM Specialty Drug 01/01/2014 KYNAMRO mipomersen sodium ADD UM: AUTHORIZATION PA applies 01/01/2014 lamivudine hbv lamivudine 01/01/2014 LETAIRIS ambrisentan 01/01/2014 CHANGE TIER Preferred Brands Generics ADD UM: CUSTOM Specialty Drug eligard,lupron leuprolide acetate depot-ped,lupron depot,leuprolide acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 eligard,lupron leuprolide acetate depot-ped,lupron depot,leuprolide acetate ADD UM: AUTHORIZATION PA applies 01/01/2014 leuprolide acetate leuprolide acetate ADD TO FORMULARY Generics 01/01/2014 CEENU,LOMUST lomustine INE ADD TO FORMULARY Preferred Brands 01/01/2014 CEENU,LOMUST lomustine INE ADD UM: CUSTOM Specialty Drug 01/01/2014 CEENU,LOMUST lomustine INE ADD UM: AUTHORIZATION PA applies 01/01/2014 CEENU,LOMUST lomustine INE ADD TO FORMULARY Preferred Brands 01/01/2014 CEENU,LOMUST lomustine INE ADD UM: CUSTOM Specialty Drug 01/01/2014 CEENU,LOMUST lomustine INE ADD UM: AUTHORIZATION PA applies 01/01/2014 CEENU,LOMUST lomustine INE ADD TO FORMULARY Preferred Brands 01/01/2014 CEENU,LOMUST lomustine INE ADD UM: CUSTOM Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 206 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 CEENU,LOMUST lomustine INE 01/01/2014 LUPANETA PACK 01/01/2014 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies leuprolide acetate/norethindrone acetate ADD UM: CUSTOM Specialty Drug LUPANETA PACK leuprolide acetate/norethindrone acetate ADD UM: AUTHORIZATION PA applies 01/01/2014 LYSODREN mitotane ADD TO FORMULARY Preferred Brands 01/01/2014 LYSODREN mitotane ADD UM: CUSTOM Specialty Drug 01/01/2014 LYSODREN mitotane ADD UM: AUTHORIZATION PA applies 01/01/2014 MAKENA hydroxyprogesterone caproate ADD UM: CUSTOM Specialty Drug 01/01/2014 MAKENA hydroxyprogesterone caproate ADD UM: AUTHORIZATION PA applies 01/01/2014 MATULANE procarbazine hcl ADD UM: CUSTOM Specialty Drug 01/01/2014 MATULANE procarbazine hcl ADD UM: AUTHORIZATION PA applies 01/01/2014 MEKINIST trametinib dimethyl sulfoxide ADD UM: CUSTOM Specialty Drug 01/01/2014 MEKINIST trametinib dimethyl sulfoxide ADD UM: AUTHORIZATION 01/01/2014 MESNEX mesna ADD UM: CUSTOM Specialty Drug 01/01/2014 MESNEX mesna ADD UM: AUTHORIZATION PA applies 01/01/2014 micrhogam ultra- rho(d) immune globulin filtered plus,hyperrho s-d ADD TO FORMULARY Preferred Brands 01/01/2014 micrhogam ultra- rho(d) immune globulin filtered plus,hyperrho s-d ADD UM: CUSTOM Specialty Drug PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 207 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 micrhogam ultra- rho(d) immune globulin filtered plus,hyperrho s-d 01/01/2014 MONOVISC 01/01/2014 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies hyaluronate sodium, stabilized ADD UM: CUSTOM Specialty Drug MONOVISC hyaluronate sodium, stabilized ADD UM: AUTHORIZATION PA applies 01/01/2014 MYOBLOC rimabotulinumtoxinb ADD UM: CUSTOM Specialty Drug 01/01/2014 MYOBLOC rimabotulinumtoxinb CHANGE UM: AUTHORIZATION PA applies 01/01/2014 NEUPOGEN filgrastim ADD TO FORMULARY Preferred Brands 01/01/2014 NEUPOGEN filgrastim ADD UM: CUSTOM Specialty Drug 01/01/2014 NEUPOGEN filgrastim ADD UM: AUTHORIZATION PA applies 01/01/2014 NEUMEGA oprelvekin ADD TO FORMULARY Preferred Brands 01/01/2014 NEUMEGA oprelvekin ADD UM: CUSTOM Specialty Drug 01/01/2014 NEUMEGA oprelvekin ADD UM: AUTHORIZATION PA applies 01/01/2014 NEULASTA pegfilgrastim ADD UM: CUSTOM Specialty Drug 01/01/2014 NEULASTA pegfilgrastim ADD UM: AUTHORIZATION PA applies 01/01/2014 NEXAVAR sorafenib tosylate ADD UM: CUSTOM Specialty Drug 01/01/2014 NEXAVAR sorafenib tosylate ADD UM: AUTHORIZATION PA applies 01/01/2014 sandostatin,sand octreotide acetate,octreotide ostatin acetate, microspheres lar,octreotide acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 sandostatin,sand octreotide acetate,octreotide ADD UM: AUTHORIZATION ostatin acetate, microspheres lar,octreotide acetate PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 208 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 sandostatin,octre octreotide acetate otide acetate ADD TO FORMULARY Preferred Brands 01/01/2014 sandostatin,octre octreotide acetate otide acetate ADD TO FORMULARY Preferred Brands 01/01/2014 octreotide acetate octreotide acetate ADD TO FORMULARY Generics 01/01/2014 sandostatin,octre octreotide acetate otide acetate ADD TO FORMULARY Preferred Brands 01/01/2014 sandostatin,octre octreotide acetate otide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 sandostatin,octre octreotide acetate otide acetate ADD TO FORMULARY Generics 01/01/2014 octreotide acetate octreotide acetate ADD TO FORMULARY Generics 01/01/2014 octreotide acetate octreotide acetate ADD TO FORMULARY Generics 01/01/2014 octreotide acetate octreotide acetate ADD TO FORMULARY Generics 01/01/2014 SANDOSTATIN octreotide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 SANDOSTATIN octreotide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 octreotide acetate octreotide acetate ADD TO FORMULARY Generics 01/01/2014 SANDOSTATIN octreotide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 octreotide acetate octreotide acetate ADD TO FORMULARY Generics 01/01/2014 SANDOSTATIN octreotide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 octreotide acetate octreotide acetate ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 209 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 octreotide acetate octreotide acetate ADD TO FORMULARY Generics 01/01/2014 octreotide acetate octreotide acetate ADD TO FORMULARY Non-Formulary 01/01/2014 OLYSIO simeprevir sodium ADD UM: CUSTOM Specialty Drug 01/01/2014 OLYSIO simeprevir sodium ADD UM: AUTHORIZATION PA applies 01/01/2014 ONCASPAR pegaspargase ADD TO FORMULARY Preferred Brands 01/01/2014 ONCASPAR pegaspargase ADD UM: CUSTOM Specialty Drug 01/01/2014 ONCASPAR pegaspargase ADD UM: AUTHORIZATION PA applies 01/01/2014 OPSUMIT macitentan ADD TO FORMULARY Non-Formulary 01/01/2014 OPSUMIT macitentan ADD UM: CUSTOM Specialty Drug 01/01/2014 OPSUMIT macitentan ADD UM: AUTHORIZATION PA applies 01/01/2014 ORENCIA abatacept CHANGE TIER Preferred Brands 01/01/2014 ORENCIA abatacept ADD UM: CUSTOM Specialty Drug 01/01/2014 ORENCIA abatacept ADD UM: AUTHORIZATION PA applies 01/01/2014 ORENCIA abatacept/maltose 01/01/2014 ORENITRAM ER treprostinil diolamine ADD UM: CUSTOM Specialty Drug 01/01/2014 ORENITRAM ER treprostinil diolamine ADD UM: AUTHORIZATION PA applies 01/01/2014 ORFADIN nitisinone ADD UM: CUSTOM Specialty Drug 01/01/2014 ORFADIN nitisinone ADD UM: AUTHORIZATION PA applies 01/01/2014 ORTHOVISC hyaluronate sodium ADD UM: CUSTOM Specialty Drug 01/01/2014 ORTHOVISC hyaluronate sodium ADD UM: AUTHORIZATION PA applies 01/01/2014 OTEZLA apremilast CHANGE TIER Preferred Brands 01/01/2014 OTEZLA apremilast ADD UM: CUSTOM Specialty Drug 01/01/2014 OTEZLA apremilast ADD UM: AUTHORIZATION PA applies CHANGE TIER Preferred Brands Not Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 210 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 OTEZLA apremilast ADD UM: CUSTOM Specialty Drug 01/01/2014 OTEZLA apremilast ADD UM: AUTHORIZATION PA applies 01/01/2014 OXSORALENULTRA methoxsalen, rapid ADD UM: CUSTOM Specialty Drug 01/01/2014 OXSORALENULTRA methoxsalen, rapid ADD UM: AUTHORIZATION PA applies 01/01/2014 PANRETIN alitretinoin ADD UM: CUSTOM Specialty Drug 01/01/2014 PANRETIN alitretinoin ADD UM: AUTHORIZATION PA applies 01/01/2014 PEGASYS,PEGA peginterferon alfa-2a SYS PROCLICK ADD UM: CUSTOM Specialty Drug 01/01/2014 PEGINTRON,SY peginterferon alfa-2b LATRON,SYLAT RON 4PACK,PEGINTR ON REDIPEN ADD UM: CUSTOM Specialty Drug 01/01/2014 POMALYST pomalidomide ADD UM: CUSTOM Specialty Drug 01/01/2014 POMALYST pomalidomide ADD UM: AUTHORIZATION PA applies 01/01/2014 EPOGEN,PROC epoetin alfa RIT ADD UM: CUSTOM Specialty Drug 01/01/2014 EPOGEN,PROC epoetin alfa RIT ADD UM: AUTHORIZATION PA applies 01/01/2014 hecoria,tacrolimu tacrolimus s,prograf,protopic ,astagraf xl 01/01/2014 PROLIA,XGEVA denosumab ADD UM: CUSTOM Specialty Drug 01/01/2014 PROLIA,XGEVA denosumab ADD UM: AUTHORIZATION PA applies 01/01/2014 PROMACTA eltrombopag olamine ADD UM: CUSTOM Specialty Drug 01/01/2014 PROMACTA eltrombopag olamine ADD UM: AUTHORIZATION PA applies REMOVE UM: CUSTOM BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 211 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 PROTOPAM CHLORIDE pralidoxime chloride ADD TO FORMULARY Preferred Brands 01/01/2014 PROTOPAM CHLORIDE pralidoxime chloride ADD UM: CUSTOM Specialty Drug 01/01/2014 PROTOPAM CHLORIDE pralidoxime chloride ADD UM: AUTHORIZATION PA applies 01/01/2014 PULMOZYME dornase alfa ADD UM: CUSTOM Specialty Drug 01/01/2014 mercaptopurine,p mercaptopurine urinethol ADD UM: CUSTOM Specialty Drug 01/01/2014 mercaptopurine,p mercaptopurine urinethol ADD UM: AUTHORIZATION PA applies 01/01/2014 QUELICIN,ANEC succinylcholine chloride TINE ADD TO FORMULARY Preferred Brands 01/01/2014 QUELICIN,ANEC succinylcholine chloride TINE ADD UM: CUSTOM Specialty Drug 01/01/2014 QUELICIN,ANEC succinylcholine chloride TINE ADD UM: AUTHORIZATION PA applies 01/01/2014 QUELICIN succinylcholine chloride ADD UM: CUSTOM Specialty Drug 01/01/2014 QUELICIN succinylcholine chloride ADD UM: AUTHORIZATION PA applies 01/01/2014 QUTENZA capsaicin/skin cleanser ADD UM: CUSTOM Specialty Drug 01/01/2014 QUTENZA capsaicin/skin cleanser ADD UM: AUTHORIZATION PA applies 01/01/2014 RADIOGARDAS prussian blue (insoluble) E ADD TO FORMULARY Non-Formulary 01/01/2014 RADIOGARDAS prussian blue (insoluble) E ADD UM: CUSTOM Specialty Drug 01/01/2014 RADIOGARDAS prussian blue (insoluble) E ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 212 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 copegus,rebetol,r ribavirin ibavirin,virazole,ri batab,ribasphere, ribasphere ribapak,moderiba ADD UM: CUSTOM Specialty Drug 01/01/2014 RELISTOR methylnaltrexone bromide ADD UM: CUSTOM Specialty Drug 01/01/2014 RELISTOR methylnaltrexone bromide ADD UM: AUTHORIZATION PA applies 01/01/2014 REMODULIN treprostinil sodium ADD UM: CUSTOM Specialty Drug 01/01/2014 REMODULIN treprostinil sodium ADD UM: AUTHORIZATION PA applies 01/01/2014 REVLIMID lenalidomide ADD UM: CUSTOM Specialty Drug 01/01/2014 REVLIMID lenalidomide ADD UM: AUTHORIZATION PA applies 01/01/2014 RHOGAM rho(d) immune globulin ULTRAFILTERED PLUS,HYPERRH O S-D ADD TO FORMULARY Preferred Brands 01/01/2014 RHOGAM rho(d) immune globulin ULTRAFILTERED PLUS,HYPERRH O S-D ADD UM: CUSTOM Specialty Drug 01/01/2014 RHOGAM rho(d) immune globulin ULTRAFILTERED PLUS,HYPERRH O S-D ADD UM: AUTHORIZATION PA applies 01/01/2014 rilutek,riluzole riluzole ADD TO FORMULARY Preferred Brands 01/01/2014 rilutek,riluzole riluzole ADD UM: CUSTOM Specialty Drug 01/01/2014 rilutek,riluzole riluzole ADD UM: AUTHORIZATION PA applies 01/01/2014 SABRIL vigabatrin ADD UM: CUSTOM Specialty Drug 01/01/2014 SABRIL vigabatrin ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 213 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 SAMSCA tolvaptan ADD TO FORMULARY Preferred Brands 01/01/2014 SAMSCA tolvaptan ADD UM: CUSTOM Specialty Drug 01/01/2014 SAMSCA tolvaptan ADD UM: AUTHORIZATION PA applies 01/01/2014 SAMSCA tolvaptan ADD TO FORMULARY Preferred Brands 01/01/2014 SAMSCA tolvaptan ADD UM: CUSTOM Specialty Drug 01/01/2014 SENSIPAR cinacalcet hcl ADD UM: CUSTOM Specialty Drug 01/01/2014 SENSIPAR cinacalcet hcl ADD UM: AUTHORIZATION PA applies 01/01/2014 SIGNIFOR pasireotide diaspartate ADD UM: CUSTOM Specialty Drug 01/01/2014 SIGNIFOR pasireotide diaspartate ADD UM: AUTHORIZATION PA applies 01/01/2014 SIMPONI,SIMPO golimumab NI ARIA ADD UM: CUSTOM Specialty Drug 01/01/2014 SIMPONI ARIA golimumab 01/01/2014 SOMATULINE DEPOT lanreotide acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 SOMATULINE DEPOT lanreotide acetate ADD UM: AUTHORIZATION PA applies 01/01/2014 SOMAVERT pegvisomant ADD UM: CUSTOM Specialty Drug 01/01/2014 SOMAVERT pegvisomant ADD UM: AUTHORIZATION PA applies 01/01/2014 soriatane,acitretin acitretin ADD UM: CUSTOM Specialty Drug 01/01/2014 soriatane,acitretin acitretin ADD UM: AUTHORIZATION PA applies 01/01/2014 soriatane,acitretin acitretin ADD TO FORMULARY Preferred Brands 01/01/2014 soriatane,acitretin acitretin ADD TO FORMULARY Preferred Brands 01/01/2014 SPRYCEL dasatinib ADD UM: CUSTOM Specialty Drug 01/01/2014 SPRYCEL dasatinib ADD UM: AUTHORIZATION PA applies 01/01/2014 STELARA ustekinumab ADD UM: CUSTOM Specialty Drug 01/01/2014 STELARA ustekinumab ADD UM: AUTHORIZATION PA applies CHANGE TIER Preferred Brands Not Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 214 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 STIVARGA regorafenib ADD UM: CUSTOM Specialty Drug 01/01/2014 STIVARGA regorafenib ADD UM: AUTHORIZATION PA applies 01/01/2014 SUCRAID sacrosidase ADD UM: CUSTOM Specialty Drug 01/01/2014 SUCRAID sacrosidase ADD UM: AUTHORIZATION PA applies 01/01/2014 SURFAXIN lucinactant ADD TO FORMULARY Non-Formulary 01/01/2014 SURFAXIN lucinactant ADD UM: CUSTOM Specialty Drug 01/01/2014 SURFAXIN lucinactant ADD UM: AUTHORIZATION PA applies 01/01/2014 SURVANTA beractant ADD TO FORMULARY Non-Formulary 01/01/2014 SURVANTA beractant ADD UM: CUSTOM Specialty Drug 01/01/2014 SURVANTA beractant ADD UM: AUTHORIZATION PA applies 01/01/2014 SUTENT sunitinib malate ADD UM: CUSTOM Specialty Drug 01/01/2014 SUTENT sunitinib malate ADD UM: AUTHORIZATION PA applies 01/01/2014 SYNAGIS palivizumab ADD UM: CUSTOM Specialty Drug 01/01/2014 SYNRIBO omacetaxine mepesuccinate ADD TO FORMULARY Non-Formulary 01/01/2014 SYNRIBO omacetaxine mepesuccinate ADD UM: CUSTOM Specialty Drug 01/01/2014 SYNRIBO omacetaxine mepesuccinate ADD UM: AUTHORIZATION 01/01/2014 SYNVISC hylan g-f 20 ADD TO FORMULARY Preferred Brands 01/01/2014 SYNVISC hylan g-f 20 ADD UM: CUSTOM Specialty Drug 01/01/2014 SYNVISC hylan g-f 20 ADD UM: AUTHORIZATION PA applies 01/01/2014 SYNVISC-ONE hylan g-f 20 ADD TO FORMULARY Preferred Brands 01/01/2014 SYNVISC-ONE hylan g-f 20 ADD UM: CUSTOM Specialty Drug 01/01/2014 SYNVISC-ONE hylan g-f 20 ADD UM: AUTHORIZATION PA applies 01/01/2014 SYPRINE trientine hcl ADD TO FORMULARY Preferred Brands 01/01/2014 SYPRINE trientine hcl ADD UM: CUSTOM Specialty Drug 01/01/2014 SYPRINE trientine hcl ADD UM: AUTHORIZATION PA applies PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 215 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 TACHOSIL fibrinogen/thrombin (human plasma derived) ADD TO FORMULARY Preferred Brands 01/01/2014 TACHOSIL fibrinogen/thrombin (human plasma derived) ADD UM: CUSTOM Specialty Drug 01/01/2014 TACHOSIL fibrinogen/thrombin (human ADD UM: AUTHORIZATION plasma derived) 01/01/2014 TAFINLAR dabrafenib mesylate ADD UM: CUSTOM Specialty Drug 01/01/2014 TAFINLAR dabrafenib mesylate ADD UM: AUTHORIZATION PA applies 01/01/2014 TARCEVA erlotinib hcl ADD UM: CUSTOM Specialty Drug 01/01/2014 TARCEVA erlotinib hcl ADD UM: AUTHORIZATION PA applies 01/01/2014 TARGRETIN bexarotene ADD UM: CUSTOM Specialty Drug 01/01/2014 TARGRETIN bexarotene ADD UM: AUTHORIZATION PA applies 01/01/2014 TASIGNA nilotinib hcl ADD UM: CUSTOM Specialty Drug 01/01/2014 tecfidera,dimethyl dimethyl fumarate fumarate ADD UM: CUSTOM Specialty Drug 01/01/2014 tecfidera,dimethyl dimethyl fumarate fumarate ADD UM: AUTHORIZATION PA applies 01/01/2014 temodar,temozol temozolomide omide CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 temodar,temozol temozolomide omide CHANGE TIER Preferred Brands Generics 01/01/2014 temodar,temozol temozolomide omide CHANGE TIER Preferred Brands Generics 01/01/2014 temodar,temozol temozolomide omide CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 TEMODAR temozolomide CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 temodar,temozol temozolomide omide CHANGE TIER Generics Non-Formulary PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 216 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 temodar,temozol temozolomide omide CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 temodar,temozol temozolomide omide CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 temodar,temozol temozolomide omide ADD UM: CUSTOM Specialty Drug 01/01/2014 temodar,temozol temozolomide omide ADD UM: AUTHORIZATION PA applies 01/01/2014 TESTRED,ANDR methyltestosterone OID ADD UM: CUSTOM Specialty Drug 01/01/2014 TESTRED,ANDR methyltestosterone OID ADD UM: AUTHORIZATION PA applies 01/01/2014 THALOMID thalidomide ADD UM: CUSTOM Specialty Drug 01/01/2014 THALOMID thalidomide ADD UM: AUTHORIZATION PA applies 01/01/2014 tobi,tobramycin tobramycin in 0.225 % sodium chloride ADD TO FORMULARY Non-Formulary 01/01/2014 TOBI PODHALER tobramycin CHANGE TIER 01/01/2014 BETHKIS tobramycin ADD UM: CUSTOM Specialty Drug 01/01/2014 BETHKIS tobramycin ADD UM: AUTHORIZATION PA applies 01/01/2014 TRACLEER bosentan ADD UM: CUSTOM Specialty Drug 01/01/2014 TRELSTAR triptorelin pamoate ADD UM: CUSTOM Specialty Drug 01/01/2014 TRELSTAR triptorelin pamoate ADD UM: AUTHORIZATION PA applies 01/01/2014 tretinoin tretinoin ADD UM: CUSTOM Specialty Drug 01/01/2014 tretinoin tretinoin ADD UM: AUTHORIZATION PA applies 01/01/2014 TYKERB lapatinib ditosylate ADD UM: CUSTOM Specialty Drug 01/01/2014 TYKERB lapatinib ditosylate ADD UM: AUTHORIZATION PA applies 01/01/2014 UVADEX methoxsalen ADD UM: CUSTOM Specialty Drug Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 217 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 UVADEX methoxsalen 01/01/2014 VELCADE 01/01/2014 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies bortezomib ADD TO FORMULARY Preferred Brands VELCADE bortezomib ADD UM: CUSTOM Specialty Drug 01/01/2014 VELCADE bortezomib ADD UM: AUTHORIZATION PA applies 01/01/2014 VENTAVIS iloprost tromethamine ADD TO FORMULARY Preferred Brands 01/01/2014 VENTAVIS iloprost tromethamine ADD UM: CUSTOM Specialty Drug 01/01/2014 VENTAVIS iloprost tromethamine ADD UM: AUTHORIZATION PA applies 01/01/2014 VENTAVIS iloprost tromethamine ADD TO FORMULARY Preferred Brands 01/01/2014 VENTAVIS iloprost tromethamine ADD UM: CUSTOM Specialty Drug 01/01/2014 VENTAVIS iloprost tromethamine ADD UM: AUTHORIZATION PA applies 01/01/2014 VICTRELIS boceprevir ADD UM: CUSTOM Specialty Drug 01/01/2014 VICTRELIS boceprevir ADD UM: AUTHORIZATION PA applies 01/01/2014 VOTRIENT pazopanib hcl ADD UM: CUSTOM Specialty Drug 01/01/2014 VOTRIENT pazopanib hcl ADD UM: AUTHORIZATION PA applies 01/01/2014 WINRHO SDF rho(d) immune globulin/maltose ADD UM: CUSTOM Specialty Drug 01/01/2014 WINRHO SDF rho(d) immune globulin/maltose ADD UM: AUTHORIZATION PA applies 01/01/2014 WINRHO SDF rho(d) immune globulin/maltose ADD TO FORMULARY Preferred Brands 01/01/2014 WINRHO SDF rho(d) immune globulin/maltose ADD TO FORMULARY Preferred Brands 01/01/2014 WINRHO SDF rho(d) immune globulin/maltose ADD TO FORMULARY Preferred Brands 01/01/2014 WINRHO SDF rho(d) immune globulin/maltose ADD TO FORMULARY Preferred Brands 01/01/2014 XALKORI crizotinib ADD UM: CUSTOM Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 218 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 XALKORI crizotinib 01/01/2014 XELJANZ 01/01/2014 XELJANZ 01/01/2014 xeloda,capecitabi capecitabine ne 01/01/2014 XENAZINE 01/01/2014 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies tofacitinib citrate ADD UM: CUSTOM Specialty Drug tofacitinib citrate ADD UM: AUTHORIZATION PA applies ADD UM: CUSTOM Specialty Drug tetrabenazine ADD TO FORMULARY Non-Formulary XENAZINE tetrabenazine ADD UM: CUSTOM Specialty Drug 01/01/2014 XENAZINE tetrabenazine ADD UM: AUTHORIZATION PA applies 01/01/2014 XENAZINE tetrabenazine ADD TO FORMULARY Non-Formulary 01/01/2014 XENAZINE tetrabenazine ADD UM: CUSTOM Specialty Drug 01/01/2014 XENAZINE tetrabenazine ADD UM: AUTHORIZATION PA applies 01/01/2014 XEOMIN incobotulinumtoxina ADD TO FORMULARY Non-Formulary 01/01/2014 XEOMIN incobotulinumtoxina ADD UM: CUSTOM Specialty Drug 01/01/2014 XEOMIN incobotulinumtoxina ADD UM: AUTHORIZATION PA applies 01/01/2014 XEOMIN incobotulinumtoxina ADD TO FORMULARY Non-Formulary 01/01/2014 XEOMIN incobotulinumtoxina ADD UM: CUSTOM Specialty Drug 01/01/2014 XEOMIN incobotulinumtoxina ADD UM: AUTHORIZATION PA applies 01/01/2014 XIAFLEX collagenase clostridium histolyticum ADD UM: CUSTOM Specialty Drug 01/01/2014 XIAFLEX collagenase clostridium histolyticum ADD UM: AUTHORIZATION PA applies 01/01/2014 XIFAXAN rifaximin CHANGE TIER Preferred Brands 01/01/2014 XIFAXAN rifaximin ADD UM: CUSTOM Specialty Drug 01/01/2014 XIFAXAN rifaximin ADD UM: AUTHORIZATION PA applies 01/01/2014 XIFAXAN rifaximin ADD TO FORMULARY Preferred Brands 01/01/2014 XIFAXAN rifaximin ADD UM: CUSTOM Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 219 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 XIFAXAN rifaximin 01/01/2014 XOLAIR 01/01/2014 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies omalizumab ADD UM: CUSTOM Specialty Drug XOLAIR omalizumab ADD UM: AUTHORIZATION PA applies 01/01/2014 XTANDI enzalutamide ADD UM: CUSTOM Specialty Drug 01/01/2014 XTANDI enzalutamide ADD UM: AUTHORIZATION PA applies 01/01/2014 XYREM sodium oxybate ADD UM: CUSTOM Specialty Drug 01/01/2014 XYREM sodium oxybate ADD UM: AUTHORIZATION PA applies 01/01/2014 ZAVESCA miglustat ADD UM: CUSTOM Specialty Drug 01/01/2014 ZAVESCA miglustat ADD UM: AUTHORIZATION PA applies 01/01/2014 ZELBORAF vemurafenib ADD TO FORMULARY Preferred Brands 01/01/2014 ZELBORAF vemurafenib ADD UM: CUSTOM Specialty Drug 01/01/2014 ZELBORAF vemurafenib ADD UM: AUTHORIZATION PA applies 01/01/2014 ZOLADEX goserelin acetate ADD TO FORMULARY Preferred Brands 01/01/2014 ZOLADEX goserelin acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 ZOLADEX goserelin acetate ADD UM: AUTHORIZATION PA applies 01/01/2014 ZOLADEX goserelin acetate ADD TO FORMULARY Preferred Brands 01/01/2014 ZOLADEX goserelin acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 ZOLADEX goserelin acetate ADD UM: AUTHORIZATION PA applies 01/01/2014 ZOLINZA vorinostat CHANGE TIER 01/01/2014 ZOLINZA vorinostat ADD UM: CUSTOM Specialty Drug 01/01/2014 ZOLINZA vorinostat ADD UM: AUTHORIZATION PA applies 01/01/2014 ZORTRESS everolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 ZORTRESS everolimus ADD UM: AUTHORIZATION PA applies 01/01/2014 ZORTRESS everolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 ZORTRESS everolimus ADD UM: AUTHORIZATION PA applies Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 220 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ZORTRESS everolimus ADD UM: CUSTOM Specialty Drug 01/01/2014 ZORTRESS everolimus ADD UM: AUTHORIZATION PA applies 01/01/2014 ZYCLARA imiquimod ADD TO FORMULARY Preferred Brands 01/01/2014 ZYCLARA imiquimod ADD UM: CUSTOM Specialty Drug 01/01/2014 ZYCLARA imiquimod ADD UM: AUTHORIZATION PA applies 01/01/2014 ZYCLARA imiquimod ADD UM: CUSTOM Specialty Drug 01/01/2014 ZYCLARA imiquimod ADD UM: AUTHORIZATION PA applies 01/01/2014 ZYCLARA imiquimod ADD UM: CUSTOM Specialty Drug 01/01/2014 ZYCLARA imiquimod ADD UM: AUTHORIZATION PA applies 01/01/2014 ZYKADIA ceritinib ADD UM: CUSTOM Specialty Drug 01/01/2014 ZYKADIA ceritinib ADD UM: AUTHORIZATION PA applies 01/01/2014 ZYTIGA abiraterone acetate ADD UM: CUSTOM Specialty Drug 01/01/2014 ZYTIGA abiraterone acetate ADD UM: AUTHORIZATION PA applies 01/01/2014 INCIVEK telaprevir ADD UM: CUSTOM Specialty Drug 01/01/2014 CORVITE FE iron,carbonyl/ferrous asparto glycinate/folic acid/mvmin27,iron,carbonyl/methylt etrahydrofolate gluc,fa/mv, min no.40 ADD UM: CUSTOM Vitamin Rider may be required 01/01/2014 CORVITE FE iron,carbonyl/ferrous asparto glycinate/folic acid/mvmin27,iron,carbonyl/methylt etrahydrofolate gluc,fa/mv, min no.40 REMOVE UM: GENDER 01/01/2014 CORVITE 150 iron,carbonyl/methyltetrahyd rofolate gluc,fa/mv, min no.41 ADD UM: CUSTOM Vitamin Rider may be required 01/01/2014 arixtra,fondaparin fondaparinux sodium ux sodium ADD UM: CUSTOM Specialty Drug Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 221 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 arixtra,fondaparin fondaparinux sodium ux sodium 01/01/2014 fluoritab sodium fluoride 01/01/2014 AUBAGIO 01/01/2014 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies ADD UM: QUANTITY 50 / 30 days teriflunomide ADD UM: AUTHORIZATION PA applies AUBAGIO teriflunomide REMOVE UM: STEP 01/01/2014 breeze 2 blood-glucose meter, disctype ADD TO FORMULARY Preventative 01/01/2014 contour next ez blood-glucose meter ADD TO FORMULARY Preventative 01/01/2014 ACTEMRA tocilizumab ADD UM: QUANTITY 4 / 28 days 01/01/2014 CIMZIA certolizumab pegol ADD UM: QUANTITY 1 / 28 days 01/01/2014 CIMZIA certolizumab pegol ADD UM: QUANTITY 1 / 180 days 01/01/2014 HUMIRA adalimumab CHANGE UM: QUANTITY 4 / 28 days 2 / 28 days 01/01/2014 HUMIRA adalimumab CHANGE UM: QUANTITY 4 / 28 days 2 / 28 days 01/01/2014 HUMIRA PEN adalimumab CHANGE UM: QUANTITY 4 / 28 days 2 / 28 days 01/01/2014 HUMIRA PEN CROHN-UC-HS STARTER adalimumab CHANGE UM: QUANTITY 4 / 28 days 1 / 180 days 01/01/2014 HUMIRA PEN PSORIASISUVEITIS adalimumab CHANGE UM: QUANTITY 4 / 28 days 1 / 180 days 01/01/2014 KINERET anakinra ADD UM: QUANTITY 30 / 30 days 01/01/2014 ORENCIA abatacept ADD UM: QUANTITY 4 / 28 days 01/01/2014 SIMPONI golimumab ADD UM: QUANTITY 1 / 28 days 01/01/2014 SIMPONI golimumab ADD UM: QUANTITY 1 / 28 days 01/01/2014 SIMPONI golimumab ADD UM: QUANTITY 1 / 28 days 01/01/2014 SIMPONI golimumab ADD UM: QUANTITY 1 / 28 days 01/01/2014 STELARA ustekinumab ADD UM: QUANTITY 1 / 84 days ST applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 222 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 STELARA ustekinumab ADD UM: QUANTITY 1 / 84 days 01/01/2014 XELJANZ tofacitinib citrate ADD UM: QUANTITY 60 / 30 days 01/01/2014 ENBREL etanercept REMOVE UM: CUSTOM 01/01/2014 ENBREL etanercept ADD UM: SPECIALTY Specialty Drug 01/01/2014 depotestosterone cypionate testosterone,test osterone cypionate ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 AVEED testosterone undecanoate ADD TO FORMULARY Non-Formulary 01/01/2014 AVEED testosterone undecanoate ADD UM: CUSTOM OTC Benefit Rider REQUIRED 01/01/2014 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 30 / 30 days 60 / 30 days 01/01/2014 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 30 / 30 days 60 / 30 days 01/01/2014 OXYCONTIN oxycodone hcl CHANGE UM: QUANTITY 30 / 30 days 60 / 30 days 01/01/2014 etoposide,toposa etoposide r 01/01/2014 MONOCLATE-P antihemophilic factor, human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 KOATE-DVI antihemophilic factor, human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 CINRYZE c1 esterase inhibitor ADD TO FORMULARY Non-Formulary 01/01/2014 MIRENA levonorgestrel ADD TO FORMULARY Non-Formulary 01/01/2014 BCG (TICE STRAIN) bcg live ADD TO FORMULARY Non-Formulary 01/01/2014 ZEMPLAR paricalcitol 01/01/2014 hectorol,doxercal doxercalciferol ciferol CHANGE TIER 01/01/2014 revonto,dantrium dantrolene sodium CHANGE TIER Specialty Drug ADD TO FORMULARY CHANGE TIER Non-Formulary Preferred Brands Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 223 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name agalsidase beta Type of Change Previous Value New Value CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 FABRAZYME 01/01/2014 zometa,zoledroni zoledronic acid c acid CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALDURAZYME laronidase CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ondansetron hcl,zofran ondansetron hcl CHANGE TIER 01/01/2014 GAMUNEX immune globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALPHANINE SD factor ix CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 FABRAZYME CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 hycamtin,topotec topotecan hcl an hcl ADD TO FORMULARY Non-Formulary 01/01/2014 EDEX alprostadil ADD TO FORMULARY Preferred Brands 01/01/2014 HECTOROL doxercalciferol ADD TO FORMULARY Non-Formulary 01/01/2014 VANTAS histrelin acetate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 TYSABRI natalizumab CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 FEIBA VH anti-inhibitor coagulant IMMUNO,FEIBA complex NF CHANGE TIER 01/01/2014 FEIBA NF anti-inhibitor coagulant complex CHANGE TIER 01/01/2014 KOGENATE FS,HELIXATE FS,RECOMBINA TE antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor viii, human recombinant ADD TO FORMULARY Non-Formulary 01/01/2014 KOGENATE FS,HELIXATE FS,RECOMBINA TE antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor viii, human recombinant ADD TO FORMULARY Non-Formulary agalsidase beta Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 224 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 KOGENATE FS,HELIXATE FS,RECOMBINA TE antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor viii, human recombinant 01/01/2014 KOATE-DVI antihemophilic factor, human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 KOATE-DVI antihemophilic factor, human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 PROFILNINE factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 PROFILNINE factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 BEBULIN VH factor ix complex, IMMUNO,BEBUL prothrombin complex conc. IN (pcc) comb. 6,factor ix complex, prothrombin cplx conc(pcc) no.6, 3-factor CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 PROFILNINE factor ix complex, prothrombin cplx conc(pcc) no.4, 3-factor CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 KOATE-DVI antihemophilic factor, human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 BENEFIX factor ix human recombinant CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 BENEFIX factor ix human recombinant CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 BENEFIX factor ix human recombinant CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 cleocin clindamycin phosphate phosphate,clinda mycin phosphate ADD TO FORMULARY Non-Formulary 01/01/2014 ceftriaxone ADD TO FORMULARY Non-Formulary ceftriaxone sodium Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 225 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change ADD TO FORMULARY Previous Value New Value 01/01/2014 ampicillinsulbactam ampicillin sodium/sulbactam sodium Non-Formulary 01/01/2014 ORENCIA abatacept/maltose CHANGE TIER Not Covered Non-Formulary 01/01/2014 FEIBA NF anti-inhibitor coagulant complex CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 boniva,ibandrona ibandronate sodium te sodium CHANGE TIER 01/01/2014 HUMATE-P antihemophilic factor, human/von willebrand factor,human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 HUMATE-P antihemophilic factor, human/von willebrand factor,human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 HUMATE-P antihemophilic factor, human/von willebrand factor,human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 heparin sodium in heparin sodium,porcine in 0.45% nacl 0.45 % sodium chloride CHANGE TIER Generics Non-Formulary 01/01/2014 heparin sodium in heparin sodium,porcine in 0.45% nacl 0.45 % sodium chloride CHANGE TIER Generics Non-Formulary 01/01/2014 heparin sodium in heparin sodium,porcine in 0.45% nacl 0.45 % sodium chloride CHANGE TIER Generics Non-Formulary 01/01/2014 HEMOFIL M antihemophilic factor, human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 HEMOFIL M antihemophilic factor, human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 KOGENATE FS,HELIXATE FS,RECOMBINA TE antihemophilic factor (fviii) recomb,full length (albfree),antihemophilic factor viii, human recombinant Non-Formulary ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 226 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 MYOZYME,LUMI alglucosidase alfa ZYME CHANGE TIER Non-Formulary 01/01/2014 ZYVOX linezolid CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ZYVOX linezolid CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ACTEMRA tocilizumab CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ACTEMRA tocilizumab CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ACTEMRA tocilizumab CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 FLUORESCITE, AK-FLUOR fluorescein sodium ADD TO FORMULARY Non-Formulary 01/01/2014 AK-FLUOR fluorescein sodium ADD TO FORMULARY Non-Formulary 01/01/2014 ARZERRA ofatumumab ADD TO FORMULARY Non-Formulary 01/01/2014 WILATE antihemophilic factor, human/von willebrand factor,human ADD TO FORMULARY Non-Formulary 01/01/2014 WILATE antihemophilic factor, human/von willebrand factor,human ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 227 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 PROVENGE sipuleucel-t/lactated ringers solution CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NOVOSEVEN RT coagulation factor viia (recombinant) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XYNTHA SOLOFUSE antihemophilic factor (factor viii) recomb,b-domain deleted CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 topotecan hcl topotecan hcl 01/01/2014 argatroban-0.9% argatroban in 0.9 % sodium nacl chloride 01/01/2014 azithromycin azithromycin CHANGE TIER 01/01/2014 ARZERRA ofatumumab ADD TO FORMULARY Non-Formulary 01/01/2014 WILATE antihemophilic factor, human/von willebrand factor,human ADD TO FORMULARY Non-Formulary 01/01/2014 HEMOFIL M antihemophilic factor, human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 HEMOFIL M antihemophilic factor, human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ADCETRIS brentuximab vedotin ADD TO FORMULARY 01/01/2014 XYNTHA SOLOFUSE antihemophilic factor (factor viii) recomb,b-domain deleted CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XYNTHA SOLOFUSE antihemophilic factor (factor viii) recomb,b-domain deleted CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 EYLEA aflibercept CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 BENEFIX factor ix human recombinant CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 BERINERT c1 esterase inhibitor ADD TO FORMULARY Non-Formulary ADD TO FORMULARY Non-Formulary Preferred Brands Non-Formulary Non-Formulary ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 228 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 XYNTHA SOLOFUSE antihemophilic factor (factor viii) recomb,b-domain deleted CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XYNTHA SOLOFUSE antihemophilic factor (factor viii) recomb,b-domain deleted CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 provisc hyaluronate sodium ADD TO FORMULARY Non-Formulary 01/01/2014 AMVISC hyaluronate sodium ADD TO FORMULARY Non-Formulary 01/01/2014 AMVISC PLUS hyaluronate sodium ADD TO FORMULARY Non-Formulary 01/01/2014 BERINERT c1 esterase inhibitor ADD TO FORMULARY Non-Formulary 01/01/2014 euflexxa,hyalgan, hyaluronate sodium supartz ADD TO FORMULARY Non-Formulary 01/01/2014 HYALGAN hyaluronate sodium ADD TO FORMULARY Non-Formulary 01/01/2014 ADVATE antihemophilic factor (fviii) recomb,full length (alb-free) 01/01/2014 DEXFERRUM iron dextran complex ADD TO FORMULARY Non-Formulary 01/01/2014 DEXFERRUM iron dextran complex ADD TO FORMULARY Non-Formulary 01/01/2014 KADCYLA ado-trastuzumab emtansine CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 KADCYLA ado-trastuzumab emtansine CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 RIXUBIS factor ix human recombinant ADD TO FORMULARY Non-Formulary 01/01/2014 RIXUBIS factor ix human recombinant ADD TO FORMULARY Non-Formulary 01/01/2014 RIXUBIS factor ix human recombinant ADD TO FORMULARY Non-Formulary 01/01/2014 RIXUBIS factor ix human recombinant ADD TO FORMULARY Non-Formulary 01/01/2014 RIXUBIS factor ix human recombinant ADD TO FORMULARY Non-Formulary 01/01/2014 SIMPONI ARIA golimumab CHANGE TIER Not Covered Non-Formulary 01/01/2014 ALPROLIX factor ix recombinant, fc fusion protein CHANGE TIER Preferred Brands Non-Formulary CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 229 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ALPROLIX factor ix recombinant, fc fusion protein CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALPROLIX factor ix recombinant, fc fusion protein CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALPROLIX factor ix recombinant, fc fusion protein ADD TO FORMULARY 01/01/2014 MONOVISC hyaluronate sodium, stabilized 01/01/2014 ELOCTATE antihemophilic factor (fviii) recombinant, fc fusion protein ADD TO FORMULARY Non-Formulary 01/01/2014 ELOCTATE antihemophilic factor (fviii) recombinant, fc fusion protein ADD TO FORMULARY Non-Formulary 01/01/2014 ELOCTATE antihemophilic factor (fviii) recombinant, fc fusion protein ADD TO FORMULARY Non-Formulary 01/01/2014 ELOCTATE antihemophilic factor (fviii) recombinant, fc fusion protein ADD TO FORMULARY Non-Formulary 01/01/2014 ELOCTATE antihemophilic factor (fviii) recombinant, fc fusion protein ADD TO FORMULARY Non-Formulary 01/01/2014 ELOCTATE antihemophilic factor (fviii) recombinant, fc fusion protein ADD TO FORMULARY Non-Formulary 01/01/2014 ELOCTATE antihemophilic factor (fviii) recombinant, fc fusion protein ADD TO FORMULARY Non-Formulary 01/01/2014 ATRYN antithrombin iii, human recombinant ADD TO FORMULARY Non-Formulary CHANGE TIER Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 230 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2014 ALPHANATE antihemophilic factor, human/von willebrand factor,human 01/01/2014 alkeran,melphala melphalan hcl n hcl 01/01/2014 mesnex,mesna 01/01/2014 Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary CHANGE TIER Non-Formulary mesna ADD TO FORMULARY Non-Formulary flebogamma dif,gammaplex immune globulin,gamma (igg)/sorbitol/iga 0 to 50 mcg/ml,immune globulin,gamm(igg)/sorbitol/ glycin/iga 0 to 50 mcg/ml ADD TO FORMULARY Non-Formulary 01/01/2014 carimune nf nanofiltered immune globulin,gamm(igg)/sucrose/ iga greater than 50 mcg/ml ADD TO FORMULARY Non-Formulary 01/01/2014 carimune nf nanofiltered immune globulin,gamm(igg)/sucrose/ iga greater than 50 mcg/ml ADD TO FORMULARY Non-Formulary 01/01/2014 GAMMAGARD S- immune D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml ADD TO FORMULARY Non-Formulary 01/01/2014 GAMMAGARD S- immune D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml ADD TO FORMULARY Non-Formulary 01/01/2014 GAMMAGARD S- immune D globulin,gamm(igg)/glycine/g lucose/iga 0 to 50 mcg/ml ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 231 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 gammagard liquid,privigen,bivi gam,flebogamma dif immune globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml,immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml,immune globul,gamma(igg)/sorbitol/i ga greater than 50 mcg/ml ADD TO FORMULARY Non-Formulary 01/01/2014 carimune nf nanofiltered immune globulin,gamm(igg)/sucrose/ iga greater than 50 mcg/ml ADD TO FORMULARY Non-Formulary 01/01/2014 CELLCEPT mycophenolate mofetil hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ZEMPLAR paricalcitol CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 zithromax,azithro azithromycin mycin CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 levocarnitine,carn levocarnitine itor CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 MONOCLATE-P antihemophilic factor, human CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALPHANINE SD factor ix CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ALPHANINE SD factor ix CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 calcitriol calcitriol ADD TO FORMULARY Non-Formulary 01/01/2014 lidocaine hcl lidocaine hcl/pf ADD TO FORMULARY Non-Formulary 01/01/2014 sandimmune,cycl cyclosporine osporine CHANGE TIER Non-Formulary 01/01/2014 BENEFIX factor ix human recombinant CHANGE TIER 01/01/2014 KOGENATE FS,HELIXATE FS antihemophilic factor (fviii) recomb,full length (alb-free) ADD TO FORMULARY Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 232 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 ADVATE UH,ADVATE antihemophilic factor (fviii) recomb,full length (alb-free) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ADVATE,ADVAT antihemophilic factor (fviii) E SH recomb,full length (alb-free) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ADVATE,ADVAT antihemophilic factor (fviii) EM recomb,full length (alb-free) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ADVATE,ADVAT antihemophilic factor (fviii) EH recomb,full length (alb-free) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ADVATE,ADVAT antihemophilic factor (fviii) EL recomb,full length (alb-free) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 ADVATE antihemophilic factor (fviii) recomb,full length (alb-free) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NOVOSEVEN RT coagulation factor viia (recombinant) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NOVOSEVEN RT coagulation factor viia (recombinant) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 NOVOSEVEN RT coagulation factor viia (recombinant) CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XYNTHA antihemophilic factor (factor viii) recomb,b-domain deleted CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XYNTHA antihemophilic factor (factor viii) recomb,b-domain deleted CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XYNTHA antihemophilic factor (factor viii) recomb,b-domain deleted CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 XYNTHA antihemophilic factor (factor viii) recomb,b-domain deleted CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 233 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 VIAGRA sildenafil citrate ADD UM: CUSTOM Benefit Rider REQUIRED 01/01/2014 VIAGRA sildenafil citrate ADD UM: CUSTOM Benefit Rider REQUIRED 01/01/2014 VIAGRA sildenafil citrate ADD UM: CUSTOM Benefit Rider REQUIRED 01/01/2014 CIALIS tadalafil ADD UM: CUSTOM Benefit Rider REQUIRED 01/01/2014 CIALIS tadalafil ADD UM: CUSTOM Benefit Rider REQUIRED 01/01/2014 LEVITRA vardenafil hcl ADD UM: CUSTOM Benefit Rider REQUIRED 01/01/2014 LEVITRA vardenafil hcl ADD UM: CUSTOM Benefit Rider REQUIRED 01/01/2014 LEVITRA vardenafil hcl ADD UM: CUSTOM Benefit Rider REQUIRED 01/01/2014 LEVITRA vardenafil hcl ADD UM: CUSTOM Benefit Rider REQUIRED 01/01/2014 prostin vr alprostadil pediatric,caverjec t,muse,alprostadil ,edex,prostaglan din e1 ADD UM: CUSTOM Benefit Rider REQUIRED 01/01/2014 VIAGRA sildenafil citrate ADD UM: GENDER Male 01/01/2014 VIAGRA sildenafil citrate ADD UM: GENDER Male 01/01/2014 VIAGRA sildenafil citrate ADD UM: GENDER Male 01/01/2014 QNASL beclomethasone dipropionate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 COREG CR carvedilol phosphate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 COREG CR carvedilol phosphate CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 234 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2014 COREG CR carvedilol phosphate CHANGE TIER Preferred Brands Non-Formulary 01/01/2014 COREG CR carvedilol phosphate CHANGE TIER Preferred Brands Not Covered 01/01/2014 arava,leflunomide leflunomide ADD UM: SPECIALTY Specialty Drug 01/01/2014 leflunomide leflunomide ADD TO FORMULARY Generics 01/01/2014 leflunomide leflunomide ADD TO FORMULARY Generics 01/01/2014 APRISO mesalamine CHANGE TIER 01/01/2015 REGIMEX benzphetamine hcl 01/01/2015 BELVIQ lorcaserin hcl 01/01/2015 QSYMIA 01/01/2015 Preferred Brands Non-Formulary ADD UM: AUTHORIZATION PA applies ADD UM: CUSTOM Anorexiant Rider May be required phentermine hcl/topiramate ADD UM: AUTHORIZATION PA applies phentermine hcl,suprenza odt,adipex-p phentermine hcl ADD UM: AUTHORIZATION PA applies 01/01/2015 BELVIQ lorcaserin hcl ADD UM: AUTHORIZATION PA applies 01/01/2015 AURYXIA ferric citrate CHANGE TIER 01/01/2015 TAMIFLU oseltamivir phosphate CHANGE TIER Preferred Brands 01/01/2015 TAMIFLU oseltamivir phosphate CHANGE TIER Preferred Brands 01/01/2015 microurine albumin test bumintest,albusti x reagent,chemstri p micral CHANGE TIER Non-Formulary 01/01/2015 LESCOL fluvastatin sodium ADD TO FORMULARY Non-Formulary 01/01/2015 digitek digoxin ADD TO FORMULARY 01/01/2015 aspirin ec aspirin CHANGE TIER Preventative 01/01/2015 aspirin ec aspirin CHANGE UM: QUANTITY 30 / 30 days 01/01/2015 aspirin ec aspirin CHANGE UM: AGE 45 to 79 yrs old Generics Non-Formulary Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 235 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Generics 01/01/2015 digitek digoxin 01/01/2015 theophylline theophylline anhydrous CHANGE TIER Generics 01/01/2015 theophylline theophylline anhydrous CHANGE TIER Generics 01/01/2015 URSO ursodiol ADD TO FORMULARY Non-Formulary 01/01/2015 nitroglycerin patch nitroglycerin ADD TO FORMULARY Generics 01/01/2015 NITRO-DUR nitroglycerin ADD TO FORMULARY Non-Formulary 01/01/2015 CARDENE SR nicardipine hcl ADD TO FORMULARY Non-Formulary 01/01/2015 PROCARDIA XL nifedipine ADD TO FORMULARY Non-Formulary 01/01/2015 PROCARDIA nifedipine ADD TO FORMULARY Non-Formulary 01/01/2015 ANTABUSE disulfiram ADD TO FORMULARY Non-Formulary 01/01/2015 nicoderm cq nicotine ADD TO FORMULARY Preventative 01/01/2015 nicoderm cq nicotine ADD TO FORMULARY Preventative 01/01/2015 k-sol potassium chloride ADD TO FORMULARY Generics 01/01/2015 PRILOSEC omeprazole ADD TO FORMULARY Non-Formulary 01/01/2015 ELOCON mometasone furoate ADD TO FORMULARY Non-Formulary 01/01/2015 CARAFATE sucralfate ADD TO FORMULARY Non-Formulary 01/01/2015 DIOVAN HCT valsartan/hydrochlorothiazid e ADD TO FORMULARY Non-Formulary 01/01/2015 CARAFATE sucralfate ADD TO FORMULARY Non-Formulary 01/01/2015 anti-diarrheal loperamide hcl CHANGE TIER Generics 01/01/2015 BILTRICIDE praziquantel ADD TO FORMULARY Non-Formulary 01/01/2015 trospium chloride trospium chloride CHANGE TIER Generics 01/01/2015 DIOVAN HCT valsartan/hydrochlorothiazid e ADD TO FORMULARY Non-Formulary 01/01/2015 DDAVP desmopressin acetate ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 236 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value REMOVE FROM FORMULARY Not Covered Non-Formulary 01/01/2015 added strength pain reliever aspirin/acetaminophen/caffei ne 01/01/2015 CORDARONE amiodarone hcl ADD TO FORMULARY Non-Formulary 01/01/2015 PACERONE amiodarone hcl ADD TO FORMULARY Non-Formulary 01/01/2015 OVCON-35 norethindrone-ethinyl estradiol ADD TO FORMULARY Non-Formulary 01/01/2015 HUMULIN R insulin regular, human ADD TO FORMULARY Preferred Brands 01/01/2015 HUMULIN R insulin regular, human ADD TO FORMULARY Preferred Brands 01/01/2015 sensorcaine bupivacaine hcl ADD TO FORMULARY 01/01/2015 MICARDIS HCT telmisartan/hydrochlorothiazi de ADD TO FORMULARY Non-Formulary 01/01/2015 MICARDIS HCT telmisartan/hydrochlorothiazi de ADD TO FORMULARY Non-Formulary 01/01/2015 nateglinide nateglinide CHANGE TIER Generics 01/01/2015 STARLIX nateglinide ADD TO FORMULARY Non-Formulary 01/01/2015 VANIQA eflornithine hcl ADD TO FORMULARY Non-Formulary 01/01/2015 PACERONE amiodarone hcl ADD TO FORMULARY Non-Formulary 01/01/2015 REMERON mirtazapine ADD TO FORMULARY Non-Formulary 01/01/2015 mirtazapine mirtazapine ADD TO FORMULARY Generics 01/01/2015 mirtazapine mirtazapine ADD TO FORMULARY Generics 01/01/2015 REMERON mirtazapine ADD TO FORMULARY Non-Formulary 01/01/2015 LOPROX ciclopirox ADD TO FORMULARY Non-Formulary 01/01/2015 EVOXAC cevimeline hcl ADD TO FORMULARY Non-Formulary 01/01/2015 desloratadine desloratadine CHANGE TIER Generics 01/01/2015 NEXIUM esomeprazole magnesium ADD TO FORMULARY Non-Formulary 01/01/2015 NEXIUM 24HR esomeprazole magnesium ADD TO FORMULARY Not Covered Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 237 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2015 NEXIUM 24HR esomeprazole magnesium 01/01/2015 fluoxetine dr 01/01/2015 Type of Change Previous Value New Value ADD UM: CUSTOM OTC Not Covered fluoxetine hcl CHANGE TIER Generics PROZAC WEEKLY fluoxetine hcl ADD TO FORMULARY Non-Formulary 01/01/2015 TOPROL XL metoprolol succinate ADD TO FORMULARY Non-Formulary 01/01/2015 mirtazapine mirtazapine ADD TO FORMULARY Generics 01/01/2015 REMERON mirtazapine ADD TO FORMULARY Non-Formulary 01/01/2015 zarah ethinyl estradiol/drospirenone ADD TO FORMULARY Non-Formulary Preventative 01/01/2015 syeda ethinyl estradiol/drospirenone ADD TO FORMULARY Non-Formulary Preventative 01/01/2015 drospirenoneethinyl estradiol ethinyl estradiol/drospirenone ADD TO FORMULARY Non-Formulary Preventative 01/01/2015 VOLTAREN-XR diclofenac sodium ADD TO FORMULARY Non-Formulary 01/01/2015 GEODON ziprasidone hcl ADD TO FORMULARY Non-Formulary 01/01/2015 GEODON ziprasidone hcl ADD TO FORMULARY Non-Formulary 01/01/2015 GEODON ziprasidone hcl ADD TO FORMULARY Non-Formulary 01/01/2015 bpo benzoyl peroxide ADD TO FORMULARY Generics 01/01/2015 ipratropiumalbuterol ipratropium bromide/albuterol sulfate CHANGE TIER Generics 01/01/2015 VALTREX valacyclovir hcl ADD TO FORMULARY Non-Formulary 01/01/2015 VALTREX valacyclovir hcl ADD TO FORMULARY Non-Formulary 01/01/2015 ACEON perindopril erbumine ADD TO FORMULARY Non-Formulary 01/01/2015 TACLONEX calcipotriene/betamethason e dipropionate ADD TO FORMULARY Non-Formulary 01/01/2015 RESTORIL temazepam ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 238 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Non-Formulary Generics 01/01/2015 temazepam temazepam ADD TO FORMULARY 01/01/2015 allergy d-12 cetirizine hcl/pseudoephedrine hcl ADD TO FORMULARY Generics 01/01/2015 allergy d-12 cetirizine hcl/pseudoephedrine hcl ADD UM: CUSTOM OTC Rider May Be Required 01/01/2015 cetirizinecetirizine pseudoephedrine hcl/pseudoephedrine hcl er ADD TO FORMULARY 01/01/2015 cetirizinecetirizine pseudoephedrine hcl/pseudoephedrine hcl er ADD UM: CUSTOM OTC Rider may be required 01/01/2015 all day allergy-d cetirizine hcl/pseudoephedrine hcl ADD TO FORMULARY Generics 01/01/2015 all day allergy-d cetirizine hcl/pseudoephedrine hcl ADD UM: CUSTOM OTC Rider may be required 01/01/2015 aller-tec d cetirizine hcl/pseudoephedrine hcl ADD TO FORMULARY Generics 01/01/2015 aller-tec d cetirizine hcl/pseudoephedrine hcl ADD UM: CUSTOM OTC Rider may be required 01/01/2015 wal-zyr d cetirizine hcl/pseudoephedrine hcl ADD TO FORMULARY Generics 01/01/2015 wal-zyr d cetirizine hcl/pseudoephedrine hcl ADD UM: CUSTOM OTC Rider may be required 01/01/2015 allergy relief-d cetirizine hcl/pseudoephedrine hcl ADD TO FORMULARY Generics 01/01/2015 allergy relief-d cetirizine hcl/pseudoephedrine hcl ADD UM: CUSTOM OTC Rider may be required 01/01/2015 allergy-d cetirizine hcl/pseudoephedrine hcl ADD TO FORMULARY Generics 01/01/2015 allergy-d cetirizine hcl/pseudoephedrine hcl ADD UM: CUSTOM OTC Rider may be required Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 239 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2015 allergy complete- cetirizine d hcl/pseudoephedrine hcl ADD TO FORMULARY Generics 01/01/2015 allergy complete- cetirizine d hcl/pseudoephedrine hcl ADD UM: CUSTOM OTC Rider may be required 01/01/2015 SANDIMMUNE cyclosporine ADD TO FORMULARY Non-Formulary 01/01/2015 SANDIMMUNE cyclosporine ADD TO FORMULARY Non-Formulary 01/01/2015 NEORAL cyclosporine, modified ADD TO FORMULARY Non-Formulary 01/01/2015 NEORAL cyclosporine, modified ADD TO FORMULARY Non-Formulary 01/01/2015 NEORAL cyclosporine, modified ADD TO FORMULARY Non-Formulary 01/01/2015 potassium citrate- potassium citrate/citric acid citric acid ADD TO FORMULARY 01/01/2015 potass cit-sod cit- sodium/potassium/potassiu citric acid m citrate/sodium citrate/cit ac ADD TO FORMULARY Generics 01/01/2015 virtrate-3 sodium/potassium/potassiu m citrate/sodium citrate/cit ac ADD TO FORMULARY Generics 01/01/2015 potassium citrate- potassium citrate/citric acid citric acid ADD TO FORMULARY Generics 01/01/2015 FAMVIR famciclovir ADD TO FORMULARY Non-Formulary 01/01/2015 FAMVIR famciclovir ADD TO FORMULARY Non-Formulary 01/01/2015 REBETOL ribavirin ADD TO FORMULARY Non-Formulary 01/01/2015 QUESTRAN cholestyramine (with sugar) ADD TO FORMULARY Non-Formulary 01/01/2015 KEPPRA XR levetiracetam ADD TO FORMULARY Non-Formulary 01/01/2015 virt-care one prenatal vit with calcium no.37/iron,aspg/folic acid/omega-3 ADD TO FORMULARY Generics Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 240 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/01/2015 virt-care one prenatal vit with calcium no.37/iron,aspg/folic acid/omega-3 01/01/2015 VIDEX EC 01/01/2015 Type of Change Previous Value New Value ADD UM: GENDER Female didanosine ADD TO FORMULARY Non-Formulary VIDEX EC didanosine ADD TO FORMULARY Non-Formulary 01/01/2015 VIDEX EC didanosine ADD TO FORMULARY Non-Formulary 01/01/2015 VIDEX EC didanosine ADD TO FORMULARY Non-Formulary 01/01/2015 albuterol sulfate albuterol sulfate CHANGE TIER Generics 01/01/2015 albuterol sulfate albuterol sulfate CHANGE TIER Generics 01/01/2015 ADDERALL XR dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate ADD TO FORMULARY Non-Formulary 01/01/2015 ADDERALL XR dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate ADD TO FORMULARY Non-Formulary 01/01/2015 ADDERALL XR dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate ADD TO FORMULARY Non-Formulary 01/01/2015 nicotine lozenge nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2015 nicorelief nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2015 quit 4 nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2015 nicotine nicotine polacrilex lozenge,nicorette, nicorelief,stop smoking aid,quit 2 CHANGE TIER Generics 01/01/2015 NICORETTE nicotine polacrilex REMOVE FROM FORMULARY Non-Formulary 01/01/2015 nicorelief nicotine polacrilex ADD TO FORMULARY Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 241 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2015 quit 2 nicotine polacrilex ADD TO FORMULARY Preventative 01/01/2015 COZAAR losartan potassium ADD TO FORMULARY Non-Formulary 01/01/2015 COZAAR losartan potassium ADD TO FORMULARY Non-Formulary 01/01/2015 HYZAAR losartan potassium/hydrochlorothiazi de ADD TO FORMULARY Non-Formulary 01/01/2015 COZAAR losartan potassium ADD TO FORMULARY Non-Formulary 01/01/2015 HYZAAR losartan potassium/hydrochlorothiazi de ADD TO FORMULARY Non-Formulary 01/01/2015 promethazine hcl promethazine hcl ADD TO FORMULARY 01/01/2015 ZYPREXA olanzapine ADD TO FORMULARY Non-Formulary 01/01/2015 ZYPREXA olanzapine ADD TO FORMULARY Non-Formulary 01/01/2015 PRAVACHOL pravastatin sodium ADD TO FORMULARY Non-Formulary 01/01/2015 URAMAXIN urea ADD TO FORMULARY Non-Formulary 01/01/2015 levalbuterol hcl levalbuterol hcl CHANGE TIER Generics 01/01/2015 UNIRETIC moexipril hcl/hydrochlorothiazide ADD TO FORMULARY Non-Formulary 01/01/2015 RITALIN methylphenidate hcl ADD TO FORMULARY Non-Formulary 01/01/2015 RITALIN methylphenidate hcl ADD TO FORMULARY Non-Formulary 01/01/2015 RITALIN methylphenidate hcl ADD TO FORMULARY Non-Formulary 01/01/2015 DILAUDID hydromorphone hcl/pf ADD TO FORMULARY Non-Formulary 01/01/2015 DILAUDID hydromorphone hcl/pf ADD TO FORMULARY Non-Formulary 01/01/2015 DILAUDID hydromorphone hcl/pf ADD TO FORMULARY Non-Formulary 01/01/2015 TRILIPIX fenofibric acid (choline) ADD TO FORMULARY Non-Formulary 01/01/2015 TRILIPIX fenofibric acid (choline) ADD TO FORMULARY Non-Formulary 01/01/2015 DILAUDID hydromorphone hcl ADD TO FORMULARY Non-Formulary Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 242 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2015 DILAUDID hydromorphone hcl ADD TO FORMULARY 01/01/2015 OLYSIO simeprevir sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2015 SOVALDI sofosbuvir ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2015 STRIBILD elvitegravir/cobicistat/emtrici REMOVE UM: SPECIALTY tabine/tenofovir disoproxil 01/01/2016 VIEKIRA PAK ombitasvir/paritaprevir/ritona vir/dasabuvir sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 OLYSIO simeprevir sodium CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 INCRUSE ELLIPTA umeclidinium bromide ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 DAKLINZA daclatasvir dihydrochloride ADD UM: SPECIALTY Specialty Drug 01/01/2016 ENVARSUS XR tacrolimus ADD UM: SPECIALTY Specialty Drug 01/01/2016 ENVARSUS XR tacrolimus ADD UM: SPECIALTY Specialty Drug 01/01/2016 ENVARSUS XR tacrolimus ADD UM: SPECIALTY Specialty Drug 01/01/2016 ENVARSUS XR tacrolimus ADD UM: QUANTITY 30 / 30 days 01/01/2016 ENVARSUS XR tacrolimus ADD UM: QUANTITY 1 / 1 days 01/01/2016 ENVARSUS XR tacrolimus ADD UM: QUANTITY 1 / 1 days 01/01/2016 ENVARSUS XR tacrolimus ADD UM: QUANTITY 1 / 1 days 01/01/2016 ODOMZO sonidegib phosphate ADD UM: QUANTITY 1 / 1 days 01/01/2016 DAKLINZA daclatasvir dihydrochloride ADD UM: QUANTITY 1 / 1 days 01/01/2016 DAKLINZA daclatasvir dihydrochloride ADD UM: QUANTITY 1 / 1 days 01/01/2016 TECHNIVIE ombitasvir/paritaprevir/ritona vir ADD UM: QUANTITY 56 / 30 days 01/01/2016 ENTRESTO sacubitril/valsartan 01/01/2016 REXULTI brexpiprazole 01/01/2016 APTENSIO XR methylphenidate hcl CHANGE UM: QUANTITY Non-Formulary 30 / 30 days ADD UM: QUANTITY CHANGE UM: QUANTITY 2 / 1 days 1 / 1 days 30 / 30 days 6 / 1 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 243 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2016 APTENSIO XR methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 days 4 / 1 days 01/01/2016 APTENSIO XR methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 days 3 / 1 days 01/01/2016 APTENSIO XR methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 days 2 / 1 days 01/01/2016 APTENSIO XR methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 days 1 / 1 days 01/01/2016 APTENSIO XR methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 days 1 / 1 days 01/01/2016 APTENSIO XR methylphenidate hcl CHANGE UM: QUANTITY 30 / 30 days 1 / 1 days 01/01/2016 APTENSIO XR methylphenidate hcl ADD UM: CUSTOM Max. 60mg per day 01/01/2016 NATESTO testosterone ADD UM: QUANTITY 3 / 1 days 01/01/2016 NATESTO testosterone ADD UM: CUSTOM Max. 3 pumps per day 01/01/2016 VIBERZI eluxadoline ADD UM: QUANTITY 2 / 1 days 01/01/2016 REPATHA SURECLICK evolocumab ADD UM: QUANTITY 0.07 / 1 days 01/01/2016 REPATHA SYRINGE evolocumab ADD UM: QUANTITY 0.07 / 1 days 01/01/2016 PRALUENT PEN alirocumab ADD UM: QUANTITY 0.07 / 1 days 01/01/2016 PRALUENT SYRINGE alirocumab ADD UM: QUANTITY 0.07 / 1 days 01/01/2016 PROAIR RESPICLICK albuterol sulfate ADD UM: QUANTITY 0.067 / 1 days 01/01/2016 INCRUSE ELLIPTA umeclidinium bromide ADD UM: QUANTITY 1 / 1 days 01/01/2016 PULMICORT budesonide CHANGE UM: QUANTITY 120 / 30 days 01/01/2016 accu-chek compact blood sugar diagnostic, drum-type ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 accu-chek compact plus blood sugar diagnostic, drum-type ADD TO FORMULARY Non-Formulary Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 244 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2016 accu-chek comfort curve blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 accu-chek aviva blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 accu-chek aviva plus blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 accu-chek smartview blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 accu-chek active blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 ORKAMBI lumacaftor/ivacaftor REMOVE UM: AUTHORIZATION PA applies 01/01/2016 glucose test strip,blood glucose test,premium blood glucose test,blood glucose test strip,test strips blood sugar diagnostic ADD TO FORMULARY Non-Formulary 01/01/2016 glucose test strip,blood glucose test,premium blood glucose test,blood glucose test strip,test strips blood sugar diagnostic CHANGE UM: QUANTITY 100 / 30 days 01/01/2016 clever choice talk blood sugar diagnostic REMOVE UM: GENDER 01/01/2016 true metrix blood sugar diagnostic glucose test strip ADD TO FORMULARY Non-Formulary 01/01/2016 true metrix blood sugar diagnostic glucose test strip ADD UM: QUANTITY 100 / 3 days Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 245 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2016 fortiscare glucose blood sugar diagnostic test strips ADD UM: QUANTITY 100 / 30 days 01/01/2016 fortiscare glucose blood sugar diagnostic test strips ADD TO FORMULARY Non-Formulary 01/01/2016 evencare mini glucose test str ADD TO FORMULARY Non-Formulary blood sugar diagnostic BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 246 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date 01/01/2016 Brand Name Generic Name contour,contour blood sugar diagnostic next,bgstar,advance test strips,assure pro,assure platinum,assure 3,assure 4,glucocard expression,pocke tchem ez,relion prime test strips,micro,relion confirmmicro,glucocard 01 sensor plus,glucocard xsensor,glucocard vital,glucocard vital sensor,evencare g2,evencare,eve ncare g3,easygluco test strips,easy gluco g2,control g3,control ast test strip,control,g4,maxima,infinity test strips,acura test strips,easygluco plus,easy pro plus,prodigy,prodi gy eject,prodigy no coding,prodigy autocode,prodigy voice,easy touch test strip,eclipse,envis Type of Change Previous Value CHANGE UM: QUANTITY New Value 100 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 247 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ion,evolution test strips,element test strips,smartdiabet es xpres,element plus,glucolab,sm artest test,glucocom glucose,glucose test strip,rightest gs300 test strips,rightest gs100 test strips,rightest gs550 test strips,ge100 blood glucose test strip,nova max glucose test strips,keynote,wa vesense jazz,wavesense presto,agamatrix amp,blood glucose test,liberty test strips,ultratrak,ult ratrak ultimate,solus v2 test strips,caresens n,smart caresens n,reveal test strip,truetest test strips,truetrack test strip,premium blood glucose test,foracare BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 248 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value gd20,fora v10,choicedm g20,fora g20,fora test strip,fora g71a,foracare gd40,premium v10,fora v12,refuah plus,surechek test strips,sure edge test strips,vocal point,ultratrak pro,truetrack smart system,easymax, easymax 15,easyplus,mygl ucohealth,accuchek comfort curve,accu-chek active,microdot,m icrodot xtra,ez smart,ez smart plus,one touch verio,fast take,surestep,on e touch test strips,onetouch ultra test strips,onetouch verio,surestep pro,glucostix,free style test strips,test strips,test strip,prestige test strips,prestige smart BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 249 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value system,precision pcx plus,precision point of care,optium ez,precision q-id,precision pcx,optium,precis ion xtra,neutek 2tek test strips,telcare,sure -test easyplus mini,accu-chek aviva,accutrend glucose,accuchek aviva plus,accu-chek smartview,ultima, on call plus test strip,on call vivid test strip,gmate test strips,gluco navii,choicedm clarus test strips,quintet,quin tet ac,easy step,easy plus,easy trak,easy talk,easy plus ii,easy check test strip,fifty50 test strip,embrace,vict ory,advocate test strip,advocate redicode,advocate redi-code+,clever choice test BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 250 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value strips,clever choice voice+ tst strip,clever choice pro,pharmacist choice,clever choice micro test strip,clever choice talk,fora d10,fora d15c,fora d15z,fora v20,fora v22,fora g30a,fora d15g,fora d20,fora g90,fora v30a,freestyle lite strips,freestyle lite test strips,freestyle insulinx test strips,freestyle insulinx,test n'go,optumrx,ele ment compact,blood glucose test strip,diatrue plus,td gold test strip,rightest gs260 test strips,rightest gs250s test strips,smart sense test strips,ascensia elite,quicktek,eas ypro,duocare,accu-chek BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 251 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value instant plus,accuchek instant,one touch ultra test strips,accu-chek advantage,exacte ch,exactech rsg,precision softact,unicheck,glucoleade r,valustrip test strips,sof-tact,one touch ii test strips,genstrip,uni strip1,embrace evo,embrace pro,on call express test strip,healthpro test strips,advanced glucose test strips,true metrix glucose test strip,fora gd50 test strips,fora test n'go test strips,fortiscare glucose test strips,assure prism multi,glucocard shine,genultimate test,evencare mini glucose test str,fora tn'g voice test strips 01/01/2016 DAKLINZA daclatasvir dihydrochloride ADD UM: AUTHORIZATION 01/01/2016 DAKLINZA daclatasvir dihydrochloride REMOVE UM: QUANTITY PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 252 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2016 TECHNIVIE ombitasvir/paritaprevir/ritona REMOVE UM: QUANTITY vir 01/01/2016 DAKLINZA daclatasvir dihydrochloride 01/01/2016 pioglitazonepioglitazone hcl/metformin metformin,actopl hcl us met,actoplus met xr 01/01/2016 CORDARONE amiodarone hcl ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COUMADIN warfarin sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COUMADIN warfarin sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COUMADIN warfarin sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COUMADIN warfarin sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COUMADIN warfarin sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COUMADIN warfarin sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COUMADIN warfarin sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COUMADIN warfarin sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COUMADIN warfarin sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 DEPAKOTE ER divalproex sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 DEPAKOTE ER divalproex sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 DEPAKOTE SPRINKLE divalproex sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 testosterone testosterone ADD UM: QUANTITY 01/01/2016 ANDROGEL testosterone CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 ANDROGEL testosterone ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 ANDROGEL testosterone ADD TO FORMULARY Non-Formulary Preferred Brands ADD TO FORMULARY 56 / 30 days Non-Formulary Preferred Brands CHANGE TIER Preferred Brands 60 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 253 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2016 BEYAZ drospirenone/ethinyl estradiol/levomefolate calcium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 ANDRODERM testosterone ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 ANDRODERM testosterone ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 APIDRA insulin glulisine ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 APIDRA SOLOSTAR insulin glulisine ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 ATROVENT ipratropium bromide CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 ATROVENT ipratropium bromide CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 comtan,entacapo entacapone ne CHANGE TIER Generics Non-Formulary 01/01/2016 COREG CR carvedilol phosphate ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COREG CR carvedilol phosphate ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COREG CR carvedilol phosphate ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 COREG CR carvedilol phosphate ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 DETROL tolterodine tartrate CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 DETROL tolterodine tartrate CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 DETROL LA tolterodine tartrate CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 DILANTIN phenytoin ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 ENJUVIA estrogens,conj.,synthetic b ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 ENJUVIA estrogens,conj.,synthetic b ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 ENJUVIA estrogens,conj.,synthetic b ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 ENJUVIA estrogens,conj.,synthetic b ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 ENJUVIA estrogens,conj.,synthetic b ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 GLYSET miglitol ADD TO FORMULARY Non-Formulary Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 254 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2016 GLYSET miglitol ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 GLYSET miglitol ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 STENDRA avanafil ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 STENDRA avanafil REMOVE UM: AUTHORIZATION PA applies 01/01/2016 AZILECT rasagiline mesylate CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 AZASAN azathioprine CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 AZASAN azathioprine CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 BUPHENYL sodium phenylbutyrate CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 CELONTIN methsuximide CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 clorpres clonidine hcl/chlorthalidone CHANGE TIER Generics Non-Formulary 01/01/2016 elixophyllin theophylline anhydrous CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 FLUORABON sodium fluoride CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 FLUOR-A-DAY sodium fluoride/xylitol CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 FLUOR-A-DAY sodium fluoride/xylitol CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 FLUOR-A-DAY sodium fluoride/xylitol CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 FLUOR-A-DAY sodium fluoride CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 HEMANGEOL propranolol hcl CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 XIGDUO XR dapagliflozin propanediol/metformin hcl 01/01/2016 ASMANEX HFA 01/01/2016 ADD TO FORMULARY Non-Formulary mometasone furoate ADD UM: QUANTITY 1 / 30 days ASMANEX HFA mometasone furoate ADD UM: QUANTITY 1 / 30 days 01/01/2016 TEGRETOL XR carbamazepine REMOVE UM: AUTHORIZATION PA applies 01/01/2016 TEGRETOL XR carbamazepine REMOVE UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 255 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ADD UM: QUANTITY 30 / 30 days 01/01/2016 TRIBENZOR olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide 01/01/2016 ZECUITY sumatriptan succinate ADD TO FORMULARY Preferred Brands 01/01/2016 ZECUITY sumatriptan succinate ADD UM: QUANTITY 9 / 30 days 01/01/2016 CIMZIA certolizumab pegol CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 ORENCIA abatacept CHANGE TIER Preferred Brands Non-Formulary 01/01/2016 EXTAVIA,BETAS interferon beta-1b ERON ADD TO FORMULARY 01/01/2016 REBIF,REBIF interferon beta-1a/albumin REBIDOSE,AVO human NEX ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 AVONEX,AVON interferon beta-1a EX PEN ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 ADCIRCA tadalafil REMOVE UM: GENDER Male 01/01/2016 FORTEO teriparatide ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 euflexxa hyaluronate sodium ADD TO FORMULARY Non-Formulary Preferred Brands 01/01/2016 euflexxa hyaluronate sodium ADD UM: AUTHORIZATION PA applies 01/01/2016 GLEEVEC imatinib mesylate ADD UM: SPECIALTY Specialty Drug 01/01/2016 eligard,lupron leuprolide acetate depot-ped,lupron depot,leuprolide acetate,lupron CHANGE TIER Preferred Brands 01/01/2016 ZOLADEX goserelin acetate CHANGE TIER 01/01/2016 CERDELGA eliglustat tartrate ADD UM: AUTHORIZATION PA applies 01/01/2016 SUTENT sunitinib malate CHANGE UM: QUANTITY 30 / 30 days 01/01/2016 SUTENT sunitinib malate CHANGE UM: AUTHORIZATION PA applies Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 256 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/01/2016 ipratropium bromide ipratropium bromide CHANGE TIER Preferred Brands Generics 01/01/2016 ipratropium bromide ipratropium bromide CHANGE TIER Preferred Brands Generics 01/06/2015 SITAVIG acyclovir ADD TO FORMULARY Non-Formulary 01/06/2015 ZENPEP lipase/protease/amylase ADD TO FORMULARY Preferred Brands 01/06/2015 eligen b12 cyanocobalamin/salcaprozat e sodium ADD UM: CUSTOM Vitamin Rider may be required 01/06/2015 LYNPARZA olaparib ADD UM: SPECIALTY Specialty Drug 01/06/2015 PKU EASY nutritional therapy for pku, combination no.56 ADD TO FORMULARY Non-Formulary 01/06/2015 REYATAZ atazanavir sulfate ADD TO FORMULARY Preferred Brands 01/06/2015 VIEKIRA PAK ombitasvir/paritaprevir/ritona vir/dasabuvir sodium ADD UM: SPECIALTY Specialty Drug 01/09/2016 norgestimateethinyl estradiol norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/09/2016 tri-lo-estarylla norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/09/2016 vienva levonorgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 01/09/2016 genvisc 850 hyaluronate sodium REMOVE FROM FORMULARY Non-Formulary 01/09/2016 trinessa lo norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/09/2016 trinessa lo norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/09/2016 blisovi fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 257 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/09/2016 blisovi fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 01/09/2016 aerovent plus inhaler, assist devices REMOVE FROM FORMULARY Non-Formulary 01/09/2016 droplet pen needle pen needle, diabetic ADD TO FORMULARY Generics 01/09/2016 droplet pen needle pen needle, diabetic ADD TO FORMULARY Generics 01/09/2016 droplet pen needle pen needle, diabetic REMOVE FROM FORMULARY Non-Formulary 01/09/2016 easy touch unislip syringe w-o needl,insulin,1 ml REMOVE FROM FORMULARY Non-Formulary 01/09/2016 easy touch unislip syringe w-o needl,insulin,1 ml REMOVE FROM FORMULARY Non-Formulary 01/09/2016 easy touch fliplock syringes syringe,safety with needle,5 ml REMOVE FROM FORMULARY Non-Formulary 01/09/2016 glyceryl distearate glyceryl distearate REMOVE FROM FORMULARY Non-Formulary 01/09/2016 glyceryl distearate glyceryl distearate REMOVE FROM FORMULARY Non-Formulary 01/09/2016 nature's tears dextran 70/hypromellose REMOVE FROM FORMULARY Non-Formulary 01/09/2016 mucus relief dm guaifenesin/dextromethorph an hbr REMOVE FROM FORMULARY Non-Formulary 01/09/2016 mucus relief dm guaifenesin/dextromethorph an hbr REMOVE FROM FORMULARY Non-Formulary 01/09/2016 nicotine patch nicotine REMOVE FROM FORMULARY Non-Formulary 01/09/2016 sodium bicarbonate sodium bicarbonate REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 258 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/09/2016 oyster shell calcium-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 01/09/2016 oyster shell calcium-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 01/09/2016 oyster shell calcium calcium carbonate REMOVE FROM FORMULARY Non-Formulary 01/09/2016 oyster shell calcium calcium carbonate REMOVE FROM FORMULARY Non-Formulary 01/09/2016 PRADAXA dabigatran etexilate mesylate ADD TO FORMULARY Preferred Brands 01/09/2016 STRAVIX human regenerative tissue matrix REMOVE FROM FORMULARY Non-Formulary 01/09/2016 STRAVIX human regenerative tissue matrix REMOVE FROM FORMULARY Non-Formulary 01/09/2016 BRIDION sugammadex sodium REMOVE FROM FORMULARY Non-Formulary 01/09/2016 BRIDION sugammadex sodium REMOVE FROM FORMULARY Non-Formulary 01/09/2016 BRIDION sugammadex sodium REMOVE FROM FORMULARY Non-Formulary 01/09/2016 ENSTILAR calcipotriene/betamethason e dipropionate ADD TO FORMULARY Non-Formulary 01/09/2016 ENSTILAR calcipotriene/betamethason e dipropionate ADD TO FORMULARY Non-Formulary 01/09/2016 OB COMPLETE GOLD prenatal vitamins no.106/iron,carbonyl/folate no.6/dha ADD TO FORMULARY Non-Formulary 01/09/2016 ASPERGILLUS FUMIGATUS allergenic extract-aspergillus fumigatus REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 259 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/09/2016 AUREOBASIDIU allergenic extractM aureobasidium pullulans REMOVE FROM FORMULARY Non-Formulary 01/09/2016 CANDIDA ALBICANS REMOVE FROM FORMULARY Non-Formulary 01/09/2016 CLADOSPORIU allergenic extractM cladosporium CLADOSPORIOI cladosporioides DES REMOVE FROM FORMULARY Non-Formulary 01/09/2016 DRECHSLERA allergenic extract-drechslera sorokiniana REMOVE FROM FORMULARY Non-Formulary 01/09/2016 DRECHSLERA allergenic extract-drechslera sorokiniana REMOVE FROM FORMULARY Non-Formulary 01/09/2016 EPICOCCUM allergenic extract-epicoccum nigrum REMOVE FROM FORMULARY Non-Formulary 01/09/2016 MUCOR allergenic extract-mucor plumbeus REMOVE FROM FORMULARY Non-Formulary 01/09/2016 MUCOR allergenic extract-mucor plumbeus REMOVE FROM FORMULARY Non-Formulary 01/09/2016 PHOMA allergenic extract-phoma herbarum REMOVE FROM FORMULARY Non-Formulary 01/11/2016 MICROGESTIN 24 FE norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Non-Formulary 01/11/2016 MICROGESTIN 24 FE norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Non-Formulary 01/11/2016 STRAVIX human regenerative tissue matrix REMOVE FROM FORMULARY Non-Formulary 01/11/2016 b-donna phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb ADD TO FORMULARY Generics allergenic extract-candida albicans BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 260 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/11/2016 pen needle pen needle, diabetic ADD TO FORMULARY Preferred Brands 01/11/2016 pen needle pen needle, diabetic ADD TO FORMULARY Preferred Brands 01/11/2016 pen needle pen needle, diabetic ADD TO FORMULARY Preferred Brands 01/11/2016 droplet pen needle pen needle, diabetic ADD TO FORMULARY Preferred Brands 01/11/2016 droplet pen needle pen needle, diabetic ADD TO FORMULARY Preferred Brands 01/11/2016 droplet pen needle pen needle, diabetic ADD TO FORMULARY Preferred Brands 01/11/2016 blood lancets lancets ADD TO FORMULARY Preferred Brands 01/11/2016 ONCCOR multivitamin with minerals/folic acid/lycopene/lutein REMOVE FROM FORMULARY Non-Formulary 01/11/2016 COATS ALOE MOISTURIZING aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 01/11/2016 COATS ALOE aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 01/11/2016 COATS ALOE MOISTURIZING aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 01/11/2016 COATS ALOE MOISTURIZING aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 01/11/2016 COATS ALOE aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 01/11/2016 COATS ALOE aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 01/11/2016 COATS ALOE ANALGESIC methyl salicylate/aloe vera extract/menthol/eucalyptus oil REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 261 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/11/2016 COATS ALOE ANALGESIC methyl salicylate/aloe vera extract/menthol/eucalyptus oil REMOVE