Levo-T TABLET 25 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 300 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 50 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 75 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 88 MCG ORAL NF 1 Formulary Enhancement N/A Lomedia 24 FE TAB 1-20 1 NF CMS Required Deletion N/A Lupron Depot-Ped (3-Month) KIT 30 NF 1 Formulary Enhancement N/A MG (Ped) Intramuscular Menomune INJECTABLE SQ 1 NF CMS Required Deletion N/A Methotrexate Sodium (PF) SOLUTION NF 1 + BD Formulary Enhancement N/A 250 MG/10ML INJECTION Morphine Sulfate SOLUTION 5 NF 1 Formulary Enhancement N/A MG/ML INJECTION Mylotarg SOLUTION NF 1 + PA2 + LA Formulary Enhancement N/A RECONSTITUTED 4.5 MG Intravenous Novarel SOLUTION RECONSTITUTED 5000 UNIT NF 1 + PA1 Formulary Enhancement N/A Intramuscular Opdivo SOLUTION 100 MG/10ML NF 1 + PA2 Formulary Enhancement N/A Intravenous Oseltamivir Phosphate SUSPENSION NF 1 Formulary Enhancement N/A RECONSTITUTED 6 MG/ML Oral Oxaliplatin SOLUTION RECONSTITUTED 100 MG NF 1 + BD Formulary Enhancement N/A Intravenous PARoxetine Mesylate CAPSULE 7.5 NF 1 Formulary Enhancement N/A MG Oral
Levo-T TABLET 25 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 300 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 50 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 75 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 88 MCG ORAL NF 1 Formulary Enhancement N/A Lomedia 24 FE TAB 1-20 1 NF CMS Required Deletion N/A Lupron Depot-Ped (3-Month) KIT 30 MG (Ped) Intramuscular NF 1 Formulary Enhancement N/A Menomune INJECTABLE SQ 1 NF CMS Required Deletion N/A Methotrexate Sodium (PF) SOLUTION 250 MG/10ML INJECTION NF 1 + BD Formulary Enhancement N/A Morphine Sulfate SOLUTION 5 MG/ML INJECTION NF 1 Formulary Enhancement N/A Mylotarg SOLUTION RECONSTITUTED 4.5 MG Intravenous NF 1 + PA2 + LA Formulary Enhancement N/A Novarel SOLUTION RECONSTITUTED 5000 UNIT Intramuscular NF 1 + PA1 Formulary Enhancement N/A Opdivo SOLUTION 100 MG/10ML Intravenous NF 1 + PA2 Formulary Enhancement N/A Oseltamivir Phosphate SUSPENSION RECONSTITUTED 6 MG/ML Oral NF 1 Formulary Enhancement N/A Oxaliplatin SOLUTION RECONSTITUTED 100 MG Intravenous NF 1 + BD Formulary Enhancement N/A PARoxetine Mesylate CAPSULE 7.5 MG Oral NF 1 Formulary Enhancement N/A
Tier1_2018_Addendum_Eff_03012018.docx