Lartruvo SOLUTION 190 MG/19ML NF 4 + PA2 Formulary Enhancement N/A Intravenous Levonorgest-Eth Est & Eth Est TABLET NF 2 Formulary Enhancement N/A 42-21-21-7 DAYS Oral Levo-T TABLET 100 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 112 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 125 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 137 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 150 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 175 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 200 MCG ORAL NF 1 Formulary Enhancement N/A 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 2 NF CMS Required Deletion N/A Lupron Depot-Ped (3-Month) KIT 30 NF 4 Formulary Enhancement N/A MG (Ped) Intramuscular Menomune INJECTABLE SQ 4 NF CMS Required Deletion N/A Methotrexate Sodium (PF) SOLUTION NF 2 + BD Formulary Enhancement N/A 250 MG/10ML INJECTION Morphine Sulfate SOLUTION 5 NF 3 Formulary Enhancement N/A MG/ML INJECTION Mylotarg SOLUTION NF 5 + PA2 + LA Formulary Enhancement N/A RECONSTITUTED 4.5 MG Intravenous
Lartruvo SOLUTION 190 MG/19ML Intravenous NF 4 + PA2 Formulary Enhancement N/A Levonorgest-Eth Est & Eth Est TABLET 42-21-21-7 DAYS Oral NF 2 Formulary Enhancement N/A Levo-T TABLET 100 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 112 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 125 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 137 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 150 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 175 MCG ORAL NF 1 Formulary Enhancement N/A Levo-T TABLET 200 MCG ORAL NF 1 Formulary Enhancement N/A 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 2 NF CMS Required Deletion N/A Lupron Depot-Ped (3-Month) KIT 30 MG (Ped) Intramuscular NF 4 Formulary Enhancement N/A Menomune INJECTABLE SQ 4 NF CMS Required Deletion N/A Methotrexate Sodium (PF) SOLUTION 250 MG/10ML INJECTION NF 2 + BD Formulary Enhancement N/A Morphine Sulfate SOLUTION 5 MG/ML INJECTION NF 3 Formulary Enhancement N/A Mylotarg SOLUTION RECONSTITUTED 4.5 MG Intravenous NF 5 + PA2 + LA Formulary Enhancement N/A
AgeWell-5-Tier_2018_Addendum_Eff_07012018.docx