FROM FORMULARY Non-Formulary 01/11/2016 COATS ALOE aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 01/11/2016 menstrual complete acetaminophen/pyrilamine maleate/caffeine REMOVE FROM FORMULARY Non-Formulary 01/11/2016 adult dm maximum guaifenesin/dextromethorph an hbr REMOVE FROM FORMULARY Non-Formulary 01/11/2016 UPTRAVI selexipag ADD TO FORMULARY Non-Formulary 01/11/2016 UPTRAVI selexipag ADD TO FORMULARY Non-Formulary 01/11/2016 UPTRAVI selexipag ADD TO FORMULARY Non-Formulary 01/11/2016 UPTRAVI selexipag ADD TO FORMULARY Non-Formulary 01/11/2016 UPTRAVI selexipag ADD TO FORMULARY Non-Formulary 01/11/2016 UPTRAVI selexipag ADD TO FORMULARY Non-Formulary 01/11/2016 UPTRAVI selexipag ADD TO FORMULARY Non-Formulary 01/11/2016 UPTRAVI selexipag ADD TO FORMULARY Non-Formulary 01/11/2016 UPTRAVI selexipag ADD TO FORMULARY Non-Formulary 01/11/2016 UPTRAVI selexipag ADD TO FORMULARY Non-Formulary 01/11/2016 menstrual acetaminophen/pyrilamine relief,midol,midol maleate/caffeine complete,menstr ual complete REMOVE FROM FORMULARY Non-Formulary 01/11/2016 UPTRAVI selexipag ADD UM: SPECIALTY Specialty Drug 01/11/2016 MICROGESTIN 24 FE norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 01/12/2016 RISPERDAL risperidone CHANGE TIER Generics Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 262 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/12/2016 RISPERDAL risperidone CHANGE TIER Generics Non-Formulary 01/12/2016 VIBRAMYCIN doxycycline hyclate CHANGE TIER Generics Non-Formulary 01/12/2016 garamycin gentamicin sulfate ADD TO FORMULARY 01/12/2016 ORTHO TRICYCLEN LO norgestimate-ethinyl estradiol CHANGE TIER Preferred Brands Non-Formulary 01/12/2016 tri-lo-sprintec norgestimate-ethinyl estradiol ADD TO FORMULARY Non-Formulary Preventative 01/12/2016 tri-lo-sprintec norgestimate-ethinyl estradiol ADD UM: GENDER Female 01/12/2016 junel fe,gildess fe,loestrin fe,microgestin fe,larin fe,blisovi fe norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE UM: GENDER Female 01/12/2016 OB COMPLETE GOLD prenatal vitamins no.106/iron,carbonyl/folate no.6/dha ADD UM: GENDER Female 01/12/2016 lessina,aviane,or levonorgestrel-ethinyl sythia,falmina,lut estradiol era,sronyx,levono rgestrel-eth estradiol,aubra,d elyla,vienva CHANGE UM: GENDER Female 01/12/2016 ortho tri-cyclen norgestimate-ethinyl lo,tri-loestradiol sprintec,norgesti mate-ethinyl estradiol,tri-loestarylla,trinessa lo CHANGE UM: GENDER Female 01/13/2015 sinelee capsaicin/menthol ADD TO FORMULARY Generics 01/13/2015 captracin capsaicin/menthol ADD TO FORMULARY Generics Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 263 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/13/2015 valsartan valsartan ADD TO FORMULARY Non-Formulary Generics 01/13/2015 valsartan valsartan ADD TO FORMULARY Non-Formulary Generics 01/13/2015 valsartan valsartan ADD TO FORMULARY Non-Formulary Generics 01/13/2015 valsartan valsartan ADD TO FORMULARY Non-Formulary Generics 01/13/2015 QNASL CHILDREN beclomethasone dipropionate ADD TO FORMULARY Non-Formulary 01/13/2015 REVESTA cholecalciferol (vit d3)/folic acid ADD TO FORMULARY Non-Formulary 01/13/2015 REVESTA cholecalciferol (vit d3)/folic acid ADD UM: CUSTOM Vitamin Rider may be required 01/13/2015 LIDOVEX lidocaine ADD TO FORMULARY Non-Formulary 01/13/2015 solaice capsaicin/menthol ADD TO FORMULARY Generics 01/15/2016 lincomycin hcl lincomycin hcl REMOVE FROM FORMULARY Non-Formulary 01/15/2016 lincomycin hcl lincomycin hcl REMOVE FROM FORMULARY Non-Formulary 01/15/2016 lincomycin hcl lincomycin hcl REMOVE FROM FORMULARY Non-Formulary 01/15/2016 inflammacin diclofenac sodium/capsicum oleoresin REMOVE FROM FORMULARY Non-Formulary 01/15/2016 virt-nate dha prenatal vitamins no.11/ferrous fumarate/folic acid/omega-3 ADD TO FORMULARY Generics 01/15/2016 droplet pen needle pen needle, diabetic ADD TO FORMULARY Generics 01/15/2016 droplet pen needle pen needle, diabetic ADD TO FORMULARY Generics 01/15/2016 droplet pen needle pen needle, diabetic ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 264 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/15/2016 easy touch fliplock syringes syringe,safety with needle,1 ml REMOVE FROM FORMULARY Non-Formulary 01/15/2016 easy touch fliplock syringes syringe,safety with needle,3 ml REMOVE FROM FORMULARY Non-Formulary 01/15/2016 easy touch fliplock syringes syringe,safety with needle,3 ml REMOVE FROM FORMULARY Non-Formulary 01/15/2016 easy touch fliplock syringes syringe,safety with needle,3 ml REMOVE FROM FORMULARY Non-Formulary 01/15/2016 easy touch fliplock syringes syringe,safety with needle,5 ml REMOVE FROM FORMULARY Non-Formulary 01/15/2016 easy touch fliplock syringes syringe,safety with needle,5 ml REMOVE FROM FORMULARY Non-Formulary 01/15/2016 easy touch fliplock syringes syringe,safety with needle,5 ml REMOVE FROM FORMULARY Non-Formulary 01/15/2016 easy touch fliplock syringes syringe,safety with needle,5 ml REMOVE FROM FORMULARY Non-Formulary 01/15/2016 easy touch fliplock syringes syringe,safety with needle,10 ml REMOVE FROM FORMULARY Non-Formulary 01/15/2016 easy touch fliplock syringes syringe,safety with needle,10 ml REMOVE FROM FORMULARY Non-Formulary 01/15/2016 pampers swaddlers diaper/brief,infant-toddler, disposable REMOVE FROM FORMULARY Non-Formulary 01/15/2016 linktemp thermometer, infrared, noncontact REMOVE FROM FORMULARY Non-Formulary 01/15/2016 pyrazinamide pyrazinamide REMOVE FROM FORMULARY Non-Formulary 01/15/2016 easy comfort insulin syringe syringe with needle,disposable,insulin 1 ml ADD TO FORMULARY Generics 01/15/2016 freestyle precision neo blood sugar diagnostic REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 265 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/15/2016 freestyle precision neo blood sugar diagnostic REMOVE FROM FORMULARY Non-Formulary 01/15/2016 freestyle precision neo meter blood-glucose meter REMOVE FROM FORMULARY Non-Formulary 01/15/2016 ONE DAILY PLUS IRON multivitamin/ferrous fumarate/folic acid REMOVE FROM FORMULARY Non-Formulary 01/15/2016 b-100 complex vit b complex 100 combo no.2 REMOVE FROM FORMULARY Non-Formulary 01/15/2016 b-100 complex vit b complex 100 combo no.2 REMOVE FROM FORMULARY Non-Formulary 01/15/2016 calcium carbonate calcium carbonate REMOVE FROM FORMULARY Non-Formulary 01/15/2016 PENICILLIUM NOTATUM allergenic extract-penicillium notatum REMOVE FROM FORMULARY Non-Formulary 01/15/2016 PENICILLIUM NOTATUM allergenic extract-penicillium notatum REMOVE FROM FORMULARY Non-Formulary 01/15/2016 RHIZOPUS allergenic extract-rhizopus oryzae REMOVE FROM FORMULARY Non-Formulary 01/15/2016 NYATA nystatin/emollient combination no.88 ADD TO FORMULARY Non-Formulary 01/15/2016 PHOXILLUM phosphate hemodialysis solution no.2 without dextrose REMOVE FROM FORMULARY Non-Formulary 01/15/2016 PHOXILLUM phosphate hemodialysis solution no.3 without ca and dextrose REMOVE FROM FORMULARY Non-Formulary 01/15/2016 SALIVAMAX saliva substitute combination no.11 ADD TO FORMULARY Non-Formulary 01/15/2016 BRIDION sugammadex sodium REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 266 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/15/2016 lincomycin hcl lincomycin hcl REMOVE FROM FORMULARY 01/21/2015 EPIVIR HBV lamivudine 01/21/2015 CERENX citicoline sodium ADD TO FORMULARY Non-Formulary 01/21/2015 EMBEDA morphine sulfate/naltrexone hcl ADD TO FORMULARY Non-Formulary 01/21/2015 EMBEDA morphine sulfate/naltrexone hcl ADD TO FORMULARY Non-Formulary 01/21/2015 EMBEDA morphine sulfate/naltrexone hcl ADD TO FORMULARY Non-Formulary 01/21/2015 EMBEDA morphine sulfate/naltrexone hcl ADD TO FORMULARY Non-Formulary 01/21/2015 EMBEDA morphine sulfate/naltrexone hcl ADD TO FORMULARY Non-Formulary 01/21/2015 OBREDON guaifenesin/hydrocodone bitartrate ADD TO FORMULARY Non-Formulary 01/21/2015 SAVAYSA edoxaban tosylate ADD TO FORMULARY Non-Formulary 01/21/2015 SAVAYSA edoxaban tosylate ADD TO FORMULARY Non-Formulary 01/21/2015 SAVAYSA edoxaban tosylate ADD TO FORMULARY Non-Formulary 01/21/2016 MIRCERA methoxy polyethylene glycol-epoetin beta ADD UM: AUTHORIZATION PA applies 01/21/2016 MIRCERA methoxy polyethylene glycol-epoetin beta ADD UM: SPECIALTY Specialty Drug 01/21/2016 kitabis pak,tobramycin tobramycin/nebulizer ADD UM: SPECIALTY Specialty Drug 01/21/2016 tobi,tobramycin tobramycin in 0.225 % sodium chloride ADD UM: SPECIALTY Specialty Drug 01/21/2016 VENTAVIS iloprost tromethamine,iloprost ADD TO FORMULARY CHANGE TIER Non-Formulary Preferred Brands Non-Formulary Non-Formulary Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 267 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Preferred Brands 01/21/2016 SUTENT sunitinib malate ADD TO FORMULARY Non-Formulary 01/21/2016 SUTENT sunitinib malate REMOVE UM: SPECIALTY Specialty Drug 01/21/2016 SUTENT sunitinib malate ADD UM: QUANTITY 30 / 30 days 01/25/2016 antifungal cream tolnaftate REMOVE FROM FORMULARY Non-Formulary 01/25/2016 clindamycin phosphate clindamycin phosphate REMOVE FROM FORMULARY Non-Formulary 01/25/2016 tri-lo-marzia norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/25/2016 tri-lo-marzia norgestimate-ethinyl estradiol ADD TO FORMULARY Preventative 01/25/2016 kaitlib fe norethindrone-ethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 01/25/2016 kaitlib fe norethindrone-ethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 01/25/2016 imatinib mesylate imatinib mesylate ADD TO FORMULARY Generics 01/25/2016 easy touch fliplock syringes syringe,safety with needle,1 ml REMOVE FROM FORMULARY Non-Formulary 01/25/2016 fora d40 blood-glucose and blood pressure meter with adult cuff REMOVE FROM FORMULARY Non-Formulary 01/25/2016 fora d40-g31 test blood sugar diagnostic strips ADD TO FORMULARY Non-Formulary 01/25/2016 CHILDREN'S DELSYM COUGH dextromethorphan polistirex REMOVE FROM FORMULARY Non-Formulary 01/25/2016 mucus relief dm max guaifenesin/dextromethorph an hbr REMOVE FROM FORMULARY Non-Formulary 01/25/2016 NUFERA iron,carbonyl/folate combo no.9/vit c/vit d3/vit b6/vit b12 ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 268 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 01/25/2016 DYANAVEL XR 01/25/2016 Generic Name amphetamine Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary imatinib mesylate imatinib mesylate ADD TO FORMULARY Generics 01/25/2016 imatinib mesylate imatinib mesylate CHANGE TIER 01/25/2016 tri-lo-marzia norgestimate-ethinyl estradiol 01/25/2016 freestyle precision neo blood sugar diagnostic 01/25/2016 virt-nate dha prenatal vitamins no.11/ferrous fumarate/folic acid/omega-3 01/26/2015 ARAVA 01/26/2015 Generics Not Covered ADD UM: GENDER Female ADD UM: QUANTITY 100 / 30 days ADD UM: GENDER Female leflunomide ADD UM: SPECIALTY Specialty Drug ARAVA leflunomide ADD UM: SPECIALTY Specialty Drug 01/27/2015 pain relief capsaicin/menthol ADD TO FORMULARY Generics 01/27/2015 amantadine amantadine hcl CHANGE TIER Generics 01/27/2015 isosource 1.5 cal,resource with fiber,isosource 1.5 cal tube feed,ensure with fiber,promote with fiber,jevity 1.2 cal lactose-reduced food/fiber,lactose-free food/fiber,nutritional supplement/fiber ADD TO FORMULARY Non-Formulary 01/27/2015 GRAFIX CORE human regenerative tissue matrix ADD TO FORMULARY Non-Formulary 01/27/2015 GRAFIX PRIME human regenerative tissue matrix ADD TO FORMULARY Non-Formulary 01/27/2015 GRAFIX PRIME human regenerative tissue matrix ADD TO FORMULARY Non-Formulary 01/27/2015 GRAFIX CORE human regenerative tissue matrix ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 269 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/27/2015 NEULASTA pegfilgrastim ADD TO FORMULARY Preferred Brands 01/27/2015 NEULASTA pegfilgrastim ADD UM: AUTHORIZATION PA applies 01/27/2015 ONEXTON clindamycin phosphate/benzoyl peroxide ADD TO FORMULARY Non-Formulary 01/27/2015 ADAZIN lidocaine hcl/benzocaine/methyl salicylate/capsaicin ADD TO FORMULARY Non-Formulary 01/27/2015 RYTARY carbidopa/levodopa ADD TO FORMULARY Non-Formulary 01/27/2015 RYTARY carbidopa/levodopa ADD TO FORMULARY Non-Formulary 01/27/2015 RYTARY carbidopa/levodopa ADD TO FORMULARY Non-Formulary 01/27/2015 RYTARY carbidopa/levodopa ADD TO FORMULARY Non-Formulary 01/27/2015 SCAR lidocaine/allantoin/petrolatu m,white ADD TO FORMULARY Non-Formulary 01/27/2016 COAGADEX coagulation factor x ADD TO FORMULARY Non-Formulary 01/27/2016 COAGADEX coagulation factor x ADD TO FORMULARY Non-Formulary 01/27/2016 NINLARO ixazomib citrate ADD UM: AUTHORIZATION PA applies 01/27/2016 gleevec,imatinib mesylate imatinib mesylate CHANGE TIER Generics 01/27/2016 gleevec,imatinib mesylate imatinib mesylate CHANGE UM: SPECIALTY Specialty Drug 01/27/2016 imatinib mesylate imatinib mesylate CHANGE TIER 01/27/2016 imatinib mesylate imatinib mesylate ADD UM: AUTHORIZATION PA applies 01/27/2016 imatinib mesylate imatinib mesylate ADD UM: SPECIALTY Specialty Drug 01/27/2016 GLEEVEC imatinib mesylate CHANGE TIER Preferred Brands Non-Formulary 01/27/2016 GLEEVEC imatinib mesylate CHANGE TIER Preferred Brands Non-Formulary 01/27/2016 imatinib mesylate imatinib mesylate ADD UM: AUTHORIZATION PA applies 01/27/2016 ALECENSA ADD UM: AUTHORIZATION PA applies alectinib hcl Not Covered Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 270 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/27/2016 ALECENSA alectinib hcl 01/27/2016 TAGRISSO 01/27/2016 Type of Change Previous Value New Value ADD UM: SPECIALTY Specialty Drug osimertinib mesylate ADD UM: AUTHORIZATION PA applies COTELLIC cobimetinib fumarate ADD UM: AUTHORIZATION PA applies 01/27/2016 COTELLIC cobimetinib fumarate ADD UM: SPECIALTY Specialty Drug 01/27/2016 STRENSIQ asfotase alfa ADD UM: AUTHORIZATION PA applies 01/27/2016 STRENSIQ asfotase alfa ADD UM: SPECIALTY Specialty Drug 01/30/2016 XYNTHA SOLOFUSE antihemophilic factor (factor viii) recomb,b-domain deleted REMOVE FROM FORMULARY Non-Formulary 01/30/2016 XYNTHA SOLOFUSE antihemophilic factor (factor viii) recomb,b-domain deleted REMOVE FROM FORMULARY Non-Formulary 01/30/2016 XYNTHA SOLOFUSE antihemophilic factor (factor viii) recomb,b-domain deleted REMOVE FROM FORMULARY Non-Formulary 01/30/2016 XYNTHA SOLOFUSE antihemophilic factor (factor viii) recomb,b-domain deleted REMOVE FROM FORMULARY Non-Formulary 01/30/2016 XYNTHA SOLOFUSE antihemophilic factor (factor viii) recomb,b-domain deleted REMOVE FROM FORMULARY Non-Formulary 01/30/2016 tegaderm + pad adhesive bandage REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock needle needles, safety REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock needle needles, safety REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock needle needles, safety REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 271 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/30/2016 easy touch fliplock needle needles, safety REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock needle needles, safety REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock needles needles, safety REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock needle needles, safety REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock needles needles, safety REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock needle needles, safety REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock needles needles, safety REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringes syringe,safety with needle,1 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringes syringe,safety with needle,3 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringes syringe,safety with needle,3 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringe syringe,safety with needle,3 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringe syringe,safety with needle,3 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringe syringe,safety with needle,3 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringe syringe,safety with needle,3 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringes syringe,safety with needle,5 ml REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 272 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/30/2016 easy touch fliplock syringe syringe,safety with needle,5 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringe syringe,safety with needle,5 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringe syringe,safety with needle,10 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringe syringe,safety with needle,10 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringes syringe,safety with needle,10 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringes syringe,safety with needle,10 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringes syringe,safety with needle,10 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringes syringe,safety with needle,10 ml REMOVE FROM FORMULARY Non-Formulary 01/30/2016 advanced healing hydrocolloid dressing bandage REMOVE FROM FORMULARY Non-Formulary 01/30/2016 easy touch fliplock syringe REMOVE FROM FORMULARY Non-Formulary 01/30/2016 advanced healing hydrocolloid dressing pad REMOVE FROM FORMULARY Non-Formulary 01/30/2016 itraconazole micronized itraconazole, micronized REMOVE FROM FORMULARY Non-Formulary 01/30/2016 polyoxyl 40 stearate nf polyoxyl 40 stearate REMOVE FROM FORMULARY Non-Formulary 01/30/2016 potassium chlorate potassium chlorate REMOVE FROM FORMULARY Non-Formulary 01/30/2016 vacustim black foam/gauze bandage/lidocaine/chlorhexi dine/isopropyl alcohol REMOVE FROM FORMULARY Non-Formulary syringe,safety with needle,3 ml BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 273 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/30/2016 CALADRYL pramoxine hcl/calamine REMOVE FROM FORMULARY Non-Formulary 01/30/2016 DURAPREP iodine povacrylex/isopropyl alcohol REMOVE FROM FORMULARY Non-Formulary 01/30/2016 DURAPREP iodine povacrylex/isopropyl alcohol REMOVE FROM FORMULARY Non-Formulary 01/30/2016 MOVE FREE JOINT HEALTH glucosamine/chondroitin/hya luronic acid/calcium fructoborate REMOVE FROM FORMULARY Non-Formulary 01/30/2016 3-DAY VAGINAL clotrimazole CREAM REMOVE FROM FORMULARY Non-Formulary 01/30/2016 despec dm-g guaifenesin/dextromethorph an hbr/phenylephrine REMOVE FROM FORMULARY Non-Formulary 01/30/2016 24 hour allergy relief fluticasone propionate REMOVE FROM FORMULARY Non-Formulary 01/30/2016 nac acetylcysteine REMOVE FROM FORMULARY Non-Formulary 01/30/2016 glucosamine daily complex glucosamine hcl/d3/boswellia serrata REMOVE FROM FORMULARY Non-Formulary 01/30/2016 melatonin melatonin REMOVE FROM FORMULARY Non-Formulary 01/30/2016 advanced exfoliating cleanser benzoyl peroxide REMOVE FROM FORMULARY Non-Formulary 01/30/2016 guaifenesin er guaifenesin REMOVE FROM FORMULARY Non-Formulary 01/30/2016 biotin biotin REMOVE FROM FORMULARY Non-Formulary 01/30/2016 benzoyl peroxide benzoyl peroxide REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 274 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 01/30/2016 benzoyl peroxide benzoyl peroxide REMOVE FROM FORMULARY Non-Formulary 01/30/2016 STANDARDIZED allergenic extract,grass TIMOTHY pollen-timothy,standard GRASS REMOVE FROM FORMULARY Non-Formulary 01/30/2016 STANDARDIZED allergenic extract, grass ORCHARD pollen-orchard grass, GRASS standard REMOVE FROM FORMULARY Non-Formulary 01/30/2016 STANDARDIZED allergenic extract,grass JUNE GRASS pollen-june(kentucky POLLEN blue),standard REMOVE FROM FORMULARY Non-Formulary 01/30/2016 ALTERNARIA REMOVE FROM FORMULARY Non-Formulary 01/30/2016 CLADOSPORIU allergenic extractM cladosporium SPHAEROSPER sphaerospermum MUM REMOVE FROM FORMULARY Non-Formulary 01/30/2016 SACCHAROMYC allergenic extractES CEREVISIAE saccharomyces cerevisiae REMOVE FROM FORMULARY Non-Formulary 01/30/2016 DS PREP PAK ADD TO FORMULARY Non-Formulary 01/30/2016 QUILLICHEW ER methylphenidate hcl ADD TO FORMULARY Non-Formulary 01/30/2016 QUILLICHEW ER methylphenidate hcl ADD TO FORMULARY Non-Formulary 01/30/2016 QUILLICHEW ER methylphenidate hcl ADD TO FORMULARY Non-Formulary 01/30/2016 KOSHER PRENATAL PLUS IRON prenatal vitamins combo no.108/iron,carbonyl/folic acid ADD TO FORMULARY Non-Formulary 01/30/2016 KOSHER PRENATAL PLUS IRON prenatal vitamins combo no.108/iron,carbonyl/folic acid ADD TO FORMULARY Non-Formulary allergenic extract-alternaria alternata diclofenac sodium/benzalkonium chloride BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 275 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 01/30/2016 morphine sulfate morphine sulfate/pf 01/30/2016 EVICEL thrombin(human plasma der)/fibrinogen/calcium chloride 01/30/2016 easy touch fliplock syringe syringe,safety with needle,3 ml Type of Change Previous Value New Value REMOVE FROM FORMULARY Non-Formulary ADD TO FORMULARY Generics REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 276 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates February, 2016 Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/01/2016 COATS ALOE aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 02/01/2016 COATS ALOE MOISTURIZING aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 02/01/2016 COATS ALOE MOISTURIZING aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 02/01/2016 COATS ALOE aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 02/01/2016 COATS ALOE aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 02/01/2016 COATS ALOE aloe vera extract/allantoin REMOVE FROM FORMULARY Non-Formulary 02/01/2016 QUILLICHEW ER methylphenidate hcl ADD UM: QUANTITY 30 / 30 days 02/01/2016 QUILLICHEW ER methylphenidate hcl ADD UM: QUANTITY 60 / 30 days 02/01/2016 QUILLICHEW ER methylphenidate hcl ADD UM: QUANTITY 30 / 30 days 02/01/2016 KOSHER PRENATAL PLUS IRON prenatal vitamins combo no.108/iron,carbonyl/folic acid ADD UM: GENDER Female 02/02/2015 HARVONI ledipasvir/sofosbuvir ADD TO FORMULARY Non-Formulary 02/02/2015 HARVONI ledipasvir/sofosbuvir REMOVE UM: AUTHORIZATION PA applies 02/02/2015 VIEKIRA PAK ombitasvir/paritaprevir/ritona vir/dasabuvir sodium ADD TO FORMULARY Non-Formulary 02/02/2015 VIEKIRA PAK ombitasvir/paritaprevir/ritona vir/dasabuvir sodium REMOVE UM: AUTHORIZATION PA applies 02/02/2015 GLEOSTINE lomustine ADD TO FORMULARY Non-Formulary 02/02/2015 GLEOSTINE lomustine ADD TO FORMULARY Non-Formulary Preferred Brands Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 277 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/02/2015 GLEOSTINE lomustine ADD TO FORMULARY Non-Formulary 02/02/2015 gildess 24 fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 02/02/2015 LOESTRIN 24 FE norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE TIER 02/02/2015 gildess 24 fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 02/02/2015 lamotrigine odt lamotrigine ADD TO FORMULARY Generics 02/02/2015 NEPTAZANE methazolamide ADD TO FORMULARY Generics 02/02/2015 PAIN RELIEF lidocaine hcl/menthol ADD TO FORMULARY Non-Formulary 02/02/2015 EVEKEO amphetamine sulfate ADD TO FORMULARY Non-Formulary 02/02/2015 EVEKEO amphetamine sulfate ADD TO FORMULARY Non-Formulary 02/02/2015 OCUVEL folic acid/vit c/vit e/zinc/cupric oxide/lutein/zeaxanthin ADD TO FORMULARY Non-Formulary 02/02/2015 VITEKTA elvitegravir ADD TO FORMULARY Non-Formulary 02/02/2015 VITEKTA elvitegravir ADD TO FORMULARY Non-Formulary 02/02/2015 lamotrigine odt lamotrigine ADD TO FORMULARY Non-Formulary 02/03/2015 NEULASTA pegfilgrastim ADD UM: SPECIALTY Specialty Drug 02/06/2016 GARDASIL human papillomavirus vaccine, quadrivalent/pf REMOVE FROM FORMULARY Non-Formulary 02/06/2016 urogesicblue,uryl,uroblue,urolet mb,me-naphosmb-hyo 1 methenamine/sodium phosphate,monobasic/meth blue/hyosc sul ADD TO FORMULARY Generics Preventative Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 278 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/06/2016 naftin,naftifine hcl naftifine hcl ADD TO FORMULARY Generics 02/06/2016 COubiquinol/mecobalamin/folic VERATROL,CO- acid/resveratrol BALAMIN ADD TO FORMULARY Generics 02/06/2016 cyclobenzaprine hcl cyclobenzaprine hcl REMOVE FROM FORMULARY Non-Formulary 02/06/2016 glumetza,metfor min hcl er metformin hcl ADD TO FORMULARY Generics 02/06/2016 delsym,cough dm dextromethorphan er,dextromethorp polistirex,dextromethorphan han hbr polistirex,children' s cough dm er,children's delsym cough REMOVE FROM FORMULARY Non-Formulary 02/06/2016 ultracin m menthol REMOVE FROM FORMULARY Non-Formulary 02/06/2016 BENEFIBER wheat dextrin REMOVE FROM FORMULARY Non-Formulary 02/06/2016 GLYTACTIN 10 PE COMPLETE nutritional therapy for pku no.62 REMOVE FROM FORMULARY Non-Formulary 02/06/2016 black cohosh black cohosh root extract,black cohosh REMOVE FROM FORMULARY Non-Formulary 02/06/2016 mucinex guaifenesin/pseudoephedrin d,guaifenesine hcl pseudoephedrine er REMOVE FROM FORMULARY Non-Formulary 02/06/2016 STANDARDIZED allergenic extract,grass RED TOP pollen-redtop, standard GRASS REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 279 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/06/2016 STANDARDIZED allergenic extract-grass MEADOW pollen-meadow fescue, FESCUE standardized REMOVE FROM FORMULARY Non-Formulary 02/06/2016 FUSARIUM allergenic extract-fusarium oxysporum REMOVE FROM FORMULARY Non-Formulary 02/06/2016 ACREMONIUM allergenic extractacremonium strictum REMOVE FROM FORMULARY Non-Formulary 02/06/2016 XEOMIN incobotulinumtoxina REMOVE FROM FORMULARY Non-Formulary 02/06/2016 ZEPATIER elbasvir/grazoprevir ADD TO FORMULARY Non-Formulary 02/06/2016 TICANASE fluticasone propionate/sodium chloride/sodium bicarbonate ADD TO FORMULARY Non-Formulary 02/06/2016 neurontin,gabape gabapentin ntin ADD TO FORMULARY Generics 02/06/2016 hydrochlorothiazi hydrochlorothiazide de CHANGE TIER Generics 02/06/2016 adalat cc,nifedipine er,nifediac cc,afeditab cr,nifedipine nifedipine ADD TO FORMULARY Generics 02/06/2016 adalat cc,nifediac nifedipine cc,nifedipine er,afeditab cr,nifedipine ADD TO FORMULARY Generics 02/06/2016 labetalol hcl,trandate CHANGE TIER Generics 02/06/2016 valium,diazepam diazepam ADD TO FORMULARY Generics 02/06/2016 labetalol labetalol hcl hcl,trandate,norm odyne CHANGE TIER Generics labetalol hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 280 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/06/2016 oxycodoneoxycodone acetaminophen,p hcl/acetaminophen ercocet,endocet CHANGE TIER Generics 02/06/2016 oxycodoneoxycodone acetaminophen,o hcl/acetaminophen xycodone hclacetaminophen,p ercocet,endocet CHANGE TIER Generics 02/06/2016 remeron,mirtazap mirtazapine ine ADD TO FORMULARY Generics 02/06/2016 depakene,valproi valproic acid c acid ADD TO FORMULARY Generics 02/06/2016 metoprolol tartrate CHANGE TIER Generics 02/06/2016 oxybutynin oxybutynin chloride chloride,oxybutyn in chloride er,ditropan CHANGE TIER Generics 02/06/2016 lopressor,metopr metoprolol tartrate olol tartrate ADD TO FORMULARY Generics 02/06/2016 carbamazepine er,carbatrol CHANGE TIER Generics 02/06/2016 lopressor,metopr metoprolol tartrate olol tartrate ADD TO FORMULARY Generics 02/06/2016 anastrozole,arimi anastrozole dex CHANGE TIER Generics 02/06/2016 baraclude,enteca entecavir vir ADD TO FORMULARY Generics 02/06/2016 baraclude,enteca entecavir vir ADD TO FORMULARY Generics metoprolol tartrate carbamazepine BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 281 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/06/2016 vsl#3,visbiome lactobacillus combination no.2/s.thermophl/bif cmb no.1,lactobacillus no.2/s.thermophilus/bifidoba cterium no.1 ADD TO FORMULARY Generics 02/06/2016 vsl#3,visbiome lactobacillus combination no.2/s.thermophl/bif cmb no.1,lactobacillus no.2/s.thermophilus/bifidoba cterium no.1 ADD TO FORMULARY Not Covered 02/06/2016 abilify,aripiprazol aripiprazole e ADD TO FORMULARY Generics 02/06/2016 gianvi,loryna,yaz, ethinyl vestura,nikki,dros estradiol/drospirenone pirenone-ethinyl estradiol CHANGE TIER Preventative 02/06/2016 naproxen sodium,aleve REMOVE FROM FORMULARY Non-Formulary 02/06/2016 camrese,seasoni levonorgestrel/ethinyl que,amethia,days estradiol and ethinyl ee,ashlyna,levon estradiol org-eth estrad eth estrad CHANGE TIER Preventative 02/06/2016 enfamil infant formula with newborn,tugaboo iron/docosahexanoic premium infant acid/arachidonic ac formula,premium infant formula,enfamil newborn nongmo REMOVE FROM FORMULARY Non-Formulary 02/06/2016 diprolene betamethasone af,betamethason dipropionate/propylene e dipropionate glycol ADD TO FORMULARY Generics naproxen sodium BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 282 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/06/2016 flonase allergy fluticasone propionate relief,fluticasone propionate,24 hour allergy relief,children's flonase allergy rlf ADD TO FORMULARY Generics 02/06/2016 dermacinrx dimethyl sulfoxide/ethyl topical,dermacinr alcohol/glycerin x tss,tdm REMOVE FROM FORMULARY Non-Formulary 02/06/2016 imdur,isosorbide isosorbide mononitrate mononitrate er,isosorbide mononitrate ADD TO FORMULARY Generics 02/06/2016 imdur,isosorbide isosorbide mononitrate mononitrate er,isosorbide mononitrate ADD TO FORMULARY Generics 02/06/2016 erythromycin,eryt erythromycin hromycin base,erythromycin stearate stearate CHANGE TIER Generics 02/06/2016 XAQUIL XR REMOVE FROM FORMULARY Non-Formulary 02/06/2016 clarithromycin,bia clarithromycin xin CHANGE TIER Generics 02/06/2016 clarithromycin,bia clarithromycin xin CHANGE TIER Generics 02/06/2016 analpram hydrocortisone hc,hydrocortisone acetate/pramoxine hcl -pramoxine ADD TO FORMULARY Generics methyltetrahydrofolate glucosamine BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 283 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/06/2016 tylenol pm extra acetaminophen/diphenhydra strength,headach mine hcl,simethicone e pm,pain relief pm,pain reliever pm,acetaminoph en pm xtra strength,acetami nophen pm,acetaminoph endiphenhydramine ,mapap pm,nonaspirin pm exstrength,nonaspirin pm,pain & sleep,pm pain relief,non-aspirin sleep aid,acetadryl,hea dache pm formula,gas relief,meditabs,medi-tabs pm,wal-nadol pm,tylenol cold relief,pain medicine,acetami nophen-sleep aid pm,night time pain medicine,eazzze the pain REMOVE FROM FORMULARY Non-Formulary 02/06/2016 amantadine hcl REMOVE FROM FORMULARY Non-Formulary 02/06/2016 estriol estriol micronized micronized,estriol REMOVE FROM FORMULARY Non-Formulary amantadine hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 284 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change 02/06/2016 humapen memoir,humapen luxura hd,adriaoncoline,triaminic flowing vapors,unisol 4 preservative free,ortho allflex,optifree,soaclens,sys tane contacts,clerz plus,opti-free replenish,irrigatio n administration set,schirmer tear test,opti-free express,secondar y set,spinal-22 wbupiv-epiephed,spinal anesthesia tray,ivex-rf filter set,evacuated container,ls plum primary setol,plumset primary setol,dial-a-flo iv extension set,dial-a-flo microdrip set,venoset secondary,soluse t with cair clamp,transfer set,decanting set,nonvented iv set 100 w- insulin admin. supplies,iv equipment,vaporizer,soft lens rinse-store solution,diaphragms, arcspring,diaphragm fitting set,arc-spring,gas permeable lens cleaner,hard lens clean-soak solution,wetting soln gas,hard and soft,soft lens adjunctive solutions,irrigation set,tear test,iv piggyback adminstration set,anesthesia tray,iv administration setfilter,container,empty,iv administration set,iv admin extension set-filter,iv admin extension set,iv administration setclamp,transfer sets,iv infusion pump accessory,blood administration set,iv administration set,nonvent,hyperalimentation equipment,miscellaneous medical supply,iv catheter kit,nerve stimulator device,blood administration equipment,iv infusion pump,in-line burette set,procedural tray,iv venipuncture needle set,iv catheter,dialysis (peritoneal) kits,blood collection set,vial,empty,feeder container with pump set,irrigation piercing pin REMOVE FROM FORMULARY Previous Value New Value Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 285 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name clamp,nitroglyceri n patient line,soluset 150x15 i.v. setsl,screw cap set,iv pump setivex-hp,blood ytype pump set,hema blood secondary pump,venoset piggyback,air filter,extension set with stopcock,anesthe sia extension set,syringe filter,cvp universal set,blood set,backcheck extension set,venoset with cair clamp,nonvented primary pg-bk wcair,blood set 78sl, y-type,blood set 82-sl,venoset t-type w-cair clamp,venoset secondary piggybk set,venoset sec piggyback,nutrimi x,abbott counting tray,cont epidural w-bupiv-epi,veniprep ii kit,veni- set,nv,calamine/zinc gelatin,inhaler, assist devices,inhaler, assist devices, accessories,facialbody sponge,n95 respirator, disposable,pen needle, diabetic,pen needle, diabetic, safety,syringe accessory,syr biopsyaspiration reusable,gloves,bloodglucose meter, disctype,blood glucose calibration control solution, normal,blood glucose calibration control solution, low,blood glucose calibration control solution, high,blood glucose calibration control high and low,lancets,lancing device,lancing device/lancets,bloodglucose meter,bloodglucose meter, wireless,jejunostomy tube,gastrostomy tube,dental plaque indicator,needleless dispensing pin,diaphragms, wide seal,heating pad,adhesive remover,gum mastic/storax/methyl salicylate/alcohol,syringe with needle,disposable,insulin 1 ml,syringe with needle,insulin,0.5 ml,condoms, latex, Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 286 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name prep iii-site-care dresng,ivex-2 filterset with ysite,veni-prep i kit,reliefband,twoway transfer device,venoset 78 w-mb piercing pin,hema access port,extension set,three-way stopcock ext 20in-sl,three-way stopcock ext 36,three-way stopcock,threeway stopcock wluer lock,threeway stopcock ext 20-sl,lifecare plum set,pca mini-bore set,pharmacy additive transfer set,y-type connecting set,extension set int-sl,brachial plexus tray,in-line burette set,venoset 78 wivex-2 nonvented,amnio centesis tray,4 leg vented transfer set,4 leg nonvented transfer set,3 leg vented transfer lubricated,activated charcoal/iron/sodium/water,s uppository mold,breast shield,adhesive,silver na hydrogen zirconium phos/hydrocolloid heel dressing,silver na hydrogen zirconium phos/hydrocolloid toe dressing,silver na hydrogen zircon phos/hydrocolloid heel&toe/cream59,nasal airflow strips,ear syringe,denture cleanser,adhesive tape,transparent dressing,facial mask,elastic bandage,pads for bedsores,nebulizer,peak flow meter/inhaler, assist devices,peak flow meter,condoms, latex, nonlubricated,sanitary pads,incontinence pad,liner,disp,ostomy supply,catheter,syringe disposable, irrigation,70 ml,urinary bag,urinary bag accessories,catheter male,external,drainage bag,gel dressing,catheterization tray,syringe disposable irrigation,colostomy bags,foam bandage,gauze bandage/elastic bandage,non-adherent bandage,ostomy adhesive,alginate Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 287 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name set,nutrimix iv empty container,extensi on tube,butterfly infusion set,platelet concentrate infusion,ivex h.p. filterset,s-a-i-f set 1 micron,clearcath,20g,2 in,clearcath,16g,1-1/4 in,clearcath,clearcath(subclav),abb ocath-t,abbocatht with syringe,butterfly,e xtension setlocking luer t,thoracentesis set,blood warming coil,y connector,inpers ol peritoneal cath. 11fr,blood collection set,doubleneedle transfer device,cont epidural wlidocaineepi,additive hinge cap,lifecare additive cap,male adapter plug,sterile empty vial,quik lok luer dressing,hydrocolloid dressing,zinc oxide,adhesive bandage,gauze bandage,syringe, disposable, 60 ml,syringe with needle,disposable, 3 ml,ostomy kit,syringe, disposable, 1 ml,underpads,diaper,brief,ad ult, disposable,syringe, disposable, 140 ml,syringe w-needle,disposab,1 ml,undercast padding,facialbody wipes,enema bag, disposable,wadding,syringe, disposable, 20 ml,syringe, disposable, 12 ml,needles, blood collection,syringe with needle, 12 ml,polyhexamethylene biguanide/gauze bandage,feeder container,eye patch,syringe, disposable, 3 ml,surgical suction tubing,compression stocking,thigh high,regular length,small,compression stocking,thigh high,short length,small,compression stocking,thigh high,regular length,medium,compression stocking,thigh high,regular length,large,compression stocking,thigh high,long length,small,compression stocking,thigh high,regular length,x-small,compression stocking,thigh high,short Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 288 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name lock adapter,sterile empty vial& injector,nv cardiac catheter set,microbore extension setsl,manifold 111sl,plum lc 5000 enteral set,pca extension set,pca set-long mini bore ol,pca cont inf mini-bore,pca set-cont inf mini bore ol,access set,catheter wcair clamp nonvent,cystomanom eter set,secondary irrigation set,t-u-r system w-flow pouch 2000,nonvented t-u-r set,cystoscopyirrigation set,nv large bore yirrigation set,pentothal dispensing pin,empty 3-in-1 mixing container,nutrimix -macro ferrules,ferrules,n utriclamp,container length, medium,compression stocking,thigh high,long length,x-small,wet dressing,compression stocking,thigh high,long length,medium,compression stocking,thigh high,long length,large,compression stocking,thigh high,short length,large,compression stocking,thigh high,regular length,x-large,compression stocking,thigh high,long length,xlarge,petrolatum,white,comp ression stocking, knee high, regular length, small,compression stocking, knee high, regular length, medium,compression stocking, knee high, regular length, large,compression stocking, knee high, regular length, x-large,compression stocking, knee high, long length, small,compression stocking, knee high, long length, medium,compression stocking, knee high,long length, large,compression stocking, knee high, long length, x-large,bismuth tribromophenate/petrolatum, white,syringe, disposable, 35 ml,syringe wneedle,disposb,0.5ml,syring e, disposable, 6 ml,syringe Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 289 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name with ytransfer,lifecare flex container,lifecare flex container 1000ml,adi sterile empty vial,snap lock device,veni loop connector,venose t 100-sl piggyback nv,burette 100ml hemoset nv,blood set w-pumpsl,pediatric microaggr blood filt,hema blood set,hema y-type blood set,microdrip micro pump setfiltr,soluset iv micro pump set,lifecare 5000 secondary cntnr,plum lc 5000 minipole,domepaste bandage,inspirea se,buf bodymate,actiprotect uf,novofine 32,novopen 3,novofine,novop en jr,innovo,novofine w-needle,disposab,6 ml,swab,syringe disposable irrig,60 ml,burn dressing,diaper/brief,infanttoddler, disposable,diaper,brief,yout h,disposable,feeder container w-gravity set,nasogastric tube,iodoform,needles, disposable,urinary bag/catheterization tray,calcium alginate,dressing, hydropolymer,porcine acell submucosa,meshed,porcine submucosa, fenestrated,peripheral nerve diagnostic device,nerve test monofilament,diabetic supplies,miscell,vacuum erection device system,penile constriction ring systm,needles, insulin disposable,neurological exam pin,syringe, needle, safety,self-contained disposal unit,1.5 ml,syringe with needle, insulin,1 ml and sharps container,syring wndl,disp,insul,0.3 ml/container,empty,syringeneedle,insulin,0.5 ml/container,empty,syringe with needle,insulin,0.3 ml,syringe with needle,insulin disposable,0.3 ml,syringe, disposable, 5 ml,syringe, Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 290 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name autocover,novotw ist,nordipen 5,nordipen 15,astra selfaspirating dental,cartridge dispenser dental,astrapro,br eeze 2,autodisc normal,ascensia autodisc,fingersti x,glucolet 2,contour link,didget,contou r next link,microlet,singl e-let,microlet 2,contour,contour next ez,contour next control solution,contour next,contour usb,contour next usb,compat gravity delivery set,compat enteral delivery pump,vivonex jejunostomy kit,compat,compa t select flo pump,compat container wpump set,compat select flo case,compat select flo baggle cage,compat yset,iv disposable, 10 ml,syringe, disposable, 30 ml,syringe, disposable, 50 ml,needles, safety huber, disposable,needles, huber disposable,needles, reusable,needles, huber reuse,needles, spinalanesthetic,needles, biopsy,bone,aspirate,syringe reusable, 0.25 ml,syringe reusable, 1 ml,syringe reusable, 2 ml,syringe reusable, 5 ml,syringe reusable, 10 ml,syringe reusable, 20 ml,syringe reusable, 30 ml,syringe reusable, 50 ml,syringe reusable, 3 ml,syringe reusable,syring w-needl 0.5 ml,kit-tray,syringe with needle 1 ml, disposable kittray,syringe with needle, 0.5 ml,syringe, irrigation, reusable,iv catheter kit accessory,syringe wcannula,disp, 3 ml,syringe w-cannula, disp, 5 ml,syringe w-cannula,disp, 10 ml,syringe with needle/cannula,disposable 10 ml,blunt needle, disposable,needles, filter,oral dosing devices,syringe, disposable, 2.5 ml,syringe,safety with needle,3 ml,syringe,safety with needle,1 ml,syringe,safety with Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 291 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name administration set,solution transfer device,beutlich ph test,hurricaine dispenser,hurrivie w,hurricaine luerlock,hurriview ii,hurricaine spry extension tube,pro-ception fertility pak,wide seal diaphragm,liqua spen,precise pain relieving,aerocha mber plus flowvu,detachol adhesive remover,mastisol, mastisol adhesive,boules quies earplugs,insulin syringe,ultra comfort,easytouch insulin syringe,condoms, thermacare,pump for liquagel,suppository mold,o-calette,pedi-skin adherent #2,pedipre,pedi-pre tape spray,hydro armor ag,hydro armor ag blister care,e-z ject needle,5 ml,syringe,safety with needle,10 ml,needles, safety,syringe with needle, 10 ml,syringe w-o needl,insulin,1 ml,syringe wneedle,disposab,5 ml,syringe with needle,insulin 0.3 ml (half unit mark),needle clipping and storage device,syringe with needle,insulin disposable,0.5 ml,needles, insulin disposable, safety,pen needle, diabetic disposable, safety,blade lancet, safety,thermometer, glass mercury (oral),thermometer, glass mercury (rectal),iv catheter kit/iv catheter kit accessory,myelogram tray,pregnancy test kit,syringe with needle, insulin, safety, 1 ml,syringe with needle, insulin, safety, 0.5 ml,blood glucose calibration control solution, high and normal,bloodglucose calib. control,ringers solution,lactated/gel dressing,silver,dressing, odor absorbent, hydropolymer,mucus clearing device,compressor, for nebulizer,nebulizer/compres sor, for nebulizer,nebulizer accessories,spirometers and accessories,ostomy Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 292 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name lancets,major comfort,nasal strips,ear syringe,denture cleanser,micropo re first aid paper,micropore first aid skintone,micropor e first aid plastic,micropore first aid waterproof,micro pore first aid cloth,tegaderm,m icropore air wrming fltr mask,micropore pollen filter mask,micropore germ filter mask,coban,resto n,durex avanti bare,aeroeclipse ii,aerotrach plus,aerochambe r z-stat plus,aerochambe r with flowsignal,aeroge ar asthma action kit,truzone peak flow meter,aerochamb er mv,aerochamber mini,relion prime,relion confirm,trustex cap,colostomy washer,colostomy belt,ostomy disinfectant,karaya gum,urostomy pouch,colostomy bag, nonsterile,colostomy-ileostomy sets, non-sterile,colostomyileostomy sets, sterile,urostomy sets, nonsterile,urostomy sets, sterile,ostomy lubricating deodorant,condoms, female,sub-q administration set,sub-q infusion pump accessory,cervical cap,biosynthetic bandage,biosynthetic glove,syring wndl,disp,insul,0.5 ml/container,empty,ovulation test kit,blood-glucose meter & wrist blood pressure monitor,insulin pump cartridge,subcutaneous insulin pump,injection ports,insulin pump syringe, 3 ml,insulin pump syringe, 1.8 ml,blood ketone test,strips,blood glucose and ketone control, normal,sub-q insulin delivery device, 40 unit, disposable,sub-q insulin delivery device, 30 unit, disposable,sub-q insulin delivery device, 20 unit,disposable,middle ear inflation device,head support, infant, small,head Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 293 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name condom,trustexria,trustex latex condom,trustex,f antasy,stayfree surefit,stayfree maxipad,stayfree ultra thin,carefree panty shield,tena serenity,serenity ultra plus,drain,bardic adaptertubing,cunningha m incontinence clamp,catheter,fe male intermittent catheter,toomey syringe,urethral catheter,reliaseal disc,dispoz-a-bag leg bag small,dispoz-abag leg bag medium,dispoza-bag leg bag large,leg bag holder,uro sheath disposable bulk,bardic uro sheath vinyl,male external catheter,deluxe fabric leg straps,catheter strap holder,twosided adhesive strips,latex extension support, infant, medium,head support, infant, large,silver sulfate/non-adherent bandage,silver sulfate/foam bandage,foam heel dressing,dressing, foam matrix/activated charcoal,silver/calcium alginate,adhesive bandage/adhesive tape/benzalkonium chloride,adhesive bandage/adhesive remover comb. no.1,hydrocolloid dressing/adhesive remover comb. no.1,medical information identification tag,nasal exhalation resistance device,syringe, safety, self-contained disposal unit, 3 ml,syringe, safety, self-contained disposal unit, 5 ml,syringe,needle,insulin,saf ety,disposal unit,0.3 ml,insulin syringeneedle,safety,disposal unit,0.5 ml,syringe,needle,insulin,saf ety,disposal unit, 1 ml,syringe with needle, safety, self-cont disposal unit, 1 ml,syringe with needle, safety, self-cont disposal unit, 3 ml,syringe with needle, safety, self-cont disposal unit, 5 ml,syringe, safety, self-contained Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 294 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name tubing,latex leg straps,bard center entry close system,urinary drainage bag,infection control bag,leg bag straps,bardex silicone foley catheter,rubber utility catheter,cleancath,protective barrier film,adhesive remover wipes,vigilon wound dressing,irrigation tray,basic irrigation tray,urethral catheter tray,bardex urethral catheter tray,universal foley catheter tray,davol complete foley kit,davol urinary drainage bag,bardia urinary drainage bag,davol foley cath insert tray,davol universal catheter tray,davol clsd disposal unit, 10 ml,syringe,safety,disp unit,10 ml,conception assistance supplies combination no.1,bloodglucose transmitter,bloodglucose meter,continuous,bloodglucose sensor,bloodglucose meter,continuous/bloodglucose transmitter,syringe, disposable,syringe wcannula,disp, 1 ml,syringe w-cannula,disp, 6 ml,needles, pharmacy compound,syrng w-ndl,dsp kit-tray,0.5ml,syrng wndl,disp. kit-tray,1ml,syringe with needle,disposable,insulin,sy ringe wneedle,disposab,3ml,syringe wneedle,disposab,6ml,syringe ,safety with needle,12 ml,syringe with cannula,disposable 12 ml,syringe wneedle,disposable,syringe with needle, insulin, safety, 0.3 ml,feeder irrigation kit,yport adapter-extension set,pump set,calcium alginate/honey,soft lens surfactant cleanser,soft lens chemical disinfectnt,hard lens cleaner,gum/polyvinyl alcohol/dental Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 295 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name sys foley cath tray,davol irrigation syringe,davol irrigation tray,davol urethral catheter tray,davol silicone foley catheter,bardex closed system cath tray,infection control tray,bardex lubricath foley tray,extra colostomy pouch,stoma urine bag,extra security pouch,extra open-end drain,scanpor tape,opsite flexifix,allevyn,all evyn heel,profore,exudry,skin-bond cement,iv 3000,uni-solve adhes remover wipes,uni-solve adhesive remover,remove wipes,remove liquid,urikleen,skinprep,no sting skin prep,hypafix,opsit adhesive,dental adhesive,toothpaste,dental polishvarnishes,polymerized rosin resin,ovulation and pregnancy test kit,sodium chloride,thermometer probe covers,thermometer, electronic,oral,corn/callus cushion,dental floss,syringe w/needle,insulin disposable 0.3 ml (half unit mark),toothbrush,thermomet er, tape,ostomy accessories, filters and bridges,ice bag,cold-hot pack,finger splint,dental gingival products,hot water bottle,fountain syringes applicator,footcare,miscellan eous,thermometer, electronic,otic,hearing aid accessory,gloves, latex,blood pressure test kitmedium,blood pressure test kit,ear plugs,contact lens case,thermometer, basal electronic,tubular gauze/tub.rubbr dressing protector,blood pressure test kit-wrist,incontinence pants, reusable,blood pressure test kit medium and large cuffs,walker,silicone adhesive,infusion set for insulin pump,pharmacy dispensing adm set,pharmacy compounding access.,catheter Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 296 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name e postop,solosite,opsite flexigrid dressing,algisite m,transigel,replic are,viscopaste pb7,opsite adhesive dressing,flexigel, cicacare,primapore iv,primapore,covr site,covrsite plus,intrasite,alle vyn cavity dressing,allevyn tracheostomy dressing,unlabele d refill bottle 240ml,spray pump,microspon ge,monoject,mon oject syringe,sharpsafe ty container,nutripor t balloon,dover advantage,dover premium,dover pediatric urine,dover advantage drainage,monoje ct tb syringe,monoject luer lock tb syringe,curity lumbar puncture tray,durasorb,sim accessories,external,syringe filter,enteral feeding dispenser, 20 ml,enteral feeding dispenser, 35 ml,enteral feeding dispenser, 60 ml,enteral feeding dispenser,1 ml,enteral feeding dispenser,3 ml,enteral feeding dispenser,5 ml,enteral feeding dispenser,10 ml,dental suction device/chlorhexidine gl/dental swab comb no.1,dental suction device/chlorhexidine/dental swab #1/mouthwash,eye pressure monitor,injector device,spray applicator kit, sterile,humidifier,thermomet er, temple electronic,disinfectant,glycin e/sodium hydroxide,ultrasonic cleaner/holding solution,protease-amylase medical equipment cleaner,transfer device, closed system,needle injector, luer, closed system,needle injector, luer lock, closed system,connector luer lock, closed system,infusion adapter, closed system,ysite line connector, closed system,assembly system, vial to transfer device, closed system,clamp, iv Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 297 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name plicity liner,telfa,maxicar e,rondic,presenc e,telfa clear,curity,kerlix, sure care protective underwear,monoj ect tb,curity maternity pad,curity ultramer 2-way catheter,webril,to uch-trol,curity cleaners medium,sharpsa-gator,enema bag,handicare,su recare,versalon,t enderskin,kendall paper tape,sure care protective undergmnt,curity foley catheter kit,curity cleaners large,dressing change-pov-iod tray,curity universal w-o drainage,suretys, monoject blood collection,confor m,monoject luer adapter,curity ureth cath closed systm,curity amd,curity urethral catheter,precision tubing,diaper,brief,adult,disp osable,blood pressure test kitlarge,cane,wheelchair,smoki ng deterrent filter,cane tips,crutch accessories,crutch,thermom eter, basal glass mercury,neck collar,feminine syringe,vaporizer-humidifier supply,rectal syringe,nasal syringe,vehicle base no. 13,topical cream metereddose device,adapter cap for bottle,rectal, vaginal applicator tip,troche mold,silver/hydrocolloid dressing,fecal collector with charcoal filter,hard lens wetting solution,hard contact lens enzymatic cleanser/pf,arm brace,leg brace,back brace,compression socks, medium,compression socks, large,blood glucose calibration control solutions high,normal,low,aloe vera/gloves, latex,nonadherent bandage/petrolatum,white,fir st aid kit,dressing holder,blood-glucose meter, drum-type,prothrombin time test strips,amniotic fluid detection test,vaginal cream applicator,suppository container, empty,vaginal suppository applicator,filter, Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 298 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 200 catheter tray,argyle,nursin g pads (breast),webril ii,curity ultramer irrg 3way cath,curity o-b sponges,vistec,ar gyle connecting tubes,wings underpad,t.e.d. anti-embolism stocking,lisco,curi ty bedside drainage set,wetpruf,sharps a gator,curity ureth cath open system,tensor,ker lix amd bandage,urinary leg medium bag,kenguard,ad d-a-foley tray,foley catheter,curity irrigation tray,heavy drainage dressing steril,robinson clear vinyl catheter,specipan collection unit,vaseline petrolatum gauze,xeroform petrolatum dressing,xerofor disposable ptfe membrane,benzalkonium chloride,allantoin,mineral oil/aloe vera/petrolatum,white/sodiu m lauryl sulfate,acemannan/alginate dressing,alginate dressing/carboxymethylcellu lose,needleless accessory device, insulin,blood sugar diagnostic test strips with disposable meter,safety seal, for bags,safety seal, for vials,safety seal, for syringes,defibrillator,automa tic,external,gel dressing/zinc acetate/meadowsweet/oak,c ellulose,oxidized/collagen,ac tivated charcoal/silver,gelmatrix pad dressing, silicone/benzalk chl/vit e/min oil,cholesterol calibration controls - high and low,cholesterol test, strips,cholesterol & blood glucose meter,prothrombin time/inr test meter,gel dressing, fenestrated,collagen,bovine, fecal collector w-charcoal filter/catheter/syringe, dispos,ostomy irrigator,activated charcoal/alginate dressing/hydrocolloid dressing,gravity feeding set,feeding pump,stethoscope,dental Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 299 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name m,dermacea,der macea nonwoven,dermacea stretch,flexwrap,aquaflo,curit y thoracentesis trays,monoject pharmacy tray,curity thoracentesiscath tray,kenline add-a-foley tray 30cc,add-a-foley cath-pre-fill syrn,curity spng counter bag strips,curity spng counter rackscale,curad,curity surgical,clean catch-benzalkon towelets,clean catch-soap towelettes,t.e.d. sequnt compress device,copa hydrophilic foam,argyle trocar,unigard,wi ngs classic youth briefs,wings classic adult briefs,wings classic,wings choice plus youth briefs,wings choice plus adult briefs,wings choice adult preparation, o.u.,bloodglucose transmitter/bloodglucose sensor,needles, subcutaneous set,iv administration set/needles, reusable,ring,cath male external-starter kit,transcutaneous electrical nerve stimulators (tens units),tens unit electrodes,blood pressure kit-extra large,propylene glycol,toe splint,disinfectant liquid soap cmb4,mineral oil/non-adherent bandage/petrolatum,hydrop hilic,weigh scale,blood pressure test kitsmall,compression socks, xlarge,blood-glucose and blood pressure meter with adult cuff,isopropyl alcohol,infusion set with insulin pump body,insulin pump controller,insulin pump/infusion set/bloodglucose meter,bacitracin zinc/polymyxin b sulfate,safety syringe with needle, disposable kit-tray, 1 ml,polyhexamethylene biguanide/non-adherent bandage,sub-q administration set, bifurcated,sub-q administration set, trifurcated,sub-q administration set, quadfurcated,alcohol swab Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 300 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name brief,foley catheter tray,dover foley catheter,curity strmlin cath wmono-flo,curity premium catheter tray,add-a-foley cath-mono-flo drng,curity bedside-mono-flo drange,monoflo,tenderol,curity ureteral drain set,curity bedside drainage bag,simplicity adult poly,simplicity,ver salon washcloth,curity washcloths,curity urine meter,dover red rubber robibson cath,dover catheter,kendall,p olyskin ii,kerlix amd,dover bulb syringe,wings,ker lix burn pack,monoject safety syr tip cap,curity detectable lap,simplicity adult flat fold xl,dover latex foley cap,tubular bandage applicator,diaphragms, coil spring,diaphragms, flat spring,cholesterol test kit,multiple test strip device,syringe, disposable, 1ml,syringe wneedle,disposab,12ml,rib belt,abdominal brace,compression pantyhose, small,compression pantyhose, medium,compression pantyhose, large,compression pantyhose,x-large,athletic support,bed pan,urinal,cushion,thermom eter, electronic (rectal),blunt filter cannula, disp.,soft lens enzymatic cleanser,transfer needle,hard lens soaking solution,incont device,muscle toner,elt,alginate dressing/hydrocolloid dressing,incontinence bed sheets,covers,venous flow controller,home hiv test kit,wetting soln gas,hard & soft,acne scrub pad,lumbar supports,contracept barrier dev, vented,gas perm. lens soaking soln,eye cup,plastic bags,chemo gowns,smocks,chemo spill clean-up kit,incontinence alarms,breast pump,iv Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 301 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name catheter,simplicit y pants,curity run arounds,curity runarounds,curity sleep pants,kangaroo gravity set,excilon,tender sorb,kangaroo nasogastric feed tube,curasilk,diap ers-disppolyethylene back,dover urine leg bag,telfa amd,kangaroo epump set,curity iodoform,curity ultra fits,tenderwrap unna boot,kerlix lite,monoject insulin syringe,curity 8000 urine meter,hypodermi c needle,curity abdominal,curity ultramer catheter,rcra hazardous waste,kendall container,dover coated latex foley,curafil,kend all cloth,maxicare underpads,wings supreme,staput,wings equipment/container,empty, sterile field,chlorhexidine gluconate,ring pessary,hard lens soak-wet solution,mercury spill cleanup kit,polyvinyl alcohol/gentian violet/methylene blue,silver/foam bandage,dressing,collagen/s ilver/sod alginate/carboxymethylcellul ose,dressing, collagen/sodium alginate/carboxymethylcellul ose,silver sulfadiazine/foam bandage,transcutaneous electrical nerve stimulators(tens)/electrodes, blood-glucose meter,for mobile device,transfer set/syringe, disposable/bandages,compr ession/tubing,gauze bandage/lanolin alc/min oil/petrolat/ceresin,zinc oxide/gauze bandage,polyquaternium6/gauze bandage,polyquaternium6/non-adherent bandage,polyquaternium6/adhesive bandage,honey/hydrocolloid dressing,eye drops dispenser,sub-q insulin pump, continuous glucose monitoring (cgm) syst,methylene blue/gentian Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 302 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name maxima,wings fluff and polymer,curistrip,bandaid,non-stick pads,first aid tape,first aid cloth tape,first aid hurtfree wrap,mirasorb,ba nd-aid flexible fabric,gauze pads,rolled gauze,soothing non-stick,kling rolls,ultraheal,spe ctragel,lancets,co mfort lancets,super thin lancets,polymem, polywic,oasis ultra,curasol gel,curasol hydrogel,wound matrix,burn matrix,neuropen, neuropen monofilaments,ca reone,kinney brand lancets,thin lancets,ultra thin lancets,incontrol ultra thin lancets,unilet lancets,autolet mini,lancing device,advanced lancing device,unifine violet/foam bandage,diaphragms, contoured,spirometer with drug delivery adapters,pen injector device,lancets with blood glucose test strips,thermometer, infrared, non-contact,foam/gauze bandage/lidocaine/chlorhexi dine/isopropyl alcohol Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 303 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pentips,pen needle,incontrol pen needle,pen needles,healthy accents unifine pentip,autolet platforms,unifine pentips plus,unilet lancet,unilet gp lancet,alternate site lancets,unilet comfortouch,adv anced travel lancets,unilet excelite,unilet excelite ii,autolet lite clinisafe,unistik,a urora super thin lancets,incontrol super thin lancets,healthy accents unilet lancet,unistik 2,incontrol lancing device,autolet lancing device,healthy accents autolet,autolet mkii clinisafe,unistik 3,autoject 2,rapport vacuum therapy,amielle vaginal trainer,rapport BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 304 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ring loading system,autopen,n eurotips,autodrop ,autosqueeze,ulti care syringe,ulticare,ul ticare pen needle,lancets thin,lancets ultra thin,fine 30 universal lancets,medlance plus,adjustable lancing device,insumed,i nsupen,glucosour ce,exel insulin syringe,insulin pen needle,tuberculin syringeneedle,exel tb with needle,exel tuberculin syringe,exel allergy syringe,allergy syringe,exel syringe,exel hypodermic needle,exel mti drawing needle,psv set,iv catheter,exel huber,exel huber needle,yale needle regular bevel,yale needle,yale BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 305 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value needle short bevel,special needle,intraveno us,arterial & blood,yale needle huber bevel,pudendal & parasympathetic, whitacre spinal needle,rosenthal, osgood,security bead needle, local,klatskin,yale glass tb syringe,yale syringe,syringe,c ornwall syringes luer-lok tip,plastic adapter kit for busher,cornwall accessories & parts,cornwall metal pipeting holder,tempaway thermometer sheath,yale spinal needle,quince spinal needle,allergist syringe,allergist syringe with needle,allergist tray,allergist syringe tray,tuberculin syringe,yale cleaner,asepto BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 306 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value bulb syringe glass tip,pipette 30ml catheter tip,pipette 45ml catheter tip,asepto bulb syringe cath tip,pipette 90ml catheter tip,pipette 120ml catheter tip,plastic adapter for busher,bulk syringe,syringe bulk,luer-lok syringe,needle,ca nnula,interlink syringe,lever lock cannula,twinpak dual cannula,interlink syringe wcannula,specialty use needles,regular bevel needles,needles, precisionglide,yal e needles,short bevel needles,blunt needle,thin wall needles,filter needle,tampertuf,oral syringe,nokor needle,nokor admix needle,cornwall BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 307 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe tip connector,glaspa k,integra syringe,integra needle,sharps collector,onepiece sharps collectors,sharps container,safetylok safety syringes,safetylok safety syringe,medsaver ,syringe storage bin,eclipse needle,syringeneedle,eclipse syringe,eclipse syringeneedle,eclipse luer-lok syringe,safety syringeneedle,syringe tip cap,safetyglide needle,safetyglid e syringe,safetyglid e insulin syringe,safetyglid e tb syringe,safetyglid e allergy syringe,safetyglid e allergy,syringeluer tip cap,luerlok syringeneedle,safety-lok syringes,syringeBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 308 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value precisionglide needle,syringe catheter tip,tb syringe,luer-lok tip syringe,luerslip syringe,bd ultrafine pen needle,bd ultrafine,bd ultra-fine ii,lancet device,magniguide magnifier,safeclip,auto injector,autoshiel d pen needle,autoshield duo pen needle,paradigm link blood glucose,vacutain er blood transfer,luer-lok access device,bd microtainer lancets,microtain er lancets,safetylok collection set,vacutainer collection set,brite sight thermometer,insy te autoguard,insyte iv catheter,angiocat h iv catheter,angiocat BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 309 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value h,saf-t-intima iv catheter,saf-tintima,nexiva,intr osyte autoguard,qsyte,e-z set winged infusion set,saf-t e-z collection set,saft e-z set,myelogram tray,precise,ibgstar,haemolance, retractable,assur e id insulin safety,hypolance, advance intuition,assure pro,assure platinum,assure dose,assure 3,assure 4,glucocard expression,pocke tchem ez,multilancet device,micro,relio n micro,glucocard 01,glucocard 01 control,glucocard 01-mini,glucocard x-meter control,glucocard xmeter,glucocard vital,techlite lancets,techlite blood lancet,techlite,ha BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 310 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value emolance,assure haemolance plus,assure lance,haemolanc e plus,ultilet safety,ultilet classic,ultilet lancets,publix lancet,ultilet insulin syringe,ultilet pen needle,ultilet basic,suresite matrix,tenderwet active,tenderwet active cavity,evencare g2,safety lancets,pressure activated lancets,silvasorb, silvasorb cavity,exuderm odorshield,evenc are,skintegrity,me dfix ez,stratasorb,bor dered gauze,exuderm satin,evencare g3,medigrip,carra syn hydrogel wound,blenderm, transpore,microfo am,micropore,dur apore,steristrip,3m nexcare,tegader m i.v.,tegaderm BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 311 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value i.v. advanced,medipo re h,medipore dressit,medipore,soft cloth,medipore plus pad,steristrip wound closure syst,tegaderm hydrocolloid,tega derm hydrocolloid thin,tegasorb thin,tegagen hi,tegagen hg,tegaderm ag mesh,tegaderm absorbent,tegade rm hp,primeaire,qua ke,liteaire,mistern eb compressor,inspir ation elite,inspiration,si destream,mistern eb pediatric compressor,innos pire elegance,mistern eb nebulizer,sidestre am mask,innospire essence,micro elite replacement filter,minielite,mic ro elite,pflex trainer,assess,ast BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 312 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value hmapack i,asthmapack ii,asthmapack iii,asthmapack children's,thresho ld imt,threshold pep,asthma check,asthmame ntor,personal best,optihaler,opti chamber,pediatri c mask,sidestream plus,inspiration elite filter,micro plus,innospire replacement filter,sidestream nebulizer,sami the seal,litetouch,sa mi the seal filter,sami the seal mask,sidestream pediatric,optionho me,mini plus nebulizer,mini elite filter replacement,optic hamber diamond,procha mber,lo-profile urostomy pouch,contour i,filter security closed pouch,stoma cap w-micropore BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 313 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value adhesive,karaya drainable ostomy pouch,karaya seal closed stoma pouch,centerpoin tlock closed pouch,stoma cap w-deodor fltrflange,stoma cap w/deodor fltr/flange,karaya 5 drainable pouch,premium drainable pouch,skin barrier w-floating flange,convex syn barr w-float flange,pouchkins skin barrier,pouchkins pediatric belt,pouchkins pouch,pouchkins drain tube,pouchkins drainable pouch,pouchkins urostomy pouch,drainable pouch with flange,stoma irrigator drain wflange,drain pouch-filterflange,drainable pouch w-filtrflange,drainable BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 314 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value mini-pouch wflange,cpl drainable pouch,drainable pouch,urostomy pouch with flange,ostomy belt,urostomy drain tube adapter,hollihesiv e skin barrier,stoma combo cone-tube irrg kit,stoma cone w-connector unit,stoma combo cone,tube irrg drn,medical adhesive,adhesiv e remover,odor eliminator,m9clea nerdecrystallizer,sto ma lubricant,adhesiv e-barrier remover wipes,filter replacement,loop ostomy bridge, sterile,premium skin barrier,adapt barrier ring,softflex skin barrier,karaya,ad apt stoma powder,karaya paste tube,skin gel protective dressing,premier BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 315 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value drainable pouch,premier urostomy pouch,premier lock n roll,premier drainable minipouch,centerpoin tlock flextend skin,drainable pouch clamp,flextend skin barrier,premier urostomy pouch/flange,eve ryday male catheter,extende d male catheter,extensio n tubing wconnector,urinary leg bag,bag-strap system,bagtubing system,vent urin leg bag sys,combo pk,wound drainage collector,universa l catheter access port,drain-tube sterile clamp,horz drain-tube attach device,vertical drain-tube attach dev,suction tube attachment device,feeding BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 316 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tube attachment device,replaceme nt neckband,retract ed penis pouch,fecal collector, drainable,bedside drainage collection,female urinary pouch,vented urinary leg bag system,fecal collector,new image skin barrier,new image flexwear,new image skin barrierflange,new image flextend,new image drainable pouch,new image irrigation sleeve,new image drainable mini-pouch,new image closed pouch,new image closed minipouch,new image,new image urostomy,new image urostomy pouch,new image colostomy-ileo kit,new image BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 317 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value kit,new image drainable kit,new image urostomy kit,adapt,adapt paste,adapt barrier,adapt convex barrier,premier closed minipouch,premier pre-sized minipouch,premier closed pouch,premier skn barr w-float flang,premier colostomyileostomy,premier urostomy,advanc e plus intermittent,incar e,fc condom, female,two-piece stoma caps,closed-end pouch,adhesive barriers,adhesive barrier,irrigation sleeve,microskin barrier,system pouch,microderm plus,one-piece drainable pouch,mini drainable pouch,urostomy pouch,platinum urostomy pouch,mini BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 318 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value urostomy pouch,one-piece urostomy pouch,microderm ,cymed seal,ilesorb,night drain adapter,microskin applicator,draina ble pouch closure,microhesi ve stoma paste,clickfine,reli on pen needles,thalaset, neria,insuflon,tub eguard,mouthpie ce,expiratory,piko 1,pocket peak,pocket chamber,pediatri c panda mask,panda mask,femcap,bio brane,biobrane dressing,biobran e-l,biobrane-l dressing,biobran e gloves,pillow mask,pillow mask for children,splash shield full,splash shield flex,splash shield short,co monitor replacement t,co monitor,disposabl e paper mouthpiece,miniBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 319 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value wright peak flow meter,airzone & miniwright afs,incheck oral,incheck nasal with mask,in-check dial,windmill trainer,one way mouthpiece,pedismall mouth adaptor,pediatric mouthpieces,airz one peak flow meter,one flow fvc,one flow spirometer,one flow mouthpiece,filtere d mouthpiece attachment,silico ne mask,breathrite,n ose clip,rubber mouthpiece,all flow 1000,all flow 2000,all flow 3000 pft,all flow 3000 kit,all flow 4000,all flow 5000,all flow 6000,all flow 7000,easygluco meter starter kit,easygluco,con trol,g-4,control solution,infinity,inf inity control solution,acura starter kit,acura BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 320 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value control solution normal,acura meter kit,acura control solution,acura control solution low,acura plus,easygluco plus,easygluco plus control normal,compact ultrasonic nebulizer,compac t compressor nebulizer,autolet impression,autole t plus,unistik czt,unistik 3 extra,unistik 3 comfort,unistik 3 neonatal,ultraco mfort,orsini insulin syringe,clearblue, easy pro plus,prodigy count-adose,prodigy mini-mist,prodigy pocket,prodigy,pr odigy eject,prodigy voice,prodigy duo,prodigy control solution,prodigy preferred,prodigy autocode pro,prodigy BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 321 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pocket pro,prodigy voice pro,prodigy twist top lancet,prodigy lancets,prodigy lancing device,prodigy pen needle,prodigy insulin syringe,actilance,droplet lancets,easy touch glucose monitor,easy touch lancing device,easy touch control solution,easy touch,easy touch insulin syringe,easy touch pen needle,omnipod, 1st choice lancets,1st tier unilet comfortouch,1st tier unifine pentips,1st tier unifine pentips plus,iport,thinset,fifty50 safety seal lancets,fifty50 reservoir,infusion set,eclipse,eclips e control solution,envision, BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 322 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value evolution blood glucose meter,evolution control solution,element blood glucose meter,element control solution,smartdia betes xpres,smartdiabe tes vantage,element plus,xpres,eleme nt plus control solution,glucolab control,glucolab,s martest,smartest lancet,smartest eject,smartest protege,smartest smart code,smartest talking,smartest pronto,smartest persona,glucoco m blood glucose,glucoco m lancets,blood glucose meter,glucocom control solution,glucoco m,glucocom autolink,glucose control solution,glucose control,bloodglucose BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 323 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value control,rightest gm300 system,bionime rightest gm300 system,rightest control solution,rightest gd500,rightest gm100 system,rightest gm550 system,rightest gl300 lancets,ge100 blood glucose system,ge100 control solution normal,nova sureflex,sureflex, nova max blood glucose meter,nova max glucose control soln,novamax plus,novamax plus glu-ket,nova safety lancets,keynote, wavesense control solution,agamatri x control,jazz wireless 2,wavesense presto,keynote pro,wavesense amp,presto pro,liberty blood glucose BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 324 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value meter,liberty control solution,vgo 40,vgo 30,vgo 20,ear popper,sterilance tl,cinis preemie halo,restore contact layer,restore contact layer silver,restore,rest ore trio,restore duo,restore foam heel dressing,restore odorabsorbent,restore ex thin hydrocolloid,resto re hydrocolloid dressing,restore calcium alginate,restore hydrogel,restore hydrogel gauze,ultraflex,burns-scaldsabrasions,skin closure,blister care,bandages,m edical id for bracelet,medical id for necklace,riteflo,pr ovent hr,provent sr,provent,ultratra k pro,ultratrak,ultral BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 325 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ance,ultratrak ultimate,safesnap syringe,safesnap insulin syringe,safesnap tuberculin syringe,safesnap allergy syringe,conceptio n,needle-pro edge,solus v2,solus v2 lancets,solus v2 lancing device,solus v2 control solution,caresens n,caresens,smart caresens n,invacare lancets,gdrive,de xcom g4,seven plus,seven system sensor,droplet lancing device,syringe without needle,filter connector,lifeshie ld blunt cannula,transfer needle,bone marrow aspir needle,filter aspirator needle,allergist tray syr-perm needle,monoject BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 326 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value allergy trayneedle,monoject tuberculin syringe,allergist tray syr-detach ndl,monoject insulin safety syrng,monoject tuberculin safety syr,monoject control syringe,monoject syringe pharmacy tray,monoject safety syringe,safety syringe with shield,monoject smartip cannula,monolet lancets,monoject or lancet device,monolet thin lancets,sharps container accessory,glove box,monoject magellan,finger grip extender,magella n tuberculin syringe,monoject megellan tb syringe,magellan insulin safety syrng,magellan insulin syringe,oral BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 327 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value medication syringe,extender caps,kangaroo pet carrying case,kangaroo pet pump frame,kangaroo pet charging cord,petrolatum gauze,xeroflo gauze dressing,viasorb, blisterfilm,ultec,qtips wood stick applicator,interso rb,expandover,ka ngaroo enteralfeed-irrig kt,kangaroo pump extension set,kangaroo 500ml pump set,kangaroo deluxe pump set,kangaroo pump set,kangaroo 1000ml gravity bag,kangaroo 1200ml deluxe pump st,kangaroo proximal spike pmp st,kangaroo screw cap pump set,kangaroo 1600ml deluxe pump st,kangaroo y-site BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 328 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value extension set,kangaroo 1200ml rigid containr,kangaro o rigid container,kangar oo plyurethane feed tube,kangaroo 100ml rigid burette,texas catheter,elastic foam strap,uridrain,two-sided adhesive strap,catheter with strap,vaseline constant care,rob-nel pvc catheter,terumo insulin syringe,terumo surguard2,thinpro insulin syringe,terumo surguard,terumo allergy syringe,terumo syringe,terumo hypodermic needlesyrin,medihoney, premier skn barr w/float flang,sensitive eyes saline,sensitive eyes BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 329 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value drops,sensitive eyes plus saline,sensitive eyes daily cleaner,renu multi-purpose,bio true,renu rewetting drops,renu multiplus,boston advance cleaner,boston conditioning solution,boston simplus solution,re-nu fresh,boston cleaner,smoker's polident,polident, super poligrip,sensodyne,d entucreme,dentugel,super wernet's denture,ctub,gallon jug with pump,jetcospray cannula,dee fog,zarosen,varn al,release,mixing container with lid,reveal pregnancy test,reveal ovulation predictor,stik it,reveal blood BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 330 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value glucose meter,reveal get pregnant quick,reveal ovulation test,mesalt,mepil ex,tendra mepilex border,probe covers,digital thermometer,und erpad,bladder control pad,water shield bandages,antibac terial bandages,foam bandages,gauze bandage,stretch gauze bandage,shield,u ndergarment,brief ,lamb's wool,fabric bandage,adhesiv e pads,clear bandages,flexible bandages,plastic bandages,banda ges sheer,callus pads,sheer bandages,sterile pads,adhesive tape,dental adhesive,hypoallergenic bandages,cotton swabs,color lancets,cosmetic puffs,cosmetic BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 331 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value squares,dental floss,flexible bandage,elastic bandage,baby wipes,pregnancy test,strong strips,waterproof strong strips,multipurpos e contact lens soln,saline solution,saline sensitive eyes,fever flash thermometer,dent ure,combine abd,toothbrush precision head,toothpaste, cotton balls,bandage,cot ton squares,cosmetic balls,toothbrush adult deluxe,lens lustre eyeglass cleaner,toothbrus h, total,pill box,pill planner,pill divider with pill box,medicine dropper,medicine spoon,forehead thermometer,ther mometer,thermo meter probe covers,brief, medium,ep brief,heatwraps,b BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 332 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value andage roll,breatherite,o. a.d.,woun'dres,co mfeel plus,comfeel plus clear,comfeel plus triangle,comfeel plus contour,comfeel plus pressure relief,comfeel ulcer care,comfeel,com feel film,female self catheter,selfcath,coloplast skin barrier,coloplast paste,ostomy paste,coloplast barrier ring,coloplast,col oplast drainable pouch,coloplast closed pouch,irrigation set,assura irrigation face plate,assura 2pc irrigation sleeve,filtrodor pouch filter,pouch clamp,assura flange,assura wound manager,assura, assura flange convex,assura BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 333 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ostomy belt,comfeel seasorb,assura 2pc drainable,assura pouch,assura standard wear,assura pediatric pouch,comfeel purilon,conveen coude intermtnt cath,conveen drip collector,assura easiclose,assura non-convex drainable,urosto my night bag,biatain,assur a extra,assura two-piece uro minicap,assura light easiclose drain,assura ac,urostomy multichamber,urostom y multi-chamber pouch,urostomy micropouch,easiclose wide outlet,coloplast paste strip,sensura easiclose wide outlet,sensura click ostomy pouch,sensura BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 334 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value flex ostomy base plate,sensura ostomy base plate,sensura flex ostomy pouch,ice bag,overnites,sur e choice pantiliners,belted undergarment,wi pes,diapers,sensi tive baby wipes,bladder control pads for women,briefs for men & women,ezject lancets,panty shields,tugaboos diapers,maxi pads,panty liners,hot-cold compress,multiuse cold pad,back & neck cold pad,cloth first aid tape,selfgrip,finge r splints,finger sleeves,rewetting ,super strip bandages,flexible fabric bandage,flexible fabric bandages,tugabo os overnights,under wear for men,premium BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 335 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value baby wipes,clear spot bandages,ovulati on predictor,kid pants,protective underwear,surec hoice,pantiliners, dental travel pack,briefs xlarge,cotton, sterile,sheer plastic strip,disposable razor,adhesive bandage,fabric strip extra large,pro sports tape,ice cap,water bottle,water bottle-fountain syringe,foam insole,cushion insole,super moleskin,over nites,instant ear thermometer,viny l gloves,multipurpose solution,eye patch,instant heat therapy,hearing aid batteries,latex gloves,true2go blood glucose system,self grip,cotton gloves,underpads ,soft touch pill BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 336 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value reminder,linen fresh,hot & cold therapy brace,instant heat,heat therapy patches,moist towelettes,ultra fine cut n crush,tablet cutter,nail clip,toenail clip,nail nippers,disposabl e probe covers,alkaline batteries,toenail nipper,finger splint,tubular gauze,non-slip underpads,delux e underpads,blood pressure monitor,underwe ar for women,foam ear plugs,guards for men,underwear menwomen,blood pressure cuff monitor,boxers for men,surgical dressing,contact lens cases,paper tape,cleaning & disinfecting lens,callus cushions,plantar BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 337 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value fasciitis arch sleeve,gel bunion cushion,clear bandage,pain free tape,flexible foam pad,push n pop pill reminder,medicin e dropper & spoon,am-pm locking pill reminder,soft-tip thermometer,und erwear for men & women,tugaboos training pants,quiet please foam ear plugs,blood glucose monitor,flexible foam bandage,disposa ble brief,daily cleaner,rewetting drops,one step ovulation test,truetrack smart system,gauze,bla dder control,heat wraps,basal thermometer,hyp o-allergenic bandage,blood pressure kit,tender tape,skin closure strips,flex fabric BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 338 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value bandage,comfortstretch,premium comfortstretch,gauze dressing,one step pregnancy test,comfortsmooth,fitted briefs,fitted brief,blister relief,ultra-soft gloves,premium nitrile gloves,quick read,adult wash,certainty,to e separators,gel toe spacers,gel toe protector,arch bandage,gel corn protectors,sleep pants,truetrack blood glucose system,trueresult blood glucose systm,flight ear plugs,sterile bandage roll,gentle adhesive bandages,plastic adhesive bandages,sheer adhesive bandages,confor ming rolled gauze,deluxe arm bp monitor,premium BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 339 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value arm bp monitor,premium baby diaper,premium training pants,flushable cleansing cloths,face mask,non-stick pad,micro thin lancets,ultra-light rollator,scar treatment,cloth tape,trueplus lancets,pain free wrap,self adherent wrap,gel bunion guard,sorespot,al l gel bunion toe spreader,well beginnings sleep pants,e.p.t.,e.p.t. digital,e-z spacer,vanishpoi nt,syringe with needle disp,sheer spot bandages,blood glucose monitoring,premi um blood glucose,accuchek spirit,sew-in pocket,accu-chek tender,accu-chek rapid d,accuchek,d-tronplus adapter,accuBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 340 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value chek ultraflex,accuchek ultraflex ii,sport belt,accuchek d-tron plus,flexlink plus infusion set,foracare gd20,choicedm g20,fora v30a,fora g71a,foracare gd40a,foracare gd40b,premium v10,fora v12,kimono,kimo no maxx,kimono microthin,kimono microthin aqua lube,kimono textured,digitex gold,rid,devilbiss pulmomate,pulm o-aide,devilbiss pulmoaide,devilbiss disposable nebulizer,devilbis s compact,sunrise compressornebulizer,devilbis s traveler,cytosafe dipensing pin,exactamed,dual rate syringe infuser,bifurcated BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 341 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value fluid tran tube set,exactamix,elbow inlet,gravity mixing set,luer lock-to-bag,fluid transfer extension set,vial adapter,bag spike,oral liquid transfer tube set,micro volume inlet,fluid transfer set,calibration bag,dual rate syr infuser tubing,minibore, microfuse minibore,pole clamp,em2400 valve set,exactamix calibration,exacta -mix eva,micromacro,s terl fluid transfer tube set,topical tip cap,topical cream dispenser,topical dispenser,sterile fluid tran tube set,syringe filling fixture,oral liq bag-tube set combo,repeater pump stand,pharmacy pump stand,0.2 BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 342 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value micron filter attachment,gel bag & tube set non-sterile,sterile exacta-med dispenspin,tamperresistant bag cap,sterile top fill bag,sterile empty collection bags,adaptacap,microfuse,trif urcate fluid tran tube set,pharmacy pack liquid dispenser,repeat er pump,vaginal cream dispenser,luer to urethral tip adapter,luer to catheter tip adapter,sterile rapid fill connector,sterile gel bag,sterile two-fer needle,exactamed tip extender,supor,la bels, 1.5" x 1.5",kwikvial,kwik-vial filling extension,kwikvial plug dispenser,t.i. seal BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 343 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value non-sterile foil,bottle adapter,3-way oral port stopcock,rapid fill adapter,sterile rapid fill adapter,oral-tooral rapid fill connec,mark-adose,oral labels,shrinksafe, port saver sterile inject port,vaginal dispenser tip cap,tip caps, nonsterile,exactamed tip cap,luer lock tip cap,luer lock tip caps, sterile,sterile luer slip tip caps,luer slip tip caps,selfrighting luer slip tip,catheter tip cap,locking,selfrighting luer tip cap,self-righting luer lock tip,bedside pack liquid dispenser,ward pack liquid dispenser,neothri ve,rapidfill,comfort bath,toothette,qcare rx,reality,first aid paper BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 344 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tape,first aid skintone paper,first aid plastic tape,first aid waterproof tape,air warming mask,dust & pollen filter mask,germ filter protective mask,cold comfort,trueplus insulin syringe,brush 'n floss,proview eye pressure monitor,autolancet mini,injectease,insuleze,insulcap,insultray,reconstitube, deluxe tablet cutter,zymogeneti cs spray applicator,vicks warm steam vaporizer,health mist,vicks cool mist,vicks warm mist,vaporizer,vic ks digital thermometer,vick s forehead thermometer,ther moscan,cetylcide g,hyde-out,power cleaner,cetylzyme,replacemen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 345 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value t j-4 cannula,mepilex border,mepilex ag,mepilex border sacrum,mefix,lite touch,medilance,aurora healthcare lancets,phaseal protector,phaseal injector luer,phaseal connector luer,phaseal adapter,phaseal y-site,phaseal assembly fixture,phaseal infusion,phaseal secondary set,saline,kotex fresh & dry,kotex overnight,depend ,huggies,huggies pull-ups,huggies baby wipes,goodnites, depend silhouette,depend real fit,poise pads,depend guards for men,kotex security,poise liners,depend overnite,depend protection,huggie s BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 346 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value goodnites,goodnit es sleep shorts,huggies ultratrim,lavender nitrile exam glove,huggies overnites,topcare belted shield,topcare underpad,topcare maxi overnight,topcare pantiliner,topcare male guard,topcare liners,topcare pads,topcare maxi pads,luvs,pamper s premium,pamper s ultra dry thin,pampers babydry,pampers unisex,pampers cruisers,underja ms,pampers easy ups,pampers extra protection,pampe rs swaddlers sensitive,pamper s preemie,pampers swaddlers,pampe rs,newborn babydry,washcloth,pa mpers BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 347 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value premature,pampe rs ultra dry,pampers newborn,pamper s rash care,pampers premie,luvs overnight,pamper s nonelasticized,pamp ers ultra phases,ultra + pampers,pamper s thick phases,pads,refu ah plus,refuah plus glucose control,sleep overs,cuties,cutie pants,glucopro,a migo insulin pump,hugo cane,hugo rolling walker,hugo transport,hugo folding walker,airgo rolling walker,universal 1,smart sense lancets,topcare universal1 thin lancet,ultra thin plus,smart sense,ultra thin plus lancets,topcare ultra comfort,renew BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 348 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value advanced microlancets,renew advanced lancing system,topcare clickfine,bullseye mini safety lancets,sms glucose control,safetylet,safety seal lancets,aqua lance lancing device,easy twist & cap lancets,surechek glucose control,sure edge blood glucose meter,sure edge glucose control soln,alternate site lancing device,vocalpoint glucose control,vocal point glucose control,one step at a time,cane tips,cane,crutch tip,hand grips,crutch accessory kit,underwear,hu midifier,crutch,co ol mist,super underpad,regular pad,super pad,cervical collar,oral BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 349 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value thermometer,bab y thermometer,femi nine combination syringe,fountain syringe,feminine folding syringe,feminine bulb syringe,vaporizer inhalant,vaporizer cleaning tablets,feminine compact travel syrnge,attachme nt set,enema syringe,nasal aspirator,rectal syringe,wheelcha ir,acapella,lipo cream base,shrink band,plastic white hdpe bottle,amber round glass bottle,topiclick,bottletop dispenser adapter,unguator lid,syringe filter, millexgp,precisedose dispenser tip cap,megapump mezzo,megapum p airless,rectalvaginal perforation BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 350 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tip,sterile clear glass vial,amber glass serum bottle,topi-click filling nozzle,enema bottle,adapter cap,glass graduated cylinder,precised ose dispenser syringe,posidyne eld,suppository shell,syringe filter, millexgs,adapter pressin bottle,troche mold,thermophor e,thermophore maxheat,ice it!,thermophore arthritis,opsite iv 3000,no-sting skin-prep swab,exu-dry slit tube,conformant 2,drynet,replicare ultra,replicare ultra sacrum,acticoat,a cticoat 7,acticoat absorbent,aquap hor gauze,hot & cold compress,sports tape,ear thermometer,non adherent pads,nonBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 351 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value adherent,adhesiv e bandages,adhesi ve foam bandages,baby darlings wipes,baby darlings diapers,combinati on water bottle,thong liners,tampons,ex tra absorbent undergarment,pu re cotton,feminine cleansing cloths,lice removal comb,heating pad,personal washcloths,traini ng pants,compmist compressor nebulizer,minico mp compressor nebulizer,earloop masks,cone masks,instant cold pack,transport chair,selfgrip,deluxe instant,lubricating & rewetting,everyda y long pantiliners,sheer BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 352 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value strips,clear strips,plastic strips,personal confidence pads,beltless undergarments,p ersonal confidence briefs,overnight brief,personal confidence underpad,flexible foam strips,slipon undergarments,b aby basics,basics for kids,butterfly closures,heavy duty fabric strips,personal confidence liners,overnight protective,clear waterproof strips,natural care bandages,camo bandages,person al confidence underwear,protec tive barrier wipes,reliamed,re liamed mini lancing device,reliamed safety seal lancets,transpare nt thin film dressing,transpar BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 353 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ent i.v. site dressing,ostomy protective powder,incontrol bp monitor,microlife peak flow,stomahesive protective,flexiseal fecal,surepress,ul ti-lance,lc d nebulizer set,lc plus,baby nebulizer,lc star,sinustar,pari lc plus nebulizer,lc sprint nebulizer,pari sinus aerosol system,pari lc sprint sinus,vios aerosol delivery system,filter, valve set for ll & lc,filter pad,filters replacement,bab y conversion pack 1,baby conversion pack 2,mask set with y-piece,mask vortex,vortex,bub bles the fish ii,wing tip tubing,adult aerosol mask,vortex ladybug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 354 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value mask,vortex frog mask,trek s portable pwr kit,trek s combo pack,trek s compact compressor,alter a nebulizer,eflow scf,eflow scf aerosol head,eflow scf nebulizer handset,smartma sk kids,proneb ultra,proneb ultra ii,proneb ultra ii deluxe,elasto-gel hot & cold wrap,elastogel,elasto-gel plus,toe aid dressing,elastogel circle dressing,elastogel cast-splint padding,boston rewetting drops,boston one step,microspacer, microchamber,ea symax v speaking,easyma x v,easymax speaking,easyma x v2,easymax l,easymax n,easymax,easy max ng,easymax 15,easyplus BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 355 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value r13n,easyplus v,anti-embolism stockings,truform compression stocking,puralin,s urgilance lancets,cut n crush,moist wipes,cold wrap,cold pack back pad,tennis elbow brace,ankle brace,elbow support,knee brace,ace back support,knee stabilizer,elbow strap,wrist support,ankle support,ace ankle support,arm sling,elbow brace,knee support,deluxe laced ankle brace,backshoulder ice & heat wrap,multipurpose ice & heat wrap,wrist brace,deluxe ankle brace,contoured back support,back stabilizer,deluxe back stabilizer,maxi BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 356 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value super,maxi deodorant,maxi regular,thumb stabilizer,deluxe wrist stabilizer,hand support,warm steam vaporizer,selfadhering,flushabl e moist wipes,ankle stabilizer,ace aerosol cloud enhancer,easiven t,daily pill box,hot & cold pack,medilice,sheer adhesive,medico ol's diasox,thermipaq, myglucohealth,m yglucohealth lancets,myglucoh ealth control solution,nessi spacer,protective pads,jumbo diapers,supreme diapers,diapers mega,kidpant,abs orbent cotton balls,stretch bandage,sheer strip,blood glucose monitor kit,bladder control pad ultra,guard BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 357 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value male,plastic swabs,diaper,inst ant cold therapy wrap,sleep comforts,gentle tape,gloves,nonadhesive pad,overnight briefs,cleansing wipes,saline sensitive,aloe vera latex gloves,flexible dressing,gauze sponges,eye pad,adhesive dressing,selfadherent gentle wrap,blood pressure cuff,contact lens relief,flex bandage,ear plugs,suresite window,procedur al face masks,advanced non-stick dressings,nonstick dressings,surgica l dressings,allpurpose dressings,dressin g sponges,cold pack,x-abs underwear,foam toe bandages,all purpose cloth BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 358 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tape,corn cushion,flex finger bandage,callus cushion,moleskin plus,first aid kit,nitrile exam gloves,portable sharps disposal,triple layer non-stick pad,qwikstrip,premium adult wash cloths,peas cold therapy,arthritis heatwraps,calciu m alginate,hydrogel dressing,hydrocol loid dressing,contact lens case,household burn kit,reusable instant heat pack,elastic stretch net,women's underwear,men's underwear,weekl y vitamin planner,saline 4,disposable latex-free gloves,overnites diaper,adhesive gauze pad,needle BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 359 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value collection & disposal,rolled absorbent cotton,iv prep antiseptic,coverle t o.r.,allevyn plus,blairex sterile saline soln,assess peak flow meter,personal best peak flow meter,coaguchek ,accu-chek safet-pro plus,chemstrip bg diary,soft touch,accu-chek voicemate,accuchek safe-tpro,softclix,accuchek softclix,microdot, 3m nexcare stomaseal,microp ore paper surgical tape,blenderm surgical tape,durapore cloth surgical tape,opticlude,sto maseal,nexcare gentle paper tape,3m nexcare durapore,nexcare all purpose mask,futuro restoring,futuro BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 360 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value antiembolism,nexcar e tegaderm,paper first aid tape,amniscreen, metercheck,normject,aimsco,aimsc o ultra thin ii,aimsco mini ultra-thin ii,ultrathin ii,ultra thin ii,ultra-thin ii lancets,pcca accupen15,supposistrip,u niversal sleeve,vaginal cream applicator,suppos itory box,filter, millex-or syringe,boston round natural,vaginal suppository applicator,bottle,l uer lock adapter,filter, millex-fg 0.2um,suppositor y shell, small,suppository shell, medium,syringe tip rectalvaginal,freedom precision airless,advanced BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 361 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value antibacterial bandage,antibact erial bandage,antibact erial pad,temple thermometer,fast read thermometer,chil d ear syringe,infant ear syringe,watchhal er,carra sorb h,carra sorb m,carra film,diab,pump for whirlpool solution,shampoo & body wash dispenser,radiafd g,carrasyn gel,gauze packing strip,wound dressing,gel pad,carrasyn spray gel,carra gauze strips,carra gauze,carrasyn v,carracolloid,ultr a-klenz,dermal wound gel,primary dressing,incontin ence skin care,carrasmart,c arradres,radiadre s,carraginate,sur esite BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 362 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value iv,suresite,suresit e flexigrid,arglaes,a rglaes film,arglaes island,optifoam,e xuderm rcd,exuderm,exu derm lp,exuderm ultra,exuderm sacrum,dermagel,medfix,maxor b,maxorb extra,tenderwet,e z smart,ez smart lancets,ez smart plus,onetouch ultra control soln,one touch delica,onetouch verio iq,one touch verio,onetouch delica,onetouch finepoint lancets,onetouch suresoft,onetouc h ultramini,onetouc h ultra system,one touch glucose control soln,onetouch verio,one touch basic system,surestep, penlet plus blood sampler,onetouc h lancets,onetouch BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 363 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ultra2,onetouch ultra smart,onetouch ultralink,surestep control solution,surestep pro,grx wound gel,alligator spoon,pre-moist pads,replacemen t pads,aerochamb er,one touch lancets,ultra fine lancets,opsite flexigrid,opsite,all evyn cavity wound dress,algisite,unif lex,needle free syringe kit a,medi-jector vision,needle free syringe kit b,needle free syringe kit c,medi-jector needle-free syr a,medi-jector needle-free syr b,medi-jector needle-free syr c,truedraw,starter kit,life medical starter,diabetic.co m starter,prestige meter,prestige,pr estige value pack,truetrack,tru BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 364 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value econtrol,truetest glucose control,sidekick,p restige smart system,prestige smart system iq,liberty lev 1 glucose control,liberty lev 2 glucose control,liberty monitor,breathe right,medisense thin lancets,medisens e glucose ketone,medisens e glucose ketone contr,medisense, precision xtra,optium,precis ion,unistik 2 normal,unistik 2 extra,steritamp,elon nail care system,flutter,2te k,e-z spacer pedspak,wonderp ants,up & up maxi pads,up & up baby diaper,telcare,telc are control solution,sure-ject insulin syringe,surelance,sure-fine pen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 365 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value needles,sure-test easyplus mini,suretouch,surepen,heartstream fr2,deltec cozmo,infusion,in sulin cartridge,adapter, belt clip,gripper plus,deltec cozmo cleo infusion set,amerigel,der mafilmhd,dermasyn,der magauze,dermav iew,dermaview ii,dermafilm,derm aginate,dermadre ss,dermalevin,fle xzan adhesive dressing,hydrocol ii,sorbsan,vial,ste rile,empty,maxifill transfer set,iv transfer spike,steri-tamp seal,chemo transfer pin,floweze,mini transfer pin,hi-volume pumping chamber,transfer pin,universal syringe tip adaptor,promogr an prisma,promogra BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 366 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value n,actisorb,silverc el,tear flo,scar care,accu-chek aviva plus,coaguchek xs,accutrend cholesterol,accutr end glucose,accutren d plus,accu-chek fastclix,accu-chek compact blue control,coaguche k xs pro,accuchek nano smartview,accuchek smartview,comfor t,cartridge pump,contact detach infusion set,cartridge stamped,onetouc h ping,insulin pump,cartridge,in set infusion set,animas 2020,inset 30 tubing,infusion pump,comfort short,inset 30 infusion set,ultima,gelpad, woundgard gauze,coolmagic, triple helix collagen,foam dressing,sanizone ostomy BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 367 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value deodorant,primab ella,flexi-seal fms,little ones active life pouch,active life drainable pouch,active life urostomy pouch,sur-fit natura stomahesive,acti ve life convex,kaltostat, kaltostat fortex,active life stoma cap,active life closed-end pouch,duoderm cgf,combiderm acd,sur-fit autolock stomahesive,surfit autolock durahesive,sur-fit autolock drain pouch,sur-fit autolock pouch,sur-fit natura drainable pouch,sur-fit natura closedend pch,sur-fit natura minipouch,sur-fit natura urostomy pouch,sur-fit natura pouch,surfit natura high output,sur-fit BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 368 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value autolock,sur-fit natura durahesive,sur-fit natura flange cap,visi-flow irrigation sleeve,visi-flow irrig starter set,sur-fit nat irrig faceplate,sur-fit natura little ones,little ones drainable pouch,little ones urostomy pouch,little ones closed-end pouch,visi-flow irrigator stoma cone,carboflex,aq uacel-ag,esteem synergy,stomahe sive,durahesive moldable convex,esteem drainable pouch,little ones skin barrier,duoderm hydroactive,duod erm,visi-flow sleeve tail closures,visi-flow stoma cone,convatec night drainage tubing,sur-fit natura convex inserts,ostomy BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 369 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value appliance belt,sur-fit-act life-tail closures,aquacel, duoderm signal,versiva,ver siva xc,allkare adhesive remover wipes,allkare protect barrier wipe,flexi-trak anchoring device,unnaflex,saf-gel,sur-fit autolock inserts,sur-fit natura adaptor,sur-fit natura lowpressure,duolock curved tail closure,eakin cohesive seals,convatec night drain container,esteem + closed pouch,esteem closed pouch,natura closed pouch,esteem synergy closed pouch,flexi-seal signal fms,stomahesive skin barrier,eakin cohesive BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 370 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value slims,aquacel foam,natura durahesive skin barrier,natura stomahesive skn barrier,aquacel extra,harmonie,dr y comfort extra,tena,dry comfort,tena pants,tena classic,tena stretch ultra,tena classic plus,tena protective underwear,flexiflo ,y-port connector,flexiflo top-fill,flexiflo feeding tube,flexiflo topfill bag,enteralite infinity,flexiflo magnaport,magnaport,flexiflo overtheguidewire,flexiflo easy-feed 500,flexiflo top-fill enteral bag,flexiflo quantum,compan ion pump,durag,nasoenteric tube,embrace,em brace adapter,embrace bag set,flexiflo BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 371 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value toptainer,flexiflo feeding bag,embrace pole clamp,quantum pump,patrol,gravi ty feeding set,tranquility premium underwear,atn brief,select underwear,select disposable briefs,select underpads,diaper booster pad,tranquility topliner pads,select kids briefs,self-taking blood pressure,a.i.r.s. nebulizer,airs disposable nebulizer,airs adult aerosol mask,airs pediatric disposable mask,comp-air elite compressor syst,reusable nebulizer kit,air tube with air plugs,micro air,comp-air nebulizer compressor,peak -air,women's BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 372 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value advanced bp monitor,stethosco pe,visine for contacts,bengay moist heat therapy,ezo,avog el,sofsensor,guardian transmitter tape,guardian rt starter kit,paradigm realtime,guardian realtime,guardian rt system,replacem ent pediatric monitor,minimed reservoir,1.5 volt batteries #357,polyfin,sofset,paradigm insulin pump pathway,polyfin qr,sofserter,paradigm infusion,quick release soft teflon,sof-set micro,paradigm,p aradigm silhouette,silhoue tte,silserter,quick-set paradigm,minime d,guardian test plug,minimed infusion,medtroni c remote BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 373 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value control,paradigm remote control,paradigm insulin pump,revel programmable pump,guardian rt charger,minilink real-time transmitter,suret,sure-t paradigm,mio infusion set,senserter,supreme,te na underwear,carefr ee pantiliners,bulkee ii,day & night brief,thermometer tip covers,urological catheter,active cath,3 step skin care,step 2moisture cream,step 3moisture barrier,step 1incontinent cleanser,ultrafresh,sleeve closure clamp,irrigation syringe,enema bag with catheter,mountin g ring,elastic belt,shut off for BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 374 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 5000 enema bag,lubriwipe,compact irrigator,colostokit irrigator,hospital pack irrigator,colostom y barium enema kit,female specimen catheter,tubing for irrigator,shut off for tubing,quick disconnectconnector,insertio n tube catheter,shield for insertion tube,travel case,laird tip,freedom t-tap leg bag kit,freedom leg bag,tube & connector kit,freedom twist port leg bag kit,colostotip,colo stotip w-quick disconnect,freedo m pak seven,freedom cath,response ii,touch ii,piston ii,economy pouch,mini-drain open end pouch,doubleBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 375 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value hesive,e-z hold,gizmo foam straps,uro-san plus,clear advantage,contin ent urinary catheter,colostop ads,cone tip,dermaguard,uro-san leg bag,plastic connector,deluxe leg bag straps,comfort leg bag straps,freedom drainage bag,gizmo,bandaid activ flex,seal tight,on call plus meter,on call plus control,on call plus lancing device,on call plus lancet,on call lancet,on call lancing device,on call vivid meter,on call vivid control,tens 502,tens 504,neurostimula tion electrodes,mask set,erapid nebulizer,erapid nebulizer handset,baby conversion BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 376 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value kit,vortex vhc ladybug mask,vortex vhc frog mask,sure comfort,poly hub needle,sure comfort lancets,sure comfort lancing pen,securely yours,quickables washcloths,ezsorb,attends,atte nds undergarments,at tends insert,attends underwear,attend s guards,tissuepak, attends light insert,attends booster,attends disposable underpads,gmate control solution,gmate voice starter,gmate voice meter,gluco navii,lancing system,choicedm clarus control soln,choicedm clarus,quintet,blo od glucose control,quintet ac,nasoneb nasal nebulizer,aeroecli BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 377 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pse,aerochamber plus z stat,monaghan z stat,easy check control solution,easy step,easy plus,easy trak,easy talk,easy plus ii,maxicomfort,mini ultra-thin ii,mini lancing device,inject ease lancets,affirm underwear,affirm pads,snap pants,mesh pants,adult brief,prevail bladder control,cuties baby wipes,cuties wash cloths,prevail,was hcloths,prevail wet wipes,prevail premium washcloths,ameri can star washcloths,proca re washcloths,perso nal cloths,pant liner large plus,pant liner large,prevail BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 378 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value underwear,nu-fit brief,breezers,per -fit brief,value buy,prevail brief,prevail stretch fit,nufit underwear,prevai l simply stretch fit,prevail boxers,procare,pr evail full coverage undrwear,nufit brief,per-fit underwear,perfit brief,prevail perfit,ben-efit,prevail breezers,prevail extra underwear,prevai l bariatric,prevail super plus,prevail protective underwear,prevai l adjustable,prevail classic fit underwear,prevai l pm,prevail ultra plus,prevail ultra bladder,prevail panty liner,prevail extra plus bladder,prevail extra bladder,prevail guards for men,prevail BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 379 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pads,prevail male guard,easy check,easy comfort,easy click,easy comfort insulin syringe,propylene glycol,easy touch lancets,toe straightener,up & up pantiliners,agiegrx,erase,erase ras-pouri,geridyne,hydrophor gauze,karaya gum,hydrocollgrx,calalgingrx,calalgin-grx rope,island gardgrx,grx hydrogel gauze,grx foam dressing,bloodglucose meter,profit,quick response,freestyl e insulinx,ultratlc lancets,medisens e control,precision glucose control,embrace glucose control soln,victory,advo cate control solution,advocate blood glucose monitor,advocate rapidBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 380 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value safe,advocate lancing device,advocate lancet,advocate redicode,advocate lancets,advocate redi-code duo,advocate duo,advocate redicode+,advocate redi-code+ ctrl soln,advocate syringes,advocat e pen needles,fabric bandages,neopre ne ankle support,neoprene knee stabilizer,neopren e knee support,neoprene wrist splint,new generation,sterile bandages,droppe r,ankle supportelastic,elbow supportelastic,wrist splint support,diabetic socks,pulmoneb lt compressor nebul,clever choice control solution,clever choice hd glucose BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 381 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syst,clever choice blood gluc sys,clever chek blood glucose syst,clever chek lancets,clever choice pro,clever chek,clever choice,pharmacis t choice,clever choice micro,clever choice talk,comfort ez,fora d10,fora control solution,fora v10,fora v20,fora v22,fora g30a,fora g20,fora d15,fora d20,fora g90,fora lancing device,foracare lancets,freestyle system,freestyle sidekick ii,freestyle lancets,freestyle control solution,freestyle flash system,freestyle unistik 2,freestyle navigator,freestyl e lite meter,freestyle freedom,freestyle freedom BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 382 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lite,freestyle precision,alcohwipe,alcohglove,t:slim,e.p.t, e.p.t digital,gmate,earl y pregnancy test,test n'go,cleo 90 infusion set,snap insulin pump-infusion set,snap insulin pump controller,dover universal,caresen sn voice,gentlecath, agamatrix amp,ezvac,natura drainable pouch,esteem synergy drainable pouch,sterile nitrile gloves,aquacelag extra,amber glass bottle,clear glass serum bottle,luer lock syringe,silverseal hydrogel,optumrx ,trueresult blood glucose meter,options liners,options pads,early ovulation test,options ultra BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 383 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value thins,little darlings,band-aid plus antibiotic,medlan ce plus special blade,easy touch fluringe,easy touch insulin safety,kangaroo 924 safety screw,easy touch syr allergy tray,easy touch fluringe flu tray,prevail curve,prevail smooth fit,excilon amd,element compact control soln,eakin cohesive,easy comfort pen needles,neria multi,element compact,depend shields for men,gmate lancing device,kendall disinfectant cap,huggies slipon,on-thego,huggies snug and dry,on call vivid pal,diatrue plus,diatrue,uroc are urinary drainage,uro-con catheter,eyelid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 384 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value cleansing pads,td gold blood glucose monitor,td gold voice glucose monitor,td gold level 1 control sol,td gold level 2 control sol,td gold level 3 control sol,sheer bandage,rightest gc250s control soln,rightest gm250s meter,rightest gm260 meter,enlite glucose sensor,minimed 530g,smart sense monitoring system,relion thin,enlite serter,dexcom g5-g4 sensor,gentle touch system,gentle touch loop ostomy sys,tubigrip,tubul ar bandage applicator,tubipad ,lyofoam,lyofoam c,lyofoam a,lyofoam t,lyofoam extra,sur-fit BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 385 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value natura post op,eakin skin barrier,eakin fistula & wound pouch,pliagel,orth odiaphragm,advan ce pregnancy test,advanced care cholesterol test,opti-one,opticlean ii daily cleaner,opti-free lens case,nutriclamp w-transfer set,ascensia elite,omnitrope pen 5,personal biometric test kit,drainable adhesive pouch,baby urine collector,sharpsa-gator disposal system,insertion tray with pvp,excilon washcloth,curity maternity belts,curagel,nurs ing pads,dermicel,wa terproof tape,topper dressing sponge,surgipad, ulcer dressing,proxistrip,healthcare BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 386 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value gloves,nu-gauze sponge,elastikon, adaptic,sof-band bulky bandage,bioclusi ve,sof-wick,sofwick drain sponge,johnson & johnson filter mask,johnson's health care gloves,steripak,g auze sponge,rescue blanket,antiseptic wipes,triangular bandage,j & j first aid kit,swabs,cotton rounds,steripad,nugauze,dentotape ribbon floss,dental floss waxed,stim-udent,cartridge filling aid,arm belt,d-tron,h-tron power pack,autolet lite,back support,rib belt,pouch arm sling,wrist brace reversible,wrist brace splint,surgical binder abdom support,sacroiliac BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 387 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value brace,herniaaid,surgical stockings,compre ssion stockings,beyond support,super socks,compressi on pantyhose,athleti c supporter,cup supporter wprotector cup,suspensory,k nee comforter,curity curad flexible bandages,curity curad flexible fabric,curad ultralite,curad kid size bandages,curity underpads,bedpa n,sitz bath,urinal,cervic al pillow,cervical traction kit,wheelchair invalid ring,wheelchair cushion,crutch pad,walker tips,sport polartec,sport neoprene,tennis elbow support,curity curad adhesive bandages,curity BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 388 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value telfa non-stick pads,curity nursing pads,curity telfa adhesive pads,curity wetpruf adhesive tape,curad super soft puffs,curad gauze pads,curad stretch gauze bandage,fever thermometer,ace rubber elastic bandage,trutouch gloves,durall,sus pensory with leg straps,suspensor y w-o leg straps,adult supporter,compre ssion shorts,swimmer supporter,ace neoprene wrist brace,ace neoprene thigh brace,ace neoprene elbow brace,ace neoprene ankle brace,ace neoprene knee brace,ace neoprene plus knee brace,ace neoprene ankle BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 389 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value wrap,ace tennis elbow brace,ace ankle brace,ace knee brace,ace wrist brace,ace elastic bandage,ace elbow brace,ace plus rigid wrist brace,ace unibody supporter,ace athletic supporter,ace swim supporter,ace cup supporter,ace plus knee brace,ace sports underwrap,ace knee strap,ace elbow strap,ace bandage clips,ace athletic bandage,ace sports tape,ace instant cold compress,ace reusable cold compress,ace hot-cold compress,ace hot-cold compression wrap,ace velcro bandage,fever thermometerimprinted,sensica BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 390 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value re,tru-fit knee support,ace plastic gloves,sentinel thermometer,quic ktek,advance microdraw,advance,sel ect-lite,anti-stick insulin,anti-stick tuberculin,ventstr eam nebulizer,zoey,fir stchoice drainable pouch,everyday self-adhes catheter,firstchoic e postop drain pouch,selfadhesive catheter,advance hydro,seaband,sea-band for children,easypro, compressor nebulizer,replace ment nebulizer,replace ment air filter,healthy living,duocare,sharps disposal by mail,monoject blunt filter cannula,saline solution,sterile BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 391 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value presrv,renu saline,sensitive eyes enzymatic,lens carrying case,crayon bandage,easy read,sudacare advanced,pediac are gentle vapors,efferdent plus,efferdent,fre sh'n brite,effergrip,oha us scout sc,iv transfer needles,venting pin,ez-lets,insultote,dermagran,la dy lite,hard contact lens cleaner,hard contact lens soak,hard contact lens wet,kotex,kotex lightdays,new freedom lightdays,kotex new freedom,lil swimmer small pant,lil swimmer medium pant,lil swimmer large pant,poise,depen d belted shields,huggies overnite,huggies newborn,huggies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 392 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value convertibles,pelvi c muscle trainer,babytherm pacifier thermometer,inco ntinent liner,dignity regular,dignity extra-duty,dignity regular duty,dignity natural extra,dignity diaper,dignity underpad,free & active super,dignity,dign ity plus,dignity plus liners,briefmates, prevent plus,dignity plus fitted brief,dignity plus regular brief,lady dignity plus brief,sir dignity plus brief,inhaler companions,asth ma control,interlink,w rist immobilizer,delux e wrist brace,ultra thin,water-proof bandages,plastic strip,heartstart,cli p& stor,fibracol,kling BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 393 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value fluff,sofkling,sheet protector,precisio n link,elta dermal,actis,rese rvoir,brief youth,promise pad,coverlet eye occlusor,real-time starter kit,ultrasoft plus,ultra-soft classic,protection plus underpad,protecti on plus,protection plus classic,home access hiv-1 test system,ultima tuckables,cairpad ,ultima incontinence,adh eres,tuffsorb,tuck ables,attends washcloths,preva il fits to a t,youth brief,adult frontal tape brief,prevail pre-moist bath cloth,pant liners,xtremefit brief,ultrathin,sto mahesive sterile wafer,sur-fit drainage container,sur-fit night drainage tubing,allkare adhesive remover BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 394 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value wipe,active life,little ones surfit ped belt,sur-fit tail closures,active life pouch,optipore,s etopress high compression,surfit natura irrig sleeve,flexiseal,active life one-piece,sur-fit natura visi-flow set,unna-flex plus,clerz-2 lubricatingrewetting,clerz2,mirasept,miras ept step 1,mirasept step 2,unisol 25 day pf saline,unisol plus,opti-one multipurpose,opticlean daily cleaner,preflex,sa line for sensitive eyes,alcon enzymatic,flexcare,opti-soak conditioning,optitears,opti-soak daily,opti-soak soothing drops,fact plus pregnancy test,primary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 395 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pump set,nylon epidural catheter,ls plum secondary setol,ivex-hp administration set,venoset-100 prim pigbk-ivexhp,screw cap set 38mm,fat emulsion iv set,primary iv setsl,soluset wpediatric ivex sl,venoset 100 piggyback wclamp,lifecare controller model 1000,lifecare pump set,lifecare model 4 macro pump,pca pump,nonvented iv set 100 with cair,venoset microdrip,lifecare 1025 controller,lc 1050 controller,flow detector 30inch,flow detector 54inch,lifecare pump,lifecare micro pump 1a,lifecare micro pump,controller lifecare model 75,pca plus BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 396 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 2,lifecare 75 flow detector,solusetivex-2 filter & cair,dual i.v. stand adapter,i.v. stabilizer bar,i.v. clip adapter,i.v. stand-pole assembly,i.v. stand-base assembly,blood set 64 with cair clamp,blood set 78 with cair clamp,blood ytype set wpump,single shot epidurallidocaine,lifecare 1050 drop detector,enteral set with container,inpersol w-o auto shutoff valv,inpersol-auto shutoff valve,plumset speciality pump set-ol,plum lifecare 5000 infuser,site-care kit,ivex h.p. pediatric exten set,nonvented secondary iv set,venoset piggyback-mb pin-clmp,pca miniBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 397 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value bore,batteries, six volt (pair),primary iv set-sl with ivexhp,500ml pressure infusion cuff,pressure infusion cuff,burette nv inline set wport,venoset dual-rate pgbkivex-2,cvc kit,venoset piggyback w-ivex filtr,lifecare shelf storage tray,primary piggyback nv ib set-sl,cvp manometer,drum -cartridge catheter,provider pump set,butterfly s.t. 19x7/8.31/2tbg,pca injector,flip-top additive cap,pump set wproximal male adapt,butterfly st,venous cannulation tray,blood set wcair clamp,tidal joint irrigation tray,cont epidural tray w-drugs,cont epidural-lido-epi BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 398 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value t-dose,cont epidural tray,spinal-22bupiv-dex-ephedepi,spinal-25bupiv-dex-ephedepi,spinalanesthesia tray,cont epidural-bupivlidocaine,inpersol peritoneal tray,caudal wlidocaineepinephrine,spina l-22-tet-ephedepi-iodine,nerve block tray wlidocaine,local infiltration wlidocaine,spinal25 w-tetra-ephedepi,saddle block anesthesia tray,saddleblock anesthesia tray,spinal-22 whitacre w-lidodext,spinal whitacre anesthesia,cont epidural w-poviodine,lumbar puncture adult,lifecare adds rack,primary piggybackconv,d ual injection BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 399 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value site,male adapter plug w-inj site,male luer cap,dual luer cap,plum lc 5000 primary setsl,plum microdrip soluset,extension set with luer lock,plum lc 5000 primary set,plum lc 5000 microdrip set-nv,plum lc 5000 with ivex,pca set-long minibore,venoset 100 soluset,pentothal dispensing cap,catheter adapter-luer plug,venoset nv piggybk micrdrp,crimping tool,transfer lok,blood set 64 w-cair & needle,hemoset 100x10 with cair clamp,blood set w-pump & cair clamp,blood surgical y-type set-clmp,blood ytype set 66-cair clamp,continuous pediatric caudal,cont epidural w-lidoBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 400 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value epi-iodin,lifecare microdrip pump set,nitroglycerin micro pump set,screw cap (40mm) set,lifecare 5000 syringe adapter,lifecare 5000 vial adapter,hema blood 30 set,bufpuf,buf-puf bodymate,buf-puf sponge,buf-puf gentle,microlet vaculance,accus ure,opti-zyme enzymatic cleaner,bard irrigation tray,3m cold-hot pack,home care underpads,takeoff,conform stretch bandage,coets,d ermilite-ii paper tape,dermicel hypo-allergenic tape,dermilite ii hypoallergenic,dermicl ear,kling bandage,waterga rd,insertion tray with bzk,foley cath silicone retn,curity foley BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 401 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 2-way ped cath,folding walker,walker wheels,cervical soft collar,molicare classic brief,ultra soft,dry time diaper,protection plus liner,economy underpad,peg elastic bandage,reston2,iamin,osmocyte ,dressing,digital therm probe cover,hypotherm thermometer,bd genie lancet,ace wrist brace with splint,ace lumbar support,statlet,disgard sharps pad,kangaroo 1000ml pump set,glucoleader,le a's shield,saline solution, unpreserved,hyp o-clear,lens lubricant,disinfect ing solution,quiksept,renu weekly cleaner,concentr ated cleaner,wetting & soaking solution,super BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 402 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value denture adhesive,disinfec ting unit,compact disinfecting unit,fashion case,lens cup,snug denture cushions,thermod ent,contact lens conditioning,niteti me,interdental stimulators,extra absorbent shield,wild hot strips,napkin hospital tabbed,foot and shoe padding,bed pad,sudacare,chil dren's sudacare,rgp wetting and soaking,rigid gas permeable cleaner,lubricatin g drops,htronplus adapter,h-tron plus-piston rod,htron plus,catheter tip cap,winged,chem oplus dispensing pin,p2 hi-risk,p2 safety plus,p2 safety plus powder free,p2 hi-risk powder BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 403 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value free,pro star powder free,oncology plus,chemoplus powder free,chemoplus,d ust-mist respirator mask,chemosafet y container,u.v. protection bags,spill proof prep mat,safelock bags,chemowast e bags,chemolinen waste bags,chemolinen hamper stand,chemowast e hamper stand,chemosafet y prep admin,personnel protection,multimix,designer,che mo plus,chemo spill kit,trudent,wetstop,dermastat,n utrastat,dermacol ,nutracol,dermasi te,sanitizer bottle,autolancet,sensitive teeth,tartar control,depend elastic leg undergarmnt,dep BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 404 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value end fitted brief,goodnite,hu ggies snuggems,huggie s convertible clip strip,huggies supreme,first choice thin lancets,slipon,entrust plus undergarment,br east pump,nebulizer,fil ters,mask,sphyg momanometer,ad apter w-disp mouthpiece,mout hpiece for truzone peak fl,mask, pediatric,proneb, pep pressure monitor,bubbles the fish,pep nebulizer,lc nebulizer,nite train'r,empty viaflex-y-transfer set,sub-q set,empty viaflex container,bed underpads,contro l pads,clear spots,7 day pill box,fancy pill box,pill pal,one weektoday,rubber finger,dosage BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 405 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value spoon,dosage syringe,dosage dropper,hot & cold wrap,super absorbent underwear,ultrathin underwear,polyrayon,3m paper pre-cut tape strips,clear first aid tape,active strips,waterproof adhesive,foam sports tape,3m non-stick pads,heat comfort,e.p.t. stick test,barrier sterile field,biopatch,nubrede,topper,tiell e,bioclusive select,bioclusive select mvp,bioclusive mvp select,nu-gel collagen,algosteri l,nu-gel,raytec,soffoam,band-aid island surgical,zonas,de rmiview,dermifor m,tielle plus,kling conforming gauze bandage,dynaflex,ultralon BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 406 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pf,maxxus pf,micro-touch pf,allergard,neutr alon 50,maxxus,neutr alon,microtouch,microtouch xp,sofloop,surgine,barri er,surgine ii,barrier n95,protectivw,protectiv plusw,biovue,protecti v,lister's suture removal kit,barrier fenestrated strl field,preptic shave prep,preptic 2 shave prep,chix,sofnet,d aylee,preptic,prevac are,autolancet device wlancets,ultratlc lancetsdevice,pocketcar e irrigator,e-z spacer mask,e-z spacer & mask,supreme glucose control,supreme meter,simplechoi ce,simplechoice quick,md BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 407 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value turbo,aerochamb er plus,airs pediatric aerosol mask,continuous glucose sensor,evacare pessary,relion blood pressure cuff,muppet strips,cleaning solution,wetting solution for hard lens,nonpreserved saline,oragrip,ho me pregnancy test,absorbent shield,poison first aid kit,facial cleansing sponge,pill divider,shave cream,blade double edge,lady's shaver plus lube strip,weekly pill planner,effervesc ent denture cleansr,effervesc ent denture,premier adult brief,safe klean,one-step blood pressure monitr,precision sof-tact,precision q-i-d,dental floss unwaxed,mercury BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 408 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value klean kit,enlite,well beginnings diapers,novopen echo,filtered extension set,rate flow regulator iv set,aerobika,accu -chek compact plus control,soothene b mesh nebulizer,onetouc h verio sync,unistrip,iport advance,hydrofer a blue,foracare gdh,acticoat site,acticoat moisture control,acticoat flex 7,acticoat flex 3,allevyn life,embrace pro,embrace evo,kendall foam border,luer slip tip cap,luer-lock syringe,amber oral-topical syringe,slip-tip syringe,caresens prem lancing device,carelance ult lancing device,acticoat surgical,luer slip tip syringe BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 409 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tray,md pump actuator b,md pump actuator a,on call express meter,on call express control soln,athletic tape,healthpro glucose monitor,healthpro glucose control soln,md pump bottle airless,md pen airless,md syringe airless,md jar airless,biostep ag,space chamber plus,compact space chamber plus,ems antiembolism stocking,allevyn adhesive,biostep, allevyn sacrum,allevyn ag adhesive,icy hot smart relief tens,icy hot smart relief tens pads,ear-loop mask,temple touch mini thermometer,pur ple nitrile gloves,allevyn ag gentle,allevyn ag,prevail BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 410 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value breezers 360,allevyn gentle border,temple touch prem thermometer,adv anced glucose meter,allevyn gentle border lite,carefine pen needle,allevyn gentle border sacrum,allevyn gentle border heel,allevyn gentle border multisit,microbore extension set,prevail per-fit 360,clear tape,transparent film dressing,gmate smart starter,gmate smart meter,true metrix blood glucose mtr,true metrix,vascuderm hydrogel wound,huggies pure & natural,varithena administration pack,band-aid gauze pads,band-aid rolled gauze,band-aid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 411 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value non-stick pads,band-aid mirasorb gauze sponge,band-aid surgipad dressing,bandaid cloth tape,band-aid paper tape,bandaid waterproof tape,sterile amber glass vial,aeroneb go,slip on knee,band-aid hurt-free,bandaid tough pads,band-aid secureflex,innospire deluxe,band-aid waterproof pad,innospire mini,novofine plus,fora test n'go voice,cuticerin,m egapumpblue,fora gd50,primer modified unna boot,fortiscare blood glucose syst,fortiscare,tel care bgm,nighttime underpants,allevy n tracheostomy,cuti nova BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 412 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value hydro,durafiber,re plicare thin,allevyn thin,surgical pads,iv3000 frame delivery,md pump actuator c,bardex lubricath foley,inspiracham ber,mepitel,aeron eb go nebulizer,lanzo,al gicell ag,bioguard gauze,bioguard packing,bioguard nonadherent,bioguar d island,fc2 female condom,hydress, aquacel ag foam,element compact v,fora test n'go bp,aquacel ag foam heel,aquacel ag foam sacral,aquacel foam sacral,devilbiss pulmoneb lt compneb,prodigy autocode,assure prism multi,glucocard shine,assure BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 413 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lance plus,esteem synergy+,sterile droptainers,assur e prism,animas vibe,sensi-care adhes remover wipes,relief knee open toe,apogee hc intermittent,unisti k safety,true metrix air glucose meter,hydrofera blue ready,push button safety lancets,t:flex,well beginnings training pants,caya contoured,estee m+ durahesive plus,esteem+ drainable pouch,urocare fabric leg straps,drymax extra,pentips,acc u-chek aviva connect,thumb support,tegaderm hydrogel,flexicha mber,goodnites tru-fit,medihoney hcs,dermagran hydrophilic wound,cool mist humidifier,mistas sist BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 414 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value kit,humatropen,m istassist,dexcom g5,fora v10-v12d10d20,evencare mini monitor system,evencare mini glucose control,tens replacement back pads,tens replacement body pads,luer tip cap tray,t:90,t:slim g4,dry time training pants,bioguard conforming,jobst anti-embolism stocking,jobst ultrasheer,fora tn'g voice,capri bladder control pads,prevail purseready,oneto uch verio flex,fora lancets,droplet pen needle,blood lancets,easy touch unislip,easy touch fliplock syringes,aerovent plus,linktemp,free style precision neo meter,fora d40,easy touch fliplock BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 415 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value needle,easy touch fliplock needles,easy touch fliplock syringe,vacustim black,tegaderm + pad,advanced healing bandage,advanc ed healing pad,easy touch sheathlock syringe 02/06/2016 naturethyroid,pork,thyroid throid,westhroid, westhroid-p,wp thyroid,thyroid CHANGE TIER Non-Formulary 02/06/2016 SILAZONE-II triamcinolone acetonide/silicones REMOVE FROM FORMULARY Non-Formulary 02/06/2016 visbiome lactobacillus no.2/s.thermophilus/bifidoba cterium no.1 ADD TO FORMULARY Non-Formulary 02/06/2016 BOTRYTIS allergenic extract-botrytis cinerea ADD TO FORMULARY Non-Formulary 02/06/2016 MIXED ASPERGILLUS allergenic extractaspergillus,mixed ADD TO FORMULARY Non-Formulary 02/06/2016 XURIDEN uridine triacetate ADD TO FORMULARY Non-Formulary 02/06/2016 XURIDEN uridine triacetate ADD TO FORMULARY Non-Formulary 02/08/2016 cetirizine hcl cetirizine hcl ADD TO FORMULARY Generics 02/08/2016 cetirizine hcl cetirizine hcl ADD TO FORMULARY Generics 02/08/2016 cetirizine hcl cetirizine hcl ADD TO FORMULARY Generics 02/08/2016 cetirizine hcl cetirizine hcl ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 416 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 02/08/2016 cetirizine hcl cetirizine hcl 02/08/2016 ZEPATIER 02/08/2016 Type of Change Previous Value New Value ADD TO FORMULARY Generics elbasvir/grazoprevir ADD UM: CUSTOM Harvoni, Sovaldi are covered ZEPATIER elbasvir/grazoprevir ADD UM: STEP ST applies 02/08/2016 drospirenoneethinyl estradiol ethinyl estradiol/drospirenone ADD UM: GENDER Female 02/08/2016 ZEPATIER elbasvir/grazoprevir ADD UM: SPECIALTY Specialty Drug 02/10/2015 GRANIX tbo-filgrastim ADD TO FORMULARY Non-Formulary 02/10/2015 GRANIX tbo-filgrastim CHANGE UM: SPECIALTY Specialty Drug 02/10/2015 GRANIX tbo-filgrastim CHANGE UM: AUTHORIZATION PA applies 02/10/2015 GRANIX tbo-filgrastim ADD TO FORMULARY Non-Formulary 02/10/2015 GRANIX tbo-filgrastim ADD UM: SPECIALTY Specialty Drug 02/10/2015 GRANIX tbo-filgrastim ADD UM: AUTHORIZATION PA applies 02/10/2015 neuvaxin capsaicin/menthol ADD TO FORMULARY Generics 02/10/2015 aflexeryl-mc capsaicin/menthol ADD TO FORMULARY Generics 02/10/2015 ZUBSOLV buprenorphine hcl/naloxone hcl ADD TO FORMULARY Non-Formulary 02/10/2015 SINELEE capsaicin/menthol ADD TO FORMULARY Non-Formulary 02/10/2015 MINIVELLE estradiol 02/10/2015 EVOTAZ atazanavir sulfate/cobicistat ADD TO FORMULARY Non-Formulary 02/10/2015 DUOPA carbidopa/levodopa ADD TO FORMULARY Non-Formulary 02/10/2015 PREZCOBIX darunavir ethanolate/cobicistat ADD TO FORMULARY Preferred Brands 02/10/2015 MOVANTIK naloxegol oxalate ADD TO FORMULARY Non-Formulary 02/10/2015 MOVANTIK naloxegol oxalate ADD TO FORMULARY Non-Formulary 02/10/2015 GLYXAMBI empagliflozin/linagliptin ADD TO FORMULARY Non-Formulary CHANGE TIER Generics Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 417 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/10/2015 GLYXAMBI empagliflozin/linagliptin ADD TO FORMULARY Non-Formulary 02/10/2015 IBRANCE palbociclib ADD TO FORMULARY Preferred Brands 02/10/2015 IBRANCE palbociclib ADD TO FORMULARY Non-Formulary 02/10/2015 IBRANCE palbociclib ADD TO FORMULARY Non-Formulary 02/10/2015 COSENTYX secukinumab SYRINGE,COSE NTYX (2 SYRINGES) ADD TO FORMULARY Non-Formulary 02/10/2015 COSENTYX secukinumab SYRINGE,COSE NTYX (2 SYRINGES) ADD UM: SPECIALTY Specialty Drug 02/10/2015 COSENTYX secukinumab SYRINGE,COSE NTYX (2 SYRINGES) ADD UM: AUTHORIZATION PA applies 02/10/2015 COSENTYX PEN secukinumab (2 PENS),COSENT YX PEN ADD TO FORMULARY Non-Formulary 02/10/2015 COSENTYX PEN secukinumab (2 PENS),COSENT YX PEN ADD UM: SPECIALTY Specialty Drug 02/10/2015 COSENTYX PEN secukinumab (2 PENS),COSENT YX PEN ADD UM: AUTHORIZATION PA applies 02/10/2015 FOCALIN XR 02/10/2015 TRICARE pnv no.20/iron PRENATAL DHA fumarate/fa/docusate na/fish ONE oil conc/dha/epa dexmethylphenidate hcl CHANGE TIER Preferred Brands ADD TO FORMULARY Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 418 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/10/2015 DONNATAL phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb ADD TO FORMULARY Non-Formulary 02/10/2015 DONNATAL phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb ADD TO FORMULARY Non-Formulary 02/11/2015 dexmethylphenid dexmethylphenidate hcl ate hcl er ADD TO FORMULARY Generics 02/11/2015 dexmethylphenid dexmethylphenidate hcl ate hcl er ADD TO FORMULARY Generics 02/11/2015 lanzo lancing device/lancets REMOVE FROM FORMULARY Non-Formulary 02/11/2015 adapter cap adapter cap for bottle REMOVE FROM FORMULARY Non-Formulary 02/11/2015 adapter cap adapter cap for bottle REMOVE FROM FORMULARY Non-Formulary 02/11/2015 adapter cap adapter cap for bottle REMOVE FROM FORMULARY Non-Formulary 02/11/2015 adapter cap adapter cap for bottle REMOVE FROM FORMULARY Non-Formulary 02/11/2015 adapter cap adapter cap for bottle REMOVE FROM FORMULARY Non-Formulary 02/11/2015 adapter cap adapter cap for bottle REMOVE FROM FORMULARY Non-Formulary 02/11/2015 adapter cap adapter cap for bottle REMOVE FROM FORMULARY Non-Formulary 02/11/2015 adapter cap adapter cap for bottle REMOVE FROM FORMULARY Non-Formulary 02/11/2015 easy comfort pen pen needle, diabetic needles REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 419 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/11/2015 RELAGESIC acetaminophen/phenyltoloxa mine citrate REMOVE FROM FORMULARY Non-Formulary 02/11/2015 ONE-A-DAY TEEN HIM VITACRAVES pediatric multivitamin no.89/cholecalciferol/phyton adione REMOVE FROM FORMULARY Non-Formulary 02/11/2015 antacid calcium carbonate/magnesium hydroxide REMOVE FROM FORMULARY Non-Formulary 02/11/2015 despec-dm guaifenesin/dextromethorph an hbr/pseudoephedrine hcl REMOVE FROM FORMULARY Non-Formulary 02/11/2015 biotin plus keratin biotin/keratin REMOVE FROM FORMULARY Non-Formulary 02/11/2015 antacid calcium carbonate/magnesium hydroxide REMOVE FROM FORMULARY Non-Formulary 02/11/2015 antacid calcium carbonate/magnesium hydroxide REMOVE FROM FORMULARY Non-Formulary 02/11/2015 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/11/2015 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/11/2015 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/11/2015 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/11/2015 children's allergy fexofenadine hcl relief REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 420 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/11/2015 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/11/2015 daily vitamin formula + iron multivitamin/ferrous fumarate/folic acid REMOVE FROM FORMULARY Non-Formulary 02/11/2015 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/11/2015 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/11/2015 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/11/2015 daily vitamin formula + iron multivitamin/ferrous fumarate/folic acid REMOVE FROM FORMULARY Non-Formulary 02/11/2015 little remedies stuffy nose sodium chloride REMOVE FROM FORMULARY Non-Formulary 02/11/2015 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/11/2015 CYKLOKAPRON tranexamic acid REMOVE FROM FORMULARY Non-Formulary 02/11/2015 CYKLOKAPRON tranexamic acid REMOVE FROM FORMULARY Non-Formulary 02/11/2015 PRECEDEX dexmedetomidine hcl in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 02/13/2016 lido-k lidocaine hcl ADD TO FORMULARY Generics 02/13/2016 multi-lancet lancing device/lancets ADD TO FORMULARY Generics 02/13/2016 topcare lancets universal1 lancet ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 421 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 02/13/2016 FUSARIUM 02/13/2016 Generic Name allergenic extract-fusarium oxysporum Type of Change Previous Value New Value REMOVE FROM FORMULARY Non-Formulary albumin (human) albumin human REMOVE FROM FORMULARY Non-Formulary 02/13/2016 CLAFORANDEXTROSE cefotaxime sodium/dextrose, iso-osmotic REMOVE FROM FORMULARY Non-Formulary 02/13/2016 CLAFORANDEXTROSE cefotaxime sodium/dextrose, iso-osmotic REMOVE FROM FORMULARY Non-Formulary 02/13/2016 amitriptyline hcl amitriptyline hcl REMOVE FROM FORMULARY Non-Formulary 02/13/2016 amitriptyline hcl amitriptyline hcl REMOVE FROM FORMULARY Non-Formulary 02/13/2016 amitriptyline hcl amitriptyline hcl REMOVE FROM FORMULARY Non-Formulary 02/13/2016 amitriptyline hcl amitriptyline hcl REMOVE FROM FORMULARY Non-Formulary 02/13/2016 cyclobenzaprine hcl cyclobenzaprine hcl REMOVE FROM FORMULARY Non-Formulary 02/13/2016 cyclobenzaprine hcl cyclobenzaprine hcl REMOVE FROM FORMULARY Non-Formulary 02/13/2016 cyclobenzaprine hcl cyclobenzaprine hcl REMOVE FROM FORMULARY Non-Formulary 02/13/2016 cyclobenzaprine hcl cyclobenzaprine hcl REMOVE FROM FORMULARY Non-Formulary 02/13/2016 gabapentin gabapentin REMOVE FROM FORMULARY Non-Formulary 02/13/2016 gabapentin gabapentin REMOVE FROM FORMULARY Non-Formulary 02/13/2016 gabapentin gabapentin REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 422 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/13/2016 gabapentin gabapentin REMOVE FROM FORMULARY Non-Formulary 02/13/2016 bupivacaine hclepinephrine bupivacaine hcl/epinephrine/pf REMOVE FROM FORMULARY Generics Non-Formulary 02/13/2016 bupivacaine hclepinephrine bupivacaine hcl/epinephrine/pf REMOVE FROM FORMULARY Generics Non-Formulary 02/13/2016 calcium citrate-vit calcium d3 citrate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/13/2016 PREVNAR 13 pneumococcal 13-valent conjugate vaccine (diphtheria crm)/pf REMOVE FROM FORMULARY Non-Formulary 02/13/2016 nighttime cough dextromethorphan hbr/doxylamine succinate REMOVE FROM FORMULARY Non-Formulary 02/13/2016 BETADINE povidone-iodine REMOVE FROM FORMULARY Non-Formulary 02/13/2016 BETADINE povidone-iodine REMOVE FROM FORMULARY Non-Formulary 02/13/2016 CARTICEL autologous cult. chondrocytes REMOVE FROM FORMULARY Non-Formulary 02/13/2016 chorionic gonadotropin chorionic gonadotropin, human REMOVE FROM FORMULARY Non-Formulary 02/13/2016 butylene glycol 1,3-butanediol REMOVE FROM FORMULARY Non-Formulary 02/13/2016 butylene glycol 1,3-butanediol REMOVE FROM FORMULARY Non-Formulary 02/13/2016 butylene glycol 1,3-butanediol REMOVE FROM FORMULARY Non-Formulary 02/13/2016 butylene glycol 1,3-butanediol REMOVE FROM FORMULARY Non-Formulary 02/16/2015 SOTYLIZE sotalol hcl ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 423 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/16/2015 SOTYLIZE sotalol hcl ADD TO FORMULARY Non-Formulary 02/16/2015 OTEZLA apremilast ADD TO FORMULARY Non-Formulary 02/16/2015 pramipexole er pramipexole di-hcl ADD TO FORMULARY Generics 02/16/2015 pramipexole er pramipexole di-hcl ADD TO FORMULARY Generics 02/16/2015 idealbase cream base no.186 REMOVE FROM FORMULARY Non-Formulary 02/16/2015 algicell ag silver/calcium alginate REMOVE FROM FORMULARY Non-Formulary 02/16/2015 BIOGAIA PROTECTIS lactobacillus reuteri/cholecalciferol (vit d3) REMOVE FROM FORMULARY Non-Formulary 02/16/2015 ALIVIO capsaicin/menthol REMOVE FROM FORMULARY Non-Formulary 02/16/2015 ALKA-SELTZER dextromethorphan/pseudoe PLUS phrine COLD+FLU hcl/acetaminophen/doxylami ne REMOVE FROM FORMULARY Non-Formulary 02/16/2015 peg3350 polyethylene glycol 3350 REMOVE FROM FORMULARY Non-Formulary 02/16/2015 probioticdigestive enzymes lactobacillus acidophilus/digestive enzymes combo no.5 REMOVE FROM FORMULARY Non-Formulary 02/16/2015 men's multivitamin multivitamin with minerals/folic acid REMOVE FROM FORMULARY Non-Formulary 02/16/2015 women's multivitamin multivitamin with minerals/folic acid REMOVE FROM FORMULARY Non-Formulary 02/16/2015 remedy phytoplex miconazole nitrate antifungal REMOVE FROM FORMULARY Non-Formulary 02/16/2015 remedy phytoplex miconazole nitrate antifungal REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 424 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/16/2015 MIRAPEX pramipexole di-hcl ADD TO FORMULARY Non-Formulary 02/16/2015 MIRAPEX pramipexole di-hcl ADD TO FORMULARY Non-Formulary 02/16/2015 MIRAPEX pramipexole di-hcl ADD TO FORMULARY Non-Formulary 02/16/2015 MIRAPEX pramipexole di-hcl ADD TO FORMULARY Non-Formulary 02/16/2015 MIRAPEX pramipexole di-hcl ADD TO FORMULARY Non-Formulary 02/20/2016 diazepam diazepam ADD TO FORMULARY Generics 02/20/2016 diazepam diazepam ADD TO FORMULARY Generics 02/20/2016 cyclopentolate hcl cyclopentolate hcl ADD TO FORMULARY Generics 02/20/2016 bitterness reducing agent flavoring agent REMOVE FROM FORMULARY Non-Formulary 02/20/2016 bitterness reducing agent flavoring agent REMOVE FROM FORMULARY Non-Formulary 02/20/2016 bitterness reducing agent flavoring agent REMOVE FROM FORMULARY Non-Formulary 02/20/2016 formoterol fumarate formoterol fumarate dihydrate, micronized REMOVE FROM FORMULARY Non-Formulary 02/20/2016 UROAV-81 methenamine/methylene blue/sod phos/p.salicylate/hyoscyami ne ADD TO FORMULARY Non-Formulary 02/20/2016 cool glucose test blood sugar diagnostic strip ADD TO FORMULARY Non-Formulary 02/20/2016 cool blood glucose meter blood-glucose meter ADD TO FORMULARY Non-Formulary 02/20/2016 KIDSTART pediatric multivitamin combination no.121 REMOVE FROM FORMULARY Non-Formulary 02/20/2016 b-12 cyanocobalamin (vitamin b12) REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 425 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/20/2016 VRAYLAR cariprazine hcl ADD TO FORMULARY Non-Formulary 02/20/2016 VRAYLAR cariprazine hcl ADD TO FORMULARY Non-Formulary 02/20/2016 VRAYLAR cariprazine hcl ADD TO FORMULARY Non-Formulary 02/20/2016 VRAYLAR cariprazine hcl ADD TO FORMULARY Non-Formulary 02/20/2016 OTIPRIO ciprofloxacin ADD TO FORMULARY Non-Formulary 02/20/2016 VRAYLAR cariprazine hcl ADD TO FORMULARY Non-Formulary 02/20/2016 ALLZITAL butalbital/acetaminophen ADD TO FORMULARY Non-Formulary 02/20/2016 cardioplegia del nido formula cardioplegic solution no.16 REMOVE FROM FORMULARY Non-Formulary 02/23/2015 OTEZLA apremilast ADD UM: AUTHORIZATION PA applies 02/23/2015 OTEZLA apremilast ADD UM: SPECIALTY Specialty Drug 02/23/2015 OTEZLA apremilast CHANGE TIER Preferred Brands Non-Formulary 02/23/2015 OTEZLA apremilast CHANGE TIER Preferred Brands Non-Formulary 02/24/2015 LENVIMA lenvatinib mesylate ADD TO FORMULARY Non-Formulary 02/24/2015 LENVIMA lenvatinib mesylate ADD UM: SPECIALTY Specialty Drug 02/27/2016 CEFOTAN cefotetan disodium REMOVE FROM FORMULARY Non-Formulary 02/27/2016 CEFOTAN cefotetan disodium REMOVE FROM FORMULARY Non-Formulary 02/27/2016 CEFOTAN cefotetan disodium REMOVE FROM FORMULARY Non-Formulary 02/27/2016 fyavolv norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative 02/27/2016 fyavolv norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative 02/27/2016 fyavolv norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 426 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/27/2016 fyavolv norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative 02/27/2016 fyavolv norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative 02/27/2016 fyavolv norethindrone acetateethinyl estradiol ADD TO FORMULARY Preventative 02/27/2016 benzphetamine hcl benzphetamine hcl ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 unilet lancets lancets ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 427 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/27/2016 easy touch sheathlock syringe syringe, disposable, 3 ml REMOVE FROM FORMULARY Non-Formulary 02/27/2016 dipropylene glycol dipropylene glycol REMOVE FROM FORMULARY Non-Formulary 02/27/2016 dipropylene glycol dipropylene glycol REMOVE FROM FORMULARY Non-Formulary 02/27/2016 dipropylene glycol dipropylene glycol REMOVE FROM FORMULARY Non-Formulary 02/27/2016 dipropylene glycol dipropylene glycol REMOVE FROM FORMULARY Non-Formulary 02/27/2016 easy touch hypodermic needle needles, disposable REMOVE FROM FORMULARY Non-Formulary 02/27/2016 easy touch hypodermic needle needles, disposable REMOVE FROM FORMULARY Non-Formulary 02/27/2016 easy touch hypodermic needle needles, disposable REMOVE FROM FORMULARY Non-Formulary 02/27/2016 easy touch hypodermic needle needles, disposable REMOVE FROM FORMULARY Non-Formulary 02/27/2016 hexylene glycol hexylene glycol REMOVE FROM FORMULARY Non-Formulary 02/27/2016 hexylene glycol hexylene glycol REMOVE FROM FORMULARY Non-Formulary 02/27/2016 hexylene glycol hexylene glycol REMOVE FROM FORMULARY Non-Formulary 02/27/2016 hexylene glycol hexylene glycol REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 428 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/27/2016 easy touch fliplock insulin syringe with needle, insulin, safety, 1 ml ADD TO FORMULARY Generics 02/27/2016 easy touch fliplock insulin syringe with needle, insulin, safety, 1 ml ADD TO FORMULARY Generics 02/27/2016 easy touch fliplock insulin syringe with needle, insulin, safety, 1 ml ADD TO FORMULARY Generics 02/27/2016 easy touch fliplock insulin syringe with needle, insulin, safety, 1 ml ADD TO FORMULARY Generics 02/27/2016 window bandages transparent dressing REMOVE FROM FORMULARY Non-Formulary 02/27/2016 testosterone micronized testosterone micronized REMOVE FROM FORMULARY Non-Formulary 02/27/2016 testosterone micronized testosterone micronized REMOVE FROM FORMULARY Non-Formulary 02/27/2016 testosterone micronized testosterone micronized REMOVE FROM FORMULARY Non-Formulary 02/27/2016 testosterone micronized testosterone micronized REMOVE FROM FORMULARY Non-Formulary 02/27/2016 testosterone micronized testosterone micronized REMOVE FROM FORMULARY Non-Formulary 02/27/2016 testosterone micronized testosterone micronized REMOVE FROM FORMULARY Non-Formulary 02/27/2016 omega-3 flaxseed oil flaxseed oil REMOVE FROM FORMULARY Non-Formulary 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 429 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 techlite pen needle pen needle, diabetic ADD TO FORMULARY Generics 02/27/2016 easy touch luer lock insulin syringe w-o needl,insulin,1 ml ADD TO FORMULARY Generics 02/27/2016 FIBER 6 bran/guar gum/fiber/cellulose/psyllium seed/kelp/apple pectn REMOVE FROM FORMULARY Non-Formulary 02/27/2016 LACTO-PECTIN lactobacillus combo no.33/bifidobacterium breve and longum REMOVE FROM FORMULARY Non-Formulary 02/27/2016 RHINOCORT ALLERGY budesonide REMOVE FROM FORMULARY Non-Formulary 02/27/2016 RHINOCORT ALLERGY budesonide REMOVE FROM FORMULARY Non-Formulary 02/27/2016 RHINOCORT ALLERGY budesonide REMOVE FROM FORMULARY Non-Formulary 02/27/2016 RHINOCORT ALLERGY budesonide REMOVE FROM FORMULARY Non-Formulary 02/27/2016 PURAMINO TODDLER nutritional therapy for impaired digestive function REMOVE FROM FORMULARY Non-Formulary 02/27/2016 SIMILAC ALIMENTUM infant form. iron, lactose free/dha/arachidonic acid (ara) REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 430 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 02/27/2016 SIMILAC ALIMENTUM infant form. iron, lactose free/dha/arachidonic acid (ara) REMOVE FROM FORMULARY Non-Formulary 02/27/2016 EYEPROTECT beta-carotene/ascorbic ac/vite ac (d,toco)/zinc ox/cupric ox REMOVE FROM FORMULARY Non-Formulary 02/27/2016 vitamin d3 cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/27/2016 vitamin d3 cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 02/27/2016 melatonin + ltheanine melatonin/herbal complex no.184 REMOVE FROM FORMULARY Non-Formulary 02/27/2016 joint health cartilage/collagen type ii/boron glycinate/hyaluronate sod REMOVE FROM FORMULARY Non-Formulary 02/27/2016 STANDARD allergenic extract-sweet SWEET VERNAL vernal, standardized GRASS REMOVE FROM FORMULARY Non-Formulary 02/27/2016 VISTOGARD uridine triacetate REMOVE FROM FORMULARY Non-Formulary 02/27/2016 VISTOGARD uridine triacetate REMOVE FROM FORMULARY Non-Formulary 02/27/2016 FLORIVA PLUS pediatric multivitamin combination no.130/sodium fluoride REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 431 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates March, 2016 Effective Date Brand Name Generic Name Type of Change Previous Value New Value Preferred Brands Non-Formulary 03/01/2016 CYCLOGYL cyclopentolate hcl CHANGE TIER 03/01/2016 cyclopentolate hcl cyclopentolate hcl ADD TO FORMULARY 03/03/2015 trandolaprilverapamil er trandolapril/verapamil hcl ADD TO FORMULARY 03/03/2015 trandolaprilverapamil er trandolapril/verapamil hcl ADD UM: QUANTITY 03/03/2015 trandolaprilverapamil er trandolapril/verapamil hcl ADD TO FORMULARY 03/03/2015 trandolaprilverapamil er trandolapril/verapamil hcl ADD UM: QUANTITY 03/03/2015 trandolaprilverapamil er trandolapril/verapamil hcl ADD TO FORMULARY 03/03/2015 trandolaprilverapamil er trandolapril/verapamil hcl ADD UM: QUANTITY 03/03/2015 trandolaprilverapamil er trandolapril/verapamil hcl ADD TO FORMULARY 03/03/2015 trandolaprilverapamil er trandolapril/verapamil hcl ADD UM: QUANTITY 30 / 30 days 03/05/2016 fentanyl citrate0.9% nacl fentanyl citrate in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 03/05/2016 fentanylbupivacaine0.9% nacl fentanyl citrate/bupivacaine hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 03/05/2016 ephedrine ephedrine sulfate in 0.9 % sulfate-0.9% nacl sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 03/05/2016 phenylephrine hcl-0.9% nacl REMOVE FROM FORMULARY Non-Formulary phenylephrine hcl in 0.9 % sodium chloride/pf Generics Non-Formulary Generics 30 / 30 days Non-Formulary Generics 30 / 30 days Non-Formulary Generics 30 / 30 days Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 432 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/05/2016 ephedrine ephedrine sulfate in 0.9 % sulfate-0.9% nacl sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 03/05/2016 magnesium magnesium sulfate in 0.9 % sulfate-0.9% nacl sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/05/2016 phenohytro phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb ADD TO FORMULARY Non-Formulary 03/05/2016 ure-k urea ADD TO FORMULARY Non-Formulary 03/05/2016 coal tar coal tar REMOVE FROM FORMULARY Non-Formulary 03/05/2016 medi-first isopropyl alcohol isopropyl alcohol REMOVE FROM FORMULARY Non-Formulary 03/05/2016 DOC-Q-LACE docusate sodium REMOVE FROM FORMULARY Non-Formulary 03/05/2016 DOC-Q-LACE docusate sodium REMOVE FROM FORMULARY Non-Formulary 03/05/2016 TYLENOL SINUS guaifenesin/phenylephrine SEVERE hcl/acetaminophen REMOVE FROM FORMULARY Non-Formulary 03/05/2016 MEDI-FIRST BURN lidocaine hcl REMOVE FROM FORMULARY Non-Formulary 03/05/2016 MEDI-FIRST ANTISEPTIC benzocaine/benzalkonium chloride REMOVE FROM FORMULARY Non-Formulary 03/05/2016 medi-first hydrogen peroxide hydrogen peroxide REMOVE FROM FORMULARY Non-Formulary 03/05/2016 glucosaminechondroitin-uc ii glucosamine hcl/chondro sulfate a/cartilage/collagen type ii REMOVE FROM FORMULARY Non-Formulary 03/05/2016 guaifenesin guaifenesin REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 433 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 03/05/2016 guaifenesin 03/05/2016 Generic Name guaifenesin Type of Change Previous Value New Value REMOVE FROM FORMULARY Non-Formulary guaifenesinguaifenesin/dextromethorph dextromethorpha an hbr n REMOVE FROM FORMULARY Non-Formulary 03/05/2016 guaifenesinguaifenesin/dextromethorph dextromethorpha an hbr n REMOVE FROM FORMULARY Non-Formulary 03/05/2016 lice complete kit 1-2-3 piperonyl butoxide/pyrethrins/permethr in REMOVE FROM FORMULARY Non-Formulary 03/05/2016 children's coldcough day dextromethorphan hbr/phenylephrine hcl REMOVE FROM FORMULARY Non-Formulary 03/05/2016 formula 3 tolnaftate REMOVE FROM FORMULARY Non-Formulary 03/05/2016 ensure compact lactose-reduced food REMOVE FROM FORMULARY Non-Formulary 03/05/2016 ensure compact lactose-reduced food REMOVE FROM FORMULARY Non-Formulary 03/05/2016 fluticasone propionate fluticasone propionate ADD TO FORMULARY Generics 03/05/2016 HYMOVIS hyaluronate sodium, modified, non-crosslinked REMOVE FROM FORMULARY Non-Formulary 03/05/2016 HUMULIN R U500 KWIKPEN insulin regular, human ADD TO FORMULARY Preferred Brands 03/05/2016 HUMULIN R U500 KWIKPEN insulin regular, human ADD TO FORMULARY Preferred Brands 03/05/2016 ODEFSEY emtricitabine/rilpivirine hcl/tenofovir alafenamide fumarate ADD TO FORMULARY Non-Formulary 03/05/2016 XELJANZ XR tofacitinib citrate ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 434 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 03/05/2016 fentanylfentanyl citrate/ropivacaine ropivacaine-0.9% hcl/sodium chloride 0.9%/pf nacl 03/05/2016 metoprolol tartrate 03/05/2016 Type of Change Previous Value New Value REMOVE FROM FORMULARY Non-Formulary metoprolol tartrate ADD TO FORMULARY Generics metoprolol tartrate metoprolol tartrate ADD TO FORMULARY Generics 03/05/2016 metoprolol tartrate metoprolol tartrate ADD TO FORMULARY Generics 03/05/2016 metoprolol tartrate metoprolol tartrate ADD TO FORMULARY Generics 03/09/2015 fentanyl fentanyl ADD TO FORMULARY Generics 03/09/2015 fentanyl fentanyl ADD TO FORMULARY Generics 03/09/2015 fentanyl fentanyl ADD TO FORMULARY Generics 03/09/2015 ROSULA sulfacetamide sodium/sulfur ADD TO FORMULARY Non-Formulary 03/10/2015 TOUJEO SOLOSTAR insulin glargine,human recombinant analog ADD TO FORMULARY Non-Formulary 03/10/2015 NUVESSA metronidazole ADD TO FORMULARY Non-Formulary 03/10/2015 NUVESSA metronidazole ADD UM: GENDER Female 03/10/2015 FARYDAK panobinostat lactate ADD TO FORMULARY Non-Formulary 03/10/2015 FARYDAK panobinostat lactate ADD UM: SPECIALTY Specialty Drug 03/11/2016 morphine sulfate- morphine sulfate in 0.9 % 0.9% nacl sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 morphine sulfate- morphine sulfate in 0.9 % 0.9% nacl sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 oxiconazole nitrate oxiconazole nitrate ADD TO FORMULARY Generics 03/11/2016 oxiconazole nitrate oxiconazole nitrate ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 435 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/11/2016 oxiconazole nitrate oxiconazole nitrate ADD TO FORMULARY Generics 03/11/2016 doxepin hcl doxepin hcl ADD TO FORMULARY Generics 03/11/2016 midazolam hcl0.9% nacl midazolam hcl in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 vancomycin hcl0.9% nacl vancomycin in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 oxytocin-0.9% nacl oxytocin in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 oxytocin-lactated oxytocin/ringers ringers solution,lactated REMOVE FROM FORMULARY Non-Formulary 03/11/2016 ketamine hcl0.9% nacl ketamine hcl in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 norepinephrine bitar-0.9% nacl norepinephrine bitartrate in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 norepinephrine bitartrate-d5w norepinephrine bitartrate/dextrose 5 % in water REMOVE FROM FORMULARY Non-Formulary 03/11/2016 hydromorphone hcl-0.9% nacl hydromorphone hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 03/11/2016 vancomycin hcl0.9% nacl vancomycin in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 vancomycin hcl0.9% nacl vancomycin in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 vancomycin hcl0.9% nacl vancomycin in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 vancomycin hcl0.9% nacl vancomycin in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 amikacin sulfate amikacin sulfate REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 436 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/11/2016 midazolam-0.9% midazolam hcl in 0.9 % nacl sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 vancomycin hcld5w vancomycin hcl/dextrose 5 % in water REMOVE FROM FORMULARY Non-Formulary 03/11/2016 amiodarone hcld5w amiodarone hcl/dextrose 5 % in water REMOVE FROM FORMULARY Non-Formulary 03/11/2016 amiodarone hcld5w amiodarone hcl/dextrose 5 % in water REMOVE FROM FORMULARY Non-Formulary 03/11/2016 hydromorphone hcl-0.9% nacl hydromorphone hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 03/11/2016 hydromorphone hcl-0.9% nacl hydromorphone hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 03/11/2016 phenylephrine hcl-0.9% nacl phenylephrine hcl in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 dynamic plus pak lidocaine hcl/glycerin REMOVE FROM FORMULARY Non-Formulary 03/11/2016 vancomycin hcl0.9% nacl vancomycin in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 dermawerx sds triamcinolone acetonide/dimethicone/silico ne, adhesive REMOVE FROM FORMULARY Non-Formulary 03/11/2016 unistik touch lancets REMOVE FROM FORMULARY Non-Formulary 03/11/2016 unistik touch lancets REMOVE FROM FORMULARY Non-Formulary 03/11/2016 unistik touch lancets REMOVE FROM FORMULARY Non-Formulary 03/11/2016 unistik touch lancets REMOVE FROM FORMULARY Non-Formulary 03/11/2016 unistik touch lancets REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 437 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/11/2016 unistik touch lancets REMOVE FROM FORMULARY Non-Formulary 03/11/2016 cool control solution blood glucose calibration control solution, normal REMOVE FROM FORMULARY Non-Formulary 03/11/2016 cool control solution blood glucose calibration control solution, high REMOVE FROM FORMULARY Non-Formulary 03/11/2016 rasagiline mesylate rasagiline mesylate REMOVE FROM FORMULARY Non-Formulary 03/11/2016 true metrix air glucose meter blood-glucose meter REMOVE FROM FORMULARY Non-Formulary 03/11/2016 true metrix air glucose meter blood-glucose meter REMOVE FROM FORMULARY Non-Formulary 03/11/2016 MAPAP acetaminophen REMOVE FROM FORMULARY Non-Formulary 03/11/2016 MTERYTI prenatal vit no.6/iron fum/folic acid/vit b12/calcium/vit d3 REMOVE FROM FORMULARY Non-Formulary 03/11/2016 all day relief naproxen sodium REMOVE FROM FORMULARY Non-Formulary 03/11/2016 DIABETIC VITAMIN multivitamin with minerals/folic acid/a lipoic acid/ubidecar REMOVE FROM FORMULARY Non-Formulary 03/11/2016 duo fusion famotidine/calcium carbonate/magnesium hydroxide REMOVE FROM FORMULARY Non-Formulary 03/11/2016 duo fusion famotidine/calcium carbonate/magnesium hydroxide REMOVE FROM FORMULARY Non-Formulary 03/11/2016 duo fusion famotidine/calcium carbonate/magnesium hydroxide REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 438 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/11/2016 duo fusion famotidine/calcium carbonate/magnesium hydroxide REMOVE FROM FORMULARY Non-Formulary 03/11/2016 IDELVION factor ix recombinant,albumin fusion protein REMOVE FROM FORMULARY Non-Formulary 03/11/2016 IDELVION factor ix recombinant,albumin fusion protein REMOVE FROM FORMULARY Non-Formulary 03/11/2016 IDELVION factor ix recombinant,albumin fusion protein REMOVE FROM FORMULARY Non-Formulary 03/11/2016 IDELVION factor ix recombinant,albumin fusion protein REMOVE FROM FORMULARY Non-Formulary 03/11/2016 DOUBLEDEX dexamethasone sodium phosphate/pf REMOVE FROM FORMULARY Non-Formulary 03/11/2016 heparin sodium0.9% nacl heparin sodium,porcine in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 03/11/2016 hydromorphone hcl-0.9% nacl hydromorphone hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 03/11/2016 alprostadil alprostadil REMOVE FROM FORMULARY 03/15/2016 SPRITAM levetiracetam ADD TO FORMULARY Non-Formulary 03/15/2016 SPRITAM levetiracetam ADD TO FORMULARY Non-Formulary 03/15/2016 SPRITAM levetiracetam ADD TO FORMULARY Non-Formulary 03/15/2016 SPRITAM levetiracetam ADD TO FORMULARY Non-Formulary 03/16/2015 methylphenidate methylphenidate hcl hcl ADD TO FORMULARY Generics 03/16/2015 methylphenidate methylphenidate hcl hcl ADD TO FORMULARY Generics Not Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 439 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/16/2015 methylphenidate methylphenidate hcl hcl ADD TO FORMULARY Generics 03/16/2015 naproxen sodium naproxen sodium cr ADD TO FORMULARY Generics 03/16/2015 niva-fol cyanocobalamin/folic acid/pyridoxine ADD TO FORMULARY Generics 03/16/2015 niva-fol cyanocobalamin/folic acid/pyridoxine ADD UM: CUSTOM Vitamin Rider may be required for coverage 03/16/2015 zenatane isotretinoin ADD TO FORMULARY Generics 03/16/2015 amnesteem,clara isotretinoin vis,absorica,zena tane,myorisan,iso tretinoin 03/16/2015 NATESTO testosterone ADD TO FORMULARY Non-Formulary 03/16/2015 NATESTO testosterone ADD UM: GENDER Male 03/16/2015 NOVOEIGHT antihemophilic factor viii recombinant, b-domain truncated ADD TO FORMULARY Non-Formulary 03/16/2015 NOVOEIGHT antihemophilic factor viii recombinant, b-domain truncated ADD UM: SPECIALTY Specialty Drug 03/18/2016 hygel hyaluronate sodium/hydroxyethylcellulos e/polyethylene glycol ADD TO FORMULARY Non-Formulary 03/19/2016 tramadol hcl er tramadol hcl ADD TO FORMULARY 03/19/2016 sulfacetamide sodium sulfacetamide sodium ADD TO FORMULARY Generics 03/19/2016 fentanylfentanyl citrate/ropivacaine ropivacaine-0.9% hcl/sodium chloride 0.9%/pf nacl REMOVE FROM FORMULARY Non-Formulary REMOVE UM: AUTHORIZATION Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 440 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/19/2016 bupivacaine hcl0.9% nacl bupivacaine hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 03/19/2016 fentanylbupivacaine0.9% nacl fentanyl citrate/bupivacaine hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 03/19/2016 darifenacin er darifenacin hydrobromide ADD TO FORMULARY Generics 03/19/2016 darifenacin er darifenacin hydrobromide ADD TO FORMULARY Generics 03/19/2016 darifenacin er darifenacin hydrobromide ADD TO FORMULARY Generics 03/19/2016 darifenacin er darifenacin hydrobromide ADD TO FORMULARY Generics 03/19/2016 darifenacin er darifenacin hydrobromide ADD TO FORMULARY Generics 03/19/2016 darifenacin er darifenacin hydrobromide ADD TO FORMULARY Generics 03/19/2016 darifenacin er darifenacin hydrobromide ADD TO FORMULARY Generics 03/19/2016 darifenacin er darifenacin hydrobromide ADD TO FORMULARY Generics 03/19/2016 fentanylfentanyl citrate/ropivacaine ropivacaine-0.9% hcl/sodium chloride 0.9%/pf nacl REMOVE FROM FORMULARY Non-Formulary 03/19/2016 fentanyl citrate REMOVE FROM FORMULARY Non-Formulary 03/19/2016 morphine sulfate- morphine sulfate in 0.9 % 0.9% nacl sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 03/19/2016 oxycodone hcl er oxycodone hcl ADD TO FORMULARY Generics 03/19/2016 oxycodone hcl er oxycodone hcl ADD TO FORMULARY Generics 03/19/2016 oxycodone hcl er oxycodone hcl ADD TO FORMULARY Generics 03/19/2016 emverm mebendazole ADD TO FORMULARY Non-Formulary 03/19/2016 grape flavor grape flavor REMOVE FROM FORMULARY Non-Formulary 03/19/2016 grape flavor grape flavor REMOVE FROM FORMULARY Non-Formulary fentanyl citrate/pf BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 441 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 03/19/2016 unifine pentips plus pen needle, diabetic 03/19/2016 methyl 5aminolevulinate hcl 03/19/2016 Type of Change Previous Value New Value ADD TO FORMULARY Generics methyl aminolevulinate hcl REMOVE FROM FORMULARY Non-Formulary easy touch hypodermic needle needles, disposable REMOVE FROM FORMULARY Non-Formulary 03/19/2016 easy touch hypodermic needle needles, disposable REMOVE FROM FORMULARY Non-Formulary 03/19/2016 easy touch hypodermic needle needles, disposable REMOVE FROM FORMULARY Non-Formulary 03/19/2016 easy touch hypodermic needle needles, disposable REMOVE FROM FORMULARY Non-Formulary 03/19/2016 easy touch hypodermic needle needles, disposable REMOVE FROM FORMULARY Non-Formulary 03/19/2016 adhesive pad adhesive bandage REMOVE FROM FORMULARY Non-Formulary 03/19/2016 tiopronin tiopronin REMOVE FROM FORMULARY Non-Formulary 03/19/2016 retinaldehyde retinal REMOVE FROM FORMULARY Non-Formulary 03/19/2016 adhesive pad adhesive bandage REMOVE FROM FORMULARY Non-Formulary 03/19/2016 easy touch syringe with needle, insulin, sheathlock insulin safety, 1 ml REMOVE FROM FORMULARY Non-Formulary 03/19/2016 easy touch syringe with needle, insulin, sheathlock insulin safety, 1 ml REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 442 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/19/2016 mango flavor flavoring agent REMOVE FROM FORMULARY Non-Formulary 03/19/2016 mango flavor flavoring agent REMOVE FROM FORMULARY Non-Formulary 03/19/2016 strawberry cream flavoring agent flavor REMOVE FROM FORMULARY Non-Formulary 03/19/2016 strawberry cream flavoring agent flavor REMOVE FROM FORMULARY Non-Formulary 03/19/2016 easy touch syringe,safety with sheathlock syrg- needle,10 ml ndl REMOVE FROM FORMULARY Non-Formulary 03/19/2016 easy touch syringe,safety with sheathlock syrg- needle,10 ml ndl REMOVE FROM FORMULARY Non-Formulary 03/19/2016 easy touch syringe,safety with sheathlock syrg- needle,10 ml ndl REMOVE FROM FORMULARY Non-Formulary 03/19/2016 bitterness suppressor bitter mask flavoring REMOVE FROM FORMULARY Non-Formulary 03/19/2016 bitterness suppressor bitter mask flavoring REMOVE FROM FORMULARY Non-Formulary 03/19/2016 vanilla flavor flavoring agent REMOVE FROM FORMULARY Non-Formulary 03/19/2016 vanilla flavor flavoring agent REMOVE FROM FORMULARY Non-Formulary 03/19/2016 base, pcca xematop cream base no.208 REMOVE FROM FORMULARY Non-Formulary 03/19/2016 ebase controller compressor, for nebulizer REMOVE FROM FORMULARY Non-Formulary 03/19/2016 coenzyme q-10 ubidecarenone REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 443 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/19/2016 coenzyme q-10 ubidecarenone REMOVE FROM FORMULARY Non-Formulary 03/19/2016 afrin oxymetazoline hcl REMOVE FROM FORMULARY Non-Formulary 03/19/2016 no drip nasal spray oxymetazoline hcl REMOVE FROM FORMULARY Non-Formulary 03/19/2016 nasal allergy triamcinolone acetonide REMOVE FROM FORMULARY Non-Formulary 03/19/2016 kids mini enema docusate sodium REMOVE FROM FORMULARY Non-Formulary 03/19/2016 mucus-er max guaifenesin REMOVE FROM FORMULARY Non-Formulary 03/19/2016 BABYBIG botulism immune globulin, human REMOVE FROM FORMULARY Non-Formulary 03/19/2016 CERAMAX emollient combination no.101 REMOVE FROM FORMULARY Non-Formulary 03/19/2016 MAKENA hydroxyprogesterone caproate REMOVE FROM FORMULARY Non-Formulary 03/19/2016 KLOR-CON M20 potassium chloride ADD TO FORMULARY Generics 03/19/2016 KLOR-CON M20 potassium chloride ADD TO FORMULARY Generics 03/24/2015 FRAGMIN dalteparin sodium,porcine CHANGE TIER Preferred Brands 03/24/2015 acetaminophencodeine acetaminophen with codeine phosphate CHANGE TIER Generics 03/24/2015 acetaminophencodeine acetaminophen with codeine phosphate CHANGE TIER Generics 03/24/2015 ANIMI-3 WITH VITAMIN D,ANIMI-3 omega3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 444 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/24/2015 bp vit 3 plus omega3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol ADD TO FORMULARY Generics 03/24/2015 bp vit 3 plus omega3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol ADD UM: CUSTOM Vitamin Rider May Be Required 03/24/2015 niva-plus prenatal vits with calcium #74/ferrous fumarate/folic acid ADD TO FORMULARY Generics 03/24/2015 niva-plus prenatal vits with calcium #74/ferrous fumarate/folic acid ADD UM: GENDER Female 03/24/2015 KALYDECO ivacaftor ADD TO FORMULARY Preferred Brands 03/24/2015 KALYDECO ivacaftor ADD UM: SPECIALTY Specialty Drug 03/24/2015 KALYDECO ivacaftor ADD UM: AUTHORIZATION PA applies 03/24/2015 KALYDECO ivacaftor ADD TO FORMULARY Preferred Brands 03/24/2015 KALYDECO ivacaftor ADD UM: SPECIALTY Specialty Drug 03/24/2015 KALYDECO ivacaftor ADD UM: AUTHORIZATION PA applies 03/24/2015 METHYLIN methylphenidate hcl CHANGE TIER Non-Formulary 03/24/2015 EDEX alprostadil CHANGE TIER Preferred Brands 03/24/2015 CAVERJECT alprostadil CHANGE TIER Non-Formulary 03/24/2015 CAVERJECT alprostadil CHANGE TIER 03/24/2015 MUSE alprostadil CHANGE TIER Non-Formulary 03/24/2015 MUSE alprostadil CHANGE TIER Non-Formulary 03/24/2015 MUSE alprostadil CHANGE TIER Non-Formulary 03/24/2015 MUSE alprostadil CHANGE TIER Non-Formulary 03/24/2015 DIVIGEL estradiol CHANGE TIER Preferred Brands Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 445 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/24/2015 DEPOPROVERA medroxyprogesterone acetate CHANGE TIER Non-Formulary 03/24/2015 MYOBLOC rimabotulinumtoxinb CHANGE TIER Preferred Brands Non-Formulary 03/24/2015 ZORBTIVE somatropin CHANGE TIER Preferred Brands Non-Formulary 03/24/2015 FOCALIN dexmethylphenidate hcl CHANGE TIER Preferred Brands Non-Formulary 03/24/2015 dexmethylphenid dexmethylphenidate hcl ate hcl CHANGE TIER Preferred Brands Generics 03/24/2015 FOCALIN dexmethylphenidate hcl CHANGE TIER Preferred Brands Non-Formulary 03/24/2015 dexmethylphenid dexmethylphenidate hcl ate hcl CHANGE TIER Preferred Brands Generics 03/24/2015 PARNATE tranylcypromine sulfate ADD TO FORMULARY Non-Formulary 03/24/2015 tranylcypromine sulfate tranylcypromine sulfate CHANGE TIER Generics 03/24/2015 PAXIL CR paroxetine hcl ADD TO FORMULARY Non-Formulary 03/24/2015 paroxetine paroxetine hcl er,paroxetine hcl,paroxetine cr CHANGE TIER Generics 03/24/2015 dantrolene sodium dantrolene sodium CHANGE TIER Generics 03/24/2015 DANTRIUM dantrolene sodium CHANGE TIER Non-Formulary 03/24/2015 dantrolene sodium dantrolene sodium CHANGE TIER Generics 03/24/2015 DANTRIUM dantrolene sodium ADD TO FORMULARY Non-Formulary 03/24/2015 dantrolene sodium dantrolene sodium CHANGE TIER Generics 03/24/2015 DANTRIUM dantrolene sodium ADD TO FORMULARY Non-Formulary 03/24/2015 SOLU-MEDROL methylprednisolone sodium succinate CHANGE TIER Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 446 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/24/2015 CARDIZEM LA diltiazem hcl ADD TO FORMULARY Non-Formulary 03/24/2015 diltiazem 24hr er,diltiazem er diltiazem hcl CHANGE TIER Generics 03/24/2015 matzim la diltiazem hcl CHANGE TIER Generics 03/24/2015 PENNSAID diclofenac sodium CHANGE TIER Non-Formulary 03/24/2015 desloratadine desloratadine CHANGE TIER 03/24/2015 methamphetamin methamphetamine hcl e hcl 03/24/2015 DESOXYN methamphetamine hcl 03/24/2015 ciprofloxacin er 03/24/2015 Preferred Brands Generics CHANGE TIER Generics ADD TO FORMULARY Non-Formulary ciprofloxacin/ciprofloxacin hcl CHANGE TIER Generics CIPRO XR ciprofloxacin/ciprofloxacin hcl ADD TO FORMULARY Non-Formulary 03/24/2015 RITALIN LA methylphenidate hcl ADD TO FORMULARY Non-Formulary 03/24/2015 methylphenidate methylphenidate hcl er,methylphenida te la CHANGE TIER Generics 03/24/2015 RITALIN LA ADD TO FORMULARY Non-Formulary 03/24/2015 methylphenidate methylphenidate hcl er,methylphenida te la CHANGE TIER Generics 03/24/2015 RITALIN LA ADD TO FORMULARY Non-Formulary 03/24/2015 methylphenidate methylphenidate hcl er,methylphenida te la CHANGE TIER Generics 03/24/2015 ELESTAT epinastine hcl ADD TO FORMULARY Non-Formulary 03/24/2015 epinastine hcl epinastine hcl CHANGE TIER Generics 03/24/2015 alendronate sodium alendronate sodium CHANGE TIER methylphenidate hcl methylphenidate hcl Preferred Brands Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 447 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/24/2015 SORIATANE acitretin ADD TO FORMULARY Non-Formulary 03/24/2015 acitretin acitretin CHANGE TIER Generics 03/24/2015 l-alanine,alanine alanine CHANGE TIER Preferred Brands 03/24/2015 alprazolam odt alprazolam CHANGE TIER Generics 03/24/2015 alprazolam odt alprazolam CHANGE TIER Generics 03/24/2015 CAVERJECT alprostadil CHANGE TIER 03/24/2015 KOGENATE FS antihemophilic factor (fviii) recomb,full length (alb-free) ADD TO FORMULARY Non-Formulary 03/24/2015 KOATE-DVI antihemophilic factor, human ADD TO FORMULARY Non-Formulary 03/24/2015 KOATE-DVI antihemophilic factor, human ADD TO FORMULARY Non-Formulary 03/24/2015 azelastine hcl azelastine hcl CHANGE TIER Generics 03/24/2015 ASTEPRO azelastine hcl ADD TO FORMULARY Non-Formulary 03/24/2015 vp-zel niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa CHANGE TIER Generics 03/24/2015 BECONASE AQ beclomethasone dipropionate CHANGE TIER Non-Formulary 03/24/2015 benzoyl peroxide benzoyl peroxide CHANGE TIER Generics 03/24/2015 BENZEFOAM benzoyl peroxide ADD TO FORMULARY Non-Formulary 03/24/2015 benzepro benzoyl peroxide CHANGE TIER Generics 03/24/2015 bp foam benzoyl peroxide CHANGE TIER Generics 03/24/2015 benzoyl peroxide benzoyl peroxide CHANGE TIER Generics 03/24/2015 BENZEFOAM ULTRA benzoyl peroxide ADD TO FORMULARY Non-Formulary 03/24/2015 benzepro benzoyl peroxide CHANGE TIER Generics Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 448 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/24/2015 bp foam benzoyl peroxide CHANGE TIER Generics 03/24/2015 bromfenac sodium bromfenac sodium CHANGE TIER Generics 03/24/2015 butalbitalacetaminophencaffe butalbital/acetaminophen/caf feine CHANGE TIER 03/24/2015 ORTHO-NESIC capsaicin/camphor/menthol CHANGE TIER 03/24/2015 QUTENZA capsaicin/skin cleanser CHANGE TIER 03/24/2015 COREG CR carvedilol phosphate CHANGE TIER Non-Formulary 03/24/2015 cefpodoxime proxetil cefpodoxime proxetil CHANGE TIER Generics 03/24/2015 cefpodoxime proxetil cefpodoxime proxetil CHANGE TIER Generics 03/24/2015 cefpodoxime proxetil cefpodoxime proxetil CHANGE TIER Generics 03/24/2015 ceftibuten ceftibuten CHANGE TIER Generics 03/24/2015 CEDAX ceftibuten dihydrate,ceftibuten ADD TO FORMULARY Non-Formulary 03/24/2015 CIMZIA certolizumab pegol CHANGE TIER Preferred Brands Non-Formulary 03/24/2015 poly-tussin d chlorcyclizine hcl/pseudoephedrine hcl/codeine phosphate CHANGE TIER Preferred Brands Generics 03/24/2015 poly-tussin chlorcyclizine hcl/codeine phosphate CHANGE TIER Preferred Brands Generics 03/24/2015 CATAPRES-TTS clonidine 1 CHANGE TIER Preferred Brands Non-Formulary 03/24/2015 clonidine clonidine CHANGE TIER Generics 03/24/2015 CATAPRES-TTS clonidine 2 CHANGE TIER Non-Formulary Preferred Brands Generics Not Covered Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 449 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/24/2015 clonidine clonidine CHANGE TIER Generics 03/24/2015 clonidine clonidine CHANGE TIER Generics 03/24/2015 CATAPRES-TTS clonidine 3 CHANGE TIER 03/24/2015 clonidine hcl er clonidine hcl CHANGE TIER Generics 03/24/2015 clorpres clonidine hcl/chlorthalidone CHANGE TIER Generics 03/24/2015 clorpres clonidine hcl/chlorthalidone CHANGE TIER Generics 03/24/2015 clorpres clonidine hcl/chlorthalidone CHANGE TIER Generics 03/24/2015 COLESTID colestipol hcl ADD TO FORMULARY Non-Formulary 03/24/2015 colestipol hcl colestipol hcl CHANGE TIER Generics 03/24/2015 colestipol hcl colestipol hcl CHANGE TIER Generics 03/24/2015 COLESTID colestipol hcl ADD TO FORMULARY Non-Formulary 03/24/2015 COLESTID colestipol hcl ADD TO FORMULARY Non-Formulary 03/24/2015 COLESTID colestipol hcl CHANGE TIER Non-Formulary 03/24/2015 XALKORI crizotinib CHANGE TIER Preferred Brands Non-Formulary 03/24/2015 XALKORI crizotinib CHANGE TIER Preferred Brands Non-Formulary 03/24/2015 EURAX crotamiton 03/24/2015 COMFORT PAC- cyclobenzaprine hcl/irritants CYCLOBENZAP counter-irritants combo #2 RINE 03/24/2015 cyclopentolate hcl cyclopentolate hcl CHANGE UM: AUTHORIZATION PA applies 03/24/2015 demeclocycline hcl demeclocycline hcl CHANGE TIER Generics 03/24/2015 demeclocycline hcl demeclocycline hcl CHANGE TIER Generics 03/24/2015 PROLIA denosumab CHANGE TIER Preferred Brands ADD TO FORMULARY CHANGE TIER Non-Formulary Non-Formulary Preferred Brands Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 450 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE TIER Preferred Brands Generics 03/24/2015 desloratadine desloratadine 03/24/2015 DESONATE desonide ADD TO FORMULARY Non-Formulary 03/25/2015 ANALPRAM E hydrocortisone acetate/pramoxine/emollient /pramoxine comb#1 ADD TO FORMULARY Non-Formulary 03/25/2015 hydrocortisonepramoxine hydrocortisone acetate/pramoxine/emollient /pramoxine comb#1 CHANGE TIER Generics 03/25/2015 hydrocortisonepramoxine hydrocortisone acetate/pramoxine/emollient /pramoxine comb#1 CHANGE TIER Generics 03/25/2015 ANALPRAM E hydrocortisone acetate/pramoxine/emollient /pramoxine comb#1 ADD TO FORMULARY Non-Formulary 03/25/2015 PICATO ingenol mebutate CHANGE TIER Preferred Brands Non-Formulary 03/25/2015 PICATO ingenol mebutate CHANGE TIER Preferred Brands Non-Formulary 03/25/2015 APIDRA SOLOSTAR insulin glulisine CHANGE TIER Preferred Brands Non-Formulary 03/25/2015 BETASERON interferon beta-1b ADD TO FORMULARY Non-Formulary 03/25/2015 EXTAVIA interferon beta-1b ADD TO FORMULARY Non-Formulary 03/25/2015 PROCARDIA XL nifedipine ADD TO FORMULARY Non-Formulary 03/25/2015 ARICEPT donepezil hcl CHANGE UM: AUTHORIZATION PA applies 03/25/2015 ARICEPT donepezil hcl CHANGE UM: AUTHORIZATION PA applies 03/26/2016 KOVALTRY antihemophilic factor (fviii) recomb,full length (alb-free) REMOVE FROM FORMULARY Non-Formulary 03/26/2016 KOVALTRY antihemophilic factor (fviii) recomb,full length (alb-free) REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 451 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/26/2016 KOVALTRY antihemophilic factor (fviii) recomb,full length (alb-free) REMOVE FROM FORMULARY Non-Formulary 03/26/2016 KOVALTRY antihemophilic factor (fviii) recomb,full length (alb-free) REMOVE FROM FORMULARY Non-Formulary 03/26/2016 KOVALTRY antihemophilic factor (fviii) recomb,full length (alb-free) REMOVE FROM FORMULARY Non-Formulary 03/26/2016 KOVALTRY antihemophilic factor (fviii) recomb,full length (alb-free) REMOVE FROM FORMULARY Non-Formulary 03/26/2016 KOVALTRY antihemophilic factor (fviii) recomb,full length (alb-free) REMOVE FROM FORMULARY Non-Formulary 03/26/2016 KOVALTRY antihemophilic factor (fviii) recomb,full length (alb-free) REMOVE FROM FORMULARY Non-Formulary 03/26/2016 KOVALTRY antihemophilic factor (fviii) recomb,full length (alb-free) REMOVE FROM FORMULARY Non-Formulary 03/26/2016 KOVALTRY antihemophilic factor (fviii) recomb,full length (alb-free) REMOVE FROM FORMULARY Non-Formulary 03/26/2016 carbamazepine er carbamazepine ADD TO FORMULARY Generics 03/26/2016 frovatriptan succinate frovatriptan succinate ADD TO FORMULARY Non-Formulary 03/26/2016 mometasone furoate mometasone furoate ADD TO FORMULARY Generics 03/26/2016 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur ADD TO FORMULARY Generics 03/26/2016 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur ADD TO FORMULARY Generics 03/26/2016 diclofenac sodium diclofenac sodium ADD TO FORMULARY Generics 03/26/2016 zolpidem tartrate zolpidem tartrate ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 452 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/26/2016 zolpidem tartrate zolpidem tartrate ADD TO FORMULARY Generics 03/26/2016 diphenhydramine diphenhydramine hcl in 0.9 -0.9% nacl % sodium chloride ADD TO FORMULARY Generics 03/26/2016 alogliptin alogliptin benzoate ADD TO FORMULARY Generics 03/26/2016 alogliptinpioglitazone alogliptin benzoate/pioglitazone hcl ADD TO FORMULARY Generics 03/26/2016 alogliptinpioglitazone alogliptin benzoate/pioglitazone hcl ADD TO FORMULARY Generics 03/26/2016 alogliptinpioglitazone alogliptin benzoate/pioglitazone hcl ADD TO FORMULARY Generics 03/26/2016 alogliptinpioglitazone alogliptin benzoate/pioglitazone hcl ADD TO FORMULARY Generics 03/26/2016 alogliptinpioglitazone alogliptin benzoate/pioglitazone hcl ADD TO FORMULARY Generics 03/26/2016 alogliptin alogliptin benzoate ADD TO FORMULARY Generics 03/26/2016 alogliptinmetformin alogliptin benzoate/metformin hcl ADD TO FORMULARY Generics 03/26/2016 alogliptinmetformin alogliptin benzoate/metformin hcl ADD TO FORMULARY Generics 03/26/2016 alogliptinpioglitazone alogliptin benzoate/pioglitazone hcl ADD TO FORMULARY Generics 03/26/2016 alogliptin alogliptin benzoate ADD TO FORMULARY Generics 03/26/2016 diclotral diclofenac sodium/capsicum oleoresin ADD TO FORMULARY Generics 03/26/2016 klofensaid ii diclofenac sodium ADD TO FORMULARY Generics 03/26/2016 unilet lancets lancets ADD TO FORMULARY Generics 03/26/2016 easy touch syringe,safety with needle,5 sheathlock syrg- ml ndl REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 453 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/26/2016 easy touch syringe,safety with needle,5 sheathlock syrg- ml ndl REMOVE FROM FORMULARY Non-Formulary 03/26/2016 easy touch syringe,safety with needle,5 sheathlock syrg- ml ndl REMOVE FROM FORMULARY Non-Formulary 03/26/2016 relizorb enteral pump accessory for fat hydrolysis REMOVE FROM FORMULARY Non-Formulary 03/26/2016 cool blood glucose blood-glucose meter REMOVE FROM FORMULARY Non-Formulary 03/26/2016 depend fit-flex diaper,brief,adult, disposable REMOVE FROM FORMULARY Non-Formulary 03/26/2016 tetrahydrobiopteri sapropterin dihydrochloride n hcl REMOVE FROM FORMULARY Non-Formulary 03/26/2016 easy mini eject lancing device lancing device REMOVE FROM FORMULARY Non-Formulary 03/26/2016 vitamin c ascorbic acid REMOVE FROM FORMULARY Non-Formulary 03/26/2016 vitamin c ascorbic acid REMOVE FROM FORMULARY Non-Formulary 03/26/2016 MURINE EAR DROPS carbamide peroxide REMOVE FROM FORMULARY Non-Formulary 03/26/2016 GALAXTRA galactose REMOVE FROM FORMULARY Non-Formulary 03/26/2016 CLEAR EYES COOLING COMFORT naphazoline hcl/glycerin REMOVE FROM FORMULARY Non-Formulary 03/26/2016 CLEAR EYES MAX REDNESS RELIEF naphazoline hcl/glycerin REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 454 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 03/26/2016 CLEAR EYES MAX REDNESS RELIEF 03/26/2016 Generic Name naphazoline hcl/glycerin Type of Change Previous Value New Value REMOVE FROM FORMULARY Non-Formulary arthritis pain relief acetaminophen REMOVE FROM FORMULARY Non-Formulary 03/26/2016 arthritis pain relief acetaminophen REMOVE FROM FORMULARY Non-Formulary 03/26/2016 melatonin melatonin REMOVE FROM FORMULARY Non-Formulary 03/26/2016 nu-mag magnesium chloride REMOVE FROM FORMULARY Non-Formulary 03/26/2016 relhist dmx guaifenesin/dextromethorph an hbr/phenylephrine REMOVE FROM FORMULARY Non-Formulary 03/26/2016 relcof dm brompheniramine maleate/phenylephrine hcl/dextromethorphan REMOVE FROM FORMULARY Non-Formulary 03/26/2016 prenatal vitamins prenatal vits with calcium#133/ferrous fumarate/folic acid REMOVE FROM FORMULARY Non-Formulary 03/26/2016 mucus d guaifenesin/pseudoephedrin e hcl REMOVE FROM FORMULARY Non-Formulary 03/26/2016 mucus d guaifenesin/pseudoephedrin e hcl REMOVE FROM FORMULARY Non-Formulary 03/26/2016 ALPROLIX factor ix recombinant, fc fusion protein REMOVE FROM FORMULARY Non-Formulary 03/26/2016 ADZENYS XRODT amphetamine ADD TO FORMULARY Non-Formulary 03/26/2016 ADZENYS XRODT amphetamine ADD TO FORMULARY Non-Formulary 03/26/2016 ADZENYS XRODT amphetamine ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 455 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/26/2016 ADZENYS XRODT amphetamine ADD TO FORMULARY Non-Formulary 03/26/2016 ADZENYS XRODT amphetamine ADD TO FORMULARY Non-Formulary 03/26/2016 ADZENYS XRODT amphetamine ADD TO FORMULARY Non-Formulary 03/26/2016 ZEMBRACE SYMTOUCH sumatriptan succinate ADD TO FORMULARY Non-Formulary 03/26/2016 ZEMBRACE SYMTOUCH sumatriptan succinate ADD TO FORMULARY Non-Formulary 03/26/2016 epinephrine hcl0.9% nacl epinephrine hcl in 0.9 % sodium chloride ADD TO FORMULARY Generics 03/26/2016 SMARTRX GABAKIT gabapentin/lidocaine hcl/menthol REMOVE FROM FORMULARY Non-Formulary 03/26/2016 easy touch syringe,safety with needle,3 sheathlock syrg- ml ndl REMOVE FROM FORMULARY Non-Formulary 03/26/2016 easy touch syringe,safety with needle,3 sheathlock syrg- ml ndl REMOVE FROM FORMULARY Non-Formulary 03/26/2016 easy touch syringe,safety with needle,3 sheathlock syrg- ml ndl REMOVE FROM FORMULARY Non-Formulary 03/26/2016 easy touch syringe,safety with needle,3 sheathlock syrg- ml ndl REMOVE FROM FORMULARY Non-Formulary 03/26/2016 easy touch syringe,safety with needle,3 sheathlock syrg- ml ndl REMOVE FROM FORMULARY Non-Formulary 03/26/2016 easy touch syringe,safety with needle,3 sheathlock syrg- ml ndl REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 456 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 03/26/2016 easy touch syringe,safety with needle,3 sheathlock syrg- ml ndl REMOVE FROM FORMULARY Non-Formulary 03/26/2016 NOURISH lactose-reduced food/fiber REMOVE FROM FORMULARY Non-Formulary 03/26/2016 vcf nonoxynol 9 REMOVE FROM FORMULARY Non-Formulary 03/26/2016 vcf nonoxynol 9 REMOVE FROM FORMULARY Non-Formulary 03/30/2015 MIRCERA methoxy polyethylene glycol-epoetin beta ADD TO FORMULARY Non-Formulary 03/30/2015 NORDITROPIN FLEXPRO somatropin ADD TO FORMULARY Preferred Brands 03/30/2015 NORDITROPIN FLEXPRO somatropin ADD UM: SPECIALTY Specialty Drug 03/30/2015 NORDITROPIN FLEXPRO somatropin ADD UM: AUTHORIZATION PA applies 03/30/2015 CRESEMBA isavuconazonium sulfate ADD TO FORMULARY Non-Formulary 03/30/2015 CRESEMBA isavuconazonium sulfate ADD TO FORMULARY Not Covered 03/30/2015 AVENOVA hypochlorous acid/sodium chloride ADD TO FORMULARY Non-Formulary 03/30/2015 recedo polydimethylsiloxanes/silico n dioxide ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 457 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates April, 2014 Effective Date Brand Name Generic Name Type of Change Previous Value Specialty Drug 04/01/2014 AUBAGIO teriflunomide REMOVE UM: CUSTOM 04/01/2014 AUBAGIO teriflunomide ADD UM: SPECIALTY 04/01/2015 PROMACTA eltrombopag olamine 04/01/2015 INVOKAMET canagliflozin/metformin hcl ADD TO FORMULARY 04/01/2015 INVOKANA canagliflozin ADD TO FORMULARY 04/01/2015 INVOKAMET canagliflozin/metformin hcl 04/01/2015 isradipine CHANGE TIER New Value Specialty Drug Preferred Brands Non-Formulary Preferred Brands Non-Formulary Preferred Brands ADD UM: QUANTITY 30 / 30 days isradipine CHANGE TIER Generics 04/01/2015 clindamycinclindamycin benzoyl peroxide phosphate/benzoyl peroxide ADD TO FORMULARY 04/01/2015 MONOCLATE-P antihemophilic factor, human ADD TO FORMULARY Non-Formulary 04/01/2015 KOATE-DVI antihemophilic factor, human ADD TO FORMULARY Non-Formulary 04/01/2015 MENEST estrogens,esterified CHANGE TIER Non-Formulary 04/01/2015 MENEST estrogens,esterified CHANGE TIER 04/01/2015 MICRONOR,ORT norethindrone HO MICRONOR CHANGE TIER 04/01/2015 SAIZEN somatropin CHANGE TIER 04/01/2015 SANDIMMUNE cyclosporine ADD UM: AUTHORIZATION PA applies 04/01/2015 SANDIMMUNE cyclosporine ADD UM: AUTHORIZATION PA applies 04/01/2015 FAMVIR famciclovir ADD TO FORMULARY Non-Formulary 04/01/2015 REBETOL ribavirin ADD UM: AUTHORIZATION PA applies 04/01/2015 SPECTRACEF cefditoren pivoxil CHANGE TIER Non-Formulary Non-Formulary Preventative Preferred Brands Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 458 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2015 dexmethylphenid dexmethylphenidate hcl ate hcl CHANGE TIER Preferred Brands Generics 04/01/2015 FOCALIN dexmethylphenidate hcl CHANGE TIER Preferred Brands Non-Formulary 04/01/2015 fondaparinux sodium fondaparinux sodium CHANGE TIER Preferred Brands Generics 04/01/2015 se bpo benzoyl peroxide microspheres ADD TO FORMULARY Non-Formulary Generics 04/01/2015 metadate er methylphenidate hcl CHANGE TIER Generics 04/01/2015 RITALIN-SR methylphenidate hcl ADD TO FORMULARY Non-Formulary 04/01/2015 morphine sulfate morphine sulfate er 04/01/2015 ROXICODONE oxycodone hcl CHANGE TIER Non-Formulary 04/01/2015 SARAFEM fluoxetine hcl ADD TO FORMULARY Non-Formulary 04/01/2015 SARAFEM fluoxetine hcl ADD TO FORMULARY Non-Formulary 04/01/2015 REMERON mirtazapine ADD TO FORMULARY Non-Formulary 04/01/2015 REMERON mirtazapine ADD TO FORMULARY Non-Formulary 04/01/2015 REMERON mirtazapine ADD TO FORMULARY Non-Formulary 04/01/2015 INOVA 8-2 salicylic acid/benzoyl peroxide/vitamin e mixed CHANGE TIER Preferred Brands Non-Formulary 04/01/2015 INOVA 4-1 salicylic acid/benzoyl peroxide/vitamin e mixed CHANGE TIER Preferred Brands Non-Formulary 04/01/2015 EFFIENT prasugrel hcl CHANGE TIER 04/01/2015 morphine sulfate morphine sulfate er 04/01/2015 STAVZOR valproic acid 04/01/2015 DEPAKOTE divalproex sodium ADD TO FORMULARY Non-Formulary 04/01/2015 DEPAKOTE divalproex sodium ADD TO FORMULARY Non-Formulary ADD TO FORMULARY Non-Formulary Generics Non-Formulary ADD TO FORMULARY Non-Formulary Generics CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 459 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2015 DEPAKOTE divalproex sodium ADD TO FORMULARY Non-Formulary 04/01/2015 DEPAKOTE SPRINKLE divalproex sodium ADD TO FORMULARY Non-Formulary 04/01/2015 ZARONTIN ethosuximide ADD TO FORMULARY Non-Formulary 04/01/2015 ZARONTIN ethosuximide ADD TO FORMULARY Non-Formulary 04/01/2015 REMODULIN treprostinil sodium CHANGE TIER Preferred Brands Non-Formulary 04/01/2015 REMODULIN treprostinil sodium CHANGE TIER Preferred Brands Non-Formulary 04/01/2015 REMODULIN treprostinil sodium CHANGE TIER Preferred Brands Non-Formulary 04/01/2015 REMODULIN treprostinil sodium CHANGE TIER Preferred Brands Non-Formulary 04/01/2015 RETIN-A MICRO tretinoin microspheres ADD TO FORMULARY Non-Formulary 04/01/2015 ADDERALL XR dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate ADD TO FORMULARY Non-Formulary 04/01/2015 ADDERALL XR dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate ADD TO FORMULARY Non-Formulary 04/01/2015 ADDERALL XR dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate ADD TO FORMULARY Non-Formulary 04/01/2015 VFEND voriconazole ADD TO FORMULARY Non-Formulary 04/01/2015 LOTREL amlodipine besylate/benazepril hcl ADD TO FORMULARY Non-Formulary 04/01/2015 URSO FORTE ursodiol ADD TO FORMULARY Non-Formulary 04/01/2015 UTA methenamine/methylene blue/salicylate/sodium phos/hyoscy ADD TO FORMULARY Non-Formulary 04/01/2015 DEPAKOTE ER divalproex sodium ADD TO FORMULARY Non-Formulary 04/01/2015 XYREM sodium oxybate REMOVE UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 460 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2015 URECHOLINE bethanechol chloride ADD TO FORMULARY Non-Formulary 04/01/2015 URECHOLINE bethanechol chloride ADD TO FORMULARY Non-Formulary 04/01/2015 URECHOLINE bethanechol chloride ADD TO FORMULARY Non-Formulary 04/01/2015 URECHOLINE bethanechol chloride ADD TO FORMULARY Non-Formulary 04/01/2015 DEPAKOTE ER divalproex sodium ADD TO FORMULARY Non-Formulary 04/01/2015 CARDIZEM LA diltiazem hcl ADD TO FORMULARY Non-Formulary 04/01/2015 CARDIZEM LA diltiazem hcl ADD TO FORMULARY Non-Formulary 04/01/2015 CARDIZEM LA diltiazem hcl ADD TO FORMULARY Non-Formulary 04/01/2015 DURAGESIC fentanyl CHANGE TIER Non-Formulary 04/01/2015 DURAGESIC fentanyl CHANGE TIER Non-Formulary 04/01/2015 DURAGESIC fentanyl CHANGE TIER Non-Formulary 04/01/2015 DURAGESIC fentanyl CHANGE TIER Non-Formulary 04/01/2015 LOPROX ciclopirox ADD TO FORMULARY Non-Formulary 04/01/2015 MAXALT rizatriptan benzoate ADD TO FORMULARY Non-Formulary 04/01/2015 MAXALT rizatriptan benzoate ADD TO FORMULARY Non-Formulary 04/01/2015 MAXALT MLT rizatriptan benzoate ADD TO FORMULARY Non-Formulary 04/01/2015 MAXALT MLT rizatriptan benzoate ADD TO FORMULARY Non-Formulary 04/01/2015 DIDREX benzphetamine hcl ADD TO FORMULARY Non-Formulary 04/01/2015 ZOFRAN ondansetron hcl ADD TO FORMULARY Non-Formulary 04/01/2015 ZOFRAN ondansetron hcl ADD TO FORMULARY Non-Formulary 04/01/2015 ZOFRAN ondansetron hcl ADD TO FORMULARY Non-Formulary 04/01/2015 ZOFRAN ODT ondansetron ADD TO FORMULARY Non-Formulary 04/01/2015 ZOFRAN ODT ondansetron ADD TO FORMULARY Non-Formulary 04/01/2015 CLIMARA estradiol CHANGE TIER Non-Formulary 04/01/2015 CLIMARA estradiol CHANGE TIER Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 461 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2015 oxycodone oxycodone hcl hcl,oxycodone hydrochloride,oxy contin,roxicodone ,oxecta,oxycodon e concentrate,roxic odone intensol,ethoxydose,oxyir,da zidox,oxycodone hcl er CHANGE TIER Generics 04/01/2015 ROXICODONE oxycodone hcl CHANGE TIER Non-Formulary 04/01/2015 ROXICODONE oxycodone hcl CHANGE TIER Non-Formulary 04/01/2015 oxycodone hcl oxycodone hcl CHANGE TIER Generics 04/01/2015 DILAUDID hydromorphone hcl ADD TO FORMULARY Non-Formulary 04/01/2015 ACULAR LS ketorolac tromethamine ADD TO FORMULARY Non-Formulary 04/01/2015 METADATE CD methylphenidate hcl ADD TO FORMULARY Non-Formulary 04/01/2015 METADATE CD methylphenidate hcl ADD TO FORMULARY Non-Formulary 04/01/2015 METADATE CD methylphenidate hcl ADD TO FORMULARY Non-Formulary 04/01/2015 DILAUDID-HP hydromorphone hcl/pf ADD TO FORMULARY Non-Formulary 04/01/2015 TOPROL XL metoprolol succinate ADD TO FORMULARY Non-Formulary 04/01/2015 TOPROL XL metoprolol succinate ADD TO FORMULARY Non-Formulary 04/01/2015 TOPROL XL metoprolol succinate ADD TO FORMULARY Non-Formulary 04/01/2015 KEPPRA XR levetiracetam ADD TO FORMULARY Non-Formulary 04/01/2016 DYMISTA azelastine hcl/fluticasone propionate ADD TO FORMULARY Non-Formulary Preferred Brands 04/01/2016 TRULICITY dulaglutide ADD TO FORMULARY Non-Formulary Preferred Brands 04/01/2016 TRULICITY dulaglutide ADD TO FORMULARY Non-Formulary Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 462 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2016 EMBEDA morphine sulfate/naltrexone hcl ADD TO FORMULARY Non-Formulary Preferred Brands 04/01/2016 NUEDEXTA dextromethorphan hbr/quinidine sulfate ADD TO FORMULARY Non-Formulary Preferred Brands 04/01/2016 GENVOYA elvitegravir/cobicistat/emtrici tabine/tenofovir alafenamide ADD UM: SPECIALTY Specialty Drug 04/01/2016 NUWIQ antihemophilic factor viii rec hek cell, b-domain deleted ADD TO FORMULARY Non-Formulary 04/01/2016 NUWIQ antihemophilic factor viii rec hek cell, b-domain deleted ADD UM: SPECIALTY Specialty Drug 04/01/2016 KEVEYIS dichlorphenamide ADD UM: SPECIALTY Specialty Drug 04/01/2016 glucophage,gluco metformin hcl phage xr,metformin hcl,metformin hcl er,riomet,glumetz a,metformin hydrochloride,fort amet ADD UM: AUTHORIZATION PA applies 04/01/2016 glumetza,metfor min hcl er 04/01/2016 PH 12 DILUENT diluent for epoprostenol FOR FLOLAN sodium (glycine) REMOVE FROM FORMULARY Non-Formulary 04/01/2016 dicyclomine hcl dicyclomine hcl REMOVE FROM FORMULARY Non-Formulary 04/01/2016 dicyclomine hcl dicyclomine hcl REMOVE FROM FORMULARY Non-Formulary 04/01/2016 fentanyl citrate0.9% nacl fentanyl citrate in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 04/01/2016 cefazolin sodium- cefazolin sodium/water for sterile water injection,sterile REMOVE FROM FORMULARY Non-Formulary metformin hcl CHANGE TIER Generics Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 463 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2016 sure result tac pak triamcinolone acetonide/dimethicone/silico ne, adhesive REMOVE FROM FORMULARY Non-Formulary 04/01/2016 sure result dss premium pack diclofenac sodium/capsicum oleoresin REMOVE FROM FORMULARY Non-Formulary 04/01/2016 dexamethasone- dexamethasone sodium 0.9% nacl phosphate in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 04/01/2016 dexamethasone- dexamethasone sodium 0.9% nacl phosphate in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 04/01/2016 diphenhydramine diphenhydramine hcl in 0.9 -0.9% nacl % sodium chloride REMOVE FROM FORMULARY Non-Formulary 04/01/2016 norepinephrine bitartrate-d5w norepinephrine bitartrate/dextrose 5 % in water REMOVE FROM FORMULARY Non-Formulary 04/01/2016 magnesium sulfate-d5w magnesium sulfate/dextrose 5 % in water REMOVE FROM FORMULARY Non-Formulary 04/01/2016 oxytocin-0.9% nacl oxytocin in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 04/01/2016 epinephrine hcl0.9% nacl epinephrine hcl in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 04/01/2016 oxytocin-lactated oxytocin/ringers ringers solution,lactated REMOVE FROM FORMULARY Non-Formulary 04/01/2016 fentanyl citrate fentanyl citrate/pf REMOVE FROM FORMULARY Non-Formulary 04/01/2016 easy touch fluringe fliplock syringe,safety with needle,1 ml REMOVE FROM FORMULARY Non-Formulary 04/01/2016 easy touch fluringe sheathlock syringe,safety with needle,1 ml REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 464 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2016 easy touch tuberculin sheathlk syringe,safety with needle,1 ml REMOVE FROM FORMULARY Non-Formulary 04/01/2016 easy touch tuberculin sheathlk syringe,safety with needle,1 ml REMOVE FROM FORMULARY Non-Formulary 04/01/2016 easy touch tuberculin sheathlk syringe,safety with needle,1 ml REMOVE FROM FORMULARY Non-Formulary 04/01/2016 alcohol prep pads alcohol antiseptic pads ADD TO FORMULARY Generics 04/01/2016 NEXIUM 24HR esomeprazole magnesium ADD TO FORMULARY Generics 04/01/2016 KETOVIE PEPTIDE 4:1 nutritional tx, ketogenic,whey REMOVE FROM FORMULARY Non-Formulary 04/01/2016 MTERYTI FOLIC prenatal vit no.6/iron 5 fum/folic acid/vit b12/calcium/vit d3 REMOVE FROM FORMULARY Non-Formulary 04/01/2016 day time cold-flu dextromethorphan relief hbr/phenylephrine hcl/acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/01/2016 nighttime cold-flu dextromethorphan relief hbr/acetaminophen/doxylam ine REMOVE FROM FORMULARY Non-Formulary 04/01/2016 famotidine famotidine REMOVE FROM FORMULARY Non-Formulary 04/01/2016 calcium 600-vit d3 calcium carbonate/cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 04/01/2016 famotidine famotidine REMOVE FROM FORMULARY Non-Formulary 04/01/2016 relcof ir guaifenesin/phenylephrine hcl REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 465 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 04/01/2016 relhist bp 04/01/2016 Generic Name brompheniramine maleate/phenylephrine hcl Type of Change Previous Value New Value REMOVE FROM FORMULARY Non-Formulary day time cold-flu dextromethorphan relief hbr/phenylephrine hcl/acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/01/2016 severe cold cough-flu REMOVE FROM FORMULARY Non-Formulary 04/01/2016 nighttime cold-flu dextromethorphan relief hbr/acetaminophen/doxylam ine REMOVE FROM FORMULARY Non-Formulary 04/01/2016 lubricating tears propylene glycol/polyethylene glycol 400 REMOVE FROM FORMULARY Non-Formulary 04/01/2016 severe cold cough-flu diphenhydramine hcl/phenylephrine hcl/acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/01/2016 lubricating tears propylene glycol/polyethylene glycol 400 REMOVE FROM FORMULARY Non-Formulary 04/01/2016 famotidine famotidine REMOVE FROM FORMULARY Non-Formulary 04/01/2016 famotidine famotidine REMOVE FROM FORMULARY Non-Formulary 04/01/2016 TALTZ ixekizumab AUTOINJECTOR (3 PACK) REMOVE FROM FORMULARY Non-Formulary 04/01/2016 TALTZ ixekizumab AUTOINJECTOR REMOVE FROM FORMULARY Non-Formulary 04/01/2016 TALTZ ixekizumab AUTOINJECTOR (2 PACK) REMOVE FROM FORMULARY Non-Formulary diphenhydramine hcl/phenylephrine hcl/acetaminophen BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 466 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/01/2016 TALTZ SYRINGE ixekizumab REMOVE FROM FORMULARY Non-Formulary 04/01/2016 TALTZ SYRINGE ixekizumab (3 PACK) REMOVE FROM FORMULARY Non-Formulary 04/01/2016 TALTZ SYRINGE ixekizumab (2 PACK) REMOVE FROM FORMULARY Non-Formulary 04/01/2016 TALTZ SYRINGE ixekizumab REMOVE FROM FORMULARY Non-Formulary 04/01/2016 ACTIVE-PAC gabapentin/lidocaine hcl/menthol REMOVE FROM FORMULARY Non-Formulary 04/01/2016 SERNIVO betamethasone dipropionate ADD TO FORMULARY Non-Formulary 04/01/2016 mupirocin mupirocin ADD TO FORMULARY Generics 04/01/2016 nicardipine hcl nicardipine hcl REMOVE FROM FORMULARY Non-Formulary 04/01/2016 succinylcholine chloride succinylcholine chloride REMOVE FROM FORMULARY Non-Formulary 04/01/2016 hydromorphone hcl-0.9% nacl hydromorphone hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 04/01/2016 temozolomide temozolomide ADD TO FORMULARY Non-Formulary Generics 04/01/2016 temozolomide temozolomide ADD TO FORMULARY Non-Formulary Generics 04/01/2016 temozolomide temozolomide ADD TO FORMULARY Non-Formulary Generics 04/01/2016 temozolomide temozolomide ADD TO FORMULARY Non-Formulary Generics 04/01/2016 XELJANZ XR tofacitinib citrate 04/06/2015 04/06/2015 REMOVE FROM FORMULARY Non-Formulary norethin-eth norethindrone-ethinyl estra-ferrous fum estradiol/ferrous fumarate ADD TO FORMULARY Preventative norethin-eth norethindrone-ethinyl estra-ferrous fum estradiol/ferrous fumarate ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 467 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/06/2015 LAYOLIS FE norethindrone-ethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 04/06/2015 LAYOLIS FE norethindrone-ethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 04/06/2015 adapalene adapalene ADD TO FORMULARY Generics 04/06/2015 CHOLBAM cholic acid ADD TO FORMULARY Non-Formulary 04/06/2015 CHOLBAM cholic acid ADD TO FORMULARY Non-Formulary 04/06/2015 NATPARA parathyroid hormone ADD TO FORMULARY Non-Formulary 04/06/2015 NATPARA parathyroid hormone ADD UM: SPECIALTY Specialty Drug 04/06/2015 OMIDRIA phenylephrine hcl/ketorolac tromethamine ADD TO FORMULARY Not Covered 04/06/2015 hydroxyzine hcl hydroxyzine hcl CHANGE TIER Generics 04/06/2015 metaxalone metaxalone ADD TO FORMULARY Generics 04/06/2015 SKELAXIN metaxalone ADD TO FORMULARY Non-Formulary 04/07/2016 UROAV-B methenamine/methylene blue/sod phos/p.salicylate/hyoscyami ne ADD TO FORMULARY Non-Formulary 04/07/2016 EVOMELA melphalan hcl REMOVE FROM FORMULARY Non-Formulary 04/07/2016 prednisone prednisone ADD TO FORMULARY Generics 04/07/2016 prednisone prednisone ADD TO FORMULARY Generics 04/07/2016 methergine methylergonovine maleate ADD TO FORMULARY Generics 04/07/2016 methergine methylergonovine maleate ADD TO FORMULARY Generics 04/07/2016 magnesiumlactated ringers magnesium sulfate/ringers solution,lactated REMOVE FROM FORMULARY Non-Formulary 04/07/2016 oxytocin-d5lactated ringers oxytocin/dextrose 5%lactated ringers REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 468 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/07/2016 cefazolin sodium- cefazolin sodium/water for sterile water injection,sterile REMOVE FROM FORMULARY Non-Formulary 04/07/2016 phenylephrine hcl-0.9% nacl REMOVE FROM FORMULARY Non-Formulary 04/07/2016 morphine sulfate- morphine sulfate in 0.9 % 0.9% nacl sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 04/07/2016 bupivacaine hcl0.9% nacl bupivacaine hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 04/07/2016 bupivacaine hcl0.9% nacl bupivacaine hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 04/07/2016 morphine sulfate- morphine sulfate in 0.9 % 0.9% nacl sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 04/07/2016 fentanylbupivacaine0.9% nacl fentanyl citrate/bupivacaine hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 04/07/2016 midazolam hcl0.9% nacl midazolam hcl in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 04/07/2016 easy touch syringe,safety with needle,1 tuberculin fliplock ml REMOVE FROM FORMULARY Non-Formulary 04/07/2016 easy touch syringe,safety with needle,1 tuberculin fliplock ml REMOVE FROM FORMULARY Non-Formulary 04/07/2016 easy touch tuberculin sheathlk syringe,safety with needle,1 ml REMOVE FROM FORMULARY Non-Formulary 04/07/2016 easy touch syringe,safety with needle,1 tuberculin fliplock ml REMOVE FROM FORMULARY Non-Formulary 04/07/2016 stevia glycerite stevioside/glycerin REMOVE FROM FORMULARY Non-Formulary 04/07/2016 stevia glycerite stevioside/glycerin REMOVE FROM FORMULARY Non-Formulary phenylephrine hcl in 0.9 % sodium chloride BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 469 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/07/2016 ADULT MULTI + multivitamin with min/folic OMEGA-3 acid/d3/omega3/dha/epa/fish oil REMOVE FROM FORMULARY Non-Formulary 04/07/2016 HAIR, SKIN AND ascorbic acid/ascorbate NAILS sodium/biotin REMOVE FROM FORMULARY Non-Formulary 04/07/2016 NEOKE MCT70 medium chain triglycerides REMOVE FROM FORMULARY Non-Formulary 04/07/2016 EMERGEN-C MSM LITE ascorbic acid/multivitamin, minerals/methylsulfonylmeth ane REMOVE FROM FORMULARY Non-Formulary 04/07/2016 EMERGEN-C ascorbic acid/multivitamin with minerals REMOVE FROM FORMULARY Non-Formulary 04/07/2016 EMERGEN-C ascorbic acid/multivitHEART HEALTH min/lycopene/plant sterol complex REMOVE FROM FORMULARY Non-Formulary 04/07/2016 EMERGEN-C VITAMIN DCALCIUM ascorbic acid/multivitmin/calcium combo no.27/vitamin d3 REMOVE FROM FORMULARY Non-Formulary 04/07/2016 EMERGEN-C ascorbic acid/multivitamin with minerals REMOVE FROM FORMULARY Non-Formulary 04/07/2016 children's painfever acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/07/2016 12-hour cough relief dextromethorphan polistirex REMOVE FROM FORMULARY Non-Formulary 04/07/2016 juniors' acetaminophen acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/07/2016 juniors' acetaminophen acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/07/2016 wart remover salicylic acid REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 470 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/07/2016 antifungal undecylenic acid REMOVE FROM FORMULARY Non-Formulary 04/07/2016 children's painfever acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/07/2016 alertness aid caffeine REMOVE FROM FORMULARY Non-Formulary 04/07/2016 allergy relief chlorpheniramine maleate REMOVE FROM FORMULARY Non-Formulary 04/07/2016 allergy relief chlorpheniramine maleate REMOVE FROM FORMULARY Non-Formulary 04/07/2016 alertness aid caffeine REMOVE FROM FORMULARY Non-Formulary 04/07/2016 guaifenesin-dm er guaifenesin/dextromethorph an hbr REMOVE FROM FORMULARY Non-Formulary 04/07/2016 protein nutritional lactose-reduced food shake REMOVE FROM FORMULARY Non-Formulary 04/07/2016 ddrops cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 04/07/2016 baby ddrops cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 04/07/2016 ddrops cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 04/07/2016 pain reliever pm acetaminophen/diphenhydra mine hcl REMOVE FROM FORMULARY Non-Formulary 04/07/2016 witch hazel witch hazel REMOVE FROM FORMULARY Non-Formulary 04/07/2016 pain reliever pm acetaminophen/diphenhydra mine hcl REMOVE FROM FORMULARY Non-Formulary 04/07/2016 witch hazel witch hazel REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 471 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/07/2016 alertness aid caffeine REMOVE FROM FORMULARY Non-Formulary 04/07/2016 alertness aid caffeine REMOVE FROM FORMULARY Non-Formulary 04/07/2016 allergy relief chlorpheniramine maleate REMOVE FROM FORMULARY Non-Formulary 04/07/2016 allergy relief chlorpheniramine maleate REMOVE FROM FORMULARY Non-Formulary 04/07/2016 DOG EPITHELIUM EXTRACT allergenic extract-dog epithelium REMOVE FROM FORMULARY Non-Formulary 04/07/2016 DOG FENNEL allergenic extract-weed pollen-dog fennel REMOVE FROM FORMULARY Non-Formulary 04/07/2016 HACKBERRY allergenic extract-tree pollen-hackberry REMOVE FROM FORMULARY Non-Formulary 04/07/2016 IV INFUSION CPI lidocaine/prilocaine with 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 04/07/2016 CINQAIR reslizumab REMOVE FROM FORMULARY Non-Formulary 04/07/2016 DESCOVY emtricitabine/tenofovir alafenamide fumarate REMOVE FROM FORMULARY Non-Formulary 04/07/2016 DEFITELIO defibrotide sodium REMOVE FROM FORMULARY Non-Formulary 04/07/2016 DEFITELIO defibrotide sodium REMOVE FROM FORMULARY Non-Formulary 04/07/2016 NOXIFOL-D3 cholecalciferol (vit d3)/folic acid REMOVE FROM FORMULARY Non-Formulary 04/07/2016 ketamine hclsterile water ketamine hcl in sterile water REMOVE FROM FORMULARY Non-Formulary 04/07/2016 meperidine hcl0.9% nacl meperidine hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 472 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/08/2015 verapamil er pm verapamil hcl CHANGE TIER Generics 04/08/2015 verapamil er,verapamil hcl verapamil hcl CHANGE TIER Generics 04/08/2016 lamotrigine er lamotrigine CHANGE TIER 04/09/2016 PLEGRIDY PEN peginterferon beta-1a ADD UM: PS Preferred Specialty 04/09/2016 PLEGRIDY PEN peginterferon beta-1a ADD UM: PS Preferred Specialty 04/09/2016 GILENYA fingolimod hcl ADD UM: PS Preferred Specialty 04/09/2016 BETASERON interferon beta-1b ADD UM: PS Preferred Specialty 04/09/2016 AVONEX PEN interferon beta-1a ADD UM: PS Preferred Specialty 04/09/2016 NORDITROPIN FLEXPRO somatropin ADD UM: PS Preferred Specialty 04/09/2016 HUMIRA adalimumab ADD UM: PS Preferred Specialty 04/09/2016 AVONEX PEN interferon beta-1a ADD UM: PS Preferred Specialty 04/09/2016 HUMIRA PEDIATRIC CROHN'S adalimumab ADD UM: PS Preferred Specialty 04/09/2016 HUMIRA PEDIATRIC CROHN'S adalimumab ADD UM: PS Preferred Specialty 04/09/2016 NORDITROPIN FLEXPRO somatropin ADD UM: PS Preferred Specialty 04/09/2016 BETASERON interferon beta-1b ADD UM: PS Preferred Specialty Generics Not Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 473 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/09/2016 TECFIDERA dimethyl fumarate ADD UM: PS Preferred Specialty 04/09/2016 TECFIDERA dimethyl fumarate ADD UM: PS Preferred Specialty 04/09/2016 BETASERON interferon beta-1b ADD UM: PS Preferred Specialty 04/09/2016 HUMIRA adalimumab ADD UM: PS Preferred Specialty 04/09/2016 COPAXONE glatiramer acetate ADD UM: PS Preferred Specialty 04/09/2016 MAKENA hydroxyprogesterone caproate ADD UM: PS Preferred Specialty 04/09/2016 TECFIDERA dimethyl fumarate ADD UM: PS Preferred Specialty 04/09/2016 SIMPONI golimumab ADD UM: PS Preferred Specialty 04/09/2016 SIMPONI golimumab ADD UM: PS Preferred Specialty 04/09/2016 PLEGRIDY peginterferon beta-1a ADD UM: PS Preferred Specialty 04/09/2016 PLEGRIDY peginterferon beta-1a ADD UM: PS Preferred Specialty 04/09/2016 BETASERON interferon beta-1b ADD UM: PS Preferred Specialty 04/09/2016 AVONEX PEN interferon beta-1a ADD UM: PS Preferred Specialty 04/09/2016 NORDITROPIN NORDIFLEX somatropin ADD UM: PS Preferred Specialty 04/09/2016 PLEGRIDY PEN peginterferon beta-1a ADD UM: PS Preferred Specialty BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 474 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/09/2016 AVONEX interferon beta-1a/albumin human ADD UM: PS Preferred Specialty 04/09/2016 ENBREL etanercept ADD UM: PS Preferred Specialty 04/09/2016 COPAXONE glatiramer acetate ADD UM: PS Preferred Specialty 04/09/2016 ENBREL etanercept ADD UM: PS Preferred Specialty 04/09/2016 ZYTIGA abiraterone acetate ADD UM: PS Preferred Specialty 04/09/2016 BETASERON interferon beta-1b ADD UM: PS Preferred Specialty 04/09/2016 ENBREL etanercept ADD UM: PS Preferred Specialty 04/09/2016 GILENYA fingolimod hcl ADD UM: PS Preferred Specialty 04/09/2016 ENBREL etanercept ADD UM: PS Preferred Specialty 04/09/2016 SIMPONI golimumab ADD UM: PS Preferred Specialty 04/09/2016 ENBREL etanercept ADD UM: PS Preferred Specialty 04/09/2016 ENBREL etanercept ADD UM: PS Preferred Specialty 04/09/2016 PLEGRIDY peginterferon beta-1a ADD UM: PS Preferred Specialty 04/09/2016 AVONEX interferon beta-1a ADD UM: PS Preferred Specialty 04/09/2016 SIMPONI golimumab ADD UM: PS Preferred Specialty BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 475 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/09/2016 COPAXONE glatiramer acetate ADD UM: PS Preferred Specialty 04/09/2016 ORTHOVISC hyaluronate sodium ADD UM: PS Preferred Specialty 04/09/2016 AVONEX interferon beta-1a/albumin human ADD UM: PS Preferred Specialty 04/09/2016 GILENYA fingolimod hcl ADD UM: PS Preferred Specialty 04/09/2016 AVONEX interferon beta-1a/albumin human ADD UM: PS Preferred Specialty 04/09/2016 ENBREL etanercept ADD UM: PS Preferred Specialty 04/09/2016 AVONEX interferon beta-1a ADD UM: PS Preferred Specialty 04/09/2016 NORDITROPIN FLEXPRO somatropin ADD UM: PS Preferred Specialty 04/09/2016 HUMIRA adalimumab ADD UM: PS Preferred Specialty 04/09/2016 NORDITROPIN FLEXPRO somatropin ADD UM: PS Preferred Specialty 04/09/2016 SYNVISC-ONE hylan g-f 20 ADD UM: PS Preferred Specialty 04/09/2016 STELARA ustekinumab ADD UM: PS Preferred Specialty 04/09/2016 SYNVISC hylan g-f 20 ADD UM: PS Preferred Specialty 04/09/2016 AVONEX interferon beta-1a ADD UM: PS Preferred Specialty 04/09/2016 ENBREL etanercept ADD UM: PS Preferred Specialty BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 476 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/09/2016 HUMIRA PEN PSORIASISUVEITIS adalimumab ADD UM: PS Preferred Specialty 04/09/2016 HUMIRA PEN adalimumab ADD UM: PS Preferred Specialty 04/09/2016 HUMIRA PEN CROHN-UC-HS STARTER adalimumab ADD UM: PS Preferred Specialty 04/09/2016 HUMIRA PEN adalimumab ADD UM: PS Preferred Specialty 04/09/2016 STELARA ustekinumab ADD UM: PS Preferred Specialty 04/13/2015 QUADRACEL DTAP-IPV diphtheria, pertussis(acell),tetanus,polio vaccine/pf REMOVE FROM FORMULARY Non-Formulary 04/13/2015 QUADRACEL DTAP-IPV diphtheria, pertussis(acell),tetanus,polio vaccine/pf REMOVE FROM FORMULARY Non-Formulary 04/13/2015 sterile droptainers eye drops dispenser REMOVE FROM FORMULARY Non-Formulary 04/13/2015 sterile droptainers eye drops dispenser REMOVE FROM FORMULARY Non-Formulary 04/13/2015 sterile droptainers eye drops dispenser REMOVE FROM FORMULARY Non-Formulary 04/13/2015 genistein genistein REMOVE FROM FORMULARY Non-Formulary 04/13/2015 latanoprost latanoprost REMOVE FROM FORMULARY Non-Formulary 04/13/2015 scar care base enhanced gel base no.184 REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 477 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/13/2015 scar care base enhanced gel base no.184 REMOVE FROM FORMULARY Non-Formulary 04/13/2015 ANASEPT sodium hypochlorite REMOVE FROM FORMULARY Non-Formulary 04/13/2015 melatonin melatonin REMOVE FROM FORMULARY Non-Formulary 04/13/2015 acidophilus lactobacillus acidophilus/bifidobacterium longum REMOVE FROM FORMULARY Non-Formulary 04/13/2015 scrub care povidone iodine povidone-iodine REMOVE FROM FORMULARY Non-Formulary 04/13/2015 probiotic colon support lactobacillus acidophilus/l. gasseri/b. bifidum/b. longum REMOVE FROM FORMULARY Non-Formulary 04/13/2015 ensure high protein-muscle lactose-reduced food REMOVE FROM FORMULARY Non-Formulary 04/13/2015 scrub care povidone iodine povidone-iodine REMOVE FROM FORMULARY Non-Formulary 04/13/2015 ensure high protein-muscle lactose-reduced food REMOVE FROM FORMULARY Non-Formulary 04/13/2015 MENVEO MENA meningococcal a diphtheriaCOMPONENT conj vaccine component 1 of 2/pf REMOVE FROM FORMULARY Non-Formulary 04/13/2015 MENVEO MENCYW-135 COMPONENT REMOVE FROM FORMULARY Non-Formulary 04/13/2015 RETIN-A MICRO tretinoin microspheres PUMP ADD TO FORMULARY Non-Formulary 04/13/2015 PENTACEL diphtheria, DTAP-IPV pertussis(acell),tetanus,polio COMPONENT,Q vaccine/pf UADRACEL DTAP-IPV REMOVE FROM FORMULARY Non-Formulary meningococcal c,y,w135,dip-conj vaccine component 2 of 2/pf BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 478 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/13/2015 venlafaxine hcl er venlafaxine hcl ADD TO FORMULARY Generics 04/13/2015 retin-a micro pump,tretinoin microsphere tretinoin microspheres ADD TO FORMULARY Non-Formulary 04/13/2015 ornithine ornithine REMOVE FROM FORMULARY Non-Formulary 04/13/2015 comtan,entacapo entacapone ne ADD TO FORMULARY Generics 04/13/2015 fexmid,cyclobenz cyclobenzaprine hcl aprine hcl ADD TO FORMULARY Generics 04/13/2015 ANASEPT SKIN- sodium hypochlorite WOUND CLEANSER,ANA SEPT REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 479 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change 04/13/2015 humapen memoir,humapen luxura hd,gentle touch system,gentle touch loop ostomy sys,tubigrip,tubul ar bandage applicator,tubipad ,lyofoam,lyofoam c,lyofoam a,lyofoam t,lyofoam extra,kaltostat,sur -fit natura post op,stomahesive,e steem synergy,eakin skin barrier,eakin fistula & wound pouch,little ones active life pouch,stomahesi ve sterile wafer,active life closed-end pouch,visi-flow stoma cone,active life drainable pouch,stomahesi ve protective,surfit drainage container,sur-fit night drainage tubing,allkare protect barrier wipe,flexi-trak insulin admin. supplies,ostomy kit,elastic bandage,tubular bandage applicator,foam bandage,alginate dressing,ostomy supply,colostomy bags,ostomy adhesive,adhesive remover,colostomy belt,ostomy cap,facial-body sponge,gel dressing,hydrocolloid dressing,ostomy irrigator,colostomy bag, nonsterile,activated charcoal/alginate dressing/hydrocolloid dressing,silver/hydrocolloid dressing,zinc oxide,nonadherent bandage,irrigation set,miscellaneous medical supply,urinary bag,iv equipment,vaporizer,soft lens rinse-store solution,hard lens cleaner,soft lens adjunctive solutions,hard lens wetting solution,contact lens case,soft lens chemical disinfectnt,diaphragms, arcspring,diaphragm fitting set,arc-spring,diaphragms, coil spring,diaphragms, flat spring,pregnancy test kit,cholesterol test kit,gas permeable lens cleaner,hard lens clean-soak solution,wetting soln REMOVE FROM FORMULARY Previous Value New Value Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 480 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name anchoring device,allkare adhesive remover wipe,active life,sur-fit natura stomahesive,acti ve life urostomy pouch,active life convex,little ones sur-fit ped belt,ostomy appliance belt,active life stoma cap,sur-fitact life-tail closures,sur-fit tail closures,duolock curved tail closure,active life pouch,sur-fit autolock stomahesive,surfit autolock durahesive,sur-fit autolock drain pouch,sur-fit autolock pouch,optipore,s af-gel,setopress high compression,kalt ostat fortex,aquacel,du oderm hydroactive,duod erm,combiderm acd,duoderm gas,hard and soft,tear test,soft lens surfactant cleanser,soft lens enzymatic cleanser,wetting soln gas,hard & soft,iv piggyback adminstration set,anesthesia tray,iv administration setfilter,container,empty,iv administration set,iv admin extension set-filter,iv admin extension set,iv administration setclamp,transfer sets,iv infusion pump accessory,blood administration set,iv administration set,nonvent,hyperalimentation equipment,iv catheter kit,nerve stimulator device,blood administration equipment,iv infusion pump,in-line burette set,procedural tray,iv venipuncture needle set,iv catheter,dialysis (peritoneal) kits,blood collection set,vial,empty,feeder container with pump set,irrigation piercing pin set,nv,pump set,iv catheter kit accessory,calamine/zinc gelatin,inhaler, assist devices,inhaler, assist devices, accessories,acne scrub pad,n95 respirator, disposable,pen needle, diabetic,pen needle, diabetic, safety,syringe Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 481 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name cgf,sur-fit natura drainable pouch,sur-fit natura closedend pch,sur-fit natura minipouch,sur-fit natura urostomy pouch,sur-fit natura pouch,surfit autolock inserts,sur-fit autolock,sur-fit natura durahesive,sur-fit natura flange cap,sur-fit natura irrig sleeve,sur-fit nat irrig faceplate,sur-fit natura little ones,visi-flow irrigator stoma cone,sur-fit natura convex inserts,durahesiv e moldable convex,flexiseal,active life one-piece,eakin cohesive seals,carboflex,v ersiva,duoderm signal,aquacelag,unnaflex,surepress,sur -fit natura visiflow set,unna-flex plus,adria- Generic Name Type of Change Previous Value New Value accessory,needles, insulin disposable,syr biopsyaspiration reusable,gloves,bloodglucose meter, disctype,blood glucose calibration control solution, normal,blood glucose calibration control solution, low,blood glucose calibration control solution, high,blood glucose calibration control high and low,lancets,lancing device,lancing device/lancets,bloodglucose meter,bloodglucose meter, wireless,jejunostomy tube,gastrostomy tube,silver/foam bandage,silver sulfadiazine/foam bandage,gauze bandage/lanolin alc/min oil/petrolat/ceresin,silicone adhesive,transparent dressing,dental plaque indicator,needleless dispensing pin,diaphragms, wide seal,heating pad,gum mastic/storax/methyl salicylate/alcohol,syringe with needle,disposable,insulin 1 ml,syringe with needle,insulin,0.5 ml,condoms, latex, lubricated,activated BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 482 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name oncoline,triaminic flowing vapors,unisol 4 preservative free,pliagel,clerz2 lubricatingrewetting,clerz2,mirasept,miras ept step 1,mirasept step 2,unisol 25 day pf saline,unisol plus,ortho allflex,orthodiaphragm,advan ce pregnancy test,advanced care cholesterol test,fact plus pregnancy test,optifree,soaclens,sys tane contacts,clerz plus,opti-free replenish,irrigatio n administration set,schirmer tear test,opti-free express,optione,opti-clean ii daily cleaner,optifree lens case,opti-one multipurpose,opticlean daily cleaner,preflex,sa line for sensitive charcoal/iron/sodium/water,c old-hot pack,suppository mold,syringe with needle,insulin disposable,0.5 ml,breast shield,adhesive,silver na hydrogen zirconium phos/hydrocolloid heel dressing,silver na hydrogen zirconium phos/hydrocolloid toe dressing,silver na hydrogen zircon phos/hydrocolloid heel&toe/cream59,nasal airflow strips,ear syringe,denture cleanser,adhesive tape,facial mask,pads for bedsores,multiple test strip device,nebulizer,peak flow meter/inhaler, assist devices,peak flow meter,mucus clearing device,blood pressure test kit-wrist,thermometer, electronic,oral,blood pressure test kitlarge,thermometer, electronic,otic,condoms, latex, nonlubricated,sanitary pads,incontinence pad,liner,disp,catheter,syrin ge disposable, irrigation,70 ml,urinary bag accessories,catheter male,external,drainage bag,catheterization tray,syringe disposable Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 483 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name eyes,alcon enzymatic,flexcare,opti-soak conditioning,optitears,opti-soak daily,opti-soak soothing drops,secondary set,spinal-22 wbupiv-epiephed,spinal anesthesia tray,ivex-rf filter set,evacuated container,ls plum primary setol,plumset primary setol,dial-a-flo iv extension set,dial-a-flo microdrip set,venoset secondary,soluse t with cair clamp,transfer set,decanting set,nonvented iv set 100 wclamp,nitroglyceri n patient line,soluset 150x15 i.v. setsl,screw cap set,iv pump setivex-hp,blood ytype pump set,hema blood secondary irrigation,needles, filter,gauze bandage/elastic bandage,adhesive bandage,gauze bandage,syringe, disposable, 60 ml,syringe with needle,disposable, 3 ml,syringe, disposable, 1 ml,underpads,diaper,brief,ad ult, disposable,syringe, disposable, 140 ml,syringe w-needle,disposab,1 ml,undercast padding,facialbody wipes,enema bag, disposable,wadding,syringe, disposable, 20 ml,syringe, disposable, 12 ml,needles, blood collection,syringe with needle, 12 ml,polyhexamethylene biguanide/gauze bandage,feeder container,eye patch,syringe, disposable, 3 ml,surgical suction tubing,compression stocking,thigh high,regular length,small,compression stocking,thigh high,short length,small,compression stocking,thigh high,regular length,medium,compression stocking,thigh high,regular length,large,compression stocking,thigh high,long length,small,compression stocking,thigh high,regular length,x-small,compression stocking,thigh high,short length, Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 484 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name pump,venoset piggyback,air filter,extension set with stopcock,anesthe sia extension set,syringe filter,cvp universal set,blood set,backcheck extension set,venoset with cair clamp,nonvented primary pg-bk wcair,blood set 78sl, y-type,blood set 82-sl,venoset t-type w-cair clamp,venoset secondary piggybk set,venoset sec piggyback,nutrimi x,abbott counting tray,cont epidural w-bupiv-epi,veniprep ii kit,veniprep iii-site-care dresng,ivex-2 filterset with ysite,veni-prep i kit,reliefband,twoway transfer device,venoset 78 w-mb piercing pin,hema access port,extension medium,compression stocking,thigh high,long length,x-small,wet dressing,compression stocking,thigh high,long length,medium,compression stocking,thigh high,long length,large,compression stocking,thigh high,short length,large,compression stocking,thigh high,regular length,x-large,compression stocking,thigh high,long length,xlarge,petrolatum,white,comp ression stocking, knee high, regular length, small,compression stocking, knee high, regular length, medium,compression stocking, knee high, regular length, large,compression stocking, knee high, regular length, x-large,compression stocking, knee high, long length, small,compression stocking, knee high, long length, medium,compression stocking, knee high,long length, large,compression stocking, knee high, long length, x-large,bismuth tribromophenate/petrolatum, white,syringe, disposable, 35 ml,syringe wneedle,disposb,0.5ml,syring e, disposable, 6 ml,syringe w-needle,disposab,6 Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 485 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name set,three-way stopcock ext 20in-sl,three-way stopcock ext 36,three-way stopcock,threeway stopcock wluer lock,threeway stopcock ext 20-sl,lifecare plum set,pca mini-bore set,pharmacy additive transfer set,y-type connecting set,extension set int-sl,brachial plexus tray,in-line burette set,venoset 78 wivex-2 nonvented,amnio centesis tray,4 leg vented transfer set,4 leg nonvented transfer set,3 leg vented transfer set,nutrimix iv empty container,extensi on tube,butterfly infusion set,platelet concentrate infusion,ivex h.p. filterset,s-a-i-f set 1 micron,clear- ml,swab,syringe disposable irrig,60 ml,burn dressing,diaper/brief,infanttoddler, disposable,diaper,brief,yout h,disposable,feeder container w-gravity set,nasogastric tube,iodoform,needles, disposable,urinary bag/catheterization tray,calcium alginate,sodium chloride,polyhexamethylene biguanide/non-adherent bandage,syringe, disposable, 1ml,syringe wneedle,disposab,12ml,diape r,brief,adult,disposable,syrin ge with needle,insulin disposable,0.3 ml,syringe wneedle,disposab,3ml,dressin g, hydropolymer,bacitracin zinc/polymyxin b sulfate,gloves, latex,first aid kit,dental floss,dental gingival products,sub-q infusion pump accessory,porcine acell submucosa,meshed,porcine submucosa, fenestrated,peripheral nerve diagnostic device,nerve test monofilament,diabetic supplies,miscell,vacuum erection device system,penile constriction ring systm,neurological exam pin,syringe, needle, safety,self-contained Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 486 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name cath,20g,2 in,clearcath,16g,1-1/4 in,clearcath,clearcath(subclav),abb ocath-t,abbocatht with syringe,butterfly,e xtension setlocking luer t,thoracentesis set,blood warming coil,y connector,inpers ol peritoneal cath. 11fr,blood collection set,doubleneedle transfer device,cont epidural wlidocaineepi,additive hinge cap,lifecare additive cap,male adapter plug,sterile empty vial,quik lok luer lock adapter,sterile empty vial& injector,nv cardiac catheter set,microbore extension setsl,manifold 111sl,plum lc 5000 enteral set,pca disposal unit,1.5 ml,syringe with needle, insulin,1 ml and sharps container,syring wndl,disp,insul,0.3 ml/container,empty,syringeneedle,insulin,0.5 ml/container,empty,syringe with needle,insulin,0.3 ml,back brace,rib belt,arm brace,abdominal brace,leg brace,compression socks, medium,compression socks, large,compression socks, xlarge,compression pantyhose, small,compression pantyhose, medium,compression pantyhose, large,compression pantyhose,x-large,athletic support,cane,bed pan,urinal,cushion,crutch accessories,cane tips,walker,neck collar,syringe, disposable, 5 ml,syringe, disposable, 10 ml,syringe, disposable, 30 ml,syringe, disposable, 50 ml,needles, safety huber, disposable,needles, huber disposable,needles, reusable,needles, huber reuse,needles, spinalanesthetic,needles, biopsy,bone,aspirate,syringe reusable, 0.25 ml,syringe reusable, 1 ml,syringe reusable, 2 ml,syringe Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 487 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name extension set,pca set-long mini bore ol,pca cont inf mini-bore,pca set-cont inf mini bore ol,access set,catheter wcair clamp nonvent,cystomanom eter set,secondary irrigation set,t-u-r system w-flow pouch 2000,nonvented t-u-r set,cystoscopyirrigation set,nv large bore yirrigation set,pentothal dispensing pin,empty 3-in-1 mixing container,nutrimix -macro ferrules,ferrules,n utriclamp,container with ytransfer,lifecare flex container,lifecare flex container 1000ml,adi sterile empty vial,snap lock device,veni loop connector,venose reusable, 5 ml,syringe reusable, 10 ml,syringe reusable, 20 ml,syringe reusable, 30 ml,syringe reusable, 50 ml,syringe reusable, 3 ml,syringe reusable,syring w-needl 0.5 ml,kit-tray,syringe with needle 1 ml, disposable kittray,syringe with needle, 0.5 ml,syringe, irrigation, reusable,syringe wcannula,disp, 3 ml,syringe w-cannula, disp, 5 ml,syringe w-cannula,disp, 10 ml,syringe with needle/cannula,disposable 10 ml,blunt needle, disposable,oral dosing devices,syringe, disposable, 2.5 ml,syringe,safety with needle,3 ml,syringe,safety with needle,1 ml,syringe,safety with needle,5 ml,syringe,safety with needle,10 ml,needles, safety,syringe with needle, 10 ml,syringe w-o needl,insulin,1 ml,syringe wneedle,disposab,5 ml,syringe with needle,insulin 0.3 ml (half unit mark),needle clipping and storage device,needles, insulin disposable, safety,pen needle, diabetic disposable, safety,blade lancet, safety,thermometer, glass mercury Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 488 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name t 100-sl piggyback nv,burette 100ml hemoset nv,blood set w-pumpsl,pediatric microaggr blood filt,hema blood set,hema y-type blood set,microdrip micro pump setfiltr,soluset iv micro pump set,lifecare 5000 secondary cntnr,plum lc 5000 minipole,nutriclamp w-transfer set,primary pump set,nylon epidural catheter,ls plum secondary setol,ivex-hp administration set,venoset-100 prim pigbk-ivexhp,screw cap set 38mm,fat emulsion iv set,primary iv setsl,soluset wpediatric ivex sl,venoset 100 piggyback wclamp,lifecare controller model 1000,lifecare (oral),thermometer, glass mercury (rectal),iv catheter kit/iv catheter kit accessory,myelogram tray,thermometer, basal glass mercury,thermometer, electronic (rectal),thermometer, basal electronic,thermometer probe covers,lumbar supports,syringe with needle, insulin, safety, 1 ml,syringe with needle, insulin, safety, 0.5 ml,blood glucose calibration control solution, high and normal,blood-glucose calib. control,ringers solution,lactated/gel dressing,silver,dressing, odor absorbent, hydropolymer,syringe with needle,disposable,insulin,co mpressor, for nebulizer,nebulizer/compres sor, for nebulizer,nebulizer accessories,spirometers and accessories,colostomy washer,ostomy disinfectant,karaya gum,urostomy pouch,colostomy-ileostomy sets, non-sterile,colostomyileostomy sets, sterile,urostomy sets, nonsterile,urostomy sets, sterile,ostomy lubricating deodorant,condoms, female,sub-q administration Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 489 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name pump set,lifecare model 4 macro pump,pca pump,nonvented iv set 100 with cair,venoset microdrip,lifecare 1025 controller,lc 1050 controller,flow detector 30inch,flow detector 54inch,lifecare pump,lifecare micro pump 1a,lifecare micro pump,controller lifecare model 75,pca plus 2,lifecare 75 flow detector,solusetivex-2 filter & cair,dual i.v. stand adapter,i.v. stabilizer bar,i.v. clip adapter,i.v. stand-pole assembly,i.v. stand-base assembly,blood set 64 with cair clamp,blood set 78 with cair clamp,blood ytype set wpump,single shot epidurallidocaine,lifecare set,sub-q administration set, bifurcated,sub-q administration set, trifurcated,sub-q administration set, quadfurcated,cervical cap,biosynthetic bandage,biosynthetic glove,syring wndl,disp,insul,0.5 ml/container,empty,ovulation test kit,blood-glucose meter & wrist blood pressure monitor,safety syringe with needle, disposable kit-tray, 1 ml,contracept barrier dev, vented,insulin pump cartridge,subcutaneous insulin pump,injection ports,insulin pump syringe, 3 ml,insulin pump syringe, 1.8 ml,blood ketone test,strips,blood glucose and ketone control, normal,sub-q insulin delivery device, 40 unit, disposable,sub-q insulin delivery device, 30 unit, disposable,sub-q insulin delivery device, 20 unit,disposable,middle ear inflation device,head support, infant, small,head support, infant, medium,head support, infant, large,silver sulfate/non-adherent bandage,silver sulfate/foam bandage,foam heel dressing,dressing, foam Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 490 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 1050 drop detector,enteral set with container,inpersol w-o auto shutoff valv,inpersol-auto shutoff valve,plumset speciality pump set-ol,plum lifecare 5000 infuser,site-care kit,ivex h.p. pediatric exten set,nonvented secondary iv set,venoset piggyback-mb pin-clmp,pca minibore,batteries, six volt (pair),primary iv set-sl with ivexhp,500ml pressure infusion cuff,pressure infusion cuff,burette nv inline set wport,venoset dual-rate pgbkivex-2,cvc kit,venoset piggyback w-ivex filtr,lifecare shelf storage tray,primary piggyback nv ib set-sl,cvp matrix/activated charcoal,silver/calcium alginate,polyvinyl alcohol/gentian violet/methylene blue,adhesive bandage/adhesive tape/benzalkonium chloride,adhesive bandage/adhesive remover comb. no.1,hydrocolloid dressing/adhesive remover comb. no.1,medical information identification tag,nasal exhalation resistance device,syringe, safety, self-contained disposal unit, 3 ml,syringe, safety, self-contained disposal unit, 5 ml,syringe,needle,insulin,saf ety,disposal unit,0.3 ml,insulin syringeneedle,safety,disposal unit,0.5 ml,syringe,needle,insulin,saf ety,disposal unit, 1 ml,syringe with needle, safety, self-cont disposal unit, 1 ml,syringe with needle, safety, self-cont disposal unit, 3 ml,syringe with needle, safety, self-cont disposal unit, 5 ml,syringe, safety, self-contained disposal unit, 10 ml,syringe,safety,disp unit,10 ml,conception assistance supplies Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 491 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name manometer,drum -cartridge catheter,provider pump set,butterfly s.t. 19x7/8.31/2tbg,pca injector,flip-top additive cap,pump set wproximal male adapt,butterfly st,venous cannulation tray,blood set wcair clamp,tidal joint irrigation tray,cont epidural tray w-drugs,cont epidural-lido-epi t-dose,cont epidural tray,spinal-22bupiv-dex-ephedepi,spinal-25bupiv-dex-ephedepi,spinalanesthesia tray,cont epidural-bupivlidocaine,inpersol peritoneal tray,caudal wlidocaineepinephrine,spina l-22-tet-ephedepi-iodine,nerve block tray wlidocaine,local combination no.1,bloodglucose transmitter,bloodglucose meter,continuous,bloodglucose sensor,bloodglucose meter,continuous/bloodglucose transmitter,syringe, disposable,syringe wcannula,disp, 1 ml,syringe w-cannula,disp, 6 ml,needles, pharmacy compound,syrng w-ndl,dsp kit-tray,0.5ml,syrng wndl,disp. kit-tray,1ml,syringe wneedle,disposab,6ml,syringe ,safety with needle,12 ml,syringe with cannula,disposable 12 ml,syringe wneedle,disposable,syringe with needle, insulin, safety, 0.3 ml,alcohol swab cap,blunt filter cannula, disp.,feeder irrigation kit,yport adapter-extension set,calcium alginate/honey,zinc oxide/gauze bandage,polyquaternium6/gauze bandage,polyquaternium6/non-adherent bandage,polyquaternium6/adhesive bandage,honey/hydrocolloid dressing,gum/polyvinyl alcohol/dental adhesive,gas Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 492 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name infiltration wlidocaine,spinal25 w-tetra-ephedepi,saddle block anesthesia tray,saddleblock anesthesia tray,spinal-22 whitacre w-lidodext,spinal whitacre anesthesia,cont epidural w-poviodine,lumbar puncture adult,lifecare adds rack,primary piggybackconv,d ual injection site,male adapter plug w-inj site,male luer cap,dual luer cap,plum lc 5000 primary setsl,plum microdrip soluset,extension set with luer lock,plum lc 5000 primary set,plum lc 5000 microdrip set-nv,plum lc 5000 with ivex,pca set-long minibore,venoset 100 soluset,pentothal dispensing perm. lens soaking soln,eye cup,dental adhesive,toothpaste,dental polishvarnishes,polymerized rosin resin,ovulation and pregnancy test kit,dental preparation, o.u.,corn/callus cushion,syringe w/needle,insulin disposable 0.3 ml (half unit mark),toothbrush,thermomet er, tape,thermometer, temple electronic,ostomy accessories, filters and bridges,ice bag,finger splint,hot water bottle,fountain syringes applicator,footcare,miscellan eous,hearing aid accessory,blood pressure test kit-medium,blood pressure test kit,ear plugs,benzalkonium chloride,tubular gauze/tub.rubbr dressing protector,incontinence pants, reusable,blood pressure test kit medium and large cuffs,humidifier,infusion set for insulin pump,insulin pump/infusion set/bloodglucose meter,pharmacy dispensing adm set,pharmacy compounding access.,catheter accessories,external,syringe filter,enteral feeding Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 493 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name cap,catheter adapter-luer plug,venoset nv piggybk micrdrp,crimping tool,transfer lok,blood set 64 w-cair & needle,hemoset 100x10 with cair clamp,blood set w-pump & cair clamp,blood surgical y-type set-clmp,blood ytype set 66-cair clamp,continuous pediatric caudal,cont epidural w-lidoepi-iodin,lifecare microdrip pump set,nitroglycerin micro pump set,screw cap (40mm) set,lifecare 5000 syringe adapter,lifecare 5000 vial adapter,hema blood 30 set,dome-paste bandage,inspirea se,buf bodymate,bufpuf,buf-puf bodymate,buf-puf sponge,buf-puf dispenser, 20 ml,enteral feeding dispenser, 35 ml,enteral feeding dispenser, 60 ml,enteral feeding dispenser,1 ml,enteral feeding dispenser,3 ml,enteral feeding dispenser,5 ml,enteral feeding dispenser,10 ml,weigh scale,transfer needle,dental suction device/chlorhexidine gl/dental swab comb no.1,dental suction device/chlorhexidine/dental swab #1/mouthwash,plastic bags,chemo gowns,smocks,chemo spill clean-up kit,eye pressure monitor,injector device,incontinence alarms,spray applicator kit, sterile,disinfectant,glycine/so dium hydroxide,ultrasonic cleaner/holding solution,protease-amylase medical equipment cleaner,transfer device, closed system,needle injector, luer, closed system,needle injector, luer lock, closed system,connector luer lock, closed system,infusion adapter, closed system,ysite line connector, closed system,assembly system, vial to transfer device, closed system,clamp, iv Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 494 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name gentle,actiprotect uf,novofine 32,novopen 3,novofine,novop en jr,innovo,novofine autocover,novotw ist,nordipen 5,nordipen 15,novopen echo,novofine plus,astra selfaspirating dental,cartridge dispenser dental,astrapro,br eeze 2,autodisc normal,ascensia autodisc,fingersti x,glucolet 2,contour link,didget,contou r next link,microlet,singl e-let,microlet 2,contour,contour next ez,contour next control solution,contour next,contour usb,contour next usb,ascensia elite,microlet vaculance,compa t gravity delivery set,compat enteral delivery pump,vivonex tubing,hard lens soaking solution,wheelchair,smoking deterrent filter,incont device,muscle toner,elt,stethoscope,breast pump,crutch,feminine syringe,vaporizer-humidifier supply,rectal syringe,nasal syringe,vehicle base no. 13,topical cream metereddose device,adapter cap for bottle,rectal, vaginal applicator tip,troche mold,isopropyl alcohol,eye drops dispenser,dressing,collagen/ silver/sod alginate/carboxymethylcellul ose,dressing, collagen/sodium alginate/carboxymethylcellul ose,transcutaneous electrical nerve stimulators(tens)/electrodes, tens unit electrodes,fecal collector with charcoal filter,dressing holder,hard contact lens enzymatic cleanser/pf,iv equipment/container,empty, blood glucose calibration control solutions high,normal,low,aloe vera/gloves, latex,nonadherent bandage/petrolatum,white,d efibrillator,automatic,externa l,blood-glucose meter, drumtype,prothrombin time test Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 495 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name jejunostomy kit,compat,compa t select flo pump,compat container wpump set,compat select flo case,compat select flo baggle cage,compat yset,acticoat moisture control,allevyn life,acticoat surgical,allevyn adhesive,allevyn, allevyn sacrum,allevyn ag adhesive,allevyn ag gentle,allevyn ag,allevyn gentle border,allevyn gentle border lite,allevyn gentle border sacrum,allevyn gentle border heel,allevyn gentle border multisit,allevyn heel,allevyn plus,cuticerin,alle vyn tracheostomy,cuti nova hydro,durafiber,ci ca-care,allevyn thin,iv strips,amniotic fluid detection test,vaginal cream applicator,suppository container, empty,vaginal suppository applicator,filter, disposable ptfe membrane,allantoin,mineral oil/aloe vera/petrolatum,white/sodiu m lauryl sulfate,acemannan/alginate dressing,alginate dressing/carboxymethylcellu lose,needleless accessory device, insulin,alginate dressing/hydrocolloid dressing,sterile field,chlorhexidine gluconate,blood sugar diagnostic test strips with disposable meter,incontinence bed sheets,covers,safety seal, for bags,safety seal, for vials,safety seal, for syringes,transfer set/syringe, disposable/bandages,compr ession/tubing,gel dressing/zinc acetate/meadowsweet/oak,v enous flow controller,cellulose,oxidized/ collagen,activated charcoal/silver,gel-matrix pad dressing, silicone/benzalk chl/vit e/min oil,cholesterol calibration controls - high and Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 496 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 3000,pregnancy test,microbore extension set,iv administration set,solution transfer device,beutlich ph test,hurricaine dispenser,hurrivie w,hurricaine luerlock,hurriview ii,hurricaine spry extension tube,lancing device,ultra thin lancets,micro thin lancets,super thin lancets,proception fertility pak,wide seal diaphragm,liqua spen,precise pain relieving,aerocha mber plus flowvu,iv transfer spike,detachol adhesive remover,mastisol, mastisol adhesive,boules quies earplugs,insulin syringe,ultra comfort,easytouch insulin syringe,condoms, thermacare,pump for liquagel,suppository low,cholesterol test, strips,cholesterol & blood glucose meter,prothrombin time/inr test meter,gel dressing, fenestrated,collagen,bovine, fecal collector w-charcoal filter/catheter/syringe, dispos,gravity feeding set,feeding pump,bloodglucose transmitter/bloodglucose sensor,needles, subcutaneous set,iv administration set/needles, reusable,ring,cath male external-starter kit,ring pessary,transcutaneous electrical nerve stimulators (tens units),blood pressure kit-extra large,home hiv test kit,blood-glucose meter,for mobile device,hard lens soak-wet solution,infusion set with insulin pump body,insulin pump controller,propylene glycol,toe splint,disinfectant liquid soap cmb4,mineral oil/non-adherent bandage/petrolatum,hydrop hilic,mercury spill clean-up kit,blood pressure test kitsmall,blood-glucose and blood pressure meter with adult cuff Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 497 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value mold,accusure,o mnitrope pen 5,ocal-ette,pedi-skin adherent #2,pedipre,pedi-pre tape spray,hydro armor ag,hydro armor ag blister care,e-z ject lancets,major comfort,nasal strips,ear syringe,denture cleanser,optizyme enzymatic cleaner,micropor e first aid paper,micropore first aid skintone,micropor e first aid plastic,micropore first aid waterproof,micro pore first aid cloth,tegaderm,m icropore air wrming fltr mask,micropore pollen filter mask,micropore germ filter mask,coban,resto n,stomaseal,dura pore cloth surgical tape,durex avanti bare,personal biometric test BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 498 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value kit,colostomy barium enema kit,aeroeclipse ii,aerotrach plus,aerochambe r z-stat plus,aerochambe r with flowsignal,aeroge ar asthma action kit,truzone peak flow meter,aerochamb er mv,aerochamber mini,aerobika,3m cold-hot pack,relion prime,relion confirm,blood pressure monitor,relion micro,digital thermometer,inst ant ear thermometer,trust ex condom,trustexria,trustex latex condom,trustex,f antasy,stayfree surefit,stayfree maxipad,stayfree ultra thin,carefree panty shield,tena serenity,serenity ultra plus,drain,bardic BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 499 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value adaptertubing,cunningha m incontinence clamp,catheter,fe male intermittent catheter,toomey syringe,urethral catheter,reliaseal disc,dispoz-a-bag leg bag small,dispoz-abag leg bag medium,dispoza-bag leg bag large,leg bag holder,uro sheath disposable bulk,bardic uro sheath vinyl,male external catheter,deluxe fabric leg straps,catheter strap holder,twosided adhesive strips,latex extension tubing,latex leg straps,bard center entry close system,urinary drainage bag,infection control bag,leg bag straps,bardex silicone foley catheter,rubber utility BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 500 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value catheter,cleancath,protective barrier film,adhesive remover wipes,vigilon wound dressing,irrigation tray,basic irrigation tray,urethral catheter tray,bardex urethral catheter tray,universal foley catheter tray,davol complete foley kit,davol urinary drainage bag,bardia urinary drainage bag,davol foley cath insert tray,davol universal catheter tray,davol clsd sys foley cath tray,davol irrigation syringe,davol irrigation tray,davol urethral catheter tray,davol silicone foley catheter,bardex closed system cath tray,infection BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 501 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value control tray,bardex lubricath foley tray,extra colostomy pouch,stoma urine bag,extra security pouch,extra open-end drain,scanpor tape,drainable adhesive pouch,baby urine collector,irrigation sleeve,bard irrigation tray,bardex lubricath foley,comfeel,filte red extension set,rate flow regulator iv set,filter needle,infusion set,opsite flexifix,profore,ex u-dry,skin-bond cement,uni-solve adhes remover wipes,uni-solve adhesive remover,remove wipes,remove liquid,urikleen,skinprep,no sting skin prep,hypafix,opsit e postBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 502 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value op,solosite,opsite flexigrid dressing,algisite m,transigel,replic are,viscopaste pb7,opsite adhesive dressing,flexigel, primapore iv,primapore,covr site,covrsite plus,intrasite,alle vyn cavity dressing,allevyn tracheostomy dressing,unlabele d refill bottle 240ml,spray pump,microspon ge,monoject,mon oject syringe,sharpsafe ty container,nutripor t balloon,dover advantage,dover premium,dover pediatric urine,dover advantage drainage,monoje ct tb syringe,monoject luer lock tb syringe,curity lumbar puncture tray,durasorb,sim plicity liner,telfa,maxicar BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 503 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value e,rondic,presenc e,telfa clear,curity,kerlix, sure care protective underwear,monoj ect tb,curity maternity pad,curity ultramer 2-way catheter,webril,to uch-trol,curity cleaners medium,sharpsa-gator,enema bag,handicare,su recare,versalon,t enderskin,kendall paper tape,sure care protective undergmnt,curity foley catheter kit,curity cleaners large,dressing change-pov-iod tray,curity universal w-o drainage,suretys, monoject blood collection,confor m,monoject luer adapter,curity ureth cath closed systm,curity amd,curity urethral catheter,precision 200 catheter tray,argyle,nursin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 504 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value g pads (breast),webril ii,curity ultramer irrg 3way cath,curity o-b sponges,vistec,ar gyle connecting tubes,wings underpad,t.e.d. anti-embolism stocking,lisco,curi ty bedside drainage set,wetpruf,sharps a gator,curity ureth cath open system,tensor,ker lix amd bandage,urinary leg medium bag,kenguard,ad d-a-foley tray,foley catheter,curity irrigation tray,heavy drainage dressing steril,robinson clear vinyl catheter,specipan collection unit,vaseline petrolatum gauze,xeroform petrolatum dressing,xerofor m,dermacea,der macea nonBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 505 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value woven,dermacea stretch,flexwrap,aquaflo,curit y thoracentesis trays,monoject pharmacy tray,curity thoracentesiscath tray,kenline add-a-foley tray 30cc,add-a-foley cath-pre-fill syrn,curity spng counter bag strips,curity spng counter rackscale,curad,curity surgical,clean catch-benzalkon towelets,clean catch-soap towelettes,t.e.d. sequnt compress device,copa hydrophilic foam,argyle trocar,unigard,wi ngs classic youth briefs,wings classic adult briefs,wings classic,wings choice plus youth briefs,wings choice plus adult briefs,wings choice adult brief,foley catheter BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 506 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tray,dover foley catheter,curity strmlin cath wmono-flo,curity premium catheter tray,add-a-foley cath-mono-flo drng,curity bedside-mono-flo drange,monoflo,tenderol,curity ureteral drain set,curity bedside drainage bag,simplicity adult poly,simplicity,ver salon washcloth,curity washcloths,curity urine meter,dover red rubber robibson cath,dover catheter,kendall,p olyskin ii,kerlix amd,dover bulb syringe,wings,ker lix burn pack,monoject safety syr tip cap,curity detectable lap,simplicity adult flat fold xl,dover latex foley catheter,simplicit y pants,curity run BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 507 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value arounds,curity runarounds,curity sleep pants,kangaroo gravity set,excilon,tender sorb,kangaroo nasogastric feed tube,curasilk,diap ers-disppolyethylene back,dover urine leg bag,telfa amd,kangaroo epump set,curity iodoform,curity ultra fits,tenderwrap unna boot,kerlix lite,monoject insulin syringe,curity 8000 urine meter,hypodermi c needle,curity abdominal,curity ultramer catheter,rcra hazardous waste,kendall container,dover coated latex foley,curafil,kend all cloth,maxicare underpads,wings supreme,staput,wings maxima,wings fluff and BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 508 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value polymer,curistrip,dover universal,kangaro o 924 safety screw,excilon amd,sharps-agator disposal system,insertion tray with pvp,excilon washcloth,curity maternity belts,curagel,hom e care underpads,confor m stretch bandage,insertio n tray with bzk,foley cath silicone retn,curity foley 2-way ped cath,kendall foam border,bandaid,non-stick pads,first aid tape,first aid cloth tape,first aid hurtfree wrap,mirasorb,ba nd-aid flexible fabric,gauze pads,rolled gauze,soothing non-stick,kling rolls,ultraheal,ban d-aid plus antibiotic,nursing pads,adhesive BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 509 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pads,dermicel,wa terproof tape,topper dressing sponge,eye pad,surgipad,ulce r dressing,release, proxistrip,healthcare gloves,nu-gauze sponge,elastikon, adaptic,sof-band bulky bandage,bioclusi ve,sof-wick,sofwick drain sponge,johnson & johnson filter mask,johnson's health care gloves,cotton balls,steripak,gau ze sponge,sports tape,elastic bandage,instant cold pack,rescue blanket,antiseptic wipes,triangular bandage,j & j first aid kit,swabs,cotton rounds,steripad,nugauze,dental floss,dentotape ribbon floss,dental floss waxed,stim-uBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 510 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value dent,takeoff,baby wipes,coets,derm ilite-ii paper tape,dermicel hypo-allergenic tape,dermilite ii hypoallergenic,dermicl ear,kling bandage,waterga rd,underpads,ban d-aid gauze pads,band-aid rolled gauze,band-aid non-stick pads,band-aid mirasorb gauze sponge,band-aid surgipad dressing,bandaid cloth tape,band-aid paper tape,bandaid waterproof tape,band-aid hurt-free,bandaid tough pads,band-aid secure-flex,bandaid waterproof pad,cartridge filling aid,arm belt,d-tron,h-tron power pack,sewin pocket,sport belt,spectragel,la ncets,comfort BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 511 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lancets,polymem, polywic,oasis ultra,curasol gel,curasol hydrogel,wound matrix,burn matrix,neuropen, neuropen monofilaments,ca reone,kinney brand lancets,thin lancets,incontrol ultra thin lancets,unilet lancets,autolet mini,advanced lancing device,unifine pentips,pen needle,incontrol pen needle,pen needles,healthy accents unifine pentip,autolet platforms,unifine pentips plus,unilet lancet,unilet gp lancet,alternate site lancets,unilet comfortouch,adv anced travel lancets,unilet excelite,unilet excelite ii,autolet lite clinisafe,unistik,a urora super thin lancets,incontrol BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 512 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value super thin lancets,healthy accents unilet lancet,unistik 2,incontrol lancing device,autolet lancing device,healthy accents autolet,autolet mkii clinisafe,unistik 3,autoject 2,rapport vacuum therapy,amielle vaginal trainer,rapport ring loading system,autopen,n eurotips,autodrop ,autosqueeze,onthe-go,autolet lite,ulticare syringe,ulticare,ul ticare pen needle,back support,rib belt,pouch arm sling,wrist brace reversible,wrist brace splint,surgical binder abdom support,elbow brace,wrist brace,knee brace,ankle brace,sacroiliac BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 513 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value brace,herniaaid,surgical stockings,compre ssion stockings,beyond support,super socks,compressi on pantyhose,athleti c supporter,cup supporter wprotector cup,suspensory,k nee comforter,curity curad flexible bandages,curity curad flexible fabric,curad ultralite,curad kid size bandages,curity underpads,cane, bedpan,sitz bath,urinal,cervic al pillow,cervical traction kit,wheelchair invalid ring,wheelchair cushion,crutch tip,hand grips,crutch pad,cane tips,walker tips,knee support,sport polartec,sport neoprene,neopre BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 514 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ne knee stabilizer,tennis elbow support,curity curad adhesive bandages,curity telfa non-stick pads,curity nursing pads,curity telfa adhesive pads,curity wetpruf adhesive tape,curad super soft puffs,curad gauze pads,curad stretch gauze bandage,folding walker,walker wheels,cervical soft collar,lancets thin,lancets ultra thin,fine 30 universal lancets,medlance plus,adjustable lancing device,insumed,i nsupen,glucosour ce,exel insulin syringe,insulin pen needle,tuberculin syringeneedle,exel tb with needle,exel tuberculin syringe,exel BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 515 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value allergy syringe,allergy syringe,exel syringe,exel hypodermic needle,exel mti drawing needle,psv set,iv catheter,exel huber,exel huber needle,yale needle regular bevel,yale needle,yale needle short bevel,special needle,intraveno us,arterial & blood,yale needle huber bevel,pudendal & parasympathetic, whitacre spinal needle,rosenthal, osgood,security bead needle, local,klatskin,yale glass tb syringe,yale syringe,syringe,c ornwall syringes luer-lok tip,plastic adapter kit for busher,cornwall accessories & parts,cornwall metal pipeting holder,tempaway BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 516 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value thermometer sheath,yale spinal needle,quince spinal needle,allergist syringe,allergist syringe with needle,allergist tray,allergist syringe tray,tuberculin syringe,yale cleaner,asepto bulb syringe glass tip,pipette 30ml catheter tip,pipette 45ml catheter tip,asepto bulb syringe cath tip,pipette 90ml catheter tip,pipette 120ml catheter tip,plastic adapter for busher,bulk syringe,syringe bulk,luer-lok syringe,needle,ca nnula,interlink syringe,lever lock cannula,twinpak dual cannula,interlink syringe wcannula,specialty use needles,regular BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 517 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value bevel needles,needles, precisionglide,yal e needles,short bevel needles,blunt needle,thin wall needles,tampertuf,oral syringe,nokor needle,nokor admix needle,cornwall syringe tip connector,glaspa k,integra syringe,integra needle,sharps collector,onepiece sharps collectors,sharps container,safetylok safety syringes,safetylok safety syringe,medsaver ,syringe storage bin,eclipse needle,syringeneedle,eclipse syringe,eclipse syringeneedle,eclipse luer-lok syringe,safety syringeneedle,syringe tip cap,safetyglide needle,safetyglid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 518 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value e syringe,safetyglid e insulin syringe,safetyglid e tb syringe,safetyglid e allergy syringe,safetyglid e allergy,syringeluer tip cap,luerlok syringeneedle,safety-lok syringes,syringeprecisionglide needle,syringe catheter tip,tb syringe,luer-lok tip syringe,luerslip syringe,bd ultrafine pen needle,bd ultrafine,bd ultra-fine ii,lancet device,magniguide magnifier,safeclip,auto injector,autoshiel d pen needle,autoshield duo pen needle,paradigm link blood glucose,vacutain er blood transfer,luer-lok access device,bd microtainer BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 519 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lancets,microtain er lancets,safetylok collection set,vacutainer collection set,brite sight thermometer,insy te autoguard,insyte iv catheter,angiocat h iv catheter,angiocat h,saf-t-intima iv catheter,saf-tintima,nexiva,intr osyte autoguard,qsyte,e-z set winged infusion set,saf-t e-z collection set,saft e-z set,myelogram tray,precise,fever thermometer,ace rubber elastic bandage,trutouch gloves,durall,sus pensory with leg straps,suspensor y w-o leg straps,adult supporter,compre ssion shorts,swimmer supporter,ace neoprene wrist BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 520 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value brace,ace neoprene thigh brace,ace neoprene elbow brace,ace neoprene ankle brace,ace neoprene knee brace,ace neoprene plus knee brace,ace neoprene ankle wrap,ace tennis elbow brace,ace ankle brace,ace knee brace,ace wrist brace,ace elastic bandage,ace elbow brace,ace plus rigid wrist brace,ace unibody supporter,ace athletic supporter,ace swim supporter,ace cup supporter,ace plus knee brace,ace sports underwrap,ace knee strap,ace elbow strap,ace bandage clips,ace athletic bandage,ace sports tape,ace BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 521 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value instant cold compress,ace reusable cold compress,ace hot-cold compress,ace hot-cold compression wrap,ace velcro bandage,ace back support,fever thermometerimprinted,sensica re,tru-fit knee support,ace plastic gloves,sentinel thermometer,ther mometer,basal thermometer,peg elastic bandage,digital therm probe cover,thermomet er probe covers,hypother m thermometer,bd genie lancet,ace wrist brace with splint,ace lumbar support,slip-tip syringe,ibgstar,haemolance, retractable,assur e id insulin safety,hypolance, advance BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 522 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value intuition,assure pro,assure platinum,assure dose,assure 3,assure 4,glucocard expression,pocke tchem ez,multilancet device,micro,gluc ocard 01,glucocard 01 control,glucocard 01-mini,glucocard x-meter control,glucocard xmeter,glucocard vital,techlite lancets,techlite blood lancet,techlite,ha emolance,assure haemolance plus,assure lance,haemolanc e plus,quicktek,adv ance microdraw,advance,sel ectlite,lanzo,assure prism multi,glucocard shine,assure lance plus,ultilet safety,ultilet classic,ultilet lancets,publix BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 523 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lancet,ultilet insulin syringe,ultilet pen needle,ultilet basic,suresite matrix,tenderwet active,tenderwet active cavity,evencare g2,safety lancets,pressure activated lancets,silvasorb, silvasorb cavity,exuderm odorshield,evenc are,skintegrity,me dfix ez,stratasorb,bor dered gauze,exuderm satin,evencare g3,medigrip,carra syn hydrogel wound,protection plus,molicare classic brief,ultra soft,dry time diaper,protection plus liner,economy underpad,underp ad,anti-stick insulin,anti-stick tuberculin,blende rm,transpore,micr ofoam,micropore, durapore,steristrip,3m BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 524 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value nexcare,tegader m i.v.,tegaderm i.v. advanced,medipo re h,medipore dressit,medipore,soft cloth,medipore plus pad,steristrip wound closure syst,tegaderm hydrocolloid,tega derm hydrocolloid thin,tegasorb thin,tegagen hi,tegagen hg,tegaderm ag mesh,tegaderm absorbent,tegade rm hp,opticlude,blen derm surgical tape,reston2,primeaire,quak e,liteaire,misterne b compressor,inspir ation elite,inspiration,si destream,mistern eb pediatric compressor,innos pire elegance,mistern eb nebulizer,sidestre am mask,innospire BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 525 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value essence,micro elite replacement filter,minielite,mic ro elite,pflex trainer,assess,ast hmapack i,asthmapack ii,asthmapack iii,asthmapack children's,thresho ld imt,threshold pep,asthma check,asthmame ntor,personal best,optihaler,opti chamber,pediatri c mask,sidestream plus,inspiration elite filter,micro plus,innospire replacement filter,sidestream nebulizer,sami the seal,litetouch,sa mi the seal filter,sami the seal mask,sidestream pediatric,optionho me,mini plus nebulizer,mini elite filter replacement,optic hamber diamond,procha mber,ventstream nebulizer,zoey,ae BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 526 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value roneb go,innospire deluxe,innospire mini,aeroneb go nebulizer,iamin,o smocyte,dressing ,lo-profile urostomy pouch,contour i,filter security closed pouch,stoma cap w-micropore adhesive,karaya drainable ostomy pouch,karaya seal closed stoma pouch,centerpoin tlock closed pouch,stoma cap w-deodor fltrflange,stoma cap w/deodor fltr/flange,karaya 5 drainable pouch,premium drainable pouch,skin barrier w-floating flange,convex syn barr w-float flange,pouchkins skin barrier,pouchkins pediatric belt,pouchkins pouch,pouchkins drain BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 527 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tube,pouchkins drainable pouch,pouchkins urostomy pouch,drainable pouch with flange,stoma irrigator drain wflange,drain pouch-filterflange,drainable pouch w-filtrflange,drainable mini-pouch wflange,cpl drainable pouch,drainable pouch,urostomy pouch with flange,ostomy belt,urostomy drain tube adapter,hollihesiv e skin barrier,stoma combo cone-tube irrg kit,stoma cone w-connector unit,stoma combo cone,tube irrg drn,medical adhesive,adhesiv e remover,odor eliminator,m9clea nerdecrystallizer,sto ma lubricant,adhesiv e-barrier remover BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 528 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value wipes,filter replacement,loop ostomy bridge, sterile,premium skin barrier,adapt barrier ring,softflex skin barrier,karaya,ad apt stoma powder,karaya paste tube,skin gel protective dressing,premier drainable pouch,premier urostomy pouch,premier lock n roll,premier drainable minipouch,centerpoin tlock flextend skin,drainable pouch clamp,flextend skin barrier,premier urostomy pouch/flange,eve ryday male catheter,extende d male catheter,extensio n tubing wconnector,urinary leg bag,bag-strap system,bagtubing system,vent urin leg bag BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 529 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value sys,combo pk,wound drainage collector,universa l catheter access port,drain-tube sterile clamp,horz drain-tube attach device,vertical drain-tube attach dev,suction tube attachment device,feeding tube attachment device,replaceme nt neckband,retract ed penis pouch,fecal collector, drainable,bedside drainage collection,female urinary pouch,vented urinary leg bag system,fecal collector,new image skin barrier,new image flexwear,new image skin barrierflange,new image flextend,new image drainable pouch,new image irrigation BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 530 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value sleeve,new image drainable mini-pouch,new image closed pouch,new image closed minipouch,new image,new image urostomy,new image urostomy pouch,new image colostomy-ileo kit,new image kit,new image drainable kit,new image urostomy kit,adapt,adapt paste,adapt barrier,adapt convex barrier,premier closed minipouch,premier pre-sized minipouch,premier closed pouch,premier skn barr w-float flang,premier colostomyileostomy,premier urostomy,advanc e plus intermittent,incar e,firstchoice drainable pouch,everyday self-adhes catheter,firstchoic BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 531 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value e postop drain pouch,selfadhesive catheter,advance hydro,fc condom, female,two-piece stoma caps,closed-end pouch,adhesive barriers,adhesive barrier,microskin barrier,system pouch,microderm plus,one-piece drainable pouch,mini drainable pouch,urostomy pouch,platinum urostomy pouch,mini urostomy pouch,one-piece urostomy pouch,microderm ,cymed seal,ilesorb,night drain adapter,microskin applicator,draina ble pouch closure,microhesi ve stoma paste,clickfine,reli on pen needles,blood glucose monitoring,smart sense monitoring system,advanced BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 532 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value glucose meter,thalaset,ne ria,insuflon,tubeg uard,neria multi,statlet,mouthpiece,ex piratory,piko 1,pocket peak,pocket chamber,pediatri c panda mask,panda mask,femcap,bio brane,biobrane dressing,biobran e-l,biobrane-l dressing,biobran e gloves,pillow mask,pillow mask for children,splash shield full,splash shield flex,splash shield short,co monitor replacement t,co monitor,disposabl e paper mouthpiece,miniwright peak flow meter,airzone & miniwright afs,incheck oral,incheck nasal with mask,in-check dial,windmill trainer,one way mouthpiece,pedismall mouth BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 533 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value adaptor,pediatric mouthpieces,airz one peak flow meter,one flow fvc,one flow spirometer,one flow mouthpiece,filtere d mouthpiece attachment,silico ne mask,breathrite,n ose clip,rubber mouthpiece,all flow 1000,all flow 2000,all flow 3000 pft,all flow 3000 kit,all flow 4000,all flow 5000,all flow 6000,all flow 7000,disgard sharps pad,easygluco meter starter kit,easygluco,con trol,g-4,control solution,infinity,inf inity control solution,acura starter kit,acura control solution normal,acura meter kit,acura control solution,acura control solution low,acura plus,easygluco BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 534 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value plus,easygluco plus control normal,compact ultrasonic nebulizer,compac t compressor nebulizer,autolet impression,autole t plus,unistik czt,unistik 3 extra,unistik 3 comfort,unistik 3 neonatal,seaband,sea-band for children,ultracomf ort,orsini insulin syringe,glucolead er,clearblue,easy pro plus,easypro,pro digy count-adose,prodigy mini-mist,prodigy pocket,prodigy,pr odigy eject,prodigy voice,prodigy duo,prodigy control solution,prodigy preferred,prodigy autocode pro,prodigy pocket pro,prodigy voice pro,prodigy twist top lancet,prodigy lancets,prodigy BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 535 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value lancing device,prodigy pen needle,prodigy insulin syringe,prodigy autocode,actilance,droplet lancets,medlance plus special blade,compresso r nebulizer,replace ment nebulizer,replace ment air filter,healthy living,easy touch glucose monitor,easy touch lancing device,easy touch control solution,easy touch,easy touch insulin syringe,easy touch pen needle,easy touch fluringe,easy touch insulin safety,easy touch syr allergy tray,easy touch fluringe flu tray,healthpro glucose monitor,healthpro BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 536 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value glucose control soln,lea's shield,omnipod,1 st choice lancets,1st tier unilet comfortouch,1st tier unifine pentips,1st tier unifine pentips plus,iport,thinset,fifty50 safety seal lancets,fifty50 reservoir,eclipse, eclipse control solution,envision, evolution blood glucose meter,evolution control solution,element blood glucose meter,element control solution,smartdia betes xpres,smartdiabe tes vantage,element plus,xpres,eleme nt plus control solution,glucolab control,glucolab,e lement compact control soln,element compact,element compact BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 537 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value v,smartest,smart est lancet,smartest eject,smartest protege,smartest smart code,smartest talking,smartest pronto,smartest persona,glucoco m blood glucose,glucoco m lancets,blood glucose meter,glucocom control solution,glucoco m,glucocom autolink,glucose control solution,glucose control,bloodglucose control,duocare,rightest gm300 system,bionime rightest gm300 system,rightest control solution,rightest gd500,rightest gm100 system,rightest gm550 system,rightest gl300 lancets,ge100 blood glucose BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 538 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value system,ge100 control solution normal,rightest gc250s control soln,rightest gm250s meter,rightest gm260 meter,nova sureflex,sureflex, nova max blood glucose meter,nova max glucose control soln,novamax plus,novamax plus glu-ket,nova safety lancets,keynote, wavesense control solution,agamatri x control,jazz wireless 2,wavesense presto,keynote pro,wavesense amp,presto pro,liberty blood glucose meter,liberty control solution,agamatri x amp,vgo 40,vgo 30,vgo 20,ear popper,sterilance tl,cinis preemie halo,restore contact BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 539 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value layer,restore contact layer silver,restore,rest ore trio,restore duo,restore foam heel dressing,restore odorabsorbent,restore ex thin hydrocolloid,resto re hydrocolloid dressing,restore calcium alginate,restore hydrogel,restore hydrogel gauze,sharps disposal by mail,hydrofera blue,ultraflex,burns-scaldsabrasions,skin closure,blister care,bandages,m edical id for bracelet,medical id for necklace,riteflo,pr ovent hr,provent sr,provent,ultratra k pro,ultratrak,ultral ance,ultratrak ultimate,safesnap syringe,safesnap insulin syringe,safesnap tuberculin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 540 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe,safesnap allergy syringe,conceptio n,needle-pro edge,solus v2,solus v2 lancets,solus v2 lancing device,solus v2 control solution,caresens n,caresens,smart caresens n,caresens n voice,caresens prem lancing device,carelance ult lancing device,invacare lancets,gdrive,de xcom g4,seven plus,seven system sensor,dexcom g5-g4 sensor,droplet lancing device,syringe without needle,filter connector,lifeshie ld blunt cannula,transfer needle,bone marrow aspir needle,filter aspirator needle,allergist tray syr-perm BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 541 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value needle,monoject allergy trayneedle,monoject tuberculin syringe,allergist tray syr-detach ndl,monoject insulin safety syrng,monoject tuberculin safety syr,monoject control syringe,monoject syringe pharmacy tray,monoject safety syringe,safety syringe with shield,monoject smartip cannula,monolet lancets,monoject or lancet device,monolet thin lancets,sharps container accessory,glove box,monoject magellan,finger grip extender,magella n tuberculin syringe,monoject megellan tb syringe,magellan insulin safety syrng,magellan insulin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 542 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe,oral medication syringe,extender caps,kendall disinfectant cap,monoject blunt filter cannula,kangaro o pet carrying case,kangaroo pet pump frame,kangaroo pet charging cord,petrolatum gauze,xeroflo gauze dressing,viasorb, blisterfilm,ultec,qtips wood stick applicator,interso rb,expandover,ka ngaroo enteralfeed-irrig kt,kangaroo pump extension set,kangaroo 500ml pump set,kangaroo deluxe pump set,kangaroo pump set,kangaroo 1000ml gravity bag,kangaroo 1200ml deluxe pump st,kangaroo proximal spike pmp st,kangaroo BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 543 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value screw cap pump set,kangaroo 1600ml deluxe pump st,kangaroo y-site extension set,kangaroo 1200ml rigid containr,kangaro o rigid container,kangar oo plyurethane feed tube,kangaroo 100ml rigid burette,texas catheter,elastic foam strap,uridrain,two-sided adhesive strap,catheter with strap,vaseline constant care,kangaroo 1000ml pump set,rob-nel pvc catheter,terumo insulin syringe,terumo surguard2,thinpro insulin syringe,terumo surguard,terumo allergy syringe,terumo syringe,terumo hypodermic needleBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 544 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syrin,medihoney, primer modified unna boot,algicell ag,bioguard gauze,bioguard packing,bioguard nonadherent,bioguar d island,super denture adhesive,premier skn barr w/float flang,sensitive eyes saline,sensitive eyes drops,sensitive eyes plus saline,sensitive eyes daily cleaner,renu multi-purpose,bio true,renu rewetting drops,renu multiplus,boston advance cleaner,boston conditioning solution,boston simplus solution,re-nu fresh,boston cleaner,saline solution,sterile presrv,renu saline,daily cleaner,sensitive eyes BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 545 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value enzymatic,lens carrying case,saline solution, unpreserved,hyp o-clear,lens lubricant,disinfect ing solution,quiksept,renu weekly cleaner,concentr ated cleaner,wetting & soaking solution,disinfecti ng unit,compact disinfecting unit,fashion case,lens cup,smoker's polident,polident, super poligrip,sensodyne,d entucreme,dentugel,super wernet's denture,ctub,gallon jug with pump,jetcospray cannula,dee fog,zarosen,varn al,mixing container with lid,reveal pregnancy test,reveal ovulation predictor,stik BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 546 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value it,reveal blood glucose meter,reveal get pregnant quick,reveal ovulation test,snug denture cushions,thermod ent,mesalt,mepile x,tendra mepilex border,probe covers,bladder control pad,water shield bandages,antibac terial bandages,foam bandages,gauze bandage,stretch gauze bandage,shield,u ndergarment,brief ,lamb's wool,fabric bandage,clear bandages,flexible bandages,plastic bandages,banda ges sheer,callus pads,sheer bandages,sterile pads,adhesive tape,dental adhesive,hypoallergenic bandages,cotton swabs,color lancets,cosmetic puffs,cosmetic BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 547 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value squares,flexible bandage,strong strips,waterproof strong strips,multipurpos e contact lens soln,saline solution,saline sensitive eyes,fever flash thermometer,dent ure,combine abd,toothbrush precision head,toothpaste, bandage,cotton squares,cosmetic balls,toothbrush adult deluxe,lens lustre eyeglass cleaner,toothbrus h, total,pill box,pill planner,pill divider with pill box,medicine dropper,medicine spoon,forehead thermometer,brief , medium,ep brief,heatwraps,b andage roll,contact lens conditioning,temp le thermometer,univ ersal 1,breatherite,o.a. d.,woun'dres,com feel plus,comfeel BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 548 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value plus clear,comfeel plus triangle,comfeel plus contour,comfeel plus pressure relief,comfeel ulcer care,comfeel film,female self catheter,selfcath,coloplast skin barrier,coloplast paste,ostomy paste,coloplast barrier ring,coloplast,col oplast drainable pouch,coloplast closed pouch,irrigation set,assura irrigation face plate,assura 2pc irrigation sleeve,filtrodor pouch filter,pouch clamp,assura flange,assura wound manager,assura, assura flange convex,assura ostomy belt,comfeel seasorb,assura 2pc BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 549 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value drainable,assura pouch,assura standard wear,assura pediatric pouch,comfeel purilon,conveen coude intermtnt cath,conveen drip collector,assura easiclose,assura non-convex drainable,urosto my night bag,biatain,assur a extra,assura two-piece uro minicap,assura light easiclose drain,assura ac,urostomy multichamber,urostom y multi-chamber pouch,urostomy micropouch,easiclose wide outlet,coloplast paste strip,sensura easiclose wide outlet,sensura click ostomy pouch,sensura flex ostomy base plate,sensura ostomy base plate,sensura flex BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 550 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ostomy pouch,ice bag,overnites,sur e choice pantiliners,belted undergarment,wi pes,diapers,sensi tive baby wipes,bladder control pads for women,briefs for men & women,ezject lancets,panty shields,tugaboos diapers,maxi pads,panty liners,hot-cold compress,multiuse cold pad,back & neck cold pad,cloth first aid tape,selfgrip,finge r splints,finger sleeves,rewetting ,super strip bandages,flexible fabric bandage,flexible fabric bandages,tugabo os overnights,under wear for men,premium baby wipes,clear spot bandages,ovulati on predictor,kid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 551 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pants,protective underwear,surec hoice,pantiliners, dental travel pack,briefs xlarge,cotton, sterile,sheer plastic strip,disposable razor,adhesive bandage,fabric strip extra large,pro sports tape,ice cap,water bottle,water bottle-fountain syringe,foam insole,cushion insole,super moleskin,over nites,vinyl gloves,multipurpose solution,eye patch,instant heat therapy,hearing aid batteries,latex gloves,true2go blood glucose system,self grip,cotton gloves,soft touch pill reminder,linen fresh,hot & cold therapy brace,instant heat,heat therapy patches,moist BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 552 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value towelettes,ultra fine cut n crush,tablet cutter,nail clip,toenail clip,nail nippers,disposabl e probe covers,alkaline batteries,toenail nipper,finger splint,tubular gauze,non-slip underpads,delux e underpads,under wear for women,foam ear plugs,guards for men,underwear menwomen,blood pressure cuff monitor,boxers for men,surgical dressing,contact lens cases,paper tape,cleaning & disinfecting lens,callus cushions,plantar fasciitis arch sleeve,gel bunion cushion,clear bandage,pain free tape,flexible foam pad,push n pop pill reminder,medicin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 553 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value e dropper & spoon,am-pm locking pill reminder,soft-tip thermometer,und erwear for men & women,tugaboos training pants,quiet please foam ear plugs,blood glucose monitor,flexible foam bandage,advanc ed antibacterial bandage,nitetime ,interdental stimulators,dispo sable brief,rewetting drops,one step ovulation test,truetrack smart system,gauze,bla dder control,heat wraps,hypoallergenic bandage,blood pressure kit,tender tape,skin closure strips,flex fabric bandage,comfortstretch,premium comfortstretch,gauze dressing,one step BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 554 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pregnancy test,comfortsmooth,fitted briefs,fitted brief,blister relief,ultra-soft gloves,premium nitrile gloves,quick read,adult wash,certainty,to e separators,gel toe spacers,gel toe protector,arch bandage,gel corn protectors,sleep pants,truetrack blood glucose system,trueresult blood glucose systm,flight ear plugs,sterile bandage roll,gentle adhesive bandages,plastic adhesive bandages,sheer adhesive bandages,confor ming rolled gauze,deluxe arm bp monitor,premium arm bp monitor,premium baby diaper,premium training BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 555 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pants,flushable cleansing cloths,face mask,non-stick pad,ultra-light rollator,scar treatment,cloth tape,trueplus lancets,pain free wrap,self adherent wrap,gel bunion guard,sorespot,al l gel bunion toe spreader,well beginnings sleep pants,early pregnancy test,humidifier,cra yon bandage,deluxe instant,easy read,well beginnings diapers,butterfly closures,athletic tape,ear-loop mask,temple touch mini thermometer,tem ple touch prem thermometer,clea r tape,transparent film dressing,extra absorbent shield,extra absorbent undergarment,ad BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 556 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ult brief,sheer strip,wild hot strips,napkin hospital tabbed,foot and shoe padding,saline,be d pad,rgp wetting and soaking,rigid gas permeable cleaner,lubricatin g drops,e.p.t.,e.p.t. digital,sudacare advanced,pediac are gentle vapors,efferdent plus,efferdent,fre sh'n brite,effergrip,sud acare,children's sudacare,e-z spacer,vanishpoi nt,syringe with needle disp,sheer spot bandages,premiu m blood glucose,accuchek spirit,accuchek tender,accu-chek rapid d,accuchek,d-tronplus adapter,accuchek ultraflex,accuchek ultraflex ii,accu-chek dBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 557 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value tron plus,flexlink plus infusion set,h-tronplus adapter,h-tron plus-piston rod,htron plus,eyelid cleansing pads,foracare gd20,choicedm g20,fora v30a,fora g71a,foracare gd40a,foracare gd40b,premium v10,fora v12,test n'go,sootheneb mesh nebulizer,fora test n'go voice,fora gd50,fora test n'go bp,kimono,kimon o maxx,kimono microthin,kimono microthin aqua lube,kimono textured,digitex gold,rid,devilbiss pulmomate,pulm o-aide,devilbiss pulmoaide,devilbiss disposable nebulizer,devilbis s compact,sunrise compressornebulizer,devilbis BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 558 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value s traveler,cytosafe dipensing pin,exactamed,dual rate syringe infuser,bifurcated fluid tran tube set,exactamix,elbow inlet,gravity mixing set,luer lock-to-bag,fluid transfer extension set,vial adapter,bag spike,oral liquid transfer tube set,micro volume inlet,fluid transfer set,calibration bag,dual rate syr infuser tubing,minibore, microfuse minibore,pole clamp,em2400 valve set,exactamix calibration,exacta -mix eva,micromacro,s terl fluid transfer tube set,topical tip cap,topical cream dispenser,topical dispenser,sterile fluid tran tube BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 559 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value set,syringe filling fixture,oral liq bag-tube set combo,repeater pump stand,pharmacy pump stand,0.2 micron filter attachment,gel bag & tube set non-sterile,sterile exacta-med dispenspin,tamperresistant bag cap,sterile top fill bag,sterile empty collection bags,adaptacap,microfuse,trif urcate fluid tran tube set,pharmacy pack liquid dispenser,repeat er pump,vaginal cream dispenser,luer to urethral tip adapter,luer to catheter tip adapter,sterile rapid fill connector,sterile gel bag,sterile two-fer needle,exactamed tip extender,supor,la BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 560 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value bels, 1.5" x 1.5",kwikvial,kwik-vial filling extension,kwikvial plug dispenser,t.i. seal non-sterile foil,bottle adapter,3-way oral port stopcock,rapid fill adapter,sterile rapid fill adapter,oral-tooral rapid fill connec,mark-adose,oral labels,shrinksafe, port saver sterile inject port,vaginal dispenser tip cap,tip caps, nonsterile,exactamed tip cap,luer lock tip cap,luer lock tip caps, sterile,sterile luer slip tip caps,luer slip tip caps,selfrighting luer slip tip,catheter tip cap,locking,selfrighting luer tip cap,self-righting luer lock tip,bedside pack liquid dispenser,ward BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 561 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pack liquid dispenser,neothri ve,rapid-fill,ohaus scout sc,iv transfer needles,venting pin,catheter tip cap,winged,comf ort bath,toothette,qcare rx,chemoplus dispensing pin,p2 hi-risk,p2 safety plus,p2 safety plus powder free,p2 hi-risk powder free,pro star powder free,oncology plus,chemoplus powder free,chemoplus,d ust-mist respirator mask,chemosafet y container,u.v. protection bags,spill proof prep mat,safelock bags,chemowast e bags,chemolinen waste bags,chemolinen hamper stand,chemowast e hamper stand,chemosafet BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 562 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value y prep admin,personnel protection,multimix,designer,che mo plus,chemo spill kit,reality,trudent,first aid paper tape,first aid skintone paper,first aid plastic tape,first aid waterproof tape,air warming mask,dust & pollen filter mask,germ filter protective mask,cold comfort,trueplus insulin syringe,trueresult blood glucose meter,truetrack,tr ue metrix blood glucose mtr,true metrix,truedraw,b rush 'n floss,proview eye pressure monitor,stretch bandage,autolancet mini,injectease,insuleze,insulcap,insul-tray,ezvac,ez-lets,insultote,wetstop,autolancet,dermagran BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 563 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ,dermastat,nutras tat,dermacol,nutr acol,dermafilm,de rmasite,reconstitu be,deluxe tablet cutter,inspiracha mber,zymogeneti cs spray applicator,vicks warm steam vaporizer,health mist,vicks cool mist,vicks warm mist,vaporizer,vic ks digital thermometer,vick s forehead thermometer,ther moscan,sensitive teeth,tartar control,cetylcide g,hyde-out,power cleaner,cetylzyme,replacemen t j-4 cannula,sanitizer bottle,mepilex border,mepilex ag,mepilex border sacrum,mefix,me pitel,lite touch,medilance,aurora healthcare lancets,lady lite,phaseal protector,phaseal injector BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 564 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value luer,phaseal connector luer,phaseal adapter,phaseal y-site,phaseal assembly fixture,phaseal infusion,phaseal secondary set,space chamber plus,compact space chamber plus,hard contact lens cleaner,hard contact lens soak,hard contact lens wet,kotex fresh & dry,kotex overnight,depend ,huggies,huggies pull-ups,huggies baby wipes,goodnites, depend silhouette,depend real fit,poise pads,depend guards for men,kotex security,poise liners,depend overnite,depend protection,huggie s goodnites,goodnit es sleep shorts,huggies ultratrim,lavender BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 565 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value nitrile exam glove,huggies overnites,depend shields for men,huggies slipon,huggies snug and dry,kotex,kotex lightdays,new freedom lightdays,kotex new freedom,lil swimmer small pant,lil swimmer medium pant,lil swimmer large pant,poise,depen d belted shields,huggies overnite,huggies newborn,huggies convertibles,depe nd elastic leg undergarmnt,dep end fitted brief,goodnite,hu ggies snuggems,huggie s convertible clip strip,huggies supreme,huggies pure & natural,first choice thin lancets,topcare belted shield,topcare underpad,topcare maxi BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 566 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value overnight,topcare pantiliner,topcare male guard,topcare liners,topcare pads,topcare maxi pads,luvs,pamper s premium,pamper s ultra dry thin,pampers babydry,pampers unisex,pampers cruisers,underja ms,pampers easy ups,pampers extra protection,pampe rs swaddlers sensitive,pamper s preemie,pampers swaddlers,pampe rs,newborn babydry,washcloth,pa mpers premature,pampe rs ultra dry,pampers newborn,pamper s rash care,pampers premie,luvs overnight,pamper s nonelasticized,pamp ers ultra BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 567 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value phases,ultra + pampers,pamper s thick phases,pads,slipon,overnight protective,refuah plus,refuah plus glucose control,sleep overs,cuties,cutie pants,heating pad,glucopro,ami go insulin pump,hugo cane,hugo rolling walker,hugo transport,hugo folding walker,airgo rolling walker,smart sense lancets,topcare universal1 thin lancet,ultra thin plus,smart sense,ultra thin plus lancets,topcare ultra comfort,renew advanced microlancets,renew advanced lancing system,topcare clickfine,relion thin,bullseye mini safety lancets,sms BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 568 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value glucose control,safetylet,safety seal lancets,aqua lance lancing device,easy twist & cap lancets,surechek glucose control,sure edge blood glucose meter,sure edge glucose control soln,alternate site lancing device,vocalpoint glucose control,vocal point glucose control,one step at a time,pelvic muscle trainer,stethosco pe,babytherm pacifier thermometer,bre ast pump,nebulizer,fil ters,mask,ear thermometer,sph ygmomanometer, crutch accessory kit,underwear,cru tch,cool mist,super underpad,regular pad,super pad,cervical collar,oral BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 569 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value thermometer,bab y thermometer,femi nine combination syringe,fountain syringe,feminine folding syringe,feminine bulb syringe,vaporizer inhalant,vaporizer cleaning tablets,feminine compact travel syrnge,attachme nt set,enema syringe,nasal aspirator,rectal syringe,wheelcha ir,incontinent liner,entrust plus undergarment,ac apella,lipo cream base,shrink band,plastic white hdpe bottle,amber round glass bottle,topiclick,bottletop dispenser adapter,unguator lid,syringe filter, millexgp,precisedose dispenser tip cap,megapump mezzo,megapum p airless,rectalBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 570 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value vaginal perforation tip,sterile clear glass vial,amber glass serum bottle,topi-click filling nozzle,enema bottle,adapter cap,glass graduated cylinder,precised ose dispenser syringe,posidyne eld,suppository shell,syringe filter, millexgs,adapter pressin bottle,troche mold,alcohwipe,alcohglove,sterile nitrile gloves,amber glass bottle,clear glass serum bottle,luer lock syringe,luer slip tip cap,luer-lock syringe,amber oral-topical syringe,luer slip tip syringe tray,md pump actuator b,md pump actuator a,md pump bottle airless,md pen airless,md BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 571 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe airless,md jar airless,purple nitrile gloves,sterile amber glass vial,md pump actuator c,sterile droptainers,therm ophore,thermoph ore maxheat,ice it!,thermophore arthritis,opsite iv 3000,no-sting skin-prep swab,exu-dry slit tube,conformant 2,drynet,replicare ultra,replicare ultra sacrum,acticoat,a cticoat 7,acticoat absorbent,aquap hor gauze,acticoat site,acticoat flex 7,acticoat flex 3,biostep ag,biostep,replica re thin,iv3000 frame delivery,hot & cold compress,non adherent pads,nonadherent,adhesiv e bandages,adhesi BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 572 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ve foam bandages,baby darlings wipes,baby darlings diapers,combinati on water bottle,thong liners,tampons,pu re cotton,feminine cleansing cloths,lice removal comb,personal washcloths,traini ng pants,compmist compressor nebulizer,minico mp compressor nebulizer,earloop masks,cone masks,transport chair,selfgrip,lubricating & rewetting,everyda y long pantiliners,little darlings,foam toe bandages,neopre ne wrist splint,neoprene knee support,first aid kit,slip on knee,nitrile exam gloves,sheer strips,clear strips,plastic BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 573 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value strips,personal confidence pads,beltless undergarments,p ersonal confidence briefs,overnight brief,personal confidence underpad,flexible foam strips,slipon undergarments,b aby basics,basics for kids,heavy duty fabric strips,personal confidence liners,clear waterproof strips,natural care bandages,camo bandages,person al confidence underwear,icy hot smart relief tens,icy hot smart relief tens pads,protective barrier wipes,reliamed,re liamed mini lancing device,reliamed safety seal lancets,transpare nt thin film dressing,transpar BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 574 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ent i.v. site dressing,ostomy protective powder,incontrol bp monitor,microlife peak flow,flexiseal fecal,ultilance,dignity regular,dignity extra-duty,dignity regular duty,dignity natural extra,dignity diaper,dignity underpad,free & active super,dignity,dign ity plus,dignity plus liners,briefmates, prevent plus,dignity plus fitted brief,dignity plus regular brief,lady dignity plus brief,sir dignity plus brief,lc d nebulizer set,lc plus,baby nebulizer,lc star,sinustar,pari lc plus nebulizer,lc sprint nebulizer,pari sinus aerosol system,pari lc BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 575 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value sprint sinus,vios aerosol delivery system,filter, valve set for ll & lc,filter pad,filters replacement,bab y conversion pack 1,baby conversion pack 2,mask set with y-piece,mask vortex,vortex,bub bles the fish ii,wing tip tubing,adult aerosol mask,vortex ladybug mask,vortex frog mask,trek s portable pwr kit,trek s combo pack,trek s compact compressor,alter a nebulizer,eflow scf,eflow scf aerosol head,eflow scf nebulizer handset,smartma sk kids,proneb ultra,proneb ultra ii,proneb ultra ii deluxe,adapter w-disp mouthpiece,mout hpiece for truzone peak BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 576 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value fl,mask, pediatric,proneb, pep pressure monitor,bubbles the fish,pep nebulizer,lc nebulizer,elastogel hot & cold wrap,elastogel,elasto-gel plus,toe aid dressing,elastogel circle dressing,elastogel cast-splint padding,boston rewetting drops,boston one step,nite train'r,microspace r,microchamber,i nhaler companions,asth ma control,interlink,e mpty viaflex-ytransfer set,sub-q set,empty viaflex container,easyma xv speaking,easyma x v,easymax speaking,easyma x v2,easymax l,easymax n,easymax,easy max ng,easymax 15,easyplus r13n,easyplus BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 577 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value v,td gold blood glucose monitor,td gold voice glucose monitor,td gold level 1 control sol,td gold level 2 control sol,td gold level 3 control sol,fortiscare blood glucose syst,fortiscare,ant i-embolism stockings,truform compression stocking,puralin,s urgilance lancets,cut n crush,moist wipes,cold wrap,cold pack back pad,tennis elbow brace,elbow support,knee stabilizer,elbow strap,wrist support,ankle support,ace ankle support,arm sling,deluxe laced ankle brace,backshoulder ice & heat wrap,multipurpose ice & heat wrap,deluxe ankle brace,contoured BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 578 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value back support,back stabilizer,deluxe back stabilizer,maxi super,maxi deodorant,maxi regular,thumb stabilizer,deluxe wrist stabilizer,hand support,warm steam vaporizer,selfadhering,flushabl e moist wipes,ankle stabilizer,wrist immobilizer,delux e wrist brace,ultra thin,ace aerosol cloud enhancer,easiven t,daily pill box,hot & cold pack,medilice,sheer adhesive,medico ol's diasox,bed underpads,contro l pads,clear spots,fabric bandages,7 day pill box,fancy pill box,pill pal,one weektoday,rubber finger,dosage spoon,dosage BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 579 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value syringe,dosage dropper,hot & cold wrap,thermipaq, myglucohealth,m yglucohealth lancets,myglucoh ealth control solution,nessi spacer,protective pads,jumbo diapers,supreme diapers,diapers mega,kidpant,abs orbent cotton balls,blood glucose monitor kit,bladder control pad ultra,guard male,plastic swabs,diaper,inst ant cold therapy wrap,sleep comforts,gentle tape,gloves,nonadhesive pad,overnight briefs,cleansing wipes,saline sensitive,aloe vera latex gloves,flexible dressing,gauze sponges,adhesiv e dressing,selfadherent gentle wrap,blood pressure cuff,contact lens BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 580 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value relief,flex bandage,ear plugs,suresite window,procedur al face masks,advanced non-stick dressings,nonstick dressings,surgica l dressings,allpurpose dressings,dressin g sponges,cold pack,x-abs underwear,all purpose cloth tape,corn cushion,flex finger bandage,callus cushion,moleskin plus,portable sharps disposal,triple layer non-stick pad,qwikstrip,premium adult wash cloths,peas cold therapy,arthritis heatwraps,calciu m alginate,hydrogel dressing,hydrocol loid dressing,contact lens case,household BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 581 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value burn kit,reusable instant heat pack,elastic stretch net,women's underwear,men's underwear,weekl y vitamin planner,saline 4,disposable latex-free gloves,overnites diaper,adhesive gauze pad,needle collection & disposal,rolled absorbent cotton,sheer bandage,waterproof bandages,plastic strip,super absorbent underwear,ultrathin underwear,polyrayon,nighttime underpants,surgi cal pads,iv prep antiseptic,coverle t o.r.,blairex sterile saline soln,assess peak flow meter,personal best peak flow meter,heartstart,c oaguchek,accuBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 582 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value chek safe-t-pro plus,chemstrip bg diary,soft touch,accu-chek voicemate,accuchek safe-tpro,softclix,accuchek softclix,microdot, clip & stor,3m nexcare stomaseal,microp ore paper surgical tape,nexcare gentle paper tape,3m nexcare durapore,nexcare all purpose mask,futuro restoring,futuro antiembolism,nexcar e tegaderm,paper first aid tape,3m paper pre-cut tape strips,clear first aid tape,active strips,waterproof adhesive,heat comfort,foam sports tape,3m non-stick pads,amniscreen, metercheck,normject,aimsco,aimsc o ultra thin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 583 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ii,aimsco mini ultra-thin ii,ultrathin ii,ultra thin ii,ultra-thin ii lancets,pcca accupen15,supposistrip,u niversal sleeve,vaginal cream applicator,suppos itory box,filter, millex-or syringe,boston round natural,vaginal suppository applicator,bottle,l uer lock adapter,filter, millex-fg 0.2um,suppositor y shell, small,suppository shell, medium,syringe tip rectalvaginal,megapum p-blue,freedom precision airless,antibacteri al bandage,antibact erial pad,fast read thermometer,chil d ear syringe,infant ear syringe,watchhal BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 584 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value er,e.p.t. stick test,carra sorb h,carra sorb m,carra film,diab,pump for whirlpool solution,shampoo & body wash dispenser,radiafd g,carrasyn gel,gauze packing strip,wound dressing,gel pad,carrasyn spray gel,carra gauze strips,carra gauze,carrasyn v,carracolloid,ultr a-klenz,dermal wound gel,primary dressing,incontin ence skin care,carrasmart,c arradres,radiadre s,carraginate,sur esite iv,suresite,suresit e flexigrid,arglaes,a rglaes film,arglaes island,optifoam,e xuderm rcd,exuderm,exu derm lp,exuderm ultra,exuderm BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 585 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value sacrum,dermagel,medfix,maxor b,maxorb extra,tenderwet,e z smart,ez smart lancets,ez smart plus,onetouch ultra control soln,one touch delica,onetouch verio iq,one touch verio,onetouch delica,onetouch finepoint lancets,onetouch suresoft,onetouc h ultramini,onetouc h ultra system,one touch glucose control soln,onetouch verio,one touch basic system,surestep, penlet plus blood sampler,onetouc h lancets,onetouch ultra2,onetouch ultra smart,onetouch ultralink,surestep control solution,surestep pro,onetouch verio sync,grx wound gel,alligator BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 586 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value spoon,pre-moist pads,replacemen t pads,aerochamb er,one touch lancets,ultra fine lancets,opsite flexigrid,opsite,all evyn cavity wound dress,algisite,unif lex,needle free syringe kit a,medi-jector vision,needle free syringe kit b,needle free syringe kit c,medi-jector needle-free syr a,medi-jector needle-free syr b,medi-jector needle-free syr c,fibracol,kling fluff,sofkling,barrier sterile field,biopatch,nubrede,topper,tiell e,bioclusive select,bioclusive select mvp,bioclusive mvp select,nu-gel collagen,algosteri l,nu-gel,raytec,soffoam,band-aid BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 587 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value island surgical,zonas,de rmiview,dermifor m,tielle plus,kling conforming gauze bandage,dynaflex,ultralon pf,maxxus pf,micro-touch pf,allergard,neutr alon 50,maxxus,neutr alon,microtouch,microtouch xp,sofloop,surgine,barri er,surgine ii,barrier n95,protectivw,protectiv plusw,biovue,protecti v,lister's suture removal kit,barrier fenestrated strl field,preptic shave prep,preptic 2 shave prep,chix,sofnet,d aylee,preptic,prevac are,starter kit,life medical starter,diabetic.co m starter,prestige meter,prestige,pr estige value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 588 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value pack,truecontrol,t ruetest glucose control,sidekick,p restige smart system,prestige smart system iq,liberty lev 1 glucose control,liberty lev 2 glucose control,liberty monitor,sheet protector,breathe right,medisense thin lancets,medisens e glucose ketone,medisens e glucose ketone contr,medisense, precision xtra,optium,precis ion,unistik 2 normal,unistik 2 extra,precision link,autolancet device wlancets,ultratlc lancetsdevice,silverseal hydrogel,hydress, steritamp,pocketcare irrigator,elon nail care system,flutter,sup reme glucose control,supreme meter,2tek,e-z BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 589 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value spacer pedspak,e-z spacer mask,e-z spacer & mask,wonderpant s,up & up maxi pads,up & up baby diaper,telcare,telc are control solution,telcare bgm,sure-ject insulin syringe,surelance,sure-fine pen needles,sure-test easyplus mini,suretouch,surepen,heartstream fr2,elta dermal,varithena administration pack,deltec cozmo,infusion,in sulin cartridge,adapter, belt clip,gripper plus,deltec cozmo cleo infusion set,amerigel,fc2 female condom,dermafil mhd,dermasyn,der magauze,dermav iew,dermaview BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 590 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value ii,dermaginate,de rmadress,dermal evin,actis,flexzan adhesive dressing,hydrocol ii,sorbsan,vial,ste rile,empty,maxifill transfer set,steritamp seal,chemo transfer pin,floweze,mini transfer pin,hi-volume pumping chamber,transfer pin,universal syringe tip adaptor,promogr an prisma,promogra n,actisorb,silverc el,e.p.t,e.p.t digital,tear flo,scar care,accu-chek aviva plus,coaguchek xs,accutrend cholesterol,accutr end glucose,accutren d plus,accu-chek fastclix,accu-chek compact blue control,coaguche k xs pro,accuchek nano smartview,accuchek smartview,accuBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 591 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value chek compact plus control,comfort,c artridge pump,contact detach infusion set,cartridge stamped,onetouc h ping,insulin pump,cartridge,in set infusion set,animas 2020,inset 30 tubing,infusion pump,comfort short,inset 30 infusion set,ultima,reservo ir,simplechoice,si mplechoice quick,gelpad,wou ndgard gauze,coolmagic, triple helix collagen,foam dressing,sanizone ostomy deodorant,md turbo,vascuderm hydrogel wound,aerocham ber plus,primabella,fl exi-seal fms,surfit natura high output,visi-flow irrigation sleeve,visi-flow irrig starter BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 592 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value set,little ones drainable pouch,little ones urostomy pouch,little ones closed-end pouch,esteem drainable pouch,little ones skin barrier,visiflow sleeve tail closures,convate c night drainage tubing,versiva xc,allkare adhesive remover wipes,sur-fit natura adaptor,sur-fit natura lowpressure,convate c night drain container,esteem + closed pouch,esteem closed pouch,natura closed pouch,esteem synergy closed pouch,flexi-seal signal fms,stomahesive skin barrier,eakin cohesive slims,aquacel foam,natura durahesive skin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 593 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value barrier,natura stomahesive skn barrier,aquacel extra,gentlecath, natura drainable pouch,esteem synergy drainable pouch,aquacelag extra,eakin cohesive,aquacel ag foam,aquacel ag foam heel,aquacel ag foam sacral,aquacel foam sacral,esteem synergy+,harmon ie,dry comfort extra,tena,dry comfort,tena pants,tena classic,tena stretch ultra,tena classic plus,tena protective underwear,brief youth,promise pad,flexiflo,y-port connector,flexiflo top-fill,flexiflo feeding tube,flexiflo topfill bag,enteralite infinity,flexiflo magnaport,magnaport,flexiflo overtheBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 594 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value guidewire,flexiflo easy-feed 500,flexiflo top-fill enteral bag,flexiflo quantum,compan ion pump,durag,nasoenteric tube,embrace,em brace adapter,embrace bag set,flexiflo toptainer,flexiflo feeding bag,embrace pole clamp,quantum pump,patrol,gravi ty feeding set,tranquility premium underwear,atn brief,select underwear,select disposable briefs,select underpads,diaper booster pad,tranquility topliner pads,select kids briefs,coverlet eye occlusor,selftaking blood pressure,a.i.r.s. nebulizer,airs disposable nebulizer,airs adult aerosol BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 595 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value mask,airs pediatric disposable mask,comp-air elite compressor syst,reusable nebulizer kit,air tube with air plugs,micro air,comp-air nebulizer compressor,peak -air,women's advanced bp monitor,airs pediatric aerosol mask,visine for contacts,bengay moist heat therapy,ezo,avog el,sofsensor,guardian transmitter tape,guardian rt starter kit,paradigm realtime,guardian realtime,guardian rt system,replacem ent pediatric monitor,minimed reservoir,1.5 volt batteries #357,polyfin,sofset,paradigm insulin pump pathway,polyfin qr,sofBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 596 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value serter,paradigm infusion,quick release soft teflon,sof-set micro,paradigm,p aradigm silhouette,silhoue tte,silserter,quick-set paradigm,minime d,guardian test plug,minimed infusion,medtroni c remote control,paradigm remote control,paradigm insulin pump,revel programmable pump,guardian rt charger,minilink real-time transmitter,suret,sure-t paradigm,mio infusion set,senserter,enlite glucose sensor,minimed 530g,enlite serter,real-time starter kit,continuous glucose sensor,enlite,iport advance,suprem e,options BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 597 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value liners,options pads,early ovulation test,tena underwear,carefr ee pantiliners,bulkee ii,ultra-soft plus,ultra-soft classic,protection plus underpad,protecti on plus classic,day & night brief,options ultra thins,thermomete r tip covers,relion blood pressure cuff,urological catheter,active cath,3 step skin care,step 2moisture cream,step 3moisture barrier,step 1incontinent cleanser,ultrafresh,sleeve closure clamp,irrigation syringe,enema bag with catheter,mountin g ring,elastic belt,shut off for 5000 enema bag,lubriBRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 598 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value wipe,compact irrigator,colostokit irrigator,hospital pack irrigator,female specimen catheter,tubing for irrigator,shut off for tubing,quick disconnectconnector,insertio n tube catheter,shield for insertion tube,travel case,laird tip,freedom t-tap leg bag kit,freedom leg bag,tube & connector kit,freedom twist port leg bag kit,colostotip,colo stotip w-quick disconnect,freedo m pak seven,freedom cath,response ii,touch ii,piston ii,economy pouch,mini-drain open end pouch,doublehesive,e-z hold,gizmo foam straps,uro-san plus,clear BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 599 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value advantage,contin ent urinary catheter,colostop ads,cone tip,dermaguard,uro-san leg bag,plastic connector,deluxe leg bag straps,comfort leg bag straps,freedom drainage bag,gizmo,evacar e pessary,bandaid activ flex,seal tight,on call plus meter,on call plus control,on call plus lancing device,on call plus lancet,on call lancet,on call lancing device,on call vivid meter,on call vivid control,optumrx,o n call vivid pal,on call express meter,on call express control soln,tens 502,tens 504,neurostimula tion electrodes,home access hiv-1 test system,mask BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 600 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value set,erapid nebulizer,erapid nebulizer handset,baby conversion kit,vortex vhc ladybug mask,vortex vhc frog mask,ems anti-embolism stocking,devilbiss pulmoneb lt comp-neb,sure comfort,poly hub needle,sure comfort lancets,sure comfort lancing pen,securely yours,quickables washcloths,ezsorb,attends,atte nds undergarments,at tends insert,attends underwear,attend s guards,tissuepak, attends light insert,attends booster,attends disposable underpads,ultima tuckables,cairpad ,ultima incontinence,adh eres,tuffsorb,tuck ables,attends BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 601 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value washcloths,gmat e control solution,gmate voice starter,gmate voice meter,gmate,gma te lancing device,gmate smart starter,gmate smart meter,gluco navii,lancing system,muppet strips,cleaning solution,wetting solution for hard lens,nonpreserved saline,oragrip,ho me pregnancy test,absorbent shield,poison first aid kit,facial cleansing sponge,pill divider,shave cream,blade double edge,lady's shaver plus lube strip,weekly pill planner,effervesc ent denture cleansr,effervesc ent denture,dental floss BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 602 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value unwaxed,choiced m clarus control soln,choicedm clarus,snap insulin pumpinfusion set,snap insulin pump controller,quintet, blood glucose control,quintet ac,nasoneb nasal nebulizer,aeroecli pse,aerochamber plus z stat,monaghan z stat,easy check control solution,easy step,easy plus,easy trak,easy talk,easy plus ii,easy comfort pen needles,easy comfort insulin syringe,maxicomfort,mini ultra-thin ii,mini lancing device,t:slim,cleo 90 infusion set,carefine pen needle,unistrip,inj ect ease lancets,affirm underwear,affirm pads,snap pants,mesh pants,prevail BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 603 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value bladder control,cuties baby wipes,cuties wash cloths,prevail,was hcloths,prevail wet wipes,prevail premium washcloths,ameri can star washcloths,proca re washcloths,perso nal cloths,pant liner large plus,pant liner large,prevail underwear,nu-fit brief,breezers,per -fit brief,value buy,prevail brief,prevail stretch fit,nufit underwear,prevai l simply stretch fit,prevail boxers,procare,pr evail full coverage undrwear,nufit brief,per-fit underwear,perfit brief,prevail perfit,ben-efit,prevail breezers,prevail extra underwear,prevai l bariatric,prevail BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 604 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value super plus,prevail protective underwear,prevai l adjustable,prevail classic fit underwear,prevai l pm,prevail ultra plus,prevail ultra bladder,prevail panty liner,prevail extra plus bladder,prevail extra bladder,prevail guards for men,prevail pads,prevail male guard,prevail curve,prevail smooth fit,prevail fits to a t,youth brief,adult frontal tape brief,prevail pre-moist bath cloth,pant liners,xtremefit brief,ultrathin,pre mier adult brief,prevail breezers 360,prevail per-fit 360,easy check,easy comfort,easy click,propylene glycol,easy touch lancets,diatrue plus,diatrue,uroc BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 605 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value are urinary drainage,uro-con catheter,toe straightener,up & up pantiliners,agiegrx,erase,erase ras-pouri,geridyne,hydrophor gauze,karaya gum,hydrocollgrx,calalgingrx,calalgin-grx rope,island gardgrx,grx hydrogel gauze,grx foam dressing,safe klean,mercury klean kit,bloodglucose meter,profit,quick response,onestep blood pressure monitr,freestyle insulinx,ultratlc lancets,medisens e control,precision glucose control,precision sof-tact,precision q-i-d,embrace glucose control soln,victory,embr ace pro,embrace evo,advocate control solution,advocate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 606 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value blood glucose monitor,advocate rapidsafe,advocate lancing device,advocate lancet,advocate redicode,advocate lancets,advocate redi-code duo,advocate duo,advocate redicode+,advocate redi-code+ ctrl soln,advocate syringes,advocat e pen needles,neopren e ankle support,new generation,sterile bandages,droppe r,ankle supportelastic,elbow supportelastic,wrist splint support,diabetic socks,pulmoneb lt compressor nebul,clever choice control solution,clever choice hd glucose syst,clever choice blood gluc sys,clever chek BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 607 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value blood glucose syst,clever chek lancets,clever choice pro,clever chek,clever choice,pharmacis t choice,clever choice micro,clever choice talk,comfort ez,fora d10,fora control solution,fora v10,fora v20,fora v22,fora g30a,fora g20,fora d15,fora d20,fora g90,fora lancing device,foracare lancets,foracare gdh,freestyle system,freestyle sidekick ii,freestyle lancets,freestyle control solution,freestyle flash system,freestyle unistik 2,freestyle navigator,freestyl e lite meter,freestyle freedom,freestyle freedom lite,freestyle precision BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 608 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date 04/13/2015 Brand Name Generic Name nutriheal,boost,co lactose-free food,lactosempleat modified reduced food,nutritional formula,isosource supplement ,boost plus,boost high protein,nutritional supplement,nutriti onal supplement plus,nutridrink,balanced nutritional,nutritio nal drink,nutritional drink plus,nutritional shake,nutrafit plus,nutrafit,comp lete nutrition,complete nutrition plus,traumacal,co mpleat,liquid nutrition plus,nutrition plus,liquid nutrition,jevity 1 cal,ensure liquid,osmolite,os molite 1 cal,ensure active high protein,promote,e nsure high protein,osmolite 1.2 cal,ensure active muscle health,ensure active clear,ensure Type of Change Previous Value REMOVE FROM FORMULARY New Value Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 609 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value muscle health,nutritional shake plus,asoy,high-protein nutritional shake,isocal,nutri tional liquid,nutritional plus liquid,ensure enlive,preferred plus,kindercal tf,kindercal,bright beginnings,ensur e active heart health,ensure active proteinmuscle,ensure active light,ensure high protein-muscle 04/13/2015 melatonin melatonin REMOVE FROM FORMULARY Non-Formulary 04/13/2015 acidophilus,probi lactobacillus otic pearls acidophilus/bifidobacterium longum REMOVE FROM FORMULARY Non-Formulary 04/13/2015 povidonepovidone-iodine,lidocaine iodine,hospital hcl/benzalkonium antiseptic,antisep chloride/alcohol tic,antiseptic solution,first aid antiseptic,periwash,grx dyne,betadine,be tagen,scrub care povidone iodine REMOVE FROM FORMULARY Non-Formulary 04/15/2015 ZONEGRAN ADD TO FORMULARY Non-Formulary zonisamide BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 610 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 04/15/2015 CLIMARA PRO estradiol/levonorgestrel 04/15/2015 HYCET hydrocodone bitartrate/acetaminophen 04/15/2015 prudoxin,doxepin doxepin hcl hcl,zonalon,silen or 04/15/2015 CLOBEX clobetasol propionate 04/15/2015 VFEND 04/15/2015 Type of Change Previous Value New Value CHANGE TIER Non-Formulary CHANGE UM: AUTHORIZATION PA applies ADD TO FORMULARY Non-Formulary CHANGE TIER Non-Formulary voriconazole ADD TO FORMULARY Non-Formulary FORTAMET metformin hcl ADD TO FORMULARY Non-Formulary 04/15/2015 FORTAMET metformin hcl ADD TO FORMULARY Non-Formulary 04/15/2015 KERALYT salicylic acid ADD TO FORMULARY Non-Formulary 04/15/2015 retintretinoin a,avita,tretinoin,at ralin,tretinx,tretinoin acid,retinoic acid,vesanoid ADD TO FORMULARY Non-Formulary 04/15/2015 RETIN-A tretinoin ADD TO FORMULARY Non-Formulary 04/15/2015 tretinoin tretinoin CHANGE TIER Generics 04/15/2015 RETIN-A tretinoin ADD TO FORMULARY Non-Formulary 04/15/2015 tretinoin tretinoin CHANGE TIER Generics 04/15/2015 tretinoin tretinoin CHANGE TIER Generics 04/15/2015 RETIN-A tretinoin ADD TO FORMULARY Non-Formulary 04/15/2015 panoxyl-4 benzoyl peroxide ADD TO FORMULARY Generics 04/15/2015 levalbuterol concentrate levalbuterol hcl CHANGE TIER Generics 04/15/2015 XOPENEX levalbuterol hcl CONCENTRATE CHANGE TIER Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 611 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 duloxetine hcl duloxetine hcl CHANGE TIER Generics 04/15/2015 CYMBALTA duloxetine hcl ADD TO FORMULARY Non-Formulary 04/15/2015 duloxetine hcl duloxetine hcl CHANGE TIER Generics 04/15/2015 CYMBALTA duloxetine hcl ADD TO FORMULARY Non-Formulary 04/15/2015 duloxetine hcl duloxetine hcl CHANGE TIER Generics 04/15/2015 CYMBALTA duloxetine hcl ADD TO FORMULARY Non-Formulary 04/15/2015 MIACALCIN calcitonin,salmon,synthetic ADD TO FORMULARY Non-Formulary 04/15/2015 PARCOPA carbidopa/levodopa CHANGE TIER Non-Formulary 04/15/2015 PARCOPA carbidopa/levodopa CHANGE TIER Non-Formulary 04/15/2015 BOTOX COSMETIC onabotulinumtoxina REMOVE UM: SPECIALTY Specialty Drug 04/15/2015 BOTOX COSMETIC onabotulinumtoxina REMOVE UM: AUTHORIZATION PA applies 04/15/2015 BOTOX COSMETIC onabotulinumtoxina REMOVE UM: CUSTOM Cosmetic Rider May Be Required 04/15/2015 BOTOX COSMETIC onabotulinumtoxina REMOVE FROM FORMULARY Not Covered Non-Formulary 04/15/2015 DRITHOCREME anthralin HP CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SAIZEN somatropin CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 telmisartan telmisartan CHANGE TIER Generics 04/15/2015 MICARDIS telmisartan ADD TO FORMULARY Non-Formulary 04/15/2015 MICARDIS telmisartan ADD TO FORMULARY Non-Formulary 04/15/2015 telmisartan telmisartan CHANGE TIER Generics 04/15/2015 TIROSINT levothyroxine sodium CHANGE TIER Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 612 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 amlodipineatorvastatin amlodipine besylate/atorvastatin calcium ADD TO FORMULARY Non-Formulary Generics 04/15/2015 amlodipineatorvastatin amlodipine besylate/atorvastatin calcium ADD TO FORMULARY Non-Formulary Generics 04/15/2015 amlodipineatorvastatin amlodipine besylate/atorvastatin calcium ADD TO FORMULARY Generics 04/15/2015 fenofibrate fenofibrate,micronized CHANGE TIER Generics 04/15/2015 fenofibrate fenofibrate,micronized CHANGE TIER Generics 04/15/2015 eszopiclone eszopiclone CHANGE TIER Generics 04/15/2015 LUNESTA eszopiclone CHANGE TIER Non-Formulary 04/15/2015 eszopiclone eszopiclone CHANGE TIER Generics 04/15/2015 LUNESTA eszopiclone CHANGE TIER Non-Formulary 04/15/2015 LUNESTA eszopiclone ADD TO FORMULARY Non-Formulary 04/15/2015 omega-3 acid ethyl esters omega-3 acid ethyl esters CHANGE TIER Generics 04/15/2015 RESTORIL temazepam ADD TO FORMULARY Non-Formulary 04/15/2015 temazepam temazepam ADD TO FORMULARY Generics 04/15/2015 ZYLET tobramycin/loteprednol etabonate CHANGE TIER Non-Formulary 04/15/2015 alprazolam odt alprazolam CHANGE TIER Generics 04/15/2015 alprazolam odt alprazolam CHANGE TIER Generics 04/15/2015 BONIVA ibandronate sodium ADD TO FORMULARY Non-Formulary 04/15/2015 fentanyl fentanyl ADD TO FORMULARY Generics 04/15/2015 DURAGESIC fentanyl CHANGE TIER Non-Formulary 04/15/2015 LAMICTAL XR lamotrigine ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 613 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 LAMICTAL XR lamotrigine ADD TO FORMULARY Non-Formulary 04/15/2015 LAMICTAL XR lamotrigine ADD TO FORMULARY Non-Formulary 04/15/2015 IMITREX sumatriptan succinate ADD TO FORMULARY Non-Formulary 04/15/2015 LAMICTAL XR lamotrigine ADD TO FORMULARY Non-Formulary 04/15/2015 albuterol sulfate albuterol sulfate CHANGE TIER Generics 04/15/2015 albuterol sulfate albuterol sulfate CHANGE TIER Generics 04/15/2015 METROGEL metronidazole ADD TO FORMULARY Non-Formulary 04/15/2015 onetouch ultra test strips,one touch ultra test strips blood sugar diagnostic REMOVE UM: AUTHORIZATION 04/15/2015 ultima blood sugar diagnostic REMOVE UM: AUTHORIZATION 04/15/2015 ez smart blood sugar diagnostic REMOVE UM: AUTHORIZATION 04/15/2015 ez smart plus blood sugar diagnostic REMOVE UM: AUTHORIZATION 04/15/2015 nova max glucose test strips blood sugar diagnostic REMOVE UM: GENDER 04/15/2015 infinity test strips blood sugar diagnostic REMOVE UM: AUTHORIZATION 04/15/2015 prodigy no coding blood sugar diagnostic REMOVE UM: AUTHORIZATION 04/15/2015 clever choice pro blood sugar diagnostic REMOVE UM: GENDER PA applies PA applies Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 614 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 doxycycline doxycycline hyclate hyclate,vibramyci n,periostat,doryx, oraxyl,morgidox,d oxy 100,vibratabs,atridox,acticl ate ADD TO FORMULARY Generics 04/15/2015 COLESTID colestipol hcl ADD TO FORMULARY Non-Formulary 04/15/2015 colestipol hcl colestipol hcl CHANGE TIER Generics 04/15/2015 INCRELEX mecasermin CHANGE TIER 04/15/2015 LOPID gemfibrozil ADD TO FORMULARY Non-Formulary 04/15/2015 HYZAAR losartan potassium/hydrochlorothiazi de ADD TO FORMULARY Non-Formulary 04/15/2015 clomid,clomiphen clomiphene citrate e citrate,serophene CHANGE UM: CUSTOM Fertility rider may be required 04/15/2015 TEV-TROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SEROSTIM somatropin CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SAIZEN somatropin CHANGE TIER 04/15/2015 HUMATROPE somatropin CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SEROSTIM somatropin CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 HUMATROPE somatropin CHANGE TIER 04/15/2015 HUMATROPE somatropin CHANGE TIER 04/15/2015 DDAVP desmopressin acetate ADD TO FORMULARY Non-Formulary 04/15/2015 DDAVP desmopressin acetate ADD TO FORMULARY Non-Formulary 04/15/2015 DDAVP desmopressin acetate ADD TO FORMULARY Non-Formulary 04/15/2015 DDAVP desmopressin acetate (nonrefrigerated) ADD TO FORMULARY Non-Formulary Preferred Brands Non-Formulary Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 615 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 TRETIN-X tretinoin/emollient combination no. 9/skin cln1 CHANGE TIER Non-Formulary 04/15/2015 TRETIN-X tretinoin/emollient combination no. 9/skin cln1 CHANGE TIER Non-Formulary 04/15/2015 TRETIN-X tretinoin/emollient combination no. 9/skin cln1 CHANGE TIER 04/15/2015 tramadol hcl er tramadol hcl ADD TO FORMULARY Generics 04/15/2015 ULTRAM ER tramadol hcl ADD TO FORMULARY Non-Formulary 04/15/2015 SEROQUEL quetiapine fumarate ADD TO FORMULARY Non-Formulary 04/15/2015 VENTAVIS iloprost tromethamine,iloprost CHANGE TIER Non-Formulary 04/15/2015 SECTRAL acebutolol hcl ADD TO FORMULARY Non-Formulary 04/15/2015 SECTRAL acebutolol hcl ADD TO FORMULARY Non-Formulary 04/15/2015 XODOL 5-300 hydrocodone bitartrate/acetaminophen,hy drocodone bit/acetaminophen CHANGE TIER Non-Formulary 04/15/2015 vicodin hydrocodone bitartrate/acetaminophen 04/15/2015 ADCIRCA 04/15/2015 Preferred Brands Non-Formulary ADD TO FORMULARY Non-Formulary Generics tadalafil CHANGE TIER Preferred Brands Non-Formulary omeprazolesodium bicarbonate omeprazole/sodium bicarbonate CHANGE TIER Generics 04/15/2015 ZEGERID omeprazole/sodium bicarbonate ADD TO FORMULARY Non-Formulary 04/15/2015 ZEGERID OTC omeprazole/sodium bicarbonate CHANGE TIER 04/15/2015 ZEGERID omeprazole/sodium bicarbonate ADD TO FORMULARY Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 616 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 DIVIGEL estradiol 04/15/2015 IMITREX sumatriptan succinate ADD TO FORMULARY Non-Formulary 04/15/2015 METADATE CD methylphenidate hcl ADD TO FORMULARY Non-Formulary 04/15/2015 METADATE CD methylphenidate hcl ADD TO FORMULARY Non-Formulary 04/15/2015 METADATE CD methylphenidate hcl ADD TO FORMULARY Non-Formulary 04/15/2015 DAYTRANA methylphenidate CHANGE TIER Non-Formulary 04/15/2015 DAYTRANA methylphenidate CHANGE TIER Non-Formulary 04/15/2015 DAYTRANA methylphenidate CHANGE TIER Non-Formulary 04/15/2015 DAYTRANA methylphenidate CHANGE TIER Non-Formulary 04/15/2015 zyvox,linezolid linezolid 04/15/2015 primlev oxycodone hcl/acetaminophen CHANGE TIER Generics 04/15/2015 primlev oxycodone hcl/acetaminophen CHANGE TIER Generics 04/15/2015 DIOVAN HCT valsartan/hydrochlorothiazid e ADD TO FORMULARY Non-Formulary 04/15/2015 DIOVAN HCT valsartan/hydrochlorothiazid e ADD TO FORMULARY Non-Formulary 04/15/2015 ashlyna levonorgestrel/ethinyl estradiol and ethinyl estradiol ADD TO FORMULARY Preventative 04/15/2015 ashlyna levonorgestrel/ethinyl estradiol and ethinyl estradiol ADD UM: GENDER Female 04/15/2015 doxycycline ir-dr doxycycline monohydrate ADD TO FORMULARY Generics 04/15/2015 prenatal-u prenatal vits without calc no5/ferrous fumarate/folic acid CHANGE TIER Generics REMOVE UM: AUTHORIZATION BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 617 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 pnv-vp-u prenatal vits without calc no5/ferrous fumarate/folic acid ADD TO FORMULARY Generics 04/15/2015 pnv-vp-u prenatal vits without calc no5/ferrous fumarate/folic acid ADD UM: GENDER Female 04/15/2015 triveen-u prenatal vits without calc no5/ferrous fumarate/folic acid ADD TO FORMULARY 04/15/2015 OPANA oxymorphone hcl ADD TO FORMULARY Non-Formulary 04/15/2015 OPANA oxymorphone hcl ADD TO FORMULARY Non-Formulary 04/15/2015 xolox oxycodone hcl/acetaminophen ADD TO FORMULARY Generics 04/15/2015 oxymorphone hcl oxymorphone hcl er CHANGE TIER Generics 04/15/2015 oxymorphone hcl oxymorphone hcl er CHANGE TIER Generics 04/15/2015 oxymorphone hcl oxymorphone hcl er CHANGE TIER Generics 04/15/2015 oxymorphone hcl oxymorphone hcl er CHANGE TIER Generics 04/15/2015 INVEGA SUSTENNA paliperidone palmitate CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 INVEGA SUSTENNA paliperidone palmitate CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 INVEGA SUSTENNA paliperidone palmitate CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 INVEGA SUSTENNA paliperidone palmitate CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 INVEGA SUSTENNA paliperidone palmitate CHANGE TIER Preferred Brands Non-Formulary Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 618 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Preferred Brands Non-Formulary 04/15/2015 latrix xm urea/lactic acid/zinc undecylenate CHANGE TIER 04/15/2015 ZIOPTAN tafluprost/pf CHANGE TIER 04/15/2015 TERBINEX terbinafine hcl/hydroxypropyl chitosan CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 folivane-prx dha nf prenatal vit with calcium no.39/iron fum/folic acid/dss/dha CHANGE TIER Preferred Brands Generics 04/15/2015 ISOSOURCE 1.5 lactose-reduced food/fiber CAL TUBE FEED ADD TO FORMULARY Non-Formulary Generics 04/15/2015 ISOSOURCE 1.5 lactose-reduced food/fiber CAL TUBE FEED ADD TO FORMULARY Non-Formulary Generics 04/15/2015 isosource 1.5 cal lactose-reduced food/fiber ADD TO FORMULARY Non-Formulary Not Covered 04/15/2015 ISOSOURCE 1.5 lactose-reduced food/fiber CAL ADD TO FORMULARY Non-Formulary Not Covered 04/15/2015 JEVITY 1.2 CAL lactose-reduced food/fiber ADD TO FORMULARY Non-Formulary Not Covered 04/15/2015 KALBITOR ecallantide REMOVE UM: AUTHORIZATION PA applies 04/15/2015 natalvirt 90 dha prenatal vit,calcium #64/iron carb,gluc/folic acid/dss/dha CHANGE TIER Generics 04/15/2015 prenaissance 90 prenatal vit,calcium #64/iron dha carb,gluc/folic acid/dss/dha CHANGE TIER Generics 04/15/2015 taron-bc prenatal vit with calcium comb no.63/iron,carbonyl/fa/b6 CHANGE TIER Preferred Brands Generics 04/15/2015 dallergy chlorpheniramine maleate/phenylephrine hcl CHANGE TIER Preferred Brands Generics 04/15/2015 SALVAX DUO PLUS salicylic acid/urea CHANGE TIER Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 619 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE TIER Preferred Brands Generics 04/15/2015 vazobid-pd brompheniramine maleate/phenylephrine hcl 04/15/2015 ss 10-2 sulfacetamide sodium/sulfur ADD TO FORMULARY Generics 04/15/2015 AVAR-E LS,AVAR-E LS CREAM sulfacetamide sodium/sulfur ADD TO FORMULARY Non-Formulary 04/15/2015 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur CHANGE TIER Generics 04/15/2015 GILTUSS TR guaifenesin/dextromethorph an hbr/phenylephrine ADD TO FORMULARY Non-Formulary Not Covered 04/15/2015 PROMACTA eltrombopag olamine CHANGE TIER Preferred Brands Not Covered 04/15/2015 paire ob plus dha prenatal vitamin no.8/iron ps complex,asp gl/folic acid/dha CHANGE TIER Preferred Brands Generics 04/15/2015 sirolimus sirolimus CHANGE TIER 04/15/2015 COMFORT PAC- tizanidine hcl/irritants TIZANIDINE counter-irritants combination no.2 CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 mexiletine hcl mexiletine hcl CHANGE TIER Preferred Brands Not Covered 04/15/2015 tranexamic acid tranexamic acid CHANGE TIER Generics 04/15/2015 CLEOCIN clindamycin phosphate CHANGE TIER Non-Formulary 04/15/2015 fioricet butalbital/acetaminophen/caf feine CHANGE TIER 04/15/2015 gatifloxacin gatifloxacin CHANGE TIER Generics 04/15/2015 ZYMAXID gatifloxacin ADD TO FORMULARY Non-Formulary 04/15/2015 tl-care dha pnv no.20/iron fumarate/fa/docusate na/fish oil conc/dha/epa ADD TO FORMULARY Generics Preferred Brands Non-Formulary Generics Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 620 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 FOVEX omega-3 fatty acids/docosahexanoic acid/epa/lutein/zeaxanth CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 VIMPAT lacosamide CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 prenaplus prenatal vits with calcium #74/ferrous fumarate/folic acid CHANGE TIER 04/15/2015 vol-plus prenatal vits with calcium #74/ferrous fumarate/folic acid ADD TO FORMULARY 04/15/2015 prenatal plus prenatal vits with calcium #72/ferrous fumarate/folic acid CHANGE TIER Generics 04/15/2015 prenatal vitamin plus low iron prenatal vits with calcium #72/ferrous fumarate/folic acid CHANGE TIER Generics 04/15/2015 preplus prenatal vits with calcium #72/ferrous fumarate/folic acid CHANGE TIER Generics 04/15/2015 VIVELLE-DOT estradiol CHANGE TIER Non-Formulary 04/15/2015 VIVELLE-DOT estradiol CHANGE TIER 04/15/2015 CLIMARA estradiol CHANGE TIER Non-Formulary 04/15/2015 CLIMARA estradiol CHANGE TIER Non-Formulary 04/15/2015 CLIMARA estradiol CHANGE TIER Non-Formulary 04/15/2015 CLIMARA estradiol CHANGE TIER 04/15/2015 millipred dp prednisolone CHANGE TIER Generics 04/15/2015 millipred dp prednisolone CHANGE TIER Generics 04/15/2015 vol-nate prenatal vits with calcium #73/ferrous fumarate/folic acid ADD TO FORMULARY Generics Non-Formulary Generics Preferred Brands Preferred Brands Non-Formulary Non-Formulary Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 621 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 04/15/2015 PRENATABS FA prenatal vits with calcium #78/ferrous fumarate/folic acid 04/15/2015 venatal-fa 04/15/2015 Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary prenatal vits with calcium #78/ferrous fumarate/folic acid CHANGE TIER Generics DALIRESP roflumilast CHANGE TIER 04/15/2015 URAMAXIN GT urea ADD TO FORMULARY Non-Formulary 04/15/2015 cem-urea urea CHANGE TIER Generics 04/15/2015 COMFORT PAC- meloxicam/irritants counterMELOXICAM irritants combination no.2 04/15/2015 PREFERA OB prenatal vit no.21/iron polysacch,heme polypep/folic acid ADD TO FORMULARY 04/15/2015 hemenatal ob prenatal vit no.21/iron polysacch,heme polypep/folic acid ADD TO FORMULARY 04/15/2015 vp-heme ob prenatal vit no.21/iron polysacch,heme polypep/folic acid CHANGE TIER Generics 04/15/2015 vinate dha prenatal vitamin comb no.79/iron fumarat/fa/lmefolate ca/dha CHANGE TIER Generics 04/15/2015 SUMAXIN TS sulfacetamide sodium/sulfur ADD TO FORMULARY Non-Formulary 04/15/2015 vena-bal dha prenatal vit no.81/sod.feredetate-iron ps/folic acid/omega-3 CHANGE TIER Generics 04/15/2015 bal-care dha prenatal vit no.81/sod.feredetate-iron ps/folic acid/omega-3 CHANGE TIER Generics 04/15/2015 DIFFERIN adapalene ADD TO FORMULARY Non-Formulary CHANGE TIER Preferred Brands Preferred Brands Non-Formulary Non-Formulary Non-Formulary Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 622 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 DIFFERIN adapalene ADD TO FORMULARY Non-Formulary 04/15/2015 tl-select prenatal vit with calcium no.80/iron fum/folic acid/dss/dha ADD TO FORMULARY 04/15/2015 prenaissance prenatal vit with calcium no.80/iron fum/folic acid/dss/dha CHANGE TIER Generics 04/15/2015 virt-select prenatal vit with calcium no.80/iron fum/folic acid/dss/dha CHANGE TIER Generics 04/15/2015 NESTABS DHA prenatal vitamins comb no.87/iron bisgly/folic acid/dha ADD TO FORMULARY Non-Formulary 04/15/2015 tri-tabs dha prenatal vitamins comb no.87/iron bisgly/folic acid/dha CHANGE TIER Generics 04/15/2015 hpr plus-mb hydrogel emol53/e.water/namgfs/nap hos/nacl/hypochlorous acid/nahypocl CHANGE TIER Preferred Brands Generics 04/15/2015 ANALPRAM ADVANCED hydrocort ac/pramox hcl/diosmin#1/aloe polysacch#1/policos CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 NEPHROCAPS QT vitamin b complex with vitamin c no.13/folic acid/vitamin d3,vitamin b complex & vitamin c no.13/folic acid/vitamin d3 CHANGE TIER 04/15/2015 cyclopentolate hcl cyclopentolate hcl CHANGE TIER Preferred Brands Not Covered 04/15/2015 hydrogel gel base no.41 CHANGE TIER Preferred Brands Not Covered 04/15/2015 racepinephrine hcl racepinephrine hcl CHANGE TIER Preferred Brands Non-Formulary Non-Formulary Generics Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 623 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 CLINDACIN ETZ clindamycin phosphate/skin cleanser comb no.19 04/15/2015 VIRASAL salicylic acid 04/15/2015 LAYOLIS FE norethindrone-ethinyl estradiol/ferrous fumarate 04/15/2015 LAMICTAL XR lamotrigine 04/15/2015 SYLATRON peginterferon alfa-2b CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SYLATRON 4PACK peginterferon alfa-2b CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SYLATRON peginterferon alfa-2b CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SYLATRON 4PACK peginterferon alfa-2b CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SYLATRON,SYL peginterferon alfa-2b ATRON 4-PACK CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 VAYACOG phosphatidyl serine/omega3 fatty acids/dha/epa CHANGE TIER Not Covered Non-Formulary 04/15/2015 VAYARIN phosphatidyl serine/omega3 fatty acids/dha/epa CHANGE TIER Not Covered Non-Formulary 04/15/2015 CICLODAN ciclopirox/urea/camphor/me nthol/eucalyptol ADD TO FORMULARY 04/15/2015 NATAFORT prenatal vitamin no.27/iron carbonyl and fumarate/folic acid CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 ZYPRAM hydrocortisone acetate/pramoxine hcl/skin cleanser no.16 CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 z-pram hydrocortisone acetate/pramoxine hcl/skin cleanser no.16 ADD TO FORMULARY Non-Formulary Generics ADD TO FORMULARY CHANGE TIER Non-Formulary Preventative Non-Formulary ADD TO FORMULARY Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 624 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PROCORT hydrocortisone acetate/pramoxine hcl 04/15/2015 SUMADAN sulfacetamide sodium/sulfur 04/15/2015 PUREFE PLUS prenatal vitamins no.4/ferrous fumarate/folic acid CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PUREFE OB PLUS prenatal vits #4/iron fumarate, polysacc complex/folic acid CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 CONZIP tramadol hcl CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 CONZIP tramadol hcl CHANGE TIER 04/15/2015 CONZIP tramadol hcl CHANGE TIER 04/15/2015 PROSCAR finasteride 04/15/2015 DUEXIS ibuprofen/famotidine CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 UDAMIN multivitamin-minerals no.28/folic acid/lycopene CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 UDAMIN SP multivitamin-minerals no.9/folic acid/saw palmetto extract,multivitamins with min no.9/folic acid/saw palmetto extract CHANGE TIER 04/15/2015 SELECT-OB + DHA prenatal vitamins combo no.33/iron ps cmplx/folic acid/dha CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 M-END MAX D dexbrompheniramine maleate/pseudoephedrine hcl/codeine phos CHANGE TIER Preferred Brands Not Covered 04/15/2015 FLUOROPLEX fluorouracil CHANGE TIER 04/15/2015 VIRT-BAL DHA prenatal vit #94/sodium feredetate-iron ps/folic acid/omega3 CHANGE TIER ADD TO FORMULARY Non-Formulary Non-Formulary Preferred Brands ADD TO FORMULARY Non-Formulary Non-Formulary Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 625 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 VIRT-BAL DHA PLUS prenatal vit #94/sodium feredetate-iron ps/folic acid/omega3 CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 POLY-VI-FLOR pediatric multivitamin no.33 with sodium fluoride CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 POLY-VI-FLOR pediatric multivitamin no.33 with sodium fluoride CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 POLY-VI-FLOR pediatric multivitamin no.33 with sodium fluoride CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur/urea ADD TO FORMULARY Generics 04/15/2015 SUMADAN sulfacetamide sodium/sulfur/skin cleanser comb no.23 ADD TO FORMULARY Non-Formulary 04/15/2015 STATUSS GREEN chlorcyclizine hcl/pseudoephedrine hcl/codeine phosphate 04/15/2015 FIRSTOMEPRAZOLE omeprazole 04/15/2015 PEDIPIROX-4 ciclopirox/nail lacquer remover, non-acet/foot deodorant#4 04/15/2015 FIRSTlansoprazole LANSOPRAZOL E 04/15/2015 DUTOPROL 04/15/2015 DUTOPROL REMOVE FROM FORMULARY Preferred Brands ADD TO FORMULARY CHANGE TIER Non-Formulary Non-Formulary Preferred Brands Non-Formulary CHANGE UM: AUTHORIZATION PA applies metoprolol succinate/hydrochlorothiazid e CHANGE TIER Non-Formulary metoprolol succinate/hydrochlorothiazid e CHANGE TIER Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 626 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PROMACTA eltrombopag olamine 04/15/2015 ULTRAVATE halobetasol propionate ADD TO FORMULARY Non-Formulary 04/15/2015 mb hydrogel emol53/e.water/namgfs/nap hos/nacl/hypochlorous acid/nahypocl ADD TO FORMULARY Generics 04/15/2015 ULTRAVATE halobetasol propionate ADD TO FORMULARY Non-Formulary 04/15/2015 OXECTA oxycodone hcl CHANGE TIER Generics Non-Formulary 04/15/2015 ZITHRANOL anthralin micronized CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SUPRENZA ODT phentermine hcl CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SUPRENZA ODT phentermine hcl REMOVE UM: AUTHORIZATION PA applies 04/15/2015 SUPRENZA ODT phentermine hcl CHANGE TIER Preferred Brands 04/15/2015 SUPRENZA ODT phentermine hcl REMOVE UM: AUTHORIZATION PA applies 04/15/2015 prena1 plus prenatal vitamins #39/iron amino acid chelate/fa combo#6/dha ADD TO FORMULARY Non-Formulary Generics 04/15/2015 AFINITOR everolimus CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 MITOSOL mitomycin CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 ZYCLARA imiquimod CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 ZOVIRAX acyclovir CHANGE TIER 04/15/2015 POLY-VI-FLOR pediatric multivitamin no.37 with sodium fluoride CHANGE TIER 04/15/2015 MOBIC meloxicam ADD TO FORMULARY Non-Formulary 04/15/2015 MOBIC meloxicam ADD TO FORMULARY Non-Formulary 04/15/2015 RETIN-A MICRO tretinoin microspheres PUMP ADD TO FORMULARY Non-Formulary Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 627 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 04/15/2015 RETIN-A MICRO tretinoin microspheres PUMP 04/15/2015 VASCULERA 04/15/2015 diosmin complex no.1 Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary CHANGE TIER Not Covered Non-Formulary BAL-CARE DHA prenatal vit 100/iron sod ESSENTIAL edta,ps complex/folic acid/omega-3 CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 FABIOR tazarotene CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 MAVIK trandolapril ADD TO FORMULARY Non-Formulary 04/15/2015 MAVIK trandolapril ADD TO FORMULARY Non-Formulary 04/15/2015 CITRANATAL B- prenatal vitamin CALM no.48/iron,carbonyl,gluconat e/folic acid/b6 ADD TO FORMULARY Non-Formulary 04/15/2015 CESINEX albumen (egg white)/tannic acid CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 QSYMIA phentermine hcl/topiramate CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 QSYMIA phentermine hcl/topiramate REMOVE UM: AUTHORIZATION PA applies 04/15/2015 NIRON KOMPLETE ferrous fumarate/iron bisgly/folic acid/vit c/vit e/vit b12 CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 QSYMIA phentermine hcl/topiramate CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 QSYMIA phentermine hcl/topiramate REMOVE UM: AUTHORIZATION PA applies 04/15/2015 QSYMIA phentermine hcl/topiramate CHANGE TIER Preferred Brands 04/15/2015 QSYMIA phentermine hcl/topiramate REMOVE UM: AUTHORIZATION PA applies 04/15/2015 QSYMIA phentermine hcl/topiramate CHANGE TIER Preferred Brands 04/15/2015 QSYMIA phentermine hcl/topiramate REMOVE UM: AUTHORIZATION PA applies Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 628 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 VP-PNV-DHA prenatal vitamins combo no.52/ferrous fumarate/fa/dha CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 TUDORZA PRESSAIR aclidinium bromide CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 RAYOS prednisone CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 RAYOS prednisone CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 RAYOS prednisone CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SUPRAX cefixime CHANGE TIER 04/15/2015 SUPRAX cefixime CHANGE TIER 04/15/2015 SUPRAX cefixime CHANGE TIER 04/15/2015 KADIAN morphine sulfate CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 KADIAN morphine sulfate CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 KADIAN morphine sulfate CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 KADIAN morphine sulfate CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 XTANDI enzalutamide CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 EXELON rivastigmine CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 VASCEPA icosapent ethyl CHANGE TIER Not Covered Non-Formulary 04/15/2015 FML fluorometholone CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 EPISIL oral mucositis and stomatitis anti-inflammatory agent comb 2 CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 TRUSOPT dorzolamide hcl 04/15/2015 SUPRAX cefixime CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 SUPRAX cefixime CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 XELJANZ tofacitinib citrate CHANGE TIER Preferred Brands Non-Formulary Non-Formulary Preferred Brands Non-Formulary Non-Formulary ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 629 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 TL-SELECT DHA prenatal vitamin no.57/iron fum/folic acid/dss/dha ADD TO FORMULARY Non-Formulary 04/15/2015 prenatal plus prenatal vits with calcium #72/iron,carbonyl/folic acid CHANGE TIER Generics 04/15/2015 ADASUVE loxapine CHANGE TIER 04/15/2015 ZYPREXA ZYDIS olanzapine ADD TO FORMULARY Non-Formulary 04/15/2015 ZYPREXA ZYDIS olanzapine ADD TO FORMULARY Non-Formulary 04/15/2015 nateglinide nateglinide CHANGE TIER Generics 04/15/2015 STARLIX nateglinide ADD TO FORMULARY Non-Formulary 04/15/2015 POMALYST pomalidomide CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 POMALYST pomalidomide CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 FOLTX cyanocobalamin/levomefolat e calcium/pyridoxine hcl ADD TO FORMULARY 04/15/2015 pnv folic acid + iron prenatal vitamins combo no.60/ferrous fumarate/folic acid CHANGE TIER 04/15/2015 LIDORX lidocaine hcl 04/15/2015 KARBINAL ER carbinoxamine maleate 04/15/2015 PRESERA emollient combination no.80 04/15/2015 EPIFIX AMNIOTIC MEMBRANE 04/15/2015 04/15/2015 Preferred Brands Non-Formulary Non-Formulary Preferred Brands ADD TO FORMULARY Generics Non-Formulary CHANGE TIER Preferred Brands Non-Formulary REMOVE UM: GENDER Female human regenerative tissue matrix CHANGE TIER Preferred Brands Non-Formulary EPIFIX AMNIOTIC MEMBRANE human regenerative tissue matrix CHANGE TIER Preferred Brands Non-Formulary SIMBRINZA brinzolamide/brimonidine tartrate CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 630 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change ADD TO FORMULARY Previous Value New Value 04/15/2015 CEREFOLIN NAC levomefolate ca/acetylcysteine/mecobala min/schiz. algal oil Non-Formulary 04/15/2015 DORYX doxycycline hyclate CHANGE TIER Generics Non-Formulary 04/15/2015 PODIAPN pyridoxal phos/methyltetrahydrofolate gluc/mecobalamin/ala CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 FOSTEUM PLUS calcium comb no.19/phosphate/genistein/d 3/citrated zinc/k2 CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 DIAMOX SEQUELS acetazolamide ADD TO FORMULARY 04/15/2015 BELVIQ lorcaserin hcl CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PROVIDA OB prenatal vits no.65/iron fumarate,polysac complex/folic acid CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 ACTIVE OB prenatal vitamins combo no.66/iron,carbonyl/folic acid/dha ADD TO FORMULARY Non-Formulary 04/15/2015 MICROZIDE hydrochlorothiazide ADD TO FORMULARY Non-Formulary 04/15/2015 prenatal 19 prenatal vitamins comb no.119/iron fumarate/folic acid/dss,prenatal vitamins comb no.115/iron fumarate/folic acid/dss ADD TO FORMULARY Generics 04/15/2015 prenatal 19 prenatal vits with calcium#118/ferrous fumarate/folic acid,prenatal vitamins comb no.115/iron fumarate/folic acid CHANGE TIER Generics 04/15/2015 MONSEL'S ferric subsulfate CHANGE TIER Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 631 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 hydrocodonehydrocodone chlorpheniramne polistirex/chlorpheniramine er polistirex CHANGE TIER Generics 04/15/2015 cyclophene cyclobenzaprine hcl CHANGE TIER 04/15/2015 ZAROXOLYN metolazone ADD TO FORMULARY Non-Formulary 04/15/2015 ZAROXOLYN metolazone ADD TO FORMULARY Non-Formulary 04/15/2015 GENADUR biotin/carbitol/equisetum xt/ethanol/hydroxypropyl chito/msm CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 HIZENTRA immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PRO-RED AC dexchlorpheniramine maleate/phenylephrine hcl/codeine CHANGE TIER Preferred Brands Not Covered 04/15/2015 PRO-RED AC dexchlorpheniramine maleate/phenylephrine hcl/codeine REMOVE UM: AUTHORIZATION PA applies 04/15/2015 VALCHLOR mechlorethamine hcl CHANGE TIER Preferred Brands 04/15/2015 OTREXUP methotrexate/pf 04/15/2015 PRILOSEC 04/15/2015 04/15/2015 Preferred Brands Non-Formulary Non-Formulary CHANGE UM: AUTHORIZATION PA applies omeprazole ADD TO FORMULARY Non-Formulary metoclopramide hcl odt metoclopramide hcl ADD TO FORMULARY Generics HALFLYTELYBISACODYL bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3350 CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 632 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 peg-prep bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3350 ADD TO FORMULARY Generics 04/15/2015 JADENU deferasirox ADD TO FORMULARY Preferred Brands 04/15/2015 JADENU deferasirox ADD UM: SPECIALTY Specialty Drug 04/15/2015 JADENU deferasirox ADD UM: AUTHORIZATION PA applies 04/15/2015 JADENU deferasirox ADD TO FORMULARY Preferred Brands 04/15/2015 JADENU deferasirox ADD UM: SPECIALTY Specialty Drug 04/15/2015 JADENU deferasirox ADD UM: AUTHORIZATION PA applies 04/15/2015 EXJADE,JADEN deferasirox U CHANGE TIER Preferred Brands 04/15/2015 EXJADE,JADEN deferasirox U CHANGE UM: SPECIALTY Specialty Drug 04/15/2015 EXJADE,JADEN deferasirox U ADD UM: AUTHORIZATION PA applies 04/15/2015 PROAIR RESPICLICK albuterol sulfate ADD TO FORMULARY Non-Formulary 04/15/2015 SAXENDA liraglutide ADD TO FORMULARY Non-Formulary 04/15/2015 PHENYLADE GMP nut. tx for pku with iron #57 ADD TO FORMULARY Non-Formulary 04/15/2015 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur/avobenzone/o ctinoxate/octyl sal ADD TO FORMULARY Generics 04/15/2015 ketone,ketostix urine acetone test,strips reagent,diascree n 1k reagent,ketone care,chemstrip k,ketocare CHANGE TIER Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 633 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 04/15/2015 ketone care urine acetone test,strips 04/15/2015 levofloxacin levofloxacin 04/15/2015 04/15/2015 Type of Change Previous Value New Value REMOVE UM: GENDER CHANGE TIER Non-Formulary diascreen urine multiple test 2gp,diascreen strips,urine multiple test 4ph,diascreen 1b reagent,diascree n 4nl reagent,chekstix,multistix 10 sg,multistix 9,multistix 9 sg,multistix 8 sg,multistix 7,uristix 4,multistix,labstix reagent,hemacombistix,combist ix reagent,uristix reagent,multistix 5,chemstrip 9,chemstrip 10 with sg,chemstrip 7,chemstrip 50b,chemstrip 2 gp,chemstrip CHANGE TIER Non-Formulary keto-diastix urine glucose-acet test reagent,diascree strip,urine gluc-acet n 10,diascreen 3 comb.tst,strip reagent,diascree n 5,diascreen 6,diascreen 7,diascreen 8,diascreen 9,diascreen 2gk reagent,diascree n 4obl,chemstrip ugk CHANGE TIER Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 634 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 LUZU luliconazole CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 TL-ICARE multivitamin-minerals no.43/lutein/omega3/dha/epa CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PROTHELIAL sucralfate malate, polymerized CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PROTHELIAL sucralfate malate, polymerized CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PROTHELIAL sucralfate malate, polymerized CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 prothelial sucralfate malate, polymerized CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 GRASTEK allergenic extract,grass pollen-timothy,standard CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 GRASTEK allergenic extract,grass pollen-timothy,standard ADD UM: SPECIALTY 04/15/2015 ORENITRAM ER treprostinil diolamine CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 ORENITRAM ER treprostinil diolamine CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 ORENITRAM ER treprostinil diolamine CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 ORENITRAM ER treprostinil diolamine CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PRODRIN isometheptene mucate/caffeine/acetaminop hen 04/15/2015 ULTRASAL-ER salicylic acid CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 VELPHORO sucroferric oxyhydroxide CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 GLYTACTIN RTD nutritional therapy for pku 10 PE with iron no.41 CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 HETLIOZ CHANGE TIER Preferred Brands Non-Formulary tasimelteon Specialty Drug ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 635 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 RHEUMATE methyltetrahydrofolate gluc/mecobalamin/herbal no.236 CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 NICADAN niacinamide/vit b6/vit c/fa/copper/mg cit/zn gluc/alip acid CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 VINATE DHA RF prenatal no.64/iron fum/lmefolate ca/algal oil/soy lecithin CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PROSOURCE TF amino acids/protein hydrolysate/whey protein isolate CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 AVEED REMOVE UM: AUTHORIZATION PA applies 04/15/2015 GLYTACTIN RTD nutritional therapy for pku 15 PE with iron no.41 CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 DERMANIC niacin no.1/fa/b12/iron/acyst zn/chrom poly/inos niac/a-cys CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 GLUTASOLVE glutamine CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 NEOCATE SPLASH nutritional therapy for impaired digestive function CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 XARTEMIS XR oxycodone hcl/acetaminophen CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PLEXION sulfacetamide sodium/sulfur CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur ADD TO FORMULARY 04/15/2015 PLEXION sulfacetamide sodium/sulfur CHANGE TIER testosterone undecanoate Generics Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 636 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur ADD TO FORMULARY Generics 04/15/2015 PLEXION sulfacetamide sodium/sulfur CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 PLEXION sulfacetamide sodium/sulfur CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 sodium sulfacetamidesulfur sulfacetamide sodium/sulfur ADD TO FORMULARY 04/15/2015 VP CH ULTRA prenatal vit no.34/iron carb,fum/folic acid/docusate/dha 04/15/2015 BYDUREON PEN 04/15/2015 Generics CHANGE TIER Preferred Brands Non-Formulary exenatide microspheres ADD TO FORMULARY Non-Formulary Preferred Brands BYDUREON exenatide microspheres ADD TO FORMULARY Non-Formulary Preferred Brands 04/15/2015 RAGWITEK allergenic extract-weed pollen-short ragweed CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 endoform extracellular matrix (ecm), ovine derived fenestrated CHANGE TIER Preferred Brands Generics 04/15/2015 endoform extracellular matrix (ecm), ovine derived fenestrated CHANGE TIER Preferred Brands Generics 04/15/2015 endoform extracellular matrix (ecm), ovine derived CHANGE TIER Preferred Brands Generics 04/15/2015 endoform extracellular matrix (ecm), ovine derived CHANGE TIER Preferred Brands Generics 04/15/2015 ZYKADIA ceritinib CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 VITAMEDMD REDICHEW RX prenatal vitamins combination no.42/folic acid 04/15/2015 VITAFOL NANO prenatal vitamins comb no.75/ferrous fumarate/folate comb #1 ADD TO FORMULARY Non-Formulary ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 637 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 TOPAMAX topiramate ADD TO FORMULARY Non-Formulary 04/15/2015 TOPAMAX topiramate ADD TO FORMULARY Non-Formulary 04/15/2015 TOPAMAX topiramate ADD TO FORMULARY Non-Formulary 04/15/2015 TOPAMAX topiramate ADD TO FORMULARY Non-Formulary 04/15/2015 THERAMINE PLUS choline bitartrate/aa no.10/gaba/herb #129/protein/soy lecit ADD TO FORMULARY Non-Formulary 04/15/2015 FOLET ONE prenatal vit no.80/iron carb,bisgl/methylfolate gluc/dss/dha ADD UM: GENDER Female 04/15/2015 INVOKAMET canagliflozin/metformin hcl CHANGE TIER Preferred Brands Non-Formulary 04/15/2015 ACTICLATE doxycycline hyclate CHANGE TIER Generics Non-Formulary 04/15/2015 ACTICLATE doxycycline hyclate CHANGE TIER Generics Non-Formulary 04/15/2015 CAMINO PRO 15 nutritional therapy for msud PE MSUD with iron 04/15/2015 CONTRAVE naltrexone hcl/bupropion hcl 04/15/2015 OXYCONTIN 04/15/2015 ADD TO FORMULARY Non-Formulary REMOVE UM: AUTHORIZATION PA applies oxycodone hcl CHANGE TIER Generics Non-Formulary OXYCONTIN oxycodone hcl CHANGE TIER Generics Non-Formulary 04/15/2015 OXYCONTIN oxycodone hcl CHANGE TIER Generics Non-Formulary 04/15/2015 OXYCONTIN oxycodone hcl CHANGE TIER Generics Non-Formulary 04/15/2015 PROAIR RESPICLICK albuterol sulfate ADD TO FORMULARY Non-Formulary Preferred Brands 04/15/2015 prednicarbate prednicarbate CHANGE TIER Generics 04/15/2015 prednicarbate prednicarbate CHANGE TIER Generics 04/15/2015 colchicine colchicine ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 638 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 ALEVICYN hypochlorous acid/sod chlor/sod sulfate/sod phosphate,mono ADD TO FORMULARY Non-Formulary 04/15/2015 FOLET DHA prenatal vit no.86/iron carb,bisgl/methylfolate gluc/dss/dha ADD UM: GENDER Female 04/15/2015 EMBEDA morphine sulfate/naltrexone hcl ADD TO FORMULARY Non-Formulary 04/15/2015 IBRANCE palbociclib CHANGE TIER 04/15/2015 FELBATOL felbamate ADD TO FORMULARY 04/15/2015 felbamate felbamate ADD TO FORMULARY 04/15/2015 HYDREA hydroxyurea ADD TO FORMULARY Non-Formulary 04/15/2015 LEVATOL penbutolol sulfate CHANGE TIER Preferred Brands 04/15/2015 BETAPACE AF sotalol hcl ADD TO FORMULARY Non-Formulary 04/15/2015 BETAPACE sotalol hcl ADD TO FORMULARY Non-Formulary 04/15/2015 BETAPACE sotalol hcl ADD TO FORMULARY Non-Formulary 04/15/2015 BETAPACE AF sotalol hcl ADD TO FORMULARY Non-Formulary 04/15/2015 BETAPACE sotalol hcl ADD TO FORMULARY Non-Formulary 04/15/2015 BETAPACE AF sotalol hcl ADD TO FORMULARY Non-Formulary 04/15/2015 BETAPACE sotalol hcl ADD TO FORMULARY Non-Formulary 04/15/2015 MEGACE megestrol acetate ADD TO FORMULARY Non-Formulary 04/15/2015 dynacin minocycline hcl ADD TO FORMULARY Generics 04/15/2015 dynacin minocycline hcl ADD TO FORMULARY Generics 04/15/2015 MONODOX doxycycline monohydrate ADD TO FORMULARY Non-Formulary 04/15/2015 MONODOX doxycycline monohydrate ADD TO FORMULARY Non-Formulary 04/15/2015 ANCOBON flucytosine ADD TO FORMULARY Non-Formulary 04/15/2015 ANCOBON flucytosine ADD TO FORMULARY Non-Formulary Preferred Brands Non-Formulary Non-Formulary Non-Formulary Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 639 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/15/2015 METROLOTION metronidazole ADD TO FORMULARY Non-Formulary 04/15/2015 METROCREAM metronidazole ADD TO FORMULARY Non-Formulary 04/15/2015 VOLTAREN diclofenac sodium CHANGE TIER Non-Formulary 04/15/2015 ELOCON mometasone furoate ADD TO FORMULARY Non-Formulary 04/15/2015 ELOCON mometasone furoate ADD TO FORMULARY Non-Formulary 04/15/2015 ropivacaine hcl ropivacaine hcl/pf CHANGE TIER Generics 04/15/2015 PRISTIQ ER desvenlafaxine succinate ADD TO FORMULARY Preferred Brands 04/16/2015 SAXENDA liraglutide ADD UM: CUSTOM Benefit Rider May Be Required 04/16/2016 active injection kit dexamethasone sodium d phosphate/pf REMOVE FROM FORMULARY Non-Formulary 04/16/2016 b-12 kit cyanocobalamin (vitamin b12) REMOVE FROM FORMULARY Non-Formulary 04/16/2016 hydrocortisone hydrocortisone REMOVE FROM FORMULARY Non-Formulary 04/16/2016 hydrocortisone hydrocortisone REMOVE FROM FORMULARY Non-Formulary 04/16/2016 hydrocortisone hydrocortisone REMOVE FROM FORMULARY Non-Formulary 04/16/2016 hydrocortisone hydrocortisone REMOVE FROM FORMULARY Non-Formulary 04/16/2016 hydrocortisone hydrocortisone REMOVE FROM FORMULARY Non-Formulary 04/16/2016 ulticare pen needle pen needle, diabetic ADD TO FORMULARY Generics 04/16/2016 ulticare pen needle pen needle, diabetic ADD TO FORMULARY Generics 04/16/2016 ulticare pen needle pen needle, diabetic ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 640 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/16/2016 ulticare insulin syringe syringe with needle,insulin 0.3 ml (half unit mark) ADD TO FORMULARY Generics 04/16/2016 push button safety lancets lancets ADD TO FORMULARY Generics 04/16/2016 pen needle pen needle, diabetic ADD TO FORMULARY Generics 04/16/2016 pen needle pen needle, diabetic ADD TO FORMULARY Generics 04/16/2016 pen needle pen needle, diabetic ADD TO FORMULARY Generics 04/16/2016 pen needle pen needle, diabetic ADD TO FORMULARY Generics 04/16/2016 ORAL RELIEF LOZENGES saliva stimulant combination no.6 REMOVE FROM FORMULARY Non-Formulary 04/16/2016 NEOKE ALCAR acetylcarnitine REMOVE FROM FORMULARY Non-Formulary 04/16/2016 antifungal nail pen undecylenic acid REMOVE FROM FORMULARY Non-Formulary 04/16/2016 medicated foot menthol REMOVE FROM FORMULARY Non-Formulary 04/16/2016 daytime-nighttime dextromethorphan cold-flu hbr/phenylephrine/acetamin ophen/doxylamine REMOVE FROM FORMULARY Non-Formulary 04/16/2016 daytime severe cold-flu REMOVE FROM FORMULARY Non-Formulary 04/16/2016 smooth calcium carbonate dissolving antacid REMOVE FROM FORMULARY Non-Formulary 04/16/2016 fiber therapy REMOVE FROM FORMULARY Non-Formulary 04/16/2016 smooth calcium carbonate dissolving antacid REMOVE FROM FORMULARY Non-Formulary 04/16/2016 hair regrowth treatment REMOVE FROM FORMULARY Non-Formulary phenylephrine hcl/dextromethorphan hbr/acetaminophen/guaifen calcium polycarbophil minoxidil BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 641 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/16/2016 fast mucus rlf congest-cough guaifenesin/dextromethorph an hbr/phenylephrine REMOVE FROM FORMULARY Non-Formulary 04/16/2016 biotin biotin REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever pm acetaminophen/diphenhydra mine hcl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever pm acetaminophen/diphenhydra mine hcl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/16/2016 naproxen sodium naproxen sodium REMOVE FROM FORMULARY Non-Formulary 04/16/2016 naproxen sodium naproxen sodium REMOVE FROM FORMULARY Non-Formulary 04/16/2016 cold-allergy chlorpheniramine maleate/phenylephrine hcl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 mucus relief pe guaifenesin/phenylephrine hcl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 sinus-allergy chlorpheniramine maleate/phenylephrine hcl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/16/2016 daytime cold-flu relief plus dextromethorphan hbr/phenylephrine hcl/acetaminophen REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 642 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/16/2016 cold-flu relief plus dextromethorphan day-night hbr/phenylephrine/acetamin ophen/doxylamine REMOVE FROM FORMULARY Non-Formulary 04/16/2016 laxative peg 3350 polyethylene glycol 3350 REMOVE FROM FORMULARY Non-Formulary 04/16/2016 laxative peg 3350 polyethylene glycol 3350 REMOVE FROM FORMULARY Non-Formulary 04/16/2016 airshield multivit-min/vit c/ascorb na/glutamine/lysin hcl/herb no.124 REMOVE FROM FORMULARY Non-Formulary 04/16/2016 mucus relief d guaifenesin/pseudoephedrin e hcl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 mucus relief d guaifenesin/pseudoephedrin e hcl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever pm acetaminophen/diphenhydra mine hcl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever pm acetaminophen/diphenhydra mine hcl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/16/2016 naproxen sodium naproxen sodium REMOVE FROM FORMULARY Non-Formulary 04/16/2016 naproxen sodium naproxen sodium REMOVE FROM FORMULARY Non-Formulary 04/16/2016 cold-allergy REMOVE FROM FORMULARY Non-Formulary chlorpheniramine maleate/phenylephrine hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 643 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/16/2016 mucus relief pe guaifenesin/phenylephrine hcl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 sinus-allergy chlorpheniramine maleate/phenylephrine hcl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 pain reliever acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/16/2016 daytime cold-flu relief plus dextromethorphan hbr/phenylephrine hcl/acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/16/2016 cold-flu relief plus dextromethorphan day-night hbr/phenylephrine/acetamin ophen/doxylamine REMOVE FROM FORMULARY Non-Formulary 04/16/2016 laxative peg 3350 polyethylene glycol 3350 REMOVE FROM FORMULARY Non-Formulary 04/16/2016 laxative peg 3350 polyethylene glycol 3350 REMOVE FROM FORMULARY Non-Formulary 04/16/2016 psyllium psyllium husk REMOVE FROM FORMULARY Non-Formulary 04/16/2016 adults 50+ multivitamin multivitamin with minerals/folic acid/lycopene/lutein REMOVE FROM FORMULARY Non-Formulary 04/16/2016 ACZONE dapsone ADD TO FORMULARY Non-Formulary 04/16/2016 ACZONE dapsone ADD TO FORMULARY Non-Formulary 04/16/2016 CLADOSPORIU allergenic extractM cladosporium CLADOSPORIOI cladosporioides DES REMOVE FROM FORMULARY Non-Formulary 04/16/2016 ACACIA REMOVE FROM FORMULARY Non-Formulary allergenic extract-tree pollen-acacia BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 644 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/16/2016 VITAFOL GUMMIES prenatal vit no.112/iron/fa/omega3/dha/epa/other omega-3s ADD TO FORMULARY Non-Formulary 04/16/2016 OTREXUP methotrexate/pf ADD TO FORMULARY Non-Formulary 04/16/2016 PROMACTA eltrombopag olamine 04/16/2016 OTREXUP methotrexate/pf ADD TO FORMULARY Non-Formulary 04/16/2016 OTREXUP methotrexate/pf ADD TO FORMULARY Non-Formulary 04/16/2016 OTREXUP methotrexate/pf ADD TO FORMULARY Non-Formulary 04/16/2016 WILATE antihemophilic factor, human/von willebrand factor,human REMOVE FROM FORMULARY Non-Formulary 04/16/2016 WILATE antihemophilic factor, human/von willebrand factor,human REMOVE FROM FORMULARY Non-Formulary 04/16/2016 VENCLEXTA venetoclax ADD TO FORMULARY Non-Formulary 04/16/2016 VENCLEXTA venetoclax ADD TO FORMULARY Non-Formulary 04/16/2016 VENCLEXTA venetoclax ADD TO FORMULARY Non-Formulary 04/16/2016 VENCLEXTA venetoclax ADD TO FORMULARY Non-Formulary 04/16/2016 VENCLEXTA venetoclax ADD TO FORMULARY Non-Formulary 04/16/2016 VENCLEXTA venetoclax ADD TO FORMULARY Non-Formulary 04/16/2016 VENCLEXTA STARTING PACK venetoclax ADD TO FORMULARY Non-Formulary 04/16/2016 CATTLE EPITHELIUM allergenic extract-cattle epithelium REMOVE FROM FORMULARY Non-Formulary 04/16/2016 GERMAN COCKROACH allergenic extract-german cockroach REMOVE FROM FORMULARY Non-Formulary 04/16/2016 ALDER allergenic extract-tree pollen-alder white REMOVE FROM FORMULARY Non-Formulary CHANGE TIER Not Covered Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 645 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/16/2016 COCKLEBUR allergenic extract-weed pollen-cocklebur REMOVE FROM FORMULARY Non-Formulary 04/16/2016 ROUGH MARSH allergenic extract-weed ELDER pollen-true marsh elder REMOVE FROM FORMULARY Non-Formulary 04/16/2016 WESTERN JUNIPER allergenic extract-tree pollen-juniper, western REMOVE FROM FORMULARY Non-Formulary 04/16/2016 QUEEN PALM allergenic extract-tree pollen-palm, queen REMOVE FROM FORMULARY Non-Formulary 04/16/2016 XRYLIX diclofenac sodium/kinesiology tape REMOVE FROM FORMULARY Non-Formulary 04/16/2016 PAIN RELIEF COLLECTION naproxen/capsaicin/menthol/ methyl salicylate REMOVE FROM FORMULARY Non-Formulary 04/16/2016 IMPAVIDO miltefosine ADD TO FORMULARY Non-Formulary 04/16/2016 CALIFORNIA PEPPER TREE allergenic extract-tree pollen-pepper tree, california REMOVE FROM FORMULARY Non-Formulary 04/16/2016 vancomycin hcl0.9% nacl vancomycin in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary 04/16/2016 hydromorphbupivac-0.9% nacl hydromorphone hcl/bupivacaine hcl in 0.9% sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 04/16/2016 bupivacaine hcl0.9% nacl bupivacaine hcl in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 04/16/2016 sodium sodium phosphate in 0.9 % phosphate-0.9% sodium chloride nacl REMOVE FROM FORMULARY Non-Formulary 04/16/2016 progesterone micronized progesterone,micronized ADD TO FORMULARY Not Covered 04/20/2015 gavilyte-h and bisacodyl bisacodyl/sodium chlor/sodium bicarb/potassium chl/peg 3350 REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 646 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/20/2015 levonorgestreleth estradiol levonorgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 04/20/2015 levonorgestreleth estradiol levonorgestrel-ethinyl estradiol ADD TO FORMULARY Preventative 04/20/2015 no-stick glucose urine glucose test strip REMOVE FROM FORMULARY Non-Formulary 04/20/2015 insulin syringe syringe with needle,insulin,0.3 ml ADD TO FORMULARY Generics 04/20/2015 insulin syringe syringe with needle,insulin,0.5 ml ADD TO FORMULARY Generics 04/20/2015 insulin syringe syringe with needle,disposable,insulin 1 ml ADD TO FORMULARY Generics 04/20/2015 insulin syringe syringe with needle,insulin,0.3 ml ADD TO FORMULARY Generics 04/20/2015 insulin syringe syringe with needle,insulin,0.5 ml ADD TO FORMULARY Generics 04/20/2015 insulin syringe syringe with needle,disposable,insulin 1 ml ADD TO FORMULARY Generics 04/20/2015 PEDIALYTE sodium/potassium/chloride/d extrose REMOVE FROM FORMULARY Non-Formulary 04/20/2015 PEDIALYTE sodium/potassium/chloride/d extrose REMOVE FROM FORMULARY Non-Formulary 04/20/2015 SUPER DAILY D3 cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 04/20/2015 ARANESP darbepoetin alfa in polysorbate 80 ADD TO FORMULARY Preferred Brands 04/20/2015 ARANESP darbepoetin alfa in polysorbate 80 ADD TO FORMULARY Preferred Brands 04/20/2015 klor-con m10 potassium chloride ADD TO FORMULARY Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 647 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/20/2015 stomach relief bismuth subsalicylate REMOVE FROM FORMULARY Non-Formulary 04/20/2015 lubricant eye carboxymethylcellulose sodium/glycerin/pf REMOVE FROM FORMULARY Non-Formulary 04/20/2015 lubricant eye carboxymethylcellulose sodium/glycerin REMOVE FROM FORMULARY Non-Formulary 04/20/2015 despec dm guaifenesin/dextromethorph an hbr/phenylephrine REMOVE FROM FORMULARY Non-Formulary 04/20/2015 ARANESP darbepoetin alfa in polysorbate 80 ADD UM: AUTHORIZATION PA applies 04/20/2015 ARANESP darbepoetin alfa in polysorbate 80 ADD UM: SPECIALTY Specialty Drug 04/20/2015 SANDOSTATIN LAR DEPOT octreotide acetate, microspheres ADD TO FORMULARY Non-Formulary 04/20/2015 SANDOSTATIN LAR DEPOT octreotide acetate, microspheres ADD UM: SPECIALTY Specialty Drug 04/20/2015 SANDOSTATIN LAR DEPOT octreotide acetate, microspheres ADD UM: AUTHORIZATION PA applies 04/20/2015 NAMZARIC memantine hcl/donepezil hcl ADD TO FORMULARY Non-Formulary 04/20/2015 klor-con m10 potassium chloride CHANGE TIER Non-Formulary 04/22/2016 ORALAIR grass pollen-orchard/sweet vernal/rye/kentucky/timothy, std. ADD TO FORMULARY Non-Formulary 04/22/2016 COLY-MYCIN S neomycin sulfate/colistin sulfate/hydrocort ac/thonzon brom ADD TO FORMULARY Non-Formulary 04/22/2016 flurandrenolide flurandrenolide ADD TO FORMULARY Generics 04/22/2016 hydromorphone hcl-0.9% nacl hydromorphone hcl in 0.9 % sodium chloride REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 648 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/22/2016 fentanyl citrate0.9% nacl fentanyl citrate in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 04/22/2016 restizan emollient combination no.60 REMOVE FROM FORMULARY Non-Formulary 04/22/2016 relief knee stocking compression stocking, knee high, regular length, medium REMOVE FROM FORMULARY Non-Formulary 04/22/2016 inspirachamber inhaler, assist devices REMOVE FROM FORMULARY Non-Formulary 04/22/2016 notraum foam bandage REMOVE FROM FORMULARY Non-Formulary 04/22/2016 notraum foam bandage REMOVE FROM FORMULARY Non-Formulary 04/22/2016 notraum extra foam bandage REMOVE FROM FORMULARY Non-Formulary 04/22/2016 notraum extra foam bandage REMOVE FROM FORMULARY Non-Formulary 04/22/2016 t:30 infusion set infusion set for insulin pump REMOVE FROM FORMULARY Non-Formulary 04/22/2016 CENTRUM multivitamin with MULTIGUMMIES minerals/folic acid REMOVE FROM FORMULARY Non-Formulary 04/22/2016 OCUVITE EYE HEALTH vitamin c/vitamin e acetate/zinc citrate/lutein/zeaxanthin REMOVE FROM FORMULARY Non-Formulary 04/22/2016 RHINASE polyethylene gly/potassium chl/propylene gly/sodium chloride REMOVE FROM FORMULARY Non-Formulary 04/22/2016 fast mucus relief phenylephrine severe cold hcl/dextromethorphan hbr/acetaminophen/guaifen REMOVE FROM FORMULARY Non-Formulary 04/22/2016 nighttime sleep aid REMOVE FROM FORMULARY Non-Formulary diphenhydramine hcl BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 649 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/22/2016 nighttime severe dextromethorphan cold-flu hbr/phenylephrine/acetamin ophen/doxylamine REMOVE FROM FORMULARY Non-Formulary 04/22/2016 daytime-cold nighttime-cld-flu diphenhydramine/phenyleph rin/dextromethorph/acetamin ophen/gg REMOVE FROM FORMULARY Non-Formulary 04/22/2016 budesonide budesonide REMOVE FROM FORMULARY Non-Formulary 04/22/2016 mucinex fast-max dextromethorphan congest-head hbr/phenylephrine hcl/acetaminophen REMOVE FROM FORMULARY Non-Formulary 04/22/2016 MIXED FEATHERS allergenic extract-mixed feathers, chicken, duck, goose REMOVE FROM FORMULARY Non-Formulary 04/22/2016 WHITE PINE allergenic extract-tree pollen-pine, white REMOVE FROM FORMULARY Non-Formulary 04/22/2016 PRIVET allergenic extract-tree pollen-privet REMOVE FROM FORMULARY Non-Formulary 04/22/2016 RENACIDIN citric acid/gluconolactone/magnes ium carbonate REMOVE FROM FORMULARY Non-Formulary 04/22/2016 ONZETRA XSAIL sumatriptan succinate ADD TO FORMULARY Non-Formulary 04/22/2016 SMARTRX GABA-V KIT gabapentin/capsaicin/methyl salicylate/menthol REMOVE FROM FORMULARY Non-Formulary 04/22/2016 hydromorphone hcl hydromorphone hcl REMOVE FROM FORMULARY Non-Formulary 04/23/2015 BETASERON interferon beta-1b ADD TO FORMULARY Preferred Brands 04/23/2015 COPAXONE glatiramer acetate REMOVE UM: AUTHORIZATION 04/23/2015 REBIF REBIDOSE interferon beta-1a/albumin human PA applies ADD UM: QUANTITY 1 / 180 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 650 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/23/2015 REBIF REBIDOSE interferon beta-1a/albumin human ADD UM: QUANTITY 12 / 28 days 04/23/2015 REBIF REBIDOSE interferon beta-1a/albumin human ADD UM: QUANTITY 12 / 28 days 04/23/2015 PLEGRIDY peginterferon beta-1a PEN,PLEGRIDY 04/23/2015 PLEGRIDY peginterferon beta-1a ADD UM: QUANTITY 1 / 180 days 04/23/2015 PLEGRIDY PEN peginterferon beta-1a ADD UM: QUANTITY 1 / 180 days 04/23/2015 PLEGRIDY PEN peginterferon beta-1a ADD UM: QUANTITY 2 / 28 days 04/23/2015 PLEGRIDY peginterferon beta-1a ADD UM: QUANTITY 2 / 28 days 04/28/2015 naratriptan hcl,naratriptan naratriptan hcl CHANGE TIER Generics 04/28/2015 naratriptan hcl,naratriptan naratriptan hcl CHANGE TIER Generics 04/29/2016 ibuprofen lysine ibuprofen lysine/pf REMOVE FROM FORMULARY Non-Formulary 04/29/2016 ibuprofen lysine ibuprofen lysine/pf REMOVE FROM FORMULARY Non-Formulary 04/29/2016 verapamil hcl verapamil hcl REMOVE FROM FORMULARY Non-Formulary 04/29/2016 fentanyl citrate0.9% nacl fentanyl citrate in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary 04/29/2016 morphine sulfate- morphine sulfate in 0.9 % 0.9% nacl sodium chloride REMOVE FROM FORMULARY Non-Formulary 04/29/2016 roweepra levetiracetam ADD TO FORMULARY Generics 04/29/2016 procto-med hc hydrocortisone ADD TO FORMULARY Generics 04/29/2016 midazolam-0.9% midazolam hcl in 0.9 % nacl sodium chloride REMOVE FROM FORMULARY Non-Formulary ADD TO FORMULARY Non-Formulary Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 651 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 04/29/2016 promethazine hcl-0.9% nacl 04/29/2016 Generic Name promethazine hcl in 0.9 % sodium chloride Type of Change Previous Value New Value REMOVE FROM FORMULARY Non-Formulary fluticasone fluticasone propionate, propionate micro micronized REMOVE FROM FORMULARY Non-Formulary 04/29/2016 fluticasone fluticasone propionate, propionate micro micronized REMOVE FROM FORMULARY Non-Formulary 04/29/2016 fluticasone fluticasone propionate, propionate micro micronized REMOVE FROM FORMULARY Non-Formulary 04/29/2016 ulticare insulin syringe syringe with needle,insulin,0.3 ml REMOVE FROM FORMULARY Non-Formulary 04/29/2016 ulticare insulin syringe syringe with needle,insulin,0.5 ml REMOVE FROM FORMULARY Non-Formulary 04/29/2016 ulticare insulin syringe syringe with needle,disposable,insulin 1 ml REMOVE FROM FORMULARY Non-Formulary 04/29/2016 ulticare insulin syringe syringe with needle,insulin,0.5 ml REMOVE FROM FORMULARY Non-Formulary 04/29/2016 ulticare insulin syringe syringe with needle,insulin,0.3 ml REMOVE FROM FORMULARY Non-Formulary 04/29/2016 ulticare insulin syringe syringe with needle,disposable,insulin 1 ml REMOVE FROM FORMULARY Non-Formulary 04/29/2016 huggies little snugglers diaper/brief,infant-toddler, disposable REMOVE FROM FORMULARY Non-Formulary 04/29/2016 eakin cohesive stomawrap ostomy barrier seal REMOVE FROM FORMULARY Non-Formulary 04/29/2016 sure comfort insulin syringe syringe with needle,insulin,0.5 ml REMOVE FROM FORMULARY Non-Formulary 04/29/2016 sure comfort insulin syringe syringe with needle,insulin,0.3 ml REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 652 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/29/2016 sure comfort insulin syringe syringe with needle,disposable,insulin 1 ml REMOVE FROM FORMULARY Non-Formulary 04/29/2016 OPTIMAL D3 M cholecalciferol (vitamin d3) REMOVE FROM FORMULARY Non-Formulary 04/29/2016 CALCOR calc/magnesium/k bicarb/boron hvp chelt/lys/threo/silicon ox REMOVE FROM FORMULARY Non-Formulary 04/29/2016 genteal tears dextran 70/hypromellose REMOVE FROM FORMULARY Non-Formulary 04/29/2016 digestive relief bismuth subsalicylate REMOVE FROM FORMULARY Non-Formulary 04/29/2016 digestive relief bismuth subsalicylate REMOVE FROM FORMULARY Non-Formulary 04/29/2016 eye health adult 50+ antioxidant multivit no.11/omega3/dha/epa/lutein/zeaxanthin REMOVE FROM FORMULARY Non-Formulary 04/29/2016 headache relief aspirin/acetaminophen/caffei ne REMOVE FROM FORMULARY Non-Formulary 04/29/2016 acid reducer ranitidine hcl REMOVE FROM FORMULARY Non-Formulary 04/29/2016 wart remover salicylic acid REMOVE FROM FORMULARY Non-Formulary 04/29/2016 fluticasone propionate fluticasone propionate REMOVE FROM FORMULARY Non-Formulary 04/29/2016 fluticasone propionate fluticasone propionate REMOVE FROM FORMULARY Non-Formulary 04/29/2016 react levonorgestrel REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 653 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/29/2016 xyzbac multivitamin combination no.34/folic acid/nadh/ubiquinone REMOVE FROM FORMULARY Non-Formulary 04/29/2016 sulfzix sulfur/sodium sulfate/sodium thiosulf/methyltetrahydrofola te REMOVE FROM FORMULARY Non-Formulary 04/29/2016 ULTRAVATE halobetasol propionate ADD TO FORMULARY Non-Formulary 04/29/2016 ORALAIR grass pollen-orchard/sweet vernal/rye/kentucky/timothy, std. ADD TO FORMULARY Non-Formulary 04/29/2016 MOUSE EPITHELIUM allergenic extract-mouse epithelium REMOVE FROM FORMULARY Non-Formulary 04/29/2016 RABBIT EPITHELIUM allergenic extract-rabbit epithelium REMOVE FROM FORMULARY Non-Formulary 04/29/2016 RABBIT EPITHELIUM allergenic extract-rabbit epithelium REMOVE FROM FORMULARY Non-Formulary 04/29/2016 FIRE ANT allergenic extract-fire ant REMOVE FROM FORMULARY Non-Formulary 04/29/2016 CURVULARIA allergenic extract-curvularia REMOVE FROM FORMULARY Non-Formulary 04/29/2016 WHITE BIRCH allergenic extract-tree pollen-white birch REMOVE FROM FORMULARY Non-Formulary 04/29/2016 FIRE ANT allergenic extract-fire ant REMOVE FROM FORMULARY Non-Formulary 04/29/2016 CARELESSWEE allergenic extract-weed D pollen-carelessweed REMOVE FROM FORMULARY Non-Formulary 04/29/2016 ARIZONA CYPRESS REMOVE FROM FORMULARY Non-Formulary 04/29/2016 BALD CYPRESS allergenic extract-tree pollen-bald cypress REMOVE FROM FORMULARY Non-Formulary allergenic extract-tree pollen-arizona cypress BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 654 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value allergenic extract-cockroach (american and german) REMOVE FROM FORMULARY Non-Formulary 04/29/2016 MIXED COCKROACH 04/29/2016 SHEEP SORREL allergenic extract-weed pollen-sheep sorrel REMOVE FROM FORMULARY Non-Formulary 04/29/2016 YELLOW DOCK allergenic extract-weed pollen-yellow dock REMOVE FROM FORMULARY Non-Formulary 04/29/2016 CEDAR ELM allergenic extract-tree pollen-elm, cedar REMOVE FROM FORMULARY Non-Formulary 04/29/2016 KOCHIA allergenic extract-weed pollen-kochia (firebush) REMOVE FROM FORMULARY Non-Formulary 04/29/2016 RED MAPLE allergenic extract-tree pollen-red maple REMOVE FROM FORMULARY Non-Formulary 04/29/2016 RED MULBERRY allergenic extract-tree pollen-mulberry, red REMOVE FROM FORMULARY Non-Formulary 04/29/2016 RED OAK allergenic extract-tree pollen-red oak REMOVE FROM FORMULARY Non-Formulary 04/29/2016 OLIVE TREE allergenic extract-tree pollen-olive REMOVE FROM FORMULARY Non-Formulary 04/29/2016 AUSTRALIAN PINE allergenic extract-tree pollen-australian pine REMOVE FROM FORMULARY Non-Formulary 04/29/2016 BLACK WILLOW allergenic extract-tree pollen-black willow REMOVE FROM FORMULARY Non-Formulary 04/29/2016 SHORT RAGWEED allergenic extract-weed pollen-short ragweed REMOVE FROM FORMULARY Non-Formulary 04/29/2016 CABOMETYX cabozantinib s-malate ADD TO FORMULARY Non-Formulary 04/29/2016 CABOMETYX cabozantinib s-malate ADD TO FORMULARY Non-Formulary 04/29/2016 CABOMETYX cabozantinib s-malate ADD TO FORMULARY Non-Formulary 04/29/2016 CAPXIB celecoxib/capsaicin/menthol REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 655 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 04/29/2016 CAPXIB celecoxib/capsaicin/menthol REMOVE FROM FORMULARY Non-Formulary 04/29/2016 EPICOCCUM allergenic extract-epicoccum nigrum REMOVE FROM FORMULARY Non-Formulary 04/29/2016 amiodarone hcld5w amiodarone hcl/dextrose 5 % in water REMOVE FROM FORMULARY Non-Formulary 04/29/2016 hydromorphhydromorphone ropiva-0.9% nacl hcl/ropivacaine in 0.9 % sodium chloride/pf REMOVE FROM FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 656 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates May, 2015 Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2015 rabeprazole sodium rabeprazole sodium CHANGE TIER Generics 05/01/2015 esomeprazole magnesium esomeprazole magnesium ADD TO FORMULARY Generics 05/01/2016 imatinib mesylate imatinib mesylate CHANGE TIER Generics Not Covered 05/01/2016 imatinib mesylate imatinib mesylate CHANGE TIER Generics Not Covered 05/01/2016 imatinib mesylate imatinib mesylate REMOVE FROM FORMULARY Not Covered Non-Formulary 05/01/2016 imatinib mesylate imatinib mesylate REMOVE FROM FORMULARY Not Covered Non-Formulary 05/01/2016 imatinib mesylate imatinib mesylate REMOVE UM: SPECIALTY Specialty Drug 05/01/2016 imatinib mesylate imatinib mesylate REMOVE UM: AUTHORIZATION PA applies 05/01/2016 imatinib mesylate imatinib mesylate REMOVE UM: SPECIALTY Specialty Drug 05/01/2016 imatinib mesylate imatinib mesylate REMOVE UM: AUTHORIZATION PA applies 05/01/2016 VIBERZI eluxadoline REMOVE UM: SPECIALTY Specialty Drug 05/01/2016 KEPIVANCE palifermin ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 KEYTRUDA pembrolizumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 KRYSTEXXA pegloticase ADD UM: CUSTOM Limited Distribution Magellan Rx BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 657 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2016 KYPROLIS carfilzomib ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 LUCENTIS ranibizumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 MYOZYME,LUMI alglucosidase alfa ZYME ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 MACUGEN pegaptanib sodium ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 MACUGEN pegaptanib sodium ADD UM: SPECIALTY Specialty Drug 05/01/2016 hydroxyprogester hydroxyprogesterone one caproate caproate,makena CHANGE UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 MEKINIST trametinib dimethyl sulfoxide ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 MOZOBIL plerixafor ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 MUGARD glycerin/carbomer homopolymer type a/potassium hydroxide ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 NINLARO ixazomib citrate ADD UM: CUSTOM Limited Distribution Magellan Rx BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 658 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2016 HUMATROPE,G somatropin ENOTROPIN,NO RDITROPIN NORDIFLEX,NO RDITROPIN FLEXPRO,NORD ITROPIN,OMNIT ROPE,SEROSTI M,SAIZEN,ZORB TIVE,NUTROPIN ,NUTROPIN AQ,NUTROPIN AQ NUSPIN,TEVTROPIN,ZOMAC TON ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 ODOMZO sonidegib phosphate ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 OPDIVO nivolumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 OZURDEX dexamethasone ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 PERJETA pertuzumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 OTEZLA apremilast ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 PLEGRIDY peginterferon beta-1a PEN,PLEGRIDY ADD UM: CUSTOM Limited Distribution Magellan Rx BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 659 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value REMOVE UM: AUTHORIZATION PA applies New Value 05/01/2016 PLEGRIDY peginterferon beta-1a PEN,PLEGRIDY 05/01/2016 PRALUENT alirocumab PEN,PRALUENT SYRINGE ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 POMALYST pomalidomide ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 PROMACTA eltrombopag olamine ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 QUTENZA capsaicin/skin cleanser ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 REPATHA evolocumab SYRINGE,REPA THA SURECLICK ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 REVLIMID lenalidomide ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 RIASTAP fibrinogen ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 RITUXAN rituximab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 SIMPONI,SIMPO golimumab NI ARIA ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 SOLIRIS ADD UM: CUSTOM Limited Distribution Magellan Rx eculizumab BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 660 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2016 SOMATULINE DEPOT lanreotide acetate ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 SUPPRELIN LA histrelin acetate ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 PEGINTRON,SY peginterferon alfa-2b LATRON,SYLAT RON 4PACK,PEGINTR ON REDIPEN ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 SYLVANT siltuximab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 SYNAGIS palivizumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 TAFINLAR dabrafenib mesylate ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 TARCEVA erlotinib hcl ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 TASIGNA nilotinib hcl ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 tecfidera,dimethyl dimethyl fumarate fumarate CHANGE UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 THALOMID ADD UM: CUSTOM Limited Distribution Magellan Rx thalidomide BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 661 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2016 THYROGEN thyrotropin alfa ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 TIKOSYN dofetilide ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 TYKERB lapatinib ditosylate ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 VANTAS histrelin acetate ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 VELCADE bortezomib ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 VISUDYNE verteporfin ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 VIVITROL naltrexone microspheres ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 VOTRIENT pazopanib hcl ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 VPRIV velaglucerase alfa ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 XEOMIN incobotulinumtoxina ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 XOLAIR omalizumab ADD UM: CUSTOM Limited Distribution Magellan Rx BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 662 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/01/2016 YERVOY ipilimumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 YONDELIS trabectedin ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 ZALTRAP ziv-aflibercept ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 ZELBORAF vemurafenib ADD UM: CUSTOM Limited Distribution Magellan Rx 05/01/2016 ZYTIGA abiraterone acetate ADD UM: CUSTOM Limited Distribution Magellan Rx 05/04/2015 cefixime cefixime ADD TO FORMULARY Generics 05/04/2015 SUPRAX cefixime CHANGE TIER 05/04/2015 cefixime cefixime ADD TO FORMULARY Generics 05/04/2015 ciferex cholecalciferol (vit d3)/folic acid ADD TO FORMULARY Generics 05/04/2015 pramipexole er pramipexole di-hcl ADD TO FORMULARY Generics 05/04/2015 KENALOG triamcinolone acetonide CHANGE TIER 05/04/2015 triamcinolone acetonide triamcinolone acetonide ADD TO FORMULARY Generics 05/04/2015 aripiprazole aripiprazole ADD TO FORMULARY Generics 05/04/2015 ABILIFY aripiprazole CHANGE TIER Non-Formulary 05/04/2015 aripiprazole aripiprazole ADD TO FORMULARY Generics 05/04/2015 ABILIFY aripiprazole CHANGE TIER Preferred Brands Non-Formulary 05/04/2015 ABILIFY aripiprazole CHANGE TIER Preferred Brands Non-Formulary Preferred Brands Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 663 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/04/2015 aripiprazole aripiprazole ADD TO FORMULARY Generics 05/04/2015 aripiprazole aripiprazole ADD TO FORMULARY Generics 05/04/2015 ABILIFY aripiprazole CHANGE TIER Non-Formulary 05/04/2015 ABILIFY aripiprazole CHANGE TIER Non-Formulary 05/04/2015 aripiprazole aripiprazole ADD TO FORMULARY Generics 05/04/2015 ABILIFY aripiprazole CHANGE TIER 05/04/2015 aripiprazole aripiprazole ADD TO FORMULARY Generics 05/04/2015 benzonatate benzonatate ADD TO FORMULARY Generics 05/04/2015 bimatoprost bimatoprost ADD TO FORMULARY Generics 05/04/2015 blanche hydroquinone ADD TO FORMULARY Generics 05/04/2015 ADVANCED DNA lidocaine hcl/glycerin MEDICATED COLLECT REMOVE UM: GENDER 05/04/2015 ADVANCED DNA lidocaine hcl/glycerin MEDICATED COLLECT ADD TO FORMULARY Non-Formulary 05/04/2015 dynamic ADD TO FORMULARY Generics 05/09/2016 venlafaxine hcl er venlafaxine hcl 05/15/2015 lidocaine hcl/glycerin Preferred Brands Non-Formulary ADD TO FORMULARY Non-Formulary Generics dexmethylphenid dexmethylphenidate hcl ate hcl er CHANGE TIER Preferred Brands Generics 05/15/2015 FOCALIN XR dexmethylphenidate hcl CHANGE TIER Preferred Brands Non-Formulary 05/15/2015 clozapine odt clozapine ADD TO FORMULARY Generics 05/15/2015 clozapine odt clozapine ADD TO FORMULARY Generics 05/15/2015 levomefolpyridoxal-mecalgal levomefolate ca/pyridoxal phos/mecobalamin/schiz. algal oil CHANGE TIER Generics BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 664 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 05/15/2015 foltanx rf levomefolate ca/pyridoxal phos/mecobalamin/schiz. algal oil 05/15/2015 l-methylfolatelevomefolate mecobalaminca/acetylcysteine/mecobala nac,levomefola- min/schiz. algal oil nac-mecobalmalgal,levomefolat e-nac-mecobalalgal 05/15/2015 SAPHRIS 05/15/2015 Type of Change Previous Value New Value ADD TO FORMULARY Non-Formulary Generics CHANGE TIER Generics asenapine maleate ADD TO FORMULARY Non-Formulary FOSRENOL lanthanum carbonate ADD TO FORMULARY Preferred Brands 05/15/2015 FOSRENOL lanthanum carbonate ADD TO FORMULARY Preferred Brands 05/15/2015 VIIBRYD vilazodone hcl ADD TO FORMULARY Non-Formulary 05/15/2015 APTENSIO XR methylphenidate hcl ADD TO FORMULARY Non-Formulary 05/15/2015 APTENSIO XR methylphenidate hcl ADD UM: QUANTITY 30 / 30 days 05/15/2015 APTENSIO XR methylphenidate hcl ADD TO FORMULARY Non-Formulary 05/15/2015 APTENSIO XR methylphenidate hcl ADD UM: QUANTITY 30 / 30 days 05/15/2015 APTENSIO XR methylphenidate hcl ADD TO FORMULARY Non-Formulary 05/15/2015 APTENSIO XR methylphenidate hcl ADD UM: QUANTITY 30 / 30 days 05/15/2015 APTENSIO XR methylphenidate hcl ADD TO FORMULARY Non-Formulary 05/15/2015 APTENSIO XR methylphenidate hcl ADD UM: QUANTITY 30 / 30 days 05/15/2015 APTENSIO XR methylphenidate hcl ADD TO FORMULARY Non-Formulary 05/15/2015 APTENSIO XR methylphenidate hcl ADD UM: QUANTITY 30 / 30 days 05/15/2015 APTENSIO XR methylphenidate hcl ADD TO FORMULARY Non-Formulary 05/15/2015 APTENSIO XR methylphenidate hcl ADD UM: QUANTITY 30 / 30 days 05/15/2015 APTENSIO XR methylphenidate hcl ADD TO FORMULARY Non-Formulary 05/15/2015 APTENSIO XR methylphenidate hcl ADD UM: QUANTITY 30 / 30 days BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 665 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2015 MACUZIN folic acid/vit c/vit e/zinc/cupric oxide/lutein/zeaxanthin ADD TO FORMULARY Non-Formulary 05/15/2015 TIVORBEX indomethacin, submicronized ADD TO FORMULARY Non-Formulary 05/15/2015 TIVORBEX indomethacin, submicronized ADD TO FORMULARY Non-Formulary 05/15/2015 ZARXIO filgrastim-sndz ADD TO FORMULARY Non-Formulary 05/15/2015 ZARXIO filgrastim-sndz ADD TO FORMULARY Non-Formulary 05/15/2015 midazolam hcl midazolam hcl CHANGE TIER Generics 05/15/2016 PLEGRIDY PEN peginterferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 PLEGRIDY PEN peginterferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 euflexxa hyaluronate sodium CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 AVONEX PEN interferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NORDITROPIN FLEXPRO somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 HUMIRA adalimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 AVONEX PEN interferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 HUMIRA PEDIATRIC CROHN'S adalimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 OMNITROPE somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 REBIF REBIDOSE interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 HUMIRA PEDIATRIC CROHN'S adalimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NORDITROPIN FLEXPRO somatropin CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 666 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2016 TECFIDERA dimethyl fumarate CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 TECFIDERA dimethyl fumarate CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 REBIF REBIDOSE interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 REBIF interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 HUMIRA adalimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 COPAXONE glatiramer acetate CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 TECFIDERA dimethyl fumarate CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 SIMPONI golimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 SIMPONI golimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 PLEGRIDY peginterferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NUTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NUTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 PLEGRIDY peginterferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NUTROPIN AQ somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 AVONEX PEN interferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 OMNITROPE somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NORDITROPIN NORDIFLEX somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 667 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2016 PLEGRIDY PEN peginterferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 AVONEX interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 ENBREL etanercept CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 REBIF REBIDOSE interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 COPAXONE glatiramer acetate CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 ENBREL etanercept CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NUTROPIN AQ NUSPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 REBIF REBIDOSE interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 ENBREL etanercept CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NUTROPIN AQ NUSPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 ENBREL etanercept CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 SIMPONI golimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NUTROPIN AQ somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 ENBREL etanercept CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 ENBREL etanercept CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 PLEGRIDY peginterferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 OMNITROPE somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NUTROPIN AQ NUSPIN somatropin CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 668 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2016 AVONEX interferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 SIMPONI golimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 COPAXONE glatiramer acetate CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NUTROPIN AQ somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 ORTHOVISC hyaluronate sodium CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 OMNITROPE somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 AVONEX interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 AVONEX interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 REBIF interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 ENBREL etanercept CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 REBIF REBIDOSE interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 AVONEX interferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NORDITROPIN FLEXPRO somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 REBIF interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 HUMIRA adalimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 NORDITROPIN FLEXPRO somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 SYNVISC-ONE hylan g-f 20 CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 REBIF interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 669 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2016 OMNITROPE somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 GENOTROPIN somatropin CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 SYNVISC hylan g-f 20 CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 AVONEX interferon beta-1a CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 ENBREL etanercept CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 HUMIRA PEN PSORIASISUVEITIS adalimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 HUMIRA PEN adalimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 HUMIRA PEN CROHN-UC-HS STARTER adalimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 REBIF interferon beta-1a/albumin human CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 HUMIRA PEN adalimumab CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 MENOPUR menotropins ADD UM: SPECIALTY Specialty Drug 05/15/2016 MENOPUR menotropins ADD UM: PS Preferred Specialty 05/15/2016 MENOPUR menotropins ADD UM: SPECIALTY Specialty Drug 05/15/2016 MENOPUR menotropins ADD UM: PS Preferred Specialty 05/15/2016 MIRENA levonorgestrel ADD UM: SPECIALTY Specialty Drug 05/15/2016 MIRENA levonorgestrel ADD UM: PS Preferred Specialty 05/15/2016 CETROTIDE cetrorelix acetate ADD UM: SPECIALTY Specialty Drug 05/15/2016 CETROTIDE cetrorelix acetate ADD UM: PS Preferred Specialty 05/15/2016 ENDOMETRIN progesterone,micronized CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 670 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2016 ENDOMETRIN progesterone,micronized ADD UM: SPECIALTY Specialty Drug 05/15/2016 ENDOMETRIN progesterone,micronized ADD UM: PS Preferred Specialty 05/15/2016 MIRENA levonorgestrel ADD UM: SPECIALTY Specialty Drug 05/15/2016 MIRENA levonorgestrel ADD UM: PS Preferred Specialty 05/15/2016 ENDOMETRIN progesterone,micronized CHANGE TIER 05/15/2016 ENDOMETRIN progesterone,micronized ADD UM: SPECIALTY Specialty Drug 05/15/2016 ENDOMETRIN progesterone,micronized ADD UM: PS Preferred Specialty 05/15/2016 ENDOMETRIN progesterone,micronized CHANGE TIER 05/15/2016 ENDOMETRIN progesterone,micronized ADD UM: SPECIALTY Specialty Drug 05/15/2016 ENDOMETRIN progesterone,micronized ADD UM: PS Preferred Specialty 05/15/2016 OVIDREL choriogonadotropin alfa ADD UM: SPECIALTY Specialty Drug 05/15/2016 OVIDREL choriogonadotropin alfa ADD UM: PS Preferred Specialty 05/15/2016 SKYLA levonorgestrel ADD UM: SPECIALTY Specialty Drug 05/15/2016 SKYLA levonorgestrel ADD UM: PS Preferred Specialty 05/15/2016 CETROTIDE cetrorelix acetate ADD UM: SPECIALTY Specialty Drug 05/15/2016 CETROTIDE cetrorelix acetate ADD UM: PS Preferred Specialty 05/15/2016 REMICADE infliximab ADD UM: SPECIALTY Specialty Drug 05/15/2016 XTANDI enzalutamide REMOVE UM: CUSTOM 05/15/2016 XTANDI enzalutamide ADD UM: SPECIALTY 05/15/2016 accu-chek compact blood sugar diagnostic, drum-type CHANGE TIER Preferred Brands Preferred Brands Non-Formulary Non-Formulary Specialty Drug Specialty Drug Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 671 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/15/2016 accu-chek compact plus blood sugar diagnostic, drum-type CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 accu-chek comfort curve blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 accu-chek aviva blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 accu-chek aviva plus blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 accu-chek smartview blood sugar diagnostic CHANGE TIER Preferred Brands Non-Formulary 05/15/2016 MAKENA hydroxyprogesterone caproate 05/15/2016 CETROTIDE 05/15/2016 ADD UM: SPECIALTY Specialty Drug cetrorelix acetate ADD UM: AUTHORIZATION PA applies CETROTIDE cetrorelix acetate ADD UM: AUTHORIZATION PA applies 05/15/2016 MAKENA hydroxyprogesterone caproate ADD UM: GENDER Female 05/15/2016 MAKENA hydroxyprogesterone caproate ADD UM: CUSTOM Specialty Drug 05/15/2016 MAKENA hydroxyprogesterone caproate ADD UM: PS Preferred Specialty 05/15/2016 MAKENA hydroxyprogesterone caproate ADD UM: SPECIALTY Specialty Drug 05/15/2016 MAKENA hydroxyprogesterone caproate ADD UM: AUTHORIZATION PA applies 05/16/2016 REVLIMID lenalidomide ADD UM: CUSTOM Dispensing restricted to Magellan Specialty Pharmacy BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 672 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/16/2016 POMALYST pomalidomide ADD UM: CUSTOM Dispensing Limited to Magellan Specialty Pharmacy 05/16/2016 THALOMID thalidomide ADD UM: CUSTOM Dispensing Limited to Magellan Specialty Pharmacy 05/16/2016 MIRENA levonorgestrel ADD TO FORMULARY Non-Formulary Preferred Brands 05/16/2016 MIRENA levonorgestrel CHANGE TIER Preferred Brands Non-Formulary 05/16/2016 HUMATROPE somatropin CHANGE TIER Preferred Brands Non-Formulary 05/16/2016 SEROSTIM somatropin CHANGE TIER Preferred Brands Non-Formulary 05/17/2016 ACTEMRA tocilizumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 ADCETRIS brentuximab vedotin ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 ZORTRESS,AFI everolimus NITOR,AFINITO R DISPERZ ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 AVASTIN bevacizumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 BENLYSTA belimumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 BETHKIS tobramycin ADD UM: CUSTOM Limited Distribution Magellan Rx BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 673 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/17/2016 CERDELGA eliglustat tartrate ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 CEREZYME imiglucerase ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 COSENTYX PEN secukinumab (2 PENS),COSENT YX PEN,COSENTYX SYRINGE,COSE NTYX (2 SYRINGES) ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 dacogen,decitabi decitabine ne ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 DAKLINZA daclatasvir dihydrochloride ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 DARZALEX daratumumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 DYSPORT abobotulinumtoxina ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 ELAPRASE idursulfase ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 EMPLICITI elotuzumab ADD UM: CUSTOM Limited Distribution Magellan Rx BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 674 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/17/2016 ENTYVIO vedolizumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 EYLEA aflibercept ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 FARYDAK panobinostat lactate ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 GAZYVA obinutuzumab ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 privigen,hizentra immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 hycamtin,topotec topotecan hcl an hcl ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 INTRON A ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 EXJADE,JADEN deferasirox U ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 KADCYLA ado-trastuzumab emtansine ADD UM: CUSTOM Limited Distribution Magellan Rx 05/17/2016 KANUMA sebelipase alfa ADD UM: CUSTOM Limited Distribution Magellan Rx 05/18/2016 XURIDEN uridine triacetate ADD UM: PS Preferred Specialty interferon alfa-2b,recomb. BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 675 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 05/18/2016 XURIDEN uridine triacetate ADD UM: SPECIALTY Specialty Drug 05/20/2016 HUMIRA adalimumab ADD UM: QUANTITY 2 / 28 days 05/25/2015 lidocainetetracaine lidocaine/tetracaine ADD TO FORMULARY Generics 05/25/2015 jinteli norethindrone acetateethinyl estradiol CHANGE TIER 05/25/2015 jinteli norethindrone acetateethinyl estradiol REMOVE UM: AUTHORIZATION 05/25/2015 norethindronethinyl estradiol norethindrone acetateethinyl estradiol ADD TO FORMULARY Generics 05/25/2015 norethindronethinyl estradiol norethindrone acetateethinyl estradiol ADD TO FORMULARY Generics 05/25/2015 TASMAR tolcapone CHANGE TIER 05/25/2015 tolcapone tolcapone ADD TO FORMULARY Generics 05/25/2015 virtrate-2 citric acid/sodium citrate ADD TO FORMULARY Generics 05/25/2015 virtrate-k potassium citrate/citric acid ADD TO FORMULARY Generics 05/25/2015 ENBRACE HR prenatal vitamins no.92/iron cysteine gly/folate no.8/psdha ADD TO FORMULARY Non-Formulary 05/25/2015 ENBRACE HR prenatal vitamins no.92/iron cysteine gly/folate no.8/psdha ADD UM: GENDER Female 05/27/2015 ATELVIA risedronate sodium CHANGE TIER 05/27/2015 risedronate sodium dr risedronate sodium ADD TO FORMULARY Generics 05/27/2015 vanatol lq butalbital/acetaminophen/caf feine ADD TO FORMULARY Non-Formulary 05/27/2015 JUXTAPID lomitapide mesylate ADD TO FORMULARY Non-Formulary 05/27/2015 TESTONE CIK testosterone cypionate ADD TO FORMULARY Non-Formulary Preferred Brands Preferred Brands Preferred Brands Non-Formulary Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 676 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name 05/27/2015 TESTONE CIK testosterone cypionate 05/27/2015 JUXTAPID 05/27/2015 JUXTAPID Type of Change Previous Value New Value ADD UM: GENDER Male lomitapide mesylate CHANGE UM: AUTHORIZATION PA applies lomitapide mesylate CHANGE UM: SPECIALTY Specialty Drug BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 677 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates June, 2014 Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/01/2014 OPSUMIT macitentan ADD TO FORMULARY Non-Formulary Preferred Brands 06/01/2015 TOUJEO SOLOSTAR insulin glargine,human recombinant analog ADD TO FORMULARY Non-Formulary Preferred Brands 06/05/2015 alosetron hcl alosetron hcl ADD TO FORMULARY 06/05/2015 LOTRONEX alosetron hcl CHANGE TIER 06/05/2015 alosetron hcl alosetron hcl ADD TO FORMULARY Generics 06/05/2015 IONSYS fentanyl hcl ADD TO FORMULARY Non-Formulary 06/05/2015 IONSYS fentanyl hcl ADD UM: AUTHORIZATION PA applies 06/05/2015 STIOLTO RESPIMAT tiotropium bromide/olodaterol hcl ADD TO FORMULARY Non-Formulary 06/05/2015 UREVAZ urea ADD TO FORMULARY Non-Formulary 06/09/2015 COSENTYX PEN secukinumab ADD UM: QUANTITY 1 / 30 days 06/09/2015 COSENTYX SYRINGE ADD UM: QUANTITY 1 / 30 days 06/09/2015 COSENTYX PEN secukinumab (2 PENS),COSENT YX PEN,COSENTYX SYRINGE,COSE NTYX (2 SYRINGES) 06/10/2015 ACTONEL 06/10/2015 06/10/2015 secukinumab Generics Preferred Brands Non-Formulary REMOVE UM: AUTHORIZATION PA applies risedronate sodium CHANGE TIER Preferred Brands risedronate sodium risedronate sodium ADD TO FORMULARY Generics risedronate sodium risedronate sodium ADD UM: QUANTITY 30 / 30 days Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 678 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Preferred Brands Non-Formulary 06/10/2015 ACTONEL risedronate sodium CHANGE TIER 06/10/2015 risedronate sodium risedronate sodium ADD TO FORMULARY Generics 06/10/2015 risedronate sodium risedronate sodium ADD UM: QUANTITY 4 / 30 days 06/10/2015 ACTONEL risedronate sodium CHANGE TIER 06/10/2015 risedronate sodium risedronate sodium ADD TO FORMULARY Generics 06/10/2015 risedronate sodium risedronate sodium ADD UM: QUANTITY 30 / 30 days 06/10/2015 larin 24 fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 06/10/2015 larin 24 fe norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 06/10/2015 junel fe 24 norethindrone acetateethinyl estradiol/ferrous fumarate ADD TO FORMULARY Preventative 06/10/2015 junel fe 24 norethindrone acetateethinyl estradiol/ferrous fumarate ADD UM: GENDER Female 06/10/2015 levonorg-eth levonorgestrel/ethinyl estrad eth estrad estradiol and ethinyl estradiol ADD TO FORMULARY Preventative 06/10/2015 levonorg-eth levonorgestrel/ethinyl estrad eth estrad estradiol and ethinyl estradiol ADD UM: GENDER Female 06/10/2015 naftifine hcl naftifine hcl ADD TO FORMULARY Generics 06/10/2015 IRENKA duloxetine hcl ADD TO FORMULARY Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 679 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/14/2016 accu-chek aviva plus blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek compact blood sugar diagnostic, drum-type ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek smartview blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek smartview blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek comfort curve blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek comfort curve blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek comfort curve blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek compact plus blood sugar diagnostic, drum-type ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek aviva plus blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek comfort curve blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek comfort curve blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek aviva plus blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek smartview blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek comfort curve blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek aviva blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 680 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/14/2016 accu-chek aviva plus blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek compact plus blood sugar diagnostic, drum-type ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek smartview blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek compact blood sugar diagnostic, drum-type ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek aviva plus blood sugar diagnostic ADD TO FORMULARY Non-Formulary Preferred Brands 06/14/2016 accu-chek aviva plus blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek compact blood sugar diagnostic, drum-type REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek smartview blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek smartview blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek comfort curve blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek comfort curve blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek comfort curve blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek compact plus blood sugar diagnostic, drum-type REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek aviva plus blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek comfort curve blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 681 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/14/2016 accu-chek comfort curve blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek aviva plus blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek smartview blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek comfort curve blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek aviva blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek aviva plus blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek compact plus blood sugar diagnostic, drum-type REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek smartview blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek compact blood sugar diagnostic, drum-type REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/14/2016 accu-chek aviva plus blood sugar diagnostic REMOVE FROM FORMULARY Preferred Brands Non-Formulary 06/16/2015 EXJADE,JADEN deferasirox U REMOVE UM: AUTHORIZATION PA applies 06/19/2014 HUMULIN R insulin regular, human ADD TO FORMULARY Not Covered 06/19/2014 NOVOLIN R insulin regular, human ADD TO FORMULARY Not Covered 06/19/2014 HUMULIN 70-30 insulin nph human isophane/insulin regular, human ADD TO FORMULARY Not Covered 06/19/2014 NOVOLIN 70-30 insulin nph human isophane/insulin regular, human ADD TO FORMULARY Not Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 682 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/19/2014 HUMULIN N insulin nph human isophane ADD TO FORMULARY Not Covered 06/19/2014 NOVOLIN N insulin nph human isophane ADD TO FORMULARY Not Covered 06/23/2015 tramadol hcl er tramadol hcl ADD TO FORMULARY Generics 06/23/2015 tramadol hcl er tramadol hcl ADD TO FORMULARY Generics 06/23/2015 tramadol hcl er tramadol hcl ADD TO FORMULARY Generics 06/23/2015 tramadol hcl er tramadol hcl ADD TO FORMULARY Generics 06/23/2015 duloxetine hcl duloxetine hcl ADD TO FORMULARY Generics 06/23/2015 salicylic acid er salicylic acid ADD TO FORMULARY Generics 06/23/2015 K-TAB ER potassium chloride ADD TO FORMULARY Non-Formulary 06/23/2015 TUZISTRA XR codeine polistirex/chlorpheniramine polistirex ADD TO FORMULARY Non-Formulary 06/23/2015 kimidess desogestrel-ethinyl estradiol/ethinyl estradiol ADD TO FORMULARY Preventative 06/23/2015 thrivite 19 prenatal vitamins comb no.119/iron fumarate/folic acid/dss ADD TO FORMULARY Generics 06/23/2015 thrivite 19 prenatal vitamins comb no.119/iron fumarate/folic acid/dss ADD UM: GENDER Female 06/23/2015 BREO ELLIPTA fluticasone furoate/vilanterol trifenatate ADD TO FORMULARY Preferred Brands 06/23/2015 TRISTART DHA prenatal vitamins no.93/iron carbonyl/fa cmb#9/dha ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 683 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change 06/25/2014 prozac weekly,symbyax, cymbalta,zyprexa ,evista,zyprexa zydis,livalo,hydre a,zerit,pravachol, naprosyn,klonopi n,copegus,boniva ,cellcept,xeloda,a naprox,anaprox ds,ecnaprosyn,prinivil,f osamax,propecia, proscar,singulair, maxalt,zocor,hyz aar,mevacor,coz aar,pepcid,maxalt mlt,sinemet 10100,sinemet 25100,sinemet 25250,sinemet cr,dyazide,coreg, parnate,requip xl,requip,effexor xr,protonix,rapam une,cordarone,co rtef,halcion,medr ol,didrex,xanax,pr overa,xanax xr,cleocin hcl,colestid,ansai d,glynase,cleocin palmitate,ogen,d etrol,detrol la,aromasin,azulfi dine,mycobutin,m egace,sanctura,s anctura xr,demerol,drisdo fluoxetine hcl,olanzapine/fluoxetine hcl,duloxetine hcl,olanzapine,raloxifene hcl,pitavastatin calcium,hydroxyurea,stavudi ne,pravastatin sodium,naproxen,clonazepa m,ribavirin,ibandronate sodium,mycophenolate mofetil,capecitabine,naproxe n sodium,lisinopril,alendronate sodium,finasteride,monteluk ast sodium,rizatriptan benzoate,simvastatin,losarta n potassium/hydrochlorothiazi de,lovastatin,losartan potassium,famotidine,carbid opa/levodopa,triamterene/hy drochlorothiazide,carvedilol,t ranylcypromine sulfate,ropinirole hcl,venlafaxine hcl,pantoprazole sodium,sirolimus,amiodaron e hcl,hydrocortisone,triazolam, methylprednisolone,benzph etamine hcl,alprazolam,medroxyprog esterone acetate,clindamycin hcl,colestipol hcl,flurbiprofen,glyburide,mic ronized,clindamycin palmitate hcl,estropipate,tolterodine ADD TO FORMULARY Previous Value New Value Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 684 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name l,kayexalate,plaq uenil,uroxatral,a mbien,ambien cr,xyzal,avapro,a valide,lomotil,ald actone,aldactazid e,daypro,arthrote c 50,arthrotec 75,cytotec,inspra, flagyl,calan,calan sr,norpace,paxil,p axil cr,prometrium,fel batol,soma,dema dex,bifera rx,diabeta,lasix,tr ental,amaryl,gluc otrol xl,antivert,cardur a,vfend,diflucan,g eodon,glucotrol,z oloft,marinol,rem eron,desogen,cyc lessa,dolophine hcl,diskets,coum adin,grifulvin v,norpramin,hipre x,rifadin,tessalon perle,vibramycin, norvasc,caduet,p rocardia,procardi a xl,zithromax,zithr omax tripak,feldene,revati o,minipress,vistar il,dilantin,lipitor,ac curetic,zarontin,n ardil,neurontin,ac tartrate,exemestane,sulfasal azine,rifabutin,megestrol acetate,trospium chloride,meperidine hcl,ergocalciferol (vitamin d2),sodium polystyrene sulfonate,hydroxychloroquin e sulfate,alfuzosin hcl,zolpidem tartrate,levocetirizine dihydrochloride,irbesartan,ir besartan/hydrochlorothiazid e,diphenoxylate hcl/atropine sulfate,spironolactone,spiron olactone/hydrochlorothiazide ,oxaprozin,diclofenac sodium/misoprostol,misopro stol,eplerenone,metronidazo le,verapamil hcl,disopyramide phosphate,paroxetine hcl,progesterone,micronized ,felbamate,carisoprodol,tors emide,iron polysacchar complx/iron heme polypeptide/folic acid/b12,glyburide,furosemi de,pentoxifylline,glimepiride, glipizide,meclizine hcl,doxazosin mesylate,voriconazole,fluco nazole,ziprasidone hcl,sertraline hcl,dronabinol,mirtazapine,d esogestrel-ethinyl estradiol,methadone hcl,warfarin sodium,griseofulvin, microsize,desipramine Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 685 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name cupril,lopid,dilanti n125,vicoprofen,m avik,biaxin,tevete n,cardizem la,niaspan,biaxin xl,synthroid,depa kote er,zemplar,depak ene,depakote sprinkle,tricor,dep akote,k-tab er,trilipix,ddavp,ril utek,parlodel,cloz aril,lescol,lamisil, sandimmune,neo ral,femara,diovan hct,exelon,comta n,trileptal,starlix,l otrel,famvir,ritalin la,focalin,myfortic ,stalevo 50,stalevo 100,stalevo 150,focalin xr,cataflam,ritalin, ritalin-sr,voltarenxr,lotensin,lotensi n hct,lopressor,lopr essor hct,tegretol,tegret ol xr,stalevo 200,stalevo 75,stalevo 125,imdur,rebetol ,temodar,clarinex ,adalat cc,avelox,avelox hcl,methenamine hippurate,rifampin,benzonat ate,doxycycline hyclate,doxycycline monohydrate,amlodipine besylate,amlodipine besylate/atorvastatin calcium,nifedipine,azithromy cin,piroxicam,sildenafil citrate,prazosin hcl,hydroxyzine pamoate,phenytoin,atorvast atin calcium,quinapril hcl/hydrochlorothiazide,etho suximide,phenelzine sulfate,phenytoin sodium extended,gabapentin,quinap ril hcl,gemfibrozil,hydrocodone/ ibuprofen,trandolapril,clarithr omycin,eprosartan mesylate,diltiazem hcl,niacin,levothyroxine sodium,divalproex sodium,paricalcitol,valproic acid,valproic acid (as sodium salt) (valproate sodium),fenofibrate nanocrystallized,potassium chloride,fenofibric acid (choline),desmopressin acetate,riluzole,bromocriptin e mesylate,clozapine,fluvastati n sodium,terbinafine hcl,cyclosporine,cyclosporin e, modified,letrozole,valsartan/ hydrochlorothiazide,rivastig Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 686 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name abc pack,biltricide,levi tra,glucophage,gl ucophage xr,glucovance,vid ex ec,allegra-d 24 hour,allegra odt,arava,verelan ,univasc,uniretic, verelan pm,colyte with flavor packets,robaxin750,venlafaxine hcl er,valium,soriatan e,macrodantin,di dronel,prandin,ac tivella,wellbutrin sr,wellbutrin,lano xin,zantac,ceftin, zofran,lamictal,m epron,zyban,ame rge,valtrex,zofran odt,lamictal (blue),epivir hbv,malarone,imit rex,lamictal xr,lovaza,innopra n xl,rythmol,rythmol sr,zovirax,ferralet 90,urocitk,citranatal harmony,citranat al 90 dha,citranatal bcalm,citranatal rx,citranatal assure,citranatal mine tartrate,entacapone,oxcarba zepine,nateglinide,amlodipin e besylate/benazepril hcl,famciclovir,methylphenid ate hcl,dexmethylphenidate hcl,mycophenolate sodium,carbidopa/levodopa/ entacapone,diclofenac potassium,diclofenac sodium,benazepril hcl,benazepril hcl/hydrochlorothiazide,meto prolol tartrate,metoprolol tartrate/hydrochlorothiazide, carbamazepine,isosorbide mononitrate,temozolomide,d esloratadine,moxifloxacin hcl,praziquantel,vardenafil hcl,metformin hcl,glyburide/metformin hcl,didanosine,fexofenadine hcl/pseudoephedrine hcl,fexofenadine hcl,leflunomide,moexipril hcl,moexipril hcl/hydrochlorothiazide,peg 3350/sod sulf/sod bicarbonate/sod chloride/potassium chl,methocarbamol,diazepa m,acitretin,nitrofurantoin macrocrystal,etidronate disodium,repaglinide,estradi ol/norethindrone acetate,bupropion hcl,digoxin,ranitidine hcl,cefuroxime axetil,ondansetron Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 687 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name dha,tindamax,ata cand,atacand hct,vimovo,prilos ec,entocort ec,toprol xl,nexium,vasote c,vaseretic,bontril pdm,wellbutrin xl,cardizem,cardi zem cd,mestinon,anco bon,librax,nephro caps,anaspaz,klo r-con 8,klor-con 10,pacerone,folg ard os,prenexa,folgar d rx,gastrografin,flu oritab,tenormin,te noretic 50,tenoretic 100,zestril,zestor etic,arimidex,sero quel,accolate,cas odex,maxzide,ma xzide-25 mg,phenytek,met hadose,anafranil, pamelor,restoril,t ofranil,tofranilpm,doryx,sarafe m,actonel,femcon fe,estrostep fe,ovcon35,estrace,armou r thyroid,flumadine, esgic- hcl,lamotrigine,atovaquone, naratriptan hcl,valacyclovir hcl,ondansetron,lamivudine, atovaquone/proguanil hcl,sumatriptan succinate,omega-3 acid ethyl esters,propranolol hcl,propafenone hcl,acyclovir,iron carbonyl,gluc/folic acid/vit b12/vit c/docusate sodium,potassium citrate,prenatal vitamins combo no.59/iron,carb/folic acid/dss/dha,prenatal vit,calcium #64/iron carb,gluc/folic acid/dss/dha,prenatal vitamin no.48/iron,carbonyl,gluconat e/folic acid/b6,prenatal vit no.22/iron cbn,gluc/folic acid/docusate sodium,prenatal vitamin no.38/iron carb,gluc/folic acid/docusat/dha,prenatal vit no.22/iron cbn,glucon/folic acid/docusate/dha,tinidazole ,candesartan cilexetil,candesartan cilexetil/hydrochlorothiazide, naproxen/esomeprazole magnesium,omeprazole,bud esonide,metoprolol succinate,esomeprazole magnesium,enalapril maleate,enalapril maleate/hydrochlorothiazide ,phendimetrazine Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 688 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name plus,tessalon,lev othroid,lexapro,ti azac,campral,cel exa,prograf,uroge sic-blue,k-phos neutral,lunglaid,d eplin,cerefolin,cer efolin nac,neevo dha,foltx,deplinalgal oil,metanx,unithro id,esgic,adderall, catapres,persanti ne,mobic,micardi s,micardis hct,viramune,flom ax,mirapex,viram une xr,twynsta,marge sic,martentab,prozac,caferg ot,lorcet plus,lorcet 10650,grispeg,zanaflex,fero trinsic,pamine,pa mine forte,adoxa,absor ica,vitamedmd one rx,vitamedmd plus rx,vitamedmd redichew rx,hematronaf,relagesic,supp ort-500,uretron ds,fibricor,colcrys, bactrim,bactrim tartrate,pyridostigmine bromide,flucytosine,chlordia zepoxide/clidinium bromide,vitamin b complex and vitamin c no.20/folic acid,hyoscyamine sulfate,calcium carb/mag oxide/vitamin d3/vit b12/fa/vit b6/boron,prenatal vit with calcium no.66/iron fum/folic acid/dss/dha,cyanocobalami n/folic acid/pyridoxine,diatrizoate meglumine/diatrizoate sodium,sodium fluoride,atenolol,atenolol/chl orthalidone,lisinopril/hydroch lorothiazide,anastrozole,que tiapine fumarate,zafirlukast,bicaluta mide,clomipramine hcl,nortriptyline hcl,temazepam,imipramine hcl,imipramine pamoate,risedronate sodium,norethindroneethinyl estradiol/ferrous fumarate,norethindrone acetate-ethinyl estradiol/ferrous fumarate,norethindroneethinyl estradiol,estradiol,thyroid,po rk,rimantadine hcl,butalbital/acetaminophen /caffeine,escitalopram oxalate,acamprosate calcium,citalopram Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 689 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name ds,qualaquin,hyc et,tl-select dha,minocin,prod rin,monodox,ribat ab,l-methylfolate formula,fazaclo,ni ravam,parcopa,g astrocrom,tri-viflor,exalgo,roxico done,reprexain,in deral la,cardene sr,cardiotekrx,lodosyn,antara ,rocaltrol,prelone, dantrium,nicazel, silenor,zenpep,au gmentin es600,augmentin,a ugmentin xr,serophene,vhist,cedax,uta,sp s,kadian,neptaza ne,phoslo,eldepry l,combivir,epivir,r etrovir,trizivir,ziag en,synalgosdc,dynacin,questr an,questran light,betapace,bet apace af,yasmin 28,yaz,cipro,cipro xr,precose,levaqu in,modicon,orthonovum,ortho tricyclen,ortho micronor,orthocept,orthocyclen,sporanox,r isperdal,risperdal hydrobromide,tacrolimus,me thenamine/sodium phosphate,monobasic/meth blue/hyosc sul,phosphorus #1,borage oil/fish oil (anchovy,sardine)/fructose/s oy lecithin,levomefolate calcium,cyanocobalamin/lev omefolate calcium/pyridoxine/riboflavin ,acetylcysteine/mecobalami n/levomefolate calcium,prenatal vitamin comb no.79/iron fumarat/fa/lmefolate ca/dha,cyanocobalamin/levo mefolate calcium/pyridoxine hcl,levomefolate calcium/schizochytrium algal oil,levomefolate ca/pyridoxal phos/mecobalamin/schiz. algal oil,dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate,clonidine hcl,dipyridamole,meloxicam, telmisartan,telmisartan/hydr ochlorothiazide,nevirapine,ta msulosin hcl,pramipexole dihcl,telmisartan/amlodipine besylate,butalbital/acetamin ophen,ergotamine tartrate/caffeine,hydrocodon e bitartrate/acetaminophen,gri seofulvin ultramicrosize,tizanidine hcl,ferrous fumarate/ascorbic acid/b12- Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 690 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name m-tab,razadyne er,razadyne,tylen ol-codeine no.3,tylenolcodeine no.4,concerta,par afon forte dsc,topamax,ultra cet,ultram er,ultram,ditropan xl,keppra,keppra xr,lortab,flexeril,n estabs dha,foltrate,ibudo ne,ziac,zebeta,lo estrin,loestrin fe,seasonique,no rdette28,loseasonique, mircette,aygestin, antabuse,vivactil, urecholine,diamo x sequels,plan b onestep,dexedrine,ro baxin,golytely,axi d,nulytely with flavor packs,macrobid,n orco,nor-qd,brevicon,norinyl 1+35,trinorinyl,dilacor xr,loxitane,microz ide,actigall,fiorina l,fiorinal with codeine #3,fioricet with codeine,nephro- if/folic acid,methscopolamine bromide,isotretinoin,prenatal vitamins combo no.25/iron fumarate/fa combo#6/dha,prenatal vitamins #39/iron amino acid chelate/fa combo#6/dha,prenatal vitamins comb no.42/folic acid comb no.6,iron,carbonyl/docusate sodium/b12-if/folic acid/multivitmin,acetaminophen/phenylt oloxamine citrate,b complex with vitamin c,methenamine/methylene blue/salicylate/sodium phos/hyoscy,methenamine/ methylene blue/sod phos/p.salicylate/hyoscyami ne,fenofibric acid,colchicine,sulfamethoxa zole/trimethoprim,quinine sulfate,prenatal vitamin no.57/iron fum/folic acid/dss/dha,minocycline hcl,isometheptene mucate/caffeine/acetaminop hen,cromolyn sodium,pediatric multivitamin a,c,and d3 no.38 with sodium fluoride,hydromorphone hcl,oxycodone hcl,nicardipine hcl,folic acid/arginine hcl/cyanocobalamin/pyridoxi Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 691 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name vite rx,hemocytef,concept ob,concept dha,integra f,integra plus,hemocyte plus,tandem plus,tussionex,m etadate cd,zaroxolyn,agry lin,carbatrol,adde rall xr,oxandrin,carnit or,truvada,tusnel pediatric,cafcit,lys teda,prosedds,adipexp,purinethol,hect orol,renvela,prote ct plus,escavite,ben tyl,carafate,urso, urso forte,ms contin,dilaudid,pl etal,keflex,robinul ,robinul forte,ponstel,fura dantin,sular,forta met,kapvay,orapr ed,methylin,xodol 10-300,xodol 5300,xodol 7.5300,fexmid,orbiva n,prenatabs fa,trinate,prenata bs rx,tapazole,cytom el,skelaxin,sonat a,corzide,avinza, ne/pepper ext,carbidopa,fenofibrate,mi cronized,calcitriol,prednisolo ne,dantrolene sodium,niacinamide/azelaic acid/zinc oxide/vit b6/copper/fa,doxepin hcl,lipase/protease/amylase, amoxicillin/potassium clavulanate,clomiphene citrate,brompheniramine maleate/phenylephrine hcl,ceftibuten dihydrate,sodium polystyrene sulfonate/sorbitol solution,morphine sulfate,methazolamide,calci um acetate,selegiline hcl,lamivudine/zidovudine,zi dovudine,abacavir sulfate/lamivudine/zidovudin e,abacavir sulfate,aspirin/caffeine/dihyd rocodeine bitartrate,cholestyramine (with sugar),cholestyramine/aspar tame,sotalol hcl,ethinyl estradiol/drospirenone,ciprof loxacin hcl,ciprofloxacin,ciprofloxaci n/ciprofloxacin hcl,acarbose,levofloxacin,no rgestimate-ethinyl estradiol,norethindrone,itrac onazole,risperidone,galanta mine hbr,acetaminophen with codeine Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 692 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name corgard,levoxyl,ti gan,altace,hepse ra,reglan,buphen yl,aciphex,aricept ,zonegran,salage n,aricept odt,doral,evoxac,l unesta,provigil,ga bitril,percodan,op ana,percocet,plav ix,icar-c plus,zutripro,ativa n,isordil titradose,viva dha,prevacid,acto s,actoplus met,duetact,prev pac,zomig,zomig zmt,trandate,imur an,zyloprim,firstomeprazole,colaz al,donnatal,ribasp here ribapak,duet dha balanced,mysolin e,vancocin hcl,mucotrol,lipof en,tricare prenatal dha one,desoxyn,tran xene ttab,alinia,obtrex dha,digex nf,sectral,tenex,z egerid,ob complete,corvite, corvite 150,fosteum,wym zya fe,prefera-ob phosphate,chlorzoxazone,to piramate,tramadol hcl/acetaminophen,tramadol hcl,oxybutynin chloride,levetiracetam,cyclo benzaprine hcl,prenatal vitamins comb no.87/iron bisgly/folic acid/dha,cyanocobalamin/fol ic acid,bisoprolol fumarate/hydrochlorothiazid e,bisoprolol fumarate,norethindrone acetate-ethinyl estradiol,levonorgestrel/ethi nyl estradiol and ethinyl estradiol,levonorgestrelethinyl estradiol,desogestrelethinyl estradiol/ethinyl estradiol,norethindrone acetate,disulfiram,protriptylin e hcl,bethanechol chloride,acetazolamide,levo norgestrel,dextroamphetami ne sulfate,nizatidine,sodium chloride/sodium bicarbonate/potassium chloride/peg,nitrofurantoin monohydrate/macrocrystals, loxapine succinate,hydrochlorothiazid e,ursodiol,butalbital/aspirin/c affeine,codeine phosphate/butalbital/aspirin/ caffeine,butalbital/acetamino phen/caffeine/codeine phosphate,vitamin b complx no.3/folic acid/ascorbic acid/biotin,ferrous Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 693 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name plus dha,prefera ob,prefera-ob one,levsin,levbid,l uvox cr,vospire er,myambutol,lith obid,aceon,tamb ocor,solodyn,lmethylfolate forte,bystolic,cher atussin ac,pediapred,nuvi gil,prezista,isentr ess,active ob,camrese lo,khedezla,renag el,tamiflu,kalexat e,xifaxan,lyrica,tiv icay,sulfatrim,ciali s,erythrocin stearate,zebutal, welchol,vitapearl,i nderal xl,pyridium,zetia, compazine,abilify ,q-tabs,prena1 chew fumarate/folic acid,prenatal vitamin no.15/iron fumarate,polysac comp/folic acid,prenatal vit no.16/iron fum,ps complex/folic acid/omega-3,iron fumarate,polysac comp/folic acid/vitamin c/niacinamide,iron fumarate,polysac cplex/folic acid/vit b comp with c #9,ferrous fumarate/folic acid/multivitamin-minerals no.15,iron fumarate-iron polysacch cplex/folic acid/multivit no.18,hydrocodone polistirex/chlorpheniramine polistirex,metolazone,anagr elide hcl,oxandrolone,levocarnitin e,levocarnitine (with sugar),emtricitabine/tenofovi r disoproxil fumarate,guaifenesin/dextro methorphan hbr/pseudoephedrine hcl,caffeine citrated,tranexamic acid,methenamine/methylen e blue/benzoic acid/salicylate/hyoscy,phent ermine hcl,mercaptopurine,doxercal ciferol,sevelamer carbonate,amino acids/multivit,th iron,other min,pediatric multivitamin no.47 with iron and sodium Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 694 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value fluoride,dicyclomine hcl,sucralfate,cilostazol,ceph alexin,glycopyrrolate,mefena mic acid,nitrofurantoin,nisoldipin e,prednisolone sod phosphate,prenatal vits with calcium #78/ferrous fumarate/folic acid,prenatal vits with calcium #73/ferrous fumarate/folic acid,prenatal vits with calcium #76/iron,carbonyl/folic acid,methimazole,liothyronin e sodium,metaxalone,zaleplon ,nadolol/bendroflumethiazid e,nadolol,trimethobenzamid e hcl,ramipril,adefovir dipivoxil,metoclopramide hcl,sodium phenylbutyrate,rabeprazole sodium,donepezil hcl,zonisamide,pilocarpine hcl,quazepam,cevimeline hcl,eszopiclone,modafinil,tia gabine hcl,oxycodone hcl/aspirin,oxymorphone hcl,oxycodone hcl/acetaminophen,clopidogr el bisulfate,iron,carbonyl/ascor bic acid/cyanocobalamin/folic acid,hydrocodone bitart/chlorpheniramine maleate/pseudoephedrine,lo razepam,isosorbide dinitrate,prenatal vitamins BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 695 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value no.11/ferrous fumarate/folic acid/omega3,lansoprazole,pioglitazone hcl,pioglitazone hcl/metformin hcl,pioglitazone hcl/glimepiride,lansoprazole/ amoxicillin trihydrate/clarithromycin,zol mitriptan,ceftibuten,labetalol hcl,azathioprine,allopurinol,b alsalazide disodium,phenobarbital/hyos cyamine sulf/atropine sulf/scopolamine hb,prenatal vitamin no.105/iron edta &polysaccha/fa/om3/dha/ep a,primidone,vancomycin hcl,mucositis & stomatitis combo 1,fenofibrate,pnv no.20/iron fumarate/fa/docusate na/fish oil conc/dha/epa,methampheta mine hcl,clorazepate dipotassium,nitazoxanide,pr enatal vitamins no.12/iron,carbonyl/fa/docus ate/omega-3,hyoscyamine sulfate/phenyltoloxamine citrate,acebutolol hcl,guanfacine hcl,omeprazole/sodium bicarbonate,iron,carbonyl/fol ic acid/multivitamin with minerals,folic acid/multivitamin,ther and minerals/lycopene/lutein,iron ,carbonyl/folic acid/vit BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 696 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value c/pyridoxine hcl/vit b12/zinc,genistein/citrated zinc bisglycinate/vitamin d3,prenatal vitamin combo no.22/iron/folic acid/omega3/dha,prenatal vit no.21/iron polysacch,heme polypep/folic acid,prenatal vitamin no.19/iron polysac,iron heme/folic acid/dha,fluvoxamine maleate,albuterol sulfate,ethambutol hcl,lithium carbonate,perindopril erbumine,flecainide acetate,nebivolol hcl,guaifenesin/codeine phosphate,levomefolate ca/acetylcysteine/mecobala min/schiz. algal oil,armodafinil,darunavir ethanolate,raltegravir potassium,prenatal vitamins combo no.66/iron,carbonyl/folic acid/dha,desvenlafaxine,sev elamer hcl,oseltamivir phosphate,rifaximin,pregaba lin,dolutegravir sodium,tadalafil,erythromyci n stearate,colesevelam hcl,prenatal vit no.71/iron fum-sodium feredetate/folic acid/dha,phenazopyridine hcl,ezetimibe,prochlorperazi ne maleate,aripiprazole,methylt etrahydrofolate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 697 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value glucosamine,prenatal vitamins combination no.42/folic acid,prenatal vit no.76/iron carbony,gluc/folic acid/docusate/dha,prenatal vit no.81/iron carbonyl,gluc/folic acid/docusate BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 698 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change 06/25/2014 TRUSOPT,COS OPT,XALATAN,A CULAR,ZYMAXI D,BETAGAN,PO LYTRIM,ALPHA GAN P,ELESTAT,ACU LAR LS,OPTIVAR,MY DRIACYL,CYCL OGYL,MAXITRO L,OMNIPRED,TO BREX,TOBRADE X,CILOXAN,IOPI DINE,ALCAINE,I SOPTO CARPINE,ISOPT O ATROPINE,ISOP TO HOMATROPINE, BLEPH-10,PRED FORTE,FML,OC UFLOX,OCUFEN ,FLURESS,BRO MDAY,FLUOR-ISTRIP AT,TIMOPTICXE,TIMOPTIC,G ARAMYCIN,ILOT YCIN,VIROPTIC, ISTALOL,PROLE NSA,LASTACAF T,COSOPT PF,ZIOPTAN,LO TEMAX,VIGAMO X dorzolamide hcl,dorzolamide hcl/timolol maleate,latanoprost,ketorola c tromethamine,gatifloxacin,le vobunolol hcl,polymyxin b sulfate/trimethoprim,brimoni dine tartrate,epinastine hcl,azelastine hcl,tropicamide,cyclopentola te hcl,neomycin/polymyxin b sulfate/dexamethasone,pred nisolone acetate,tobramycin,tobramy cin/dexamethasone,ciproflox acin hcl,apraclonidine hcl,proparacaine hcl,pilocarpine hcl,atropine sulfate,homatropine hbr,sulfacetamide sodium,fluorometholone,oflo xacin,flurbiprofen sodium,benoxinate hcl/fluorescein sodium,bromfenac sodium,fluorescein sodium,timolol maleate,gentamicin sulfate,erythromycin base,trifluridine,alcaftadine,d orzolamide hcl/timolol maleate/pf,tafluprost/pf,lotep rednol etabonate,moxifloxacin hcl ADD TO FORMULARY Previous Value New Value Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 699 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 SAPHRIS,SUBO asenapine XONE,LEVSIN- maleate,buprenorphine SL,NITROSTAT hcl/naloxone hcl,hyoscyamine sulfate,nitroglycerin ADD TO FORMULARY Non-Formulary 06/25/2014 ARIXTRA,LOVE NOX,EXTAVIA,I MITREX,ALSUM A,SEROSTIM,SA IZEN,EGRIFTA,B ETASERON,IPRI VASK,TEVTROPIN,LYMPH AZURIN,NOVOL OG FLEXPEN,ZOLA DEX,LANTUS SOLOSTAR,HU MALOG MIX 7525 ADD TO FORMULARY Non-Formulary fondaparinux sodium,enoxaparin sodium,interferon beta1b,sumatriptan succinate,somatropin,tesam orelin acetate,desirudin,isosulfan blue,insulin aspart,goserelin acetate,insulin glargine,human recombinant analog,insulin lispro protamine and insulin lispro BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 700 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change 06/25/2014 ULTANE,TOBI,P ROVENTIL HFA,VENTOLIN HFA,PULMICOR T,ETHRANE,FO RANE,SPIRIVA, HYPERSAL,DUONEB,A CCUNEB,ATROV ENT HFA,PROAIR HFA,XOPENEX, XOPENEX CONCENTRATE, FLOVENT DISKUS,COMBI VENT RESPIMAT,ADV AIR DISKUS,SYMBIC ORT sevoflurane,tobramycin in 0.225 % sodium chloride,albuterol sulfate,budesonide,enfluran e,isoflurane,tiotropium bromide,sodium chloride for inhalation,ipratropium bromide/albuterol sulfate,ipratropium bromide,levalbuterol hcl,fluticasone propionate,fluticasone propionate/salmeterol xinafoate,budesonide/formot erol fumarate CHANGE TIER Previous Value New Value Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 701 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change 06/25/2014 CLEOCIN T,BACTROBAN, RETIN-A,RETINA MICRO,RETINA MICRO PUMP,BIAFINE, PRUDOXIN,XEN ADERM,BENZAC LIN,DERMATOP, BENZAMYCIN,K LARON,PENLAC ,ELOCON,DIPR OLENE AF,DIPROLENE, LOTRISONE,DR YSOL,LUXIQ,EV OCLIN,VELTIN,D UAC,AVAR-E LS,AVAR LS,OVACE PLUS,OVACE PLUS WASH,OVACE,E LDOPAQUE FORTE,ZOVIRA X,EFUDEX,ALUV EA,VECTICAL,B ENZAC AC,METROGEL, METROCREAM, METROLOTION, CLOBEX,CLIND AGEL,DESOWE N,DIFFERIN,ALA -CORT,ALASCALP,AVITA,M ENTAX,PREATTACHED LTA KIT,TEMOVATE, clindamycin phosphate,mupirocin,mupiro cin calcium,tretinoin,tretinoin microspheres,emollient combination no.10,doxepin hcl,trypsin/balsam peru/castor oil,clindamycin phosphate/benzoyl peroxide,prednicarbate,eryth romycin base/benzoyl peroxide,sulfacetamide sodium,ciclopirox,mometaso ne furoate,betamethasone dipropionate/propylene glycol,clotrimazole/betameth asone dipropionate,aluminum chloride,betamethasone valerate,clindamycin phosphate/tretinoin,sulfacet amide sodium/sulfur,hydroquinone/ ferric oxide,acyclovir,fluorouracil,u rea,calcitriol,benzoyl peroxide,metronidazole,clob etasol propionate,desonide,adapal ene,hydrocortisone,butenafi ne hcl,lidocaine hcl,clobetasol propionate/emollient base,fluticasone propionate,hydrocortisone acetate/pramoxine hcl,protectives combination no.2/ceramides 1,3,611,silver sulfadiazine,hydrocortisone ADD TO FORMULARY Previous Value New Value Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 702 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name TEMOVATE EMOLLIENT,CU TIVATE,PRAMO SONE,TETRIX,T HERMAZENE,CA RMOL HC,KEROL,SOL ARAZE,ZONALO N,LACHYDRIN,ULTRA VATE,WESTCO RT,ULTRAVATE PAC,FINACEA,D ESONATE,KERA LYT,SALEX,LOC OID,LOCOID LIPOCREAM,CL ARIFOAM EF,SALKERA,HY LATOPIC,BENZE FOAM,HYLATOP ICPLUS,BENZEF OAM ULTRA,AURSTA T,PENNSAID,HY DRO 40,DERMASMOOTHEFS,VIRASAL,SU MAXIN,PACNEX, SUMAXIN TS,SUMADAN,U RAMAXIN,URAM AXIN GT,CENTANY,CI CLODAN,SYNAL AR,SSD,TACLO NEX,DOVONEX, NIZORAL,SULFA MYLON,TRIPLE acetate/urea,urea/lactic acid/salicylic acid,diclofenac sodium,ammonium lactate,halobetasol propionate,hydrocortisone valerate,halobetasol propionate/ammonium lactate,azelaic acid,salicylic acid,salicylic acid/ceramides 1,3,6-11,hydrocortisone butyrate,hydrocortisone butyrate/emollient base,salicylic acid/ammonium lactate/aloe vera,emollient combination no.44,emollient combination no.53,emol53/e.water/namgf s/naphos/nacl/hypochlorous acid/nahypocl,fluocinolone acetonide/shower cap,fluocinolone acetonide,sulfacetamide sodium/sulfur/skin cleanser comb no.23,ciclopirox/urea/camph or/menthol/eucalyptol,calcip otriene/betamethasone dipropionate,calcipotriene,ke toconazole,mafenide acetate,gentian violet/brilliant green/proflavine,desoximeta sone,malathion,spinosad,po dofilox,lidocaine/prilocaine,li docaine,eflornithine hcl,emollient combination no.43,clocortolone pivalate,vitamin e acet (dl,tocopheryl)/grape/hyaluro Type of Change Previous Value New Value BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 703 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value DYE,TOPICORT, OVIDE,NATROB A,CONDYLOX,SI LVADENE,OLUX ,EXTINA,OLUXE,EMLA,LIDODE RM,VANIQA,PR OMISEB,CLODE RM,UMECTA,LO PROX,ATOPICL AIR,ALDARA,ZIA NA,VANOS,EPIF IX AMNIOTIC MEMBRANE,LID ORX,GRAFIX CORE,GRAFIX PRIME nic acid,imiquimod,fluocinonide, human regenerative tissue matrix 06/25/2014 DIASTAT ACUDIAL,ANALP RAM E,ANALPRAM HC,SPS,CORTE NEMA,PROCTO CORT,DIASTAT, SFROWASA,RO WASA,COMPAZI NE diazepam,hydrocortisone acetate/pramoxine/emollient /pramoxine comb#1,hydrocortisone acetate/pramoxine hcl,sodium polystyrene sulfonate/sorbitol solution,hydrocortisone,hydr ocortisone acetate,mesalamine,mesala mine with cleansing wipes,prochlorperazine ADD TO FORMULARY Non-Formulary 06/25/2014 PHYSIOLYTE,A MINOACETIC ACID,PHYSIOSO L,NEOSPORIN G.U. IRRIGANT physiological irrigating solution combo #1,glycine urologic solution,neomycin sulfate/polymyxin b sulfate ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 704 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 ASTELIN,ASTEP RO,NASACORT AQ,DDAVP,MIA CALCIN,FLONA SE,IMITREX,RHI NOCORT AQUA,MIGRANA L,FORTICAL,AT ROVENT,NASO NEX azelastine hcl,triamcinolone acetonide,desmopressin acetate,desmopressin acetate (nonrefrigerated),calcitonin,salm on,synthetic,fluticasone propionate,sumatriptan,bude sonide,dihydroergotamine mesylate,ipratropium bromide,mometasone furoate ADD TO FORMULARY Non-Formulary 06/25/2014 VOSOL HC,DERMOTIC, CORTISPORIN,C ETRAXAL,CIPR ODEX acetic acid/hydrocortisone,fluocinol one acetonide oil,neomycin sulfate/polymyxin b sulfate/hydrocortisone,ciprofl oxacin hcl,ciprofloxacin hcl/dexamethasone ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 705 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change 06/25/2014 kenalog40,kenalog10,azactam,roce phin,depomedrol,cleocin phosphate,solucortef,auviq,claforan,unasyn ,ddavp,sandostati n,desferal,desfer al mesylate,celesto ne,glucagen,lano xin,zinacef,zanta c,fortaz,maxipime ,carbocaine,isupr el,marcaine,marc aineepinephrine,marc aine spinal,pontocaine ,quelicin,indigo carmine,cortrosy n,ativan,duramor ph,phenergan,rob inul,anectine,winr ho sdf,gamunexc,fentanyl citrate,alfentanil hcl,ic green,adrenalin chloride,colymycin m parenteral,ketalar ,pitocin,pitressin, epipen 2pak,haldol,epoge n,dilaudid,dilaudi d- triamcinolone acetonide,aztreonam,ceftria xone sodium,methylprednisolone acetate,clindamycin phosphate,hydrocortisone sod succinate,epinephrine,cefota xime sodium,ampicillin sodium/sulbactam sodium,desmopressin acetate,octreotide acetate,deferoxamine mesylate,betamethasone acetate/betamethasone sodium phosphate,glucagon,human recombinant,digoxin,cefuroxi me sodium,ranitidine hcl,ceftazidime,cefepime hcl,mepivacaine hcl/pf,mepivacaine hcl,isoproterenol hcl,bupivacaine hcl/pf,bupivacaine hcl,bupivacaine hcl/epinephrine/pf,bupivacai ne hcl/epinephrine,bupivacaine hcl/dextrosewater/pf,tetracaine hcl/pf,succinylcholine chloride,indigotindisulfonate sodium,cosyntropin,lorazepa m,morphine sulfate/pf,promethazine hcl,glycopyrrolate,rho(d) immune globulin/maltose,immune ADD TO FORMULARY Previous Value New Value Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 706 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name hp,vidaza,procrit, hepagam b,astramorphpf,sensorcainempf epinephrine,sens orcainempf,sensorcaine, nesacainempf,xylocaine with epinephrine,xyloc aine,xylocainempf with epinephrine,xyloc ainempf,d.h.e.45,cog entin,vitrase,gam maked,adrenaclic k,swabflush,cere byx,sculptra globulin,gamm(igg)/glycine/i ga greater than 50 mcg/ml,fentanyl citrate/pf,alfentanil hcl,indocyanine green,colistin (as colistimethate sodium),ketamine hcl,oxytocin,vasopressin,hal operidol lactate,epoetin alfa,hydromorphone hcl/pf,azacitidine,hepatitis b immune globulin/maltose,chloroproca ine hcl/pf,lidocaine hcl/epinephrine,lidocaine hcl,lidocaine hcl/epinephrine/pf,lidocaine hcl/pf,dihydroergotamine mesylate,benztropine mesylate,hyaluronidase,ovin e,0.9 % sodium chloride,fosphenytoin sodium,poly-l-lactic acid/carboxymethylcellulose sodium/mannitol Type of Change Previous Value New Value 06/25/2014 ACTOPLUS MET pioglitazone hcl/metformin XR hcl ADD UM: GENDER Female 06/25/2014 ACTOPLUS MET pioglitazone hcl/metformin XR hcl ADD UM: GENDER Female 06/25/2014 ACTOS pioglitazone hcl ADD UM: GENDER Female 06/25/2014 ADOXA doxycycline monohydrate ADD UM: GENDER Female 06/25/2014 ADVICOR niacin/lovastatin ADD UM: GENDER Female 06/25/2014 ADVICOR niacin/lovastatin ADD UM: GENDER Female 06/25/2014 alprazolam odt alprazolam ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 707 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 alprazolam odt alprazolam ADD UM: GENDER Female 06/25/2014 alprazolam odt alprazolam ADD UM: GENDER Female 06/25/2014 ANIMI-3 omega3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol ADD UM: GENDER Female 06/25/2014 ANIMI-3 WITH VITAMIN D omega3/dha/epa/d3/b12/folic acid/pyridox hcl/phytosterol ADD UM: GENDER Female 06/25/2014 ANORO ELLIPTA umeclidinium bromide/vilanterol trifenatate ADD UM: GENDER Female 06/25/2014 BIAXIN XL clarithromycin ADD UM: GENDER Female 06/25/2014 BIAXIN XL clarithromycin ADD UM: GENDER Female 06/25/2014 BREVICON norethindrone-ethinyl estradiol ADD UM: GENDER Female 06/25/2014 CAVERJECT alprostadil ADD UM: GENDER Male 06/25/2014 CAVERJECT alprostadil ADD UM: GENDER Male 06/25/2014 CAVERJECT alprostadil ADD UM: GENDER Male 06/25/2014 CAVERJECT alprostadil ADD UM: GENDER Male 06/25/2014 CAYSTON aztreonam lysine ADD UM: GENDER Male 06/25/2014 CEDAX ceftibuten dihydrate ADD UM: GENDER Male 06/25/2014 CEDAX ceftibuten ADD UM: GENDER Male 06/25/2014 CENESTIN estrogens,conj.,synthetic a ADD UM: GENDER Female 06/25/2014 CENESTIN estrogens,conj.,synthetic a ADD UM: GENDER Female 06/25/2014 CEREFOLIN NAC levomefolate ca/acetylcysteine/mecobala min/schiz. algal oil ADD UM: GENDER Female 06/25/2014 CESAMET nabilone ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 708 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 CETACAINE ANESTHETIC tetracaine/benzocaine/buta mben ADD UM: GENDER Female 06/25/2014 CLARINEX desloratadine ADD UM: GENDER Female 06/25/2014 CLARINEX desloratadine ADD UM: GENDER Female 06/25/2014 CLARINEX desloratadine ADD UM: GENDER Female 06/25/2014 clever choice pro blood sugar diagnostic ADD UM: GENDER Female 06/25/2014 clever choice talk blood sugar diagnostic ADD UM: GENDER Female 06/25/2014 CLIMARA estradiol ADD UM: GENDER Female 06/25/2014 CLIMARA estradiol ADD UM: GENDER Female 06/25/2014 CLIMARA estradiol ADD UM: GENDER Female 06/25/2014 CLIMARA estradiol ADD UM: GENDER Female 06/25/2014 CLIMARA estradiol ADD UM: GENDER Female 06/25/2014 CLIMARA PRO estradiol/levonorgestrel ADD UM: GENDER Female 06/25/2014 CLINDACIN ETZ clindamycin phosphate/skin cleanser comb no.19 ADD UM: GENDER Female 06/25/2014 CLINDACIN PAC clindamycin phosphate/skin cleanser comb no.19 ADD UM: GENDER Female 06/25/2014 CLINDESSE clindamycin phosphate ADD UM: GENDER Female 06/25/2014 clonidine clonidine ADD UM: GENDER Female 06/25/2014 COZAAR losartan potassium ADD UM: GENDER Female 06/25/2014 ketone care urine acetone test,strips ADD UM: GENDER Female 06/25/2014 CYCLESSA desogestrel-ethinyl estradiol ADD UM: GENDER Female 06/25/2014 cyclopentolate hcl cyclopentolate hcl ADD UM: GENDER Female 06/25/2014 DESOXYN methamphetamine hcl ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 709 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 ADVANCED DNA lidocaine hcl/glycerin MEDICATED COLLECT ADD UM: GENDER Female 06/25/2014 DONNATAL phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb ADD UM: GENDER Female 06/25/2014 DONNATAL phenobarbital/hyoscyamine sulf/atropine sulf/scopolamine hb ADD UM: GENDER Female 06/25/2014 EDEX alprostadil ADD UM: GENDER Male 06/25/2014 EDEX alprostadil ADD UM: GENDER Male 06/25/2014 eemt estrogens,esterified/methylt estosterone ADD UM: GENDER Male 06/25/2014 EFFEXOR XR venlafaxine hcl ADD UM: GENDER Male 06/25/2014 EFFEXOR XR venlafaxine hcl ADD UM: GENDER Male 06/25/2014 EFFEXOR XR venlafaxine hcl ADD UM: GENDER Male 06/25/2014 FEMHRT norethindrone acetateethinyl estradiol ADD UM: GENDER Female 06/25/2014 fenofibrate fenofibrate,micronized ADD UM: GENDER Female 06/25/2014 fenofibrate fenofibrate,micronized ADD UM: GENDER Female 06/25/2014 fenofibrate fenofibrate,micronized ADD UM: GENDER Female 06/25/2014 FOLLISTIM AQ follitropin beta,recomb ADD UM: GENDER Female 06/25/2014 GEODON ziprasidone hcl ADD UM: GENDER Female 06/25/2014 HETLIOZ tasimelteon ADD UM: GENDER Female 06/25/2014 HIZENTRA immune globulin,gamma (igg)/proline/iga 0 to 50 mcg/ml ADD UM: GENDER Female 06/25/2014 LEVITRA vardenafil hcl ADD UM: GENDER Male BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 710 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 LEVITRA vardenafil hcl ADD UM: GENDER Male 06/25/2014 LEVITRA vardenafil hcl ADD UM: GENDER Male 06/25/2014 levofloxacin levofloxacin ADD UM: GENDER Male 06/25/2014 levofloxacin levofloxacin ADD UM: GENDER Male 06/25/2014 levofloxacin levofloxacin ADD UM: GENDER Male 06/25/2014 lofibra fenofibrate,micronized ADD UM: GENDER Female 06/25/2014 lofibra fenofibrate,micronized ADD UM: GENDER Female 06/25/2014 lofibra fenofibrate ADD UM: GENDER Female 06/25/2014 MAVIK trandolapril ADD UM: GENDER Female 06/25/2014 METADATE CD methylphenidate hcl ADD UM: GENDER Female 06/25/2014 METADATE CD methylphenidate hcl ADD UM: GENDER Female 06/25/2014 MUSE alprostadil ADD UM: GENDER Male 06/25/2014 MUSE alprostadil ADD UM: GENDER Male 06/25/2014 MUSE alprostadil ADD UM: GENDER Male 06/25/2014 MUSE alprostadil ADD UM: GENDER Male 06/25/2014 MUSE alprostadil ADD UM: GENDER Male 06/25/2014 MYOBLOC rimabotulinumtoxinb ADD UM: GENDER Male 06/25/2014 MYRBETRIQ mirabegron ADD UM: GENDER Male 06/25/2014 MYRBETRIQ mirabegron ADD UM: GENDER Male 06/25/2014 nateglinide nateglinide ADD UM: GENDER Female 06/25/2014 nateglinide nateglinide ADD UM: GENDER Female 06/25/2014 NEORAL cyclosporine, modified ADD UM: GENDER Female 06/25/2014 NEORAL cyclosporine, modified ADD UM: GENDER Female 06/25/2014 NEORAL cyclosporine, modified ADD UM: GENDER Female 06/25/2014 NEUPRO rotigotine ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 711 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 NEUPRO rotigotine ADD UM: GENDER Female 06/25/2014 NEUPRO rotigotine ADD UM: GENDER Female 06/25/2014 nova max glucose test strips blood sugar diagnostic ADD UM: GENDER Female 06/25/2014 NYMALIZE nimodipine ADD UM: GENDER Female 06/25/2014 NYMALIZE nimodipine ADD UM: GENDER Female 06/25/2014 NYMALIZE nimodipine ADD UM: GENDER Female 06/25/2014 OLEPTRO ER trazodone hcl ADD UM: GENDER Female 06/25/2014 OLUX clobetasol propionate ADD UM: GENDER Female 06/25/2014 OXISTAT oxiconazole nitrate ADD UM: GENDER Female 06/25/2014 oxycodone hcl oxycodone hcl ADD UM: GENDER Female 06/25/2014 pnv folic acid + iron prenatal vitamins combo no.60/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal plus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal plus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal plus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 PODIAPN pyridoxal phos/methyltetrahydrofolate gluc/mecobalamin/ala ADD UM: GENDER Female 06/25/2014 poly-tussin d chlorcyclizine hcl/pseudoephedrine hcl/codeine phosphate ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 712 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 poly-tussin chlorcyclizine hcl/codeine phosphate ADD UM: GENDER Female 06/25/2014 prenaissance prenatal vit with calcium no.80/iron fum/folic acid/dss/dha ADD UM: GENDER Female 06/25/2014 PRENAISSANCE prenatal vit/folic NEXT-B acid/b6/calcium carb/ginger ADD UM: GENDER Female 06/25/2014 prenaplus prenatal vits with calcium #74/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 PRENATA prenatal vitamins combo no.37/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 PRENATABS FA prenatal vits with calcium #78/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal 19 prenatal vitamins comb no.115/iron fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal 19 prenatal vitamins comb no.115/iron fumarate/folic acid/dss ADD UM: GENDER Female 06/25/2014 prenatal plus prenatal vits with calcium #72/iron,carbonyl/folic acid ADD UM: GENDER Female 06/25/2014 prenatal plus prenatal vits with calcium #72/iron,carbonyl/folic acid ADD UM: GENDER Female 06/25/2014 prenatal plus prenatal vits with calcium #72/iron,carbonyl/folic acid ADD UM: GENDER Female 06/25/2014 prenatal plus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 713 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 prenatal plus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal plus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal plus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal plus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal plus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal vitamin plus low iron prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal vitamin plus low iron prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 prenatal-u prenatal vits without calc no5/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 PRENATE AM prenatal vitamins no.114/methyltetrahydfolate gluc,fa/ginger ADD UM: GENDER Female 06/25/2014 PRENATE DHA prenatal vitamins no.38/iron fumarate/folate comb no.6/dha ADD UM: GENDER Female 06/25/2014 PRENATE ELITE prenatal vitamins combo #36/ferrous fumarate/folate combo #6 ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 714 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 PRENATE ELITE prenatal vitamins combo #36/ferrous fumarate/folate combo #6 ADD UM: GENDER Female 06/25/2014 PRENATE ENHANCE prenatal vitamin combo no.68/iron fumarate/fa combo no.6/dha ADD UM: GENDER Female 06/25/2014 PRENATE ESSENTIAL pnv no.35/iron fumarate/folate comb. #6/dha ADD UM: GENDER Female 06/25/2014 PRENATE MINI prenatal vitamins #44/iron,carbonyl/folic acid/dha ADD UM: GENDER Female 06/25/2014 PRENATE RESTORE prenatal vitamins combo no.69/iron fumarate/fa comb no.6/dha ADD UM: GENDER Female 06/25/2014 preplus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 preplus prenatal vits with calcium #72/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 PREPOPIK sodium picosulfate/magnesium oxide/citric acid ADD UM: GENDER Female 06/25/2014 PREPOPIK sodium picosulfate/magnesium oxide/citric acid ADD UM: GENDER Female 06/25/2014 PRESERA emollient combination no.80 ADD UM: GENDER Female 06/25/2014 PREVACID lansoprazole ADD UM: GENDER Female 06/25/2014 STIVARGA regorafenib ADD UM: GENDER Male 06/25/2014 STIVARGA regorafenib ADD UM: GENDER Male BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 715 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 STRATTERA atomoxetine hcl ADD UM: GENDER Male 06/25/2014 TEVETEN HCT eprosartan mesylate/hydrochlorothiazid e ADD UM: GENDER Male 06/25/2014 TEVETEN HCT eprosartan mesylate/hydrochlorothiazid e ADD UM: GENDER Male 06/25/2014 tl-select prenatal vit with calcium no.80/iron fum/folic acid/dss/dha ADD UM: GENDER Female 06/25/2014 TL-SELECT DHA prenatal vitamin no.57/iron fum/folic acid/dss/dha ADD UM: GENDER Female 06/25/2014 TOBI PODHALER tobramycin ADD UM: GENDER Female 06/25/2014 TOBI PODHALER tobramycin ADD UM: GENDER Female 06/25/2014 TOBI PODHALER tobramycin ADD UM: GENDER Female 06/25/2014 TRETIN-X tretinoin ADD UM: GENDER Male 06/25/2014 TRETIN-X tretinoin/emollient combination no. 9/skin cln1 ADD UM: GENDER Male 06/25/2014 triveen-prx rnf prenatal vit with calcium no.66/iron fum/folic acid/dss/dha ADD UM: GENDER Female 06/25/2014 triveen-prx rnf prenatal vit with calcium no.66/iron fum/folic acid/dss/dha ADD UM: GENDER Female 06/25/2014 triveen-u prenatal vits without calc no5/ferrous fumarate/folic acid ADD UM: GENDER Female BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 716 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 tri-vitamin with fluoride pediatric multivit with a,c,d3 no.21/sodium fluoride ADD UM: GENDER Female 06/25/2014 tri-vitamin with fluoride pediatric multivit with a,c,d3 no.21/sodium fluoride ADD UM: GENDER Female 06/25/2014 TROKENDI XR topiramate ADD UM: GENDER Female 06/25/2014 VERAMYST fluticasone furoate ADD UM: GENDER Female 06/25/2014 VIRASAL salicylic acid ADD UM: GENDER Female 06/25/2014 virt-select prenatal vit with calcium no.80/iron fum/folic acid/dss/dha ADD UM: GENDER Female 06/25/2014 VITAMEDMD REDICHEW RX prenatal vitamins combination no.42/folic acid ADD UM: GENDER Female 06/25/2014 vol-plus prenatal vits with calcium #74/ferrous fumarate/folic acid ADD UM: GENDER Female 06/25/2014 XALATAN latanoprost ADD UM: GENDER Female 06/25/2014 XALKORI crizotinib ADD UM: GENDER Female 06/25/2014 YAZ ethinyl estradiol/drospirenone ADD UM: GENDER Female 06/25/2014 zaleplon zaleplon ADD UM: GENDER Female 06/25/2014 zaleplon zaleplon ADD UM: GENDER Female 06/25/2014 zaleplon zaleplon ADD UM: GENDER Female 06/25/2014 ACTEMRA tocilizumab ADD UM: AUTHORIZATION PA applies 06/25/2014 ACTIVE FE iron,carbonyl/folic acid/multivitamin with minerals ADD UM: AUTHORIZATION PA applies 06/25/2014 ACTIVE OB prenatal vitamins combo no.66/iron,carbonyl/folic acid/dha ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 717 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 ACTIVELLA estradiol/norethindrone acetate ADD UM: AUTHORIZATION PA applies 06/25/2014 alanine alanine ADD UM: AUTHORIZATION PA applies 06/25/2014 alanine alanine ADD UM: AUTHORIZATION PA applies 06/25/2014 ALREX loteprednol etabonate ADD UM: AUTHORIZATION PA applies 06/25/2014 ALREX loteprednol etabonate ADD UM: AUTHORIZATION PA applies 06/25/2014 ALREX loteprednol etabonate ADD UM: AUTHORIZATION PA applies 06/25/2014 ARICEPT donepezil hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 ARICEPT donepezil hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 ARIXTRA fondaparinux sodium ADD UM: AUTHORIZATION PA applies 06/25/2014 AURSTAT sod mag ADD UM: AUTHORIZATION fluorosilic/cyclometh/phosph ac/sod bicarb/sod chlor PA applies 06/25/2014 AURSTAT emol#53/na mg ADD UM: AUTHORIZATION fluorosilicate/cyclometh/pho sph ac/nahco3/nacl PA applies 06/25/2014 AVINZA morphine sulfate ADD UM: AUTHORIZATION PA applies 06/25/2014 BENEFIX factor ix human recombinant ADD UM: AUTHORIZATION PA applies 06/25/2014 BENEFIX factor ix human recombinant ADD UM: AUTHORIZATION PA applies 06/25/2014 BENZEFOAM benzoyl peroxide ADD UM: AUTHORIZATION PA applies 06/25/2014 BENZEFOAM benzoyl peroxide ADD UM: AUTHORIZATION PA applies 06/25/2014 BENZEFOAM ULTRA benzoyl peroxide ADD UM: AUTHORIZATION PA applies 06/25/2014 BETASERON interferon beta-1b ADD UM: AUTHORIZATION PA applies 06/25/2014 BETASERON interferon beta-1b ADD UM: AUTHORIZATION PA applies 06/25/2014 BEYAZ drospirenone/ethinyl estradiol/levomefolate calcium ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 718 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 BEYAZ drospirenone/ethinyl estradiol/levomefolate calcium ADD UM: AUTHORIZATION PA applies 06/25/2014 BIAXIN XL clarithromycin ADD UM: AUTHORIZATION PA applies 06/25/2014 bp foam benzoyl peroxide ADD UM: AUTHORIZATION PA applies 06/25/2014 bp foam benzoyl peroxide ADD UM: AUTHORIZATION PA applies 06/25/2014 bp foam benzoyl peroxide ADD UM: AUTHORIZATION PA applies 06/25/2014 BREVICON norethindrone-ethinyl estradiol ADD UM: AUTHORIZATION PA applies 06/25/2014 CEDAX ceftibuten ADD UM: AUTHORIZATION PA applies 06/25/2014 chemstrip 10 with urine multiple test strips sg ADD UM: AUTHORIZATION PA applies 06/25/2014 cyclopentolate hcl cyclopentolate hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 EYLEA aflibercept ADD UM: AUTHORIZATION PA applies 06/25/2014 E-Z DISK barium sulfate ADD UM: AUTHORIZATION PA applies 06/25/2014 ez smart plus blood sugar diagnostic ADD UM: AUTHORIZATION PA applies 06/25/2014 ez smart blood sugar diagnostic ADD UM: AUTHORIZATION PA applies 06/25/2014 FIRSTlansoprazole LANSOPRAZOL E ADD UM: AUTHORIZATION PA applies 06/25/2014 FIRSTlansoprazole LANSOPRAZOL E ADD UM: AUTHORIZATION PA applies 06/25/2014 FOLLISTIM AQ follitropin beta,recomb ADD UM: AUTHORIZATION PA applies 06/25/2014 FOLLISTIM AQ follitropin beta,recomb ADD UM: AUTHORIZATION PA applies 06/25/2014 foltanx mecobalamin/levomefolate ADD UM: AUTHORIZATION calcium/pyridoxal phosphate PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 719 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 FOLTX cyanocobalamin/levomefolat ADD UM: AUTHORIZATION e calcium/pyridoxine hcl PA applies 06/25/2014 FORFIVO XL bupropion hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 FOSAMAX PLUS alendronate D sodium/cholecalciferol (vitamin d3) ADD UM: AUTHORIZATION PA applies 06/25/2014 GLYTACTIN 15 nutritional therapy for pku PE BETTERMILK with iron no.41 ADD UM: AUTHORIZATION PA applies 06/25/2014 GLYTACTIN RTD nutritional therapy for pku 10 PE with iron no.41 ADD UM: AUTHORIZATION PA applies 06/25/2014 GLYTACTIN RTD nutritional therapy for pku 10 PE with iron no.41 ADD UM: AUTHORIZATION PA applies 06/25/2014 GLYTACTIN RTD nutritional therapy for pku 15 PE with iron no.41 ADD UM: AUTHORIZATION PA applies 06/25/2014 GLYTACTIN RTD nutritional therapy for pku 15 PE with iron no.41 ADD UM: AUTHORIZATION PA applies 06/25/2014 GRALISE gabapentin ADD UM: AUTHORIZATION PA applies 06/25/2014 GRALISE gabapentin ADD UM: AUTHORIZATION PA applies 06/25/2014 GRALISE gabapentin ADD UM: AUTHORIZATION PA applies 06/25/2014 GRALISE gabapentin ADD UM: AUTHORIZATION PA applies 06/25/2014 GRANIX tbo-filgrastim ADD UM: AUTHORIZATION PA applies 06/25/2014 GRANIX tbo-filgrastim ADD UM: AUTHORIZATION PA applies 06/25/2014 GRANIX tbo-filgrastim ADD UM: AUTHORIZATION PA applies 06/25/2014 GRANIX tbo-filgrastim ADD UM: AUTHORIZATION PA applies 06/25/2014 GRASTEK allergenic extract,grass pollen-timothy,standard ADD UM: AUTHORIZATION PA applies 06/25/2014 HELIXATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 720 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 HELIXATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 HELIXATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 HELIXATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 HELIXATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 hema-combistix urine multiple test strips ADD UM: AUTHORIZATION PA applies 06/25/2014 hemenatal ob + dha prenatal vitamin combo ADD UM: AUTHORIZATION no.22/iron/folic acid/omega3/dha PA applies 06/25/2014 hemenatal ob prenatal vit no.21/iron polysacch,heme polypep/folic acid ADD UM: AUTHORIZATION PA applies 06/25/2014 hpr plus emollient combination no.53 ADD UM: AUTHORIZATION PA applies 06/25/2014 hpr plus emollient combination no.53 ADD UM: AUTHORIZATION PA applies 06/25/2014 hpr plus-mb hydrogel emol53/e.water/namgfs/nap ADD UM: AUTHORIZATION hos/nacl/hypochlorous acid/nahypocl PA applies 06/25/2014 HUMATROPE somatropin ADD UM: AUTHORIZATION PA applies 06/25/2014 HUMATROPE somatropin ADD UM: AUTHORIZATION PA applies 06/25/2014 HYCET hydrocodone bitartrate/acetaminophen ADD UM: AUTHORIZATION PA applies 06/25/2014 HYDREA hydroxyurea ADD UM: AUTHORIZATION PA applies 06/25/2014 hydrocodonehydrocodone chlorpheniramne polistirex/chlorpheniramine er polistirex ADD UM: AUTHORIZATION PA applies 06/25/2014 IMBRUVICA ADD UM: AUTHORIZATION PA applies ibrutinib BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 721 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 06/25/2014 INFERGEN 06/25/2014 Generic Name interferon alfacon-1 Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies infinity test strips blood sugar diagnostic ADD UM: AUTHORIZATION PA applies 06/25/2014 infinity test strips blood sugar diagnostic ADD UM: AUTHORIZATION PA applies 06/25/2014 INLYTA axitinib ADD UM: AUTHORIZATION PA applies 06/25/2014 INVEGA SUSTENNA paliperidone palmitate ADD UM: AUTHORIZATION PA applies 06/25/2014 INVEGA SUSTENNA paliperidone palmitate ADD UM: AUTHORIZATION PA applies 06/25/2014 INVOKANA canagliflozin ADD UM: AUTHORIZATION PA applies 06/25/2014 INVOKANA canagliflozin ADD UM: AUTHORIZATION PA applies 06/25/2014 INVOKANA canagliflozin ADD UM: AUTHORIZATION PA applies 06/25/2014 JAKAFI ruxolitinib phosphate ADD UM: AUTHORIZATION PA applies 06/25/2014 JAKAFI ruxolitinib phosphate ADD UM: AUTHORIZATION PA applies 06/25/2014 JENTADUETO linagliptin/metformin hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 JENTADUETO linagliptin/metformin hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 JENTADUETO linagliptin/metformin hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 jinteli norethindrone acetateethinyl estradiol ADD UM: AUTHORIZATION PA applies 06/25/2014 KADIAN morphine sulfate ADD UM: AUTHORIZATION PA applies 06/25/2014 KADIAN morphine sulfate ADD UM: AUTHORIZATION PA applies 06/25/2014 KARBINAL ER carbinoxamine maleate ADD UM: AUTHORIZATION PA applies 06/25/2014 KAZANO alogliptin benzoate/metformin hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 KOATE-DVI antihemophilic factor, human ADD UM: AUTHORIZATION PA applies 06/25/2014 KOATE-DVI antihemophilic factor, human ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 722 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 KOGENATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 KOGENATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 KOGENATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 KOGENATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 KOGENATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 KOGENATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 KOGENATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 KOGENATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 KOGENATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 KOGENATE FS antihemophilic factor (fviii) ADD UM: AUTHORIZATION recomb,full length (alb-free) PA applies 06/25/2014 KORLYM mifepristone ADD UM: AUTHORIZATION PA applies 06/25/2014 KORLYM mifepristone ADD UM: AUTHORIZATION PA applies 06/25/2014 KRISTALOSE lactulose ADD UM: AUTHORIZATION PA applies 06/25/2014 l-alanine alanine ADD UM: AUTHORIZATION PA applies 06/25/2014 l-alanine alanine ADD UM: AUTHORIZATION PA applies 06/25/2014 matzim la diltiazem hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 matzim la diltiazem hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 METADATE CD methylphenidate hcl ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 723 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 METADATE CD methylphenidate hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 MYRBETRIQ mirabegron ADD UM: AUTHORIZATION PA applies 06/25/2014 NEEVODHA prenatal no.64/iron fum/lmefolate ca/algal oil/soy lecithin ADD UM: AUTHORIZATION PA applies 06/25/2014 NORDITROPIN NORDIFLEX somatropin ADD UM: AUTHORIZATION PA applies 06/25/2014 NORINYL 1+50 norethindrone-mestranol ADD UM: AUTHORIZATION PA applies 06/25/2014 normlgel ag silver carbonate ADD UM: AUTHORIZATION PA applies 06/25/2014 NOROXIN norfloxacin ADD UM: AUTHORIZATION PA applies 06/25/2014 omeprazolesodium bicarbonate omeprazole/sodium bicarbonate ADD UM: AUTHORIZATION PA applies 06/25/2014 OMNITROPE somatropin ADD UM: AUTHORIZATION PA applies 06/25/2014 OMNITROPE somatropin ADD UM: AUTHORIZATION PA applies 06/25/2014 onetouch ultra test strips blood sugar diagnostic ADD UM: AUTHORIZATION PA applies 06/25/2014 onetouch ultra test strips blood sugar diagnostic ADD UM: AUTHORIZATION PA applies 06/25/2014 onetouch ultra test strips blood sugar diagnostic ADD UM: AUTHORIZATION PA applies 06/25/2014 ONMEL itraconazole ADD UM: AUTHORIZATION PA applies 06/25/2014 ONMEL itraconazole ADD UM: AUTHORIZATION PA applies 06/25/2014 OPANA oxymorphone hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 ORENITRAM ER treprostinil diolamine ADD UM: AUTHORIZATION PA applies 06/25/2014 ORENITRAM ER treprostinil diolamine ADD UM: AUTHORIZATION PA applies 06/25/2014 OTREXUP methotrexate/pf ADD UM: AUTHORIZATION PA applies 06/25/2014 OTREXUP methotrexate/pf ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 724 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 OTREXUP methotrexate/pf ADD UM: AUTHORIZATION PA applies 06/25/2014 OTREXUP methotrexate/pf ADD UM: AUTHORIZATION PA applies 06/25/2014 OTREXUP methotrexate/pf ADD UM: AUTHORIZATION PA applies 06/25/2014 OVCON-35 norethindrone-ethinyl estradiol ADD UM: AUTHORIZATION PA applies 06/25/2014 OVIDREL choriogonadotropin alfa ADD UM: AUTHORIZATION PA applies 06/25/2014 OXECTA oxycodone hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 oxycodone hcl oxycodone hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 POMALYST pomalidomide ADD UM: AUTHORIZATION PA applies 06/25/2014 POMALYST pomalidomide ADD UM: AUTHORIZATION PA applies 06/25/2014 POMALYST pomalidomide ADD UM: AUTHORIZATION PA applies 06/25/2014 POMALYST pomalidomide ADD UM: AUTHORIZATION PA applies 06/25/2014 POMALYST pomalidomide ADD UM: AUTHORIZATION PA applies 06/25/2014 POTIGA ezogabine ADD UM: AUTHORIZATION PA applies 06/25/2014 POTIGA ezogabine ADD UM: AUTHORIZATION PA applies 06/25/2014 POTIGA ezogabine ADD UM: AUTHORIZATION PA applies 06/25/2014 prodigy no coding blood sugar diagnostic ADD UM: AUTHORIZATION PA applies 06/25/2014 prodigy no coding blood sugar diagnostic ADD UM: AUTHORIZATION PA applies 06/25/2014 PROMACTA eltrombopag olamine ADD UM: AUTHORIZATION PA applies 06/25/2014 PROMACTA eltrombopag olamine ADD UM: AUTHORIZATION PA applies 06/25/2014 PRO-RED AC dexchlorpheniramine maleate/phenylephrine hcl/codeine,pyrilamine maleate/phenylephrine hcl/codeine phosphate ADD UM: AUTHORIZATION PA applies 06/25/2014 PROSCAR finasteride ADD UM: AUTHORIZATION PA applies 06/25/2014 PROSCAR finasteride ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 725 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name 06/25/2014 REBETOL 06/25/2014 Generic Name ribavirin Type of Change Previous Value New Value ADD UM: AUTHORIZATION PA applies RECOMBINATE antihemophilic factor viii, human recombinant ADD UM: AUTHORIZATION PA applies 06/25/2014 RECOMBINATE antihemophilic factor viii, human recombinant ADD UM: AUTHORIZATION PA applies 06/25/2014 RECOMBINATE antihemophilic factor viii, human recombinant ADD UM: AUTHORIZATION PA applies 06/25/2014 RECOMBINATE antihemophilic factor viii, human recombinant ADD UM: AUTHORIZATION PA applies 06/25/2014 RECOMBINATE antihemophilic factor viii, human recombinant ADD UM: AUTHORIZATION PA applies 06/25/2014 RECOMBINATE antihemophilic factor viii, human recombinant ADD UM: AUTHORIZATION PA applies 06/25/2014 RECOMBINATE antihemophilic factor viii, human recombinant ADD UM: AUTHORIZATION PA applies 06/25/2014 RECOMBIVAX HB hepatitis b virus vaccine recombinant/pf ADD UM: AUTHORIZATION PA applies 06/25/2014 RECOMBIVAX HB hepatitis b virus vaccine recombinant/pf ADD UM: AUTHORIZATION PA applies 06/25/2014 RECOMBIVAX HB hepatitis b virus vaccine recombinant/pf ADD UM: AUTHORIZATION PA applies 06/25/2014 RECOMBIVAX HB hepatitis b virus vaccine recombinant/pf ADD UM: AUTHORIZATION PA applies 06/25/2014 RECOMBIVAX HB hepatitis b virus vaccine recombinant/pf ADD UM: AUTHORIZATION PA applies 06/25/2014 RELENZA zanamivir ADD UM: AUTHORIZATION PA applies 06/25/2014 RELENZA zanamivir ADD UM: AUTHORIZATION PA applies 06/25/2014 RELENZA zanamivir ADD UM: AUTHORIZATION PA applies 06/25/2014 REMODULIN treprostinil sodium ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 726 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 REMODULIN treprostinil sodium ADD UM: AUTHORIZATION PA applies 06/25/2014 RENVELA sevelamer carbonate ADD UM: AUTHORIZATION PA applies 06/25/2014 RENVELA sevelamer carbonate ADD UM: AUTHORIZATION PA applies 06/25/2014 RENVELA sevelamer carbonate ADD UM: AUTHORIZATION PA applies 06/25/2014 REZYST saccharomyces boulardii ADD UM: AUTHORIZATION PA applies 06/25/2014 RHEUMATE methyltetrahydrofolate gluc/mecobalamin/herbal no.236 ADD UM: AUTHORIZATION PA applies 06/25/2014 RHINOCORT AQUA budesonide ADD UM: AUTHORIZATION PA applies 06/25/2014 SALVAX DUO PLUS salicylic acid/urea ADD UM: AUTHORIZATION PA applies 06/25/2014 SANCTURA trospium chloride ADD UM: AUTHORIZATION PA applies 06/25/2014 SANDIMMUNE cyclosporine ADD UM: AUTHORIZATION PA applies 06/25/2014 SOMAVERT pegvisomant ADD UM: AUTHORIZATION PA applies 06/25/2014 SOMAVERT pegvisomant ADD UM: AUTHORIZATION PA applies 06/25/2014 SOMAVERT pegvisomant ADD UM: AUTHORIZATION PA applies 06/25/2014 SOMAVERT pegvisomant ADD UM: AUTHORIZATION PA applies 06/25/2014 SOMAVERT pegvisomant ADD UM: AUTHORIZATION PA applies 06/25/2014 SONATA zaleplon ADD UM: AUTHORIZATION PA applies 06/25/2014 SONATA zaleplon ADD UM: AUTHORIZATION PA applies 06/25/2014 SONATA zaleplon ADD UM: AUTHORIZATION PA applies 06/25/2014 SPORANOX itraconazole ADD UM: AUTHORIZATION PA applies 06/25/2014 STENDRA avanafil ADD UM: AUTHORIZATION PA applies 06/25/2014 STENDRA avanafil ADD UM: AUTHORIZATION PA applies 06/25/2014 STRATTERA atomoxetine hcl ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 727 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 STRATTERA atomoxetine hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 SUBOXONE buprenorphine hcl/naloxone ADD UM: AUTHORIZATION hcl PA applies 06/25/2014 SYLATRON peginterferon alfa-2b ADD UM: AUTHORIZATION PA applies 06/25/2014 SYLATRON peginterferon alfa-2b ADD UM: AUTHORIZATION PA applies 06/25/2014 SYMLINPEN 120 pramlintide acetate ADD UM: AUTHORIZATION PA applies 06/25/2014 SYMLINPEN 60 pramlintide acetate ADD UM: AUTHORIZATION PA applies 06/25/2014 SYNALAR fluocinolone acetonide/emollient combination no.65 ADD UM: AUTHORIZATION PA applies 06/25/2014 TAMIFLU oseltamivir phosphate ADD UM: AUTHORIZATION PA applies 06/25/2014 TAMIFLU oseltamivir phosphate ADD UM: AUTHORIZATION PA applies 06/25/2014 TARGRETIN bexarotene ADD UM: AUTHORIZATION PA applies 06/25/2014 TARKA trandolapril/verapamil hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 TARKA trandolapril/verapamil hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 TECFIDERA dimethyl fumarate ADD UM: AUTHORIZATION PA applies 06/25/2014 TEGRETOL XR carbamazepine ADD UM: AUTHORIZATION PA applies 06/25/2014 TEGRETOL XR carbamazepine ADD UM: AUTHORIZATION PA applies 06/25/2014 THEO-24 theophylline anhydrous ADD UM: AUTHORIZATION PA applies 06/25/2014 THEO-24 theophylline anhydrous ADD UM: AUTHORIZATION PA applies 06/25/2014 TOPAMAX topiramate ADD UM: AUTHORIZATION PA applies 06/25/2014 TOPAMAX topiramate ADD UM: AUTHORIZATION PA applies 06/25/2014 TOPAMAX topiramate ADD UM: AUTHORIZATION PA applies 06/25/2014 ultima blood sugar diagnostic ADD UM: AUTHORIZATION PA applies 06/25/2014 VIDEX didanosine ADD UM: AUTHORIZATION PA applies 06/25/2014 VIDEX EC didanosine ADD UM: AUTHORIZATION PA applies BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 728 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/25/2014 VINATE DHA RF prenatal no.64/iron fum/lmefolate ca/algal oil/soy lecithin ADD UM: AUTHORIZATION PA applies 06/25/2014 VIRAMUNE XR nevirapine ADD UM: AUTHORIZATION PA applies 06/25/2014 XELJANZ tofacitinib citrate ADD UM: AUTHORIZATION PA applies 06/25/2014 XERESE acyclovir/hydrocortisone ADD UM: AUTHORIZATION PA applies 06/25/2014 YASMIN 28 ethinyl estradiol/drospirenone ADD UM: AUTHORIZATION PA applies 06/25/2014 YAZ ethinyl estradiol/drospirenone ADD UM: AUTHORIZATION PA applies 06/25/2014 ZONALON doxepin hcl ADD UM: AUTHORIZATION PA applies 06/25/2014 ZYVOX linezolid ADD UM: AUTHORIZATION PA applies 06/26/2014 ROBAXIN methocarbamol CHANGE TIER Preferred Brands Not Covered 06/26/2014 cosyntropin cosyntropin CHANGE TIER Generics Not Covered 06/26/2014 cosyntropin cosyntropin CHANGE TIER Generics Not Covered 06/26/2014 oxytocin oxytocin CHANGE TIER Generics Not Covered 06/26/2014 VANIQA eflornithine hcl CHANGE TIER Preferred Brands Not Covered 06/26/2014 VASCEPA icosapent ethyl CHANGE TIER Preferred Brands Not Covered 06/26/2014 ROBAXIN methocarbamol CHANGE TIER Preferred Brands Not Covered 06/26/2014 kendall 0.9% nacl 0.9 % sodium chloride with cap CHANGE TIER Generics Not Covered 06/26/2014 oxytocin oxytocin CHANGE TIER Generics Not Covered 06/26/2014 oxytocin oxytocin CHANGE TIER Generics Not Covered 06/26/2014 ARISTOSPAN triamcinolone hexacetonide CHANGE TIER Preferred Brands Not Covered 06/26/2014 VAYACOG phosphatidyl serine/omega3 fatty acids/dha/epa CHANGE TIER Preferred Brands Not Covered 06/26/2014 oxytocin oxytocin CHANGE TIER Generics Not Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 729 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 oxytocin oxytocin CHANGE TIER Generics Not Covered 06/26/2014 LATISSE bimatoprost CHANGE TIER Preferred Brands Not Covered 06/26/2014 BOTOX COSMETIC onabotulinumtoxina CHANGE TIER Preferred Brands Not Covered 06/26/2014 oxytocin oxytocin CHANGE TIER Generics Not Covered 06/26/2014 ARISTOSPAN triamcinolone hexacetonide CHANGE TIER Preferred Brands Not Covered 06/26/2014 oxytocin oxytocin CHANGE TIER Generics Not Covered 06/26/2014 VAYAROL phytosterol/omega-3 fatty acids/dha/epa/fish oil CHANGE TIER Preferred Brands Not Covered 06/26/2014 oxytocin oxytocin CHANGE TIER Generics Not Covered 06/26/2014 kendall 0.9% nacl 0.9 % sodium chloride with cap CHANGE TIER Generics Not Covered 06/26/2014 cosyntropin cosyntropin CHANGE TIER Generics Not Covered 06/26/2014 oxytocin oxytocin CHANGE TIER Generics Not Covered 06/26/2014 cosyntropin cosyntropin CHANGE TIER Generics Not Covered 06/26/2014 CATHFLO ACTIVASE alteplase CHANGE TIER Preferred Brands Not Covered 06/26/2014 VASCULERA diosmin complex no.1 CHANGE TIER Preferred Brands Not Covered 06/26/2014 oxytocin oxytocin CHANGE TIER Generics Not Covered 06/26/2014 ARISTOSPAN triamcinolone hexacetonide CHANGE TIER Preferred Brands Not Covered 06/26/2014 kendall 0.9% nacl 0.9 % sodium chloride with cap CHANGE TIER Generics Not Covered 06/26/2014 VAYARIN phosphatidyl serine/omega3 fatty acids/dha/epa CHANGE TIER Preferred Brands Not Covered 06/26/2014 oxytocin oxytocin CHANGE TIER Generics Not Covered 06/26/2014 cosyntropin cosyntropin CHANGE TIER Generics Not Covered BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 730 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 CATHFLO ACTIVASE alteplase CHANGE TIER Preferred Brands Not Covered 06/26/2014 VANIQA eflornithine hcl CHANGE TIER Preferred Brands Not Covered 06/26/2014 LATISSE bimatoprost CHANGE TIER Preferred Brands Not Covered 06/26/2014 LATISSE bimatoprost CHANGE TIER Preferred Brands Not Covered 06/26/2014 cosyntropin cosyntropin CHANGE TIER Generics Not Covered 06/26/2014 VENELEX balsam peru/castor oil CHANGE TIER Preferred Brands Not Covered 06/26/2014 FIRAZYR icatibant acetate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 temazepam temazepam CHANGE TIER 06/26/2014 FIRAZYR icatibant acetate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FANAPT iloperidone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KALBITOR ecallantide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DENAVIR penciclovir CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 temazepam temazepam CHANGE TIER 06/26/2014 SYNALAR fluocinolone acetonide/emollient combination no.65 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OSPHENA ospemifene CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PROTOPIC tacrolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ACIPHEX SPRINKLE rabeprazole sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 lortab hydrocodone bitartrate/acetaminophen CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LANOXIN digoxin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SUBOXONE buprenorphine hcl/naloxone hcl CHANGE TIER Preferred Brands Non-Formulary Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 731 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 SUBOXONE buprenorphine hcl/naloxone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FANATREX gabapentin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 lortab hydrocodone bitartrate/acetaminophen CHANGE TIER Generics Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 adipex-p phentermine hcl CHANGE TIER Generics Non-Formulary 06/26/2014 ZYFLO zileuton CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PEXEVA paroxetine mesylate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 vol-plus prenatal vits with calcium #74/ferrous fumarate/folic acid CHANGE TIER 06/26/2014 FEMHRT norethindrone acetateethinyl estradiol CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EXELDERM sulconazole nitrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 POLIBAR ACB barium sulfate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 POLIBAR ACB barium sulfate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BYSTOLIC nebivolol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 dynacin minocycline hcl CHANGE TIER Generics Non-Formulary 06/26/2014 RAPAFLO silodosin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 POLY-VI-FLOR WITH IRON pediatric multivitamin no.33/sodium fluoride/iron carbonyl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 MIRAPEX ER pramipexole di-hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ATRAPRO HYDROGEL emollient combination no.60 CHANGE TIER Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 732 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 ONGLYZA saxagliptin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TIKOSYN dofetilide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SILVRSTAT silver CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TIKOSYN dofetilide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SPRIX ketorolac tromethamine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SILVRSTAT silver CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NAPRELAN naproxen sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZORBTIVE somatropin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CLARINEX-D 24 desloratadine/pseudoephedr HOUR ine sulfate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EXFORGE amlodipine besylate/valsartan CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OSENI alogliptin benzoate/pioglitazone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 SPRIX ketorolac tromethamine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VENTAVIS iloprost tromethamine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 THEO-24 theophylline anhydrous CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NALFON fenoprofen calcium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EXFORGE HCT amlodipine besylate/valsartan/hydrochlo rothiazide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 REZYST IM lactobacillus acidophilus/bifidobacterium bifidum/b. longum CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 QUFLORA pediatric multivitamin no.63 with sodium fluoride CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 733 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 PROTONIX pantoprazole sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PROTONIX pantoprazole sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 TRACLEER bosentan CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PROTOPIC tacrolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ULTRAVATE X halobetasol propionate/lactic acid CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TRACLEER bosentan CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CARAC fluorouracil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ASTAGRAF XL tacrolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AMRIX cyclobenzaprine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VIIBRYD vilazodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 KERAFOAM urea CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ULTRAVATE PAC halobetasol propionate/ammonium lactate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DEMEROL meperidine hcl/pf CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CARNITOR SF levocarnitine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BYSTOLIC nebivolol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 JUVISYNC sitagliptin phosphate/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 HORIZANT gabapentin enacarbil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 734 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 JUVISYNC sitagliptin phosphate/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 INFERGEN interferon alfacon-1 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RAPAFLO silodosin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NORDITROPIN FLEXPRO somatropin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LAMICTAL XR (GREEN) lamotrigine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TIKOSYN dofetilide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZOLPIMIST zolpidem tartrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SAVELLA milnacipran hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RIFATER rifampin/isoniazid/pyrazinam ide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 LAMISIL terbinafine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LAMISIL terbinafine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CYTOSE ribose CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ESCAVITE LQ pediatric multivitamin no.86 with iron & sodium fluoride CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 tramadol hcl er tramadol hcl CHANGE TIER Generics Non-Formulary 06/26/2014 SYNERA lidocaine/tetracaine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 tri-vitamin with fluoride pediatric multivit with a,c,d3 no.21/sodium fluoride CHANGE TIER 06/26/2014 FABIOR tazarotene CHANGE TIER 06/26/2014 vol-plus prenatal vits with calcium #74/ferrous fumarate/folic acid CHANGE TIER 06/26/2014 FABIOR tazarotene CHANGE TIER Non-Formulary Preferred Brands Non-Formulary Non-Formulary Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 735 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 z-pram hydrocortisone acetate/pramoxine hcl/skin cleanser no.16 CHANGE TIER Generics Non-Formulary 06/26/2014 NYMALIZE nimodipine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FACTIVE gemifloxacin mesylate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ERIVEDGE vismodegib CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FACTIVE gemifloxacin mesylate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER 06/26/2014 lofibra fenofibrate CHANGE TIER Generics Non-Formulary 06/26/2014 ADDERALL dextroamphetamine sulfsaccharate/amphetamine sulf-aspartate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ACTOPLUS MET pioglitazone hcl/metformin XR hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morgidox doxycycline hyclate CHANGE TIER Generics Non-Formulary 06/26/2014 tri-vitamin with fluoride pediatric multivit with a,c,d3 no.21/sodium fluoride CHANGE TIER Generics Non-Formulary 06/26/2014 avar-e sulfacetamide sodium/sulfur CHANGE TIER Generics Non-Formulary 06/26/2014 OPSUMIT macitentan CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MAXIDONE hydrocodone bitartrate/acetaminophen CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 hecoria tacrolimus CHANGE TIER Generics Non-Formulary 06/26/2014 AZASITE azithromycin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 LAMISIL CHANGE TIER Preferred Brands Non-Formulary terbinafine hcl Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 736 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 vicodin hydrocodone bitartrate/acetaminophen CHANGE TIER Generics Non-Formulary 06/26/2014 ZORVOLEX diclofenac submicronized CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RANEXA ranolazine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 PACNEX LP benzoyl peroxide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 ALDACTAZIDE spironolactone/hydrochlorot hiazide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CARDIZEM LA diltiazem hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 JUVISYNC sitagliptin phosphate/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 lofibra fenofibrate,micronized CHANGE TIER 06/26/2014 OPSUMIT macitentan CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RESPA A.R. pseudoephedrine hcl/chlorpheniramine maleate/bellad alk CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 AURSTAT sod mag fluorosilic/cyclometh/phosph ac/sod bicarb/sod chlor CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VENTAVIS iloprost tromethamine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NEXIUM esomeprazole magnesium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 virt-vite forte cyanocobalamin/folic acid/pyridoxine CHANGE TIER Generics Non-Formulary 06/26/2014 GLYCATE glycopyrrolate CHANGE TIER Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 737 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Preferred Brands Non-Formulary 06/26/2014 ATRAPRO CP emollient combination no.47/emollient combination no.60 CHANGE TIER 06/26/2014 tl-care dha pnv no.20/iron fumarate/fa/docusate na/fish oil conc/dha/epa CHANGE TIER 06/26/2014 SORILUX calcipotriene CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SORILUX calcipotriene CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CELESTONE betamethasone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LIPTRUZET ezetimibe/atorvastatin calcium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VIIBRYD vilazodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LANOXIN PEDIATRIC digoxin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NUCYNTA tapentadol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 NUCYNTA tapentadol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DUET DHA prenatal vitamin no.106/sod ferede-iron poly/fa/om3/dha/epa CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LAMICTAL ODT lamotrigine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GILENYA fingolimod hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GESTICARE DHA prenatal vit with calcium #60/iron/folic acid/dha CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BYSTOLIC nebivolol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MAXARON FORTE iron glycin,sulfumu/vitc/b12/methyltetrahy drofolate calcium CHANGE TIER Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 738 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 LAMICTAL ODT (ORANGE) lamotrigine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CORVITE FE iron,carbonyl/methyltetrahyd rofolate gluc,fa/mv, min no.40 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 AZASITE azithromycin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MAXAIR AUTOHALER pirbuterol acetate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXISTAT oxiconazole nitrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ICLUSIG ponatinib hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SAVELLA milnacipran hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZAVESCA miglustat CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZENZEDI dextroamphetamine sulfate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MAXIDONE hydrocodone bitartrate/acetaminophen CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EPICERAM emollient combination no.32 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 vol-plus prenatal vits with calcium #74/ferrous fumarate/folic acid CHANGE TIER 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SYNERA lidocaine/tetracaine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 AZOPT brinzolamide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXTELLAR XR oxcarbazepine CHANGE TIER Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 739 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 REZYST IM lactobacillus acidophilus/bifidobacterium bifidum/b. longum CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OVIDREL choriogonadotropin alfa CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TOZAL multivitamin-minerals no.22/lutein/omega3/dha/epa CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LIPTRUZET ezetimibe/atorvastatin calcium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DEMEROL meperidine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BOTOX onabotulinumtoxina CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AZOPT brinzolamide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 tizanidine hcl tizanidine hcl CHANGE TIER Generics Non-Formulary 06/26/2014 NORPACE CR disopyramide phosphate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FINACEA PLUS azelaic acid/ceramides (1,3,6-11) CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EXELDERM sulconazole nitrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZORTRESS everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 lorcet hd hydrocodone bitartrate/acetaminophen CHANGE TIER Generics Non-Formulary 06/26/2014 INOVA benzoyl peroxide/vitamin e mixed CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 vicodin hydrocodone bitartrate/acetaminophen CHANGE TIER Generics Non-Formulary 06/26/2014 ZORTRESS everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 HORIZANT gabapentin enacarbil CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 740 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 JUVISYNC sitagliptin phosphate/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TROPAZONE emollient combination no.48 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RIAX benzoyl peroxide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PREVACID lansoprazole CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FOLLISTIM AQ follitropin beta,recomb CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GILOTRIF afatinib dimaleate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ACTIVE FE iron,carbonyl/folic acid/multivitamin with minerals CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TAFINLAR dabrafenib mesylate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SAIZEN somatropin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 REZYST saccharomyces boulardii CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MEKINIST trametinib dimethyl sulfoxide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 vicodin es hydrocodone bitartrate/acetaminophen CHANGE TIER Generics Non-Formulary 06/26/2014 SUBSYS fentanyl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NORPACE CR disopyramide phosphate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VESICARE solifenacin succinate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ORAPRED ODT prednisolone sod phosphate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morgidox doxycycline hyclate CHANGE TIER Generics Non-Formulary 06/26/2014 EXELON rivastigmine tartrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FOSAMAX PLUS alendronate D sodium/cholecalciferol (vitamin d3) CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TRADJENTA linagliptin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 STRATTERA atomoxetine hcl CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 741 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 VESICARE solifenacin succinate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CARAC fluorouracil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 UCERIS budesonide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LAMICTAL lamotrigine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OSENI alogliptin benzoate/pioglitazone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FAZACLO clozapine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 JAKAFI ruxolitinib phosphate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 dynacin minocycline hcl CHANGE TIER Generics Non-Formulary 06/26/2014 NEXIUM esomeprazole magnesium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VIRT-VITE PLUS folic acid/vitamin b complex with vitamin c no.17 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PRENATE ELITE prenatal vitamins combo #36/ferrous fumarate/folate combo #6 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 vicodin hp hydrocodone bitartrate/acetaminophen CHANGE TIER Generics Non-Formulary 06/26/2014 SILENOR doxepin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 INNOPRAN XL propranolol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AZOR amlodipine besylate/olmesartan medoxomil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TRADJENTA linagliptin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OB COMPLETE PETITE prenatal no56/iron carbonyl,asparto glycinate/folic acid/dha CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KRISTALOSE lactulose CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SIGNIFOR pasireotide diaspartate CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 742 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 CENESTIN estrogens,conj.,synthetic a CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FETZIMA levomilnacipran hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AVAR LS sulfacetamide sodium/sulfur CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TROKENDI XR topiramate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SIMCOR niacin/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SILENOR doxepin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LANOXIN digoxin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GLUTARADE GA-1 nutritional therapy, glutaric aciduria 1/flaxseed/fiber CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CUVPOSA glycopyrrolate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PAXIL paroxetine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 lorcet hydrocodone bitartrate/acetaminophen CHANGE TIER Generics Non-Formulary 06/26/2014 OTREXUP methotrexate/pf CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OTREXUP methotrexate/pf CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 temazepam temazepam CHANGE TIER 06/26/2014 tramadol hcl er tramadol hcl CHANGE TIER Generics Non-Formulary 06/26/2014 CENESTIN estrogens,conj.,synthetic a CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 TROKENDI XR topiramate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TARKA trandolapril/verapamil hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LOESTRIN 24 FE norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TRIGLIDE fenofibrate nanocrystallized CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 THYROLAR-3 liotrix CHANGE TIER Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 743 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 INVOKANA canagliflozin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LO LOESTRIN FE norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CETACAINE ANESTHETIC tetracaine/benzocaine/buta mben CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ALTOPREV lovastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CETACAINE ANESTHETIC tetracaine/benzocaine/buta mben CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 tramadol hcl er tramadol hcl CHANGE TIER Generics Non-Formulary 06/26/2014 GLYTACTIN 10 nutritional therapy for pku PE BETTERMILK with iron no.41 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NESTABS prenatal vitamin no.86/iron bis-glycinate/folic acid CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LIPTRUZET ezetimibe/atorvastatin calcium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SYNALAR fluocinolone acetonide/emollient combination no.65 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SELRX selenium sulfide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KERAFOAM urea CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NYMALIZE nimodipine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LIPTRUZET ezetimibe/atorvastatin calcium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DUET DHA EC prenatal vitamin no.107/sod ferede-iron poly/fa/om3/dha/epa CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 THYROLAR-1/2 liotrix CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FULYZAQ crofelemer CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 744 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 EXFORGE HCT amlodipine besylate/valsartan/hydrochlo rothiazide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NYMALIZE nimodipine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 THEO-24 theophylline anhydrous CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 temazepam temazepam CHANGE TIER 06/26/2014 FANAPT iloperidone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SAVELLA milnacipran hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZYDONE hydrocodone bitartrate/acetaminophen CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RECTIV nitroglycerin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NESTABS ABC prenatal vitamin comb no.86/iron ps cmplx/folic acid/dha/epa CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER 06/26/2014 KERAFOAM urea CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EDECRIN ethacrynic acid CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TRADJENTA linagliptin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SUBSYS fentanyl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SIGNIFOR pasireotide diaspartate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 INVEGA paliperidone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZORTRESS everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TOPICORT desoximetasone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AFINITOR everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SYMLINPEN 120 pramlintide acetate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NUCYNTA ER CHANGE TIER Preferred Brands Non-Formulary tapentadol hcl Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 745 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 SUBSYS fentanyl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 JUVISYNC sitagliptin phosphate/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FLO-PRED prednisolone acetate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NAPRELAN naproxen sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AFINITOR everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SUMAVEL DOSEPRO sumatriptan succinate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 LIPTRUZET ezetimibe/atorvastatin calcium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 vicodin es hydrocodone bitartrate/acetaminophen CHANGE TIER Generics Non-Formulary 06/26/2014 PRENATE ENHANCE prenatal vitamin combo no.68/iron fumarate/fa combo no.6/dha CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 lofibra fenofibrate,micronized CHANGE TIER 06/26/2014 VALCYTE valganciclovir hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CLINDACIN PAC clindamycin phosphate/skin cleanser comb no.19 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZMAX azithromycin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CORVITE 150 iron,carbonyl/methyltetrahyd rofolate gluc,fa/mv, min no.41 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AROMASIN exemestane 06/26/2014 PROTOPIC tacrolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EGRIFTA tesamorelin acetate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CARDIZEM LA diltiazem hcl CHANGE TIER Preferred Brands Non-Formulary Non-Formulary ADD TO FORMULARY Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 746 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 vicodin hp hydrocodone bitartrate/acetaminophen CHANGE TIER Generics Non-Formulary 06/26/2014 AFINITOR everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 OMECLAMOXPAK omeprazole/clarithromycin/a moxicillin trihydrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PRENATE AM prenatal vitamins no.114/methyltetrahydfolate gluc,fa/ginger CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FETZIMA levomilnacipran hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZYTIGA abiraterone acetate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TARGRETIN bexarotene CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 mirtazapine mirtazapine CHANGE TIER 06/26/2014 ARCALYST rilonacept CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EURAX crotamiton CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PRENATE ESSENTIAL pnv no.35/iron fumarate/folate comb. #6/dha CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ONGLYZA saxagliptin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 JUVISYNC sitagliptin phosphate/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FOLLISTIM AQ follitropin beta,recomb CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 747 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value iron/folate no.8/ps-dha/psepa/fad/nadh/betaine/multivi t #47 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ENLYTE 06/26/2014 VICTOZA 2-PAK liraglutide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VICTOZA 3-PAK liraglutide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FROVA frovatriptan succinate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FAZACLO clozapine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 tl-care dha pnv no.20/iron fumarate/fa/docusate na/fish oil conc/dha/epa CHANGE TIER 06/26/2014 KOMBIGLYZE XR saxagliptin hcl/metformin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SUMAVEL DOSEPRO sumatriptan succinate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LEVITRA vardenafil hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ORBIVAN butalbital/acetaminophen/caf feine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 lindane lindane CHANGE TIER 06/26/2014 SUBSYS fentanyl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ibudone hydrocodone/ibuprofen CHANGE TIER Generics Non-Formulary 06/26/2014 AFINITOR everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 zenzedi dextroamphetamine sulfate CHANGE TIER Generics Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 AVAR LS sulfacetamide sodium/sulfur CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TARGRETIN bexarotene CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TOPICORT desoximetasone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TOPICORT desoximetasone CHANGE TIER Preferred Brands Non-Formulary Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 748 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 SUBSYS fentanyl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TOPICORT desoximetasone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 tizanidine hcl tizanidine hcl CHANGE TIER Generics Non-Formulary 06/26/2014 PRENATE ELITE prenatal vitamins combo #36/ferrous fumarate/folate combo #6,prenatal vitamins no.79/ferrous aspart glycinate/folate no.1 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LIPTRUZET ezetimibe/atorvastatin calcium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GRALISE gabapentin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CARDIZEM LA diltiazem hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 ONFI clobazam CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NOROXIN norfloxacin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FANAPT iloperidone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BRINTELLIX vortioxetine hydrobromide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 pacerone amiodarone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 MYRBETRIQ mirabegron CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FML FORTE fluorometholone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OB COMPLETE ONE pnv no.85/iron carb,aspart.glycinate/folic acid/dha/fish oil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VIDEX didanosine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KRISTALOSE lactulose CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 749 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 THYROLAR-1/4 liotrix CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 JENTADUETO linagliptin/metformin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NORDITROPIN FLEXPRO somatropin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SAVELLA milnacipran hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GRALISE gabapentin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AZOR amlodipine besylate/olmesartan medoxomil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 STAXYN vardenafil hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NORINYL 1+50 norethindrone-mestranol CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SILENOR doxepin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AFINITOR DISPERZ everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 PRILOSEC omeprazole magnesium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 COSOPT PF dorzolamide hcl/timolol maleate/pf CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 mirtazapine mirtazapine CHANGE TIER Generics Non-Formulary 06/26/2014 OXYCONTIN oxycodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FACTIVE gemifloxacin mesylate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FML FORTE fluorometholone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FACTIVE gemifloxacin mesylate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BYSTOLIC nebivolol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 750 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 TECFIDERA dimethyl fumarate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SOVALDI sofosbuvir CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GLYTACTIN 15 nutritional therapy for pku PE BETTERMILK with iron no.41 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZEGERID CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 OXYCONTIN oxycodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AMRIX cyclobenzaprine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GRALISE gabapentin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EDARBI azilsartan medoxomil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ARICEPT donepezil hcl 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 INTERMEZZO zolpidem tartrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VYTORIN ezetimibe/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CORTANE-B hydrocortisone/pramoxine hcl/chloroxylenol CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CENTANY AT mupirocin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 STENDRA avanafil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 mirtazapine mirtazapine CHANGE TIER 06/26/2014 SUBSYS fentanyl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RAPAMUNE sirolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TYVASO REFILL treprostinil/nebulizer KIT accessories CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl CHANGE TIER Generics Non-Formulary omeprazole/sodium bicarbonate oxycodone hcl ADD TO FORMULARY Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 751 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 TYVASO STARTER KIT treprostinil/nebulizer and accessories CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RAPAMUNE sirolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MONUROL fosfomycin tromethamine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CYSTARAN cysteamine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 POTIGA ezogabine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXISTAT oxiconazole nitrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 HORIZANT gabapentin enacarbil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BYDUREON exenatide microspheres CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PRENATA prenatal vitamins combo no.37/ferrous fumarate/folic acid CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CARDENE SR nicardipine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FIRSThydrocortisone HYDROCORTIS ONE CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ENABLEX darifenacin hydrobromide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LUXIQ betamethasone valerate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXYCONTIN oxycodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 mirtazapine mirtazapine CHANGE TIER 06/26/2014 NEXA SELECT prenatal vitamin no.58/iron fumarate/folic acid/dss/dha CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RIOMET metformin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RIOMET metformin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ALTOPREV lovastatin CHANGE TIER Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 752 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 SYLATRON 4PACK peginterferon alfa-2b CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SYLATRON peginterferon alfa-2b CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 rosadan metronidazole CHANGE TIER Generics Non-Formulary 06/26/2014 SUBSYS fentanyl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LASTACAFT alcaftadine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VERSACLOZ clozapine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 JUVISYNC sitagliptin phosphate/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 lortab hydrocodone bitartrate/acetaminophen CHANGE TIER Generics Non-Formulary 06/26/2014 NORPACE CR disopyramide phosphate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FETZIMA levomilnacipran hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 tramadol hcl er tramadol hcl CHANGE TIER Generics Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 ENABLEX CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 RENVELA sevelamer carbonate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NAFTIN naftifine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 pacerone amiodarone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 SYMLINPEN 60 pramlintide acetate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RENVELA sevelamer carbonate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VYTORIN ezetimibe/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXYCONTIN oxycodone hcl CHANGE TIER Preferred Brands Non-Formulary darifenacin hydrobromide BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 753 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 VESICARE solifenacin succinate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SIGNIFOR pasireotide diaspartate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AVAR sulfacetamide sodium/sulfur CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AFINITOR DISPERZ everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 LORZONE chlorzoxazone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 HALOG halcinonide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AUBAGIO teriflunomide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ENJUVIA estrogens,conj.,synthetic b CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NUCORT hydrocortisone acetate/aloe vera CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 COSOPT PF dorzolamide hcl/timolol maleate/pf CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 HELIDAC bismuth subsalicylate/metronidazole/ tetracycline hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 COSOPT PF dorzolamide hcl/timolol maleate/pf CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BYSTOLIC nebivolol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KINERET anakinra CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PROTECT NATAL pnv cmb#82/iron ps cmplx/folic acid/omega 3/dha/epa/fish oil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CEFTIN cefuroxime axetil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 hecoria tacrolimus CHANGE TIER Generics Non-Formulary 06/26/2014 INFERGEN interferon alfacon-1 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PLIAGLIS lidocaine/tetracaine CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 754 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 LAMICTAL (ORANGE) lamotrigine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EURAX crotamiton CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GENADUR carbitol/equisetum ext/ethanol/hydroxypropyl chitosan/msm CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FORFIVO XL bupropion hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NEXIUM esomeprazole magnesium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FARXIGA dapagliflozin propanediol CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EXFORGE amlodipine besylate/valsartan CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ONFI clobazam CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SYNERA lidocaine/tetracaine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PROCYSBI cysteamine bitartrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KUVAN sapropterin dihydrochloride CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KRISTALOSE lactulose CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VYTORIN ezetimibe/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 THYROLAR-2 liotrix CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NORPACE CR disopyramide phosphate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LAMICTAL ODT lamotrigine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 MAXALT rizatriptan benzoate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AVAR sulfacetamide sodium/sulfur CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 mirtazapine mirtazapine CHANGE TIER Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 755 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 MINASTRIN 24 FE norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ENJUVIA estrogens,conj.,synthetic b CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXYCONTIN oxycodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CEFTIN cefuroxime axetil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VYTORIN ezetimibe/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OTREXUP methotrexate/pf CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DUET DHA BALANCED prenatal vitamin no.110/iron edta &polysaccha/fa/om3/dha/ep a CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OTREXUP methotrexate/pf CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ACTOPLUS MET pioglitazone hcl/metformin XR hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SYNERA lidocaine/tetracaine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LAMICTAL ODT lamotrigine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GLUMETZA metformin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 RIFAMATE rifampin/isoniazid CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DELZICOL mesalamine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FYCOMPA perampanel CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AUGMENTIN amoxicillin/potassium clavulanate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AUGMENTIN amoxicillin/potassium clavulanate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EDARBI azilsartan medoxomil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 STRATTERA atomoxetine hcl CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 756 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 OXYCONTIN oxycodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AZOR amlodipine besylate/olmesartan medoxomil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AUGMENTIN amoxicillin/potassium clavulanate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LANOXIN PEDIATRIC digoxin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXYCONTIN oxycodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MYRBETRIQ mirabegron CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TYVASO treprostinil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXYCONTIN oxycodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SOMAVERT pegvisomant CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 IPRIVASK desirudin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SOMAVERT pegvisomant CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GIAZO balsalazide disodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KOMBIGLYZE XR saxagliptin hcl/metformin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PLIAGLIS lidocaine/tetracaine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AVAR sulfacetamide sodium/sulfur CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ASTAGRAF XL tacrolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 tramadol hcl er tramadol hcl CHANGE TIER Generics Non-Formulary 06/26/2014 VIIBRYD vilazodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AZOR amlodipine besylate/olmesartan medoxomil CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NAFTIN naftifine hcl CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 757 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 PERFOROMIST formoterol fumarate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OMNITROPE CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PEDIADERM HC hydrocortisone/emollient combination no.45 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MARNATAL-F prenatal vit with calcium comb no.65/iron polysacch cmplx/fa CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ketodan ketoconazole CHANGE TIER Generics Non-Formulary 06/26/2014 SOMAVERT pegvisomant CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 THEO-24 theophylline anhydrous CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NUCYNTA ER tapentadol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXTELLAR XR oxcarbazepine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BRINTELLIX vortioxetine hydrobromide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SYLATRON peginterferon alfa-2b CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 reprexain hydrocodone/ibuprofen CHANGE TIER Generics Non-Formulary 06/26/2014 SOMAVERT pegvisomant CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 IPRIVASK desirudin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GLYTACTIN 15 nutritional therapy for pku PE BETTERMILK with iron no.41 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PERCOCET oxycodone hcl/acetaminophen CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 STELARA ustekinumab CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 lortab hydrocodone bitartrate/acetaminophen CHANGE TIER Generics Non-Formulary 06/26/2014 SYLATRON 4PACK peginterferon alfa-2b CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EMEND aprepitant CHANGE TIER Preferred Brands Non-Formulary somatropin BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 758 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 EMEND aprepitant CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EMEND aprepitant CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZORTRESS everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CARDURA XL doxazosin mesylate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MEDIHONEY honey CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ANGELIQ drospirenone/estradiol CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXISTAT oxiconazole nitrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GLYSET miglitol CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ANGELIQ drospirenone/estradiol CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MEDIHONEY honey CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VEREGEN sinecatechins CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VYTORIN ezetimibe/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 SUMAXIN CP sulfacetamide sodium/sulfur/skin cleanser comb no.23 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CORVITE FE iron,carbonyl/ferrous asparto glycinate/folic acid/mvmin27 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 OB COMPLETE WITH DHA prenatal vit no.30/iron carbonyl,asp glyc/folic acid/omega-3 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 OMNITROPE somatropin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZENZEDI dextroamphetamine sulfate CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 759 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 VIMOVO naproxen/esomeprazole magnesium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TECFIDERA dimethyl fumarate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SOLODYN minocycline hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TREXIMET sumatriptan succinate/naproxen sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AFINITOR DISPERZ everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ADVICOR niacin/lovastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CANASA mesalamine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DUET DHA EC prenatal vitamin no.107/sod ferede-iron poly/fa/om3/dha/epa CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MIACALCIN calcitonin,salmon,synthetic CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ARICEPT donepezil hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CENESTIN estrogens,conj.,synthetic a CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KINERET anakinra CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FOLLISTIM AQ follitropin beta,recomb CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DEMEROL meperidine hcl/pf CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BYSTOLIC nebivolol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NAFTIN naftifine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CICLODAN ciclopirox olamine/skin cleanser combination no.28 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 avar-e sulfacetamide sodium/sulfur CHANGE TIER Generics Non-Formulary 06/26/2014 ZOMIG ZMT zolmitriptan CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VYTORIN ezetimibe/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NEXIUM esomeprazole magnesium CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 760 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 DYMISTA azelastine hcl/fluticasone propionate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SOLODYN minocycline hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MINASTRIN 24 FE norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 MIRAPEX ER pramipexole di-hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BEPREVE bepotastine besilate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LYCELLE citric/citronellyl/hydroxyprop yl/methyl salicylate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PERCURA choline/amino acid #21/gaba/inositol/griffonia/gl ucose/creat CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KORLYM mifepristone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ADVICOR niacin/lovastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RITALIN LA methylphenidate hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZOMIG zolmitriptan CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 KORLYM mifepristone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NUCYNTA tapentadol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 ADEMPAS CHANGE TIER Preferred Brands Non-Formulary riociguat BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 761 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 NUCYNTA tapentadol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CANASA mesalamine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ADEMPAS riociguat CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ORAPRED ODT prednisolone sod phosphate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LAMISIL terbinafine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZOHYDRO ER hydrocodone bitartrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VYTORIN ezetimibe/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OVACE PLUS sulfacetamide sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MIRAPEX ER pramipexole di-hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RAPAMUNE sirolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 METOZOLV ODT metoclopramide hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BYSTOLIC nebivolol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VENLAFAXINE HCL ER venlafaxine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 tramadol hcl er tramadol hcl CHANGE TIER Generics Non-Formulary 06/26/2014 VENLAFAXINE HCL ER venlafaxine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DIGIBAR barium sulfate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ADEMPAS riociguat CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZORVOLEX diclofenac submicronized CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 ADEMPAS riociguat CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MYRBETRIQ mirabegron CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VEREGEN sinecatechins CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 762 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 LAMISIL terbinafine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RAPAMUNE sirolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LAMISIL terbinafine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ARIMIDEX anastrozole 06/26/2014 PERFOROMIST formoterol fumarate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZYVOX linezolid CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VITAFOL-PN prenatal vit with calcium cmb 11/ferrous fumarate/folic acid CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZYVOX linezolid CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 HALOG halcinonide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZYDONE hydrocodone bitartrate/acetaminophen CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DENAVIR penciclovir CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 JENTADUETO linagliptin/metformin hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 rosadan metronidazole CHANGE TIER Generics Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KINERET anakinra CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EXFORGE HCT amlodipine besylate/valsartan/hydrochlo rothiazide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EPANED enalapril maleate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MIRAPEX ER pramipexole di-hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ARICEPT donepezil hcl ADD TO FORMULARY 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER ADD TO FORMULARY Non-Formulary Non-Formulary Generics Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 763 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 NESINA alogliptin benzoate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 INLYTA axitinib CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 ANTARA fenofibrate,micronized CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AFINITOR DISPERZ everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 HALOG halcinonide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VYTORIN ezetimibe/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VICTRELIS boceprevir CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VICTRELIS boceprevir CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 OSENI alogliptin benzoate/pioglitazone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MENOPUR menotropins CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MENOPUR menotropins CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 VITAFOLOB+DHA prenatal vitamins comb 10/ferrous fumarate/folic acid/dha CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXISTAT oxiconazole nitrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ENJUVIA estrogens,conj.,synthetic b CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NALFON fenoprofen calcium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SOMATULINE DEPOT lanreotide acetate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 INVEGA paliperidone CHANGE TIER Preferred Brands Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 764 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 JAKAFI ruxolitinib phosphate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BYSTOLIC nebivolol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TREXIMET sumatriptan succinate/naproxen sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 METVIXIA methyl aminolevulinate hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 HALOG halcinonide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FIRSTlansoprazole LANSOPRAZOL E CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DERMASORB HC CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FIRSTlansoprazole LANSOPRAZOL E CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DEMEROL meperidine hcl/pf CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 INFERGEN interferon alfacon-1 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 temazepam temazepam CHANGE TIER 06/26/2014 INVEGA paliperidone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FINACEA azelaic acid CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 MAGNACET CHANGE TIER Preferred Brands Non-Formulary hydrocortisone/skin cleanser combination no.35 oxycodone hcl/acetaminophen Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 765 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 SUCLEAR polyethylene glycol 3350/bowel prep #2,two part prep CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NOXAFIL posaconazole CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OVACE PLUS sulfacetamide sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 temazepam temazepam CHANGE TIER 06/26/2014 OLEPTRO ER trazodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TARKA trandolapril/verapamil hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SYLATRON 4PACK peginterferon alfa-2b CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SYLATRON peginterferon alfa-2b CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NAPRELAN naproxen sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 foltanx rf levomefolate ca/pyridoxal phos/mecobalamin/schiz. algal oil CHANGE TIER Generics Non-Formulary 06/26/2014 MINASTRIN 24 FE norethindrone acetateethinyl estradiol/ferrous fumarate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MEGACE ES megestrol acetate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 MAGNACET oxycodone hcl/acetaminophen CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GABADONE aa comb.no8/acetylcarnitine hcl/grape/cocoa/hrb cb126 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 AXERT almotriptan malate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FIRSTlansoprazole LANSOPRAZOL E CHANGE TIER Preferred Brands Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 766 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 CEDAX ceftibuten CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CEDAX ceftibuten CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CEDAX ceftibuten CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AFINITOR everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 XYREM sodium oxybate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 REPRONEX menotropins CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PEXEVA paroxetine mesylate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SUBSYS fentanyl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 FYCOMPA perampanel CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 VYTORIN ezetimibe/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 TACHOSIL fibrinogen/thrombin (human plasma derived) CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 STRATTERA atomoxetine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 VYTORIN ezetimibe/simvastatin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PRILOSEC omeprazole magnesium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PYLERA colloidal bismuth subcitrate/metronidazole/tetr acycline hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PREPOPIK sodium picosulfate/magnesium oxide/citric acid CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 767 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value Preferred Brands Non-Formulary 06/26/2014 PREPOPIK sodium picosulfate/magnesium oxide/citric acid CHANGE TIER 06/26/2014 lindane lindane CHANGE TIER 06/26/2014 PACNEX MX benzoyl peroxide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZOHYDRO ER hydrocodone bitartrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CITRANATAL 90 prenatal vit no.72/iron DHA carbony,gluc/folic acid/docusate/dha CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SOMATULINE DEPOT lanreotide acetate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OMNITROPE somatropin CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AFINITOR everolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 NOXAFIL posaconazole CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 IMBRUVICA ibrutinib CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary 06/26/2014 venlafaxine hcl er venlafaxine hcl CHANGE TIER Generics Non-Formulary 06/26/2014 hemenatal ob prenatal vit no.21/iron polysacch,heme polypep/folic acid CHANGE TIER 06/26/2014 DUET DHA EC prenatal vitamin no.107/sod ferede-iron poly/fa/om3/dha/epa CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 venlafaxine hcl er venlafaxine hcl CHANGE TIER Generics Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 JUVISYNC sitagliptin phosphate/simvastatin CHANGE TIER Preferred Brands Non-Formulary Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 768 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 PROTECT IRON multivitamin-minerals no.24/iron polysaccharide complex/fa CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXECTA oxycodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DENAVIR penciclovir CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 tl-select prenatal vit with calcium no.80/iron fum/folic acid/dss/dha CHANGE TIER 06/26/2014 BYSTOLIC nebivolol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 pnv-ob with dha prenatal vitamins comb 10/ferrous fumarate/folic acid/dha CHANGE TIER Generics Non-Formulary 06/26/2014 NAPRELAN naproxen sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 INVEGA paliperidone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DENAVIR penciclovir CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BYDUREON exenatide microspheres CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ARICEPT ODT donepezil hcl ADD TO FORMULARY 06/26/2014 INVEGA paliperidone CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 IMBRUVICA ibrutinib CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 GLYTACTIN 15 nutritional therapy for pku PE BETTERMILK with iron no.41 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 tramadol hcl er tramadol hcl CHANGE TIER Generics Non-Formulary 06/26/2014 CAMBIA diclofenac potassium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BEPREVE bepotastine besilate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 KERAFOAM urea CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CAMBIA diclofenac potassium CHANGE TIER Preferred Brands Non-Formulary Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 769 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 INTUNIV guanfacine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 XOLAIR omalizumab CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXYCONTIN oxycodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NUCYNTA tapentadol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OPANA ER oxymorphone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NUCYNTA tapentadol hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DERMASORB TA triamcinolone acetonide/emollient combination no.86 CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 PROTOPIC tacrolimus CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 lofibra fenofibrate CHANGE TIER 06/26/2014 GILOTRIF afatinib dimaleate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 CITRANATAL ASSURE prenatal vit no.73/iron carbony,gluc/folic acid/docusate/dha CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 LESCOL XL fluvastatin sodium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ARICEPT donepezil hcl ADD TO FORMULARY 06/26/2014 ONMEL itraconazole CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER Generics Non-Formulary 06/26/2014 morphine sulfate morphine sulfate er CHANGE TIER 06/26/2014 INTUNIV guanfacine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 RELENZA zanamivir CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 HALOG halcinonide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 INTUNIV guanfacine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 oxycodone hcl oxycodone hcl CHANGE TIER Generics Non-Formulary Non-Formulary Non-Formulary Non-Formulary BRAND-NAME DRUGS are CAPITALIZED. Generic drugs are lower-case italics. PAGE 770 UPDATED 10/2016 4D Pharmacy Managed Formulary Updates Effective Date Brand Name Generic Name Type of Change Previous Value New Value 06/26/2014 DICLEGIS doxylamine succinate/pyridoxine hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ZETONNA ciclesonide CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 POTIGA ezogabine CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 OXYCONTIN oxycodone hcl CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 SIRTURO bedaquiline fumarate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 JAKAFI ruxolitinib phosphate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 BOTOX onabotulinumtoxina CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 DUET DHA EC prenatal vitamin no.107/sod ferede-iron poly/fa/om3/dha/epa CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 QNASL beclomethasone dipropionate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 EXELDERM sulconazole nitrate CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 ONMEL itraconazole CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 NEXIUM esomeprazole magnesium CHANGE TIER Preferred Brands Non-Formulary 06/26/2014 AFINITOR everolimus CHANGE TIER Preferred Brands Non-Formulary 0
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