Ethynodiol Diac-Eth Estradiol TABLET NF 1 Formulary Enhancement N/A 1-35 MG-MCG Oral Fosamprenavir Calcium TABLET 700 NF 1 Formulary Enhancement N/A MG Oral Glatiramer Acetate Solution Prefilled NF 2 + PA1 Formulary Enhancement N/A Syringe 20 MG/ML Subcutaneous Glatiramer Acetate Solution Prefilled NF 2 + PA1 Formulary Enhancement N/A Syringe 40 MG/ML Subcutaneous Gocovri CAPSULE EXTENDED NF 2 + PA1 Formulary Enhancement N/A RELEASE 24 HOUR 137 MG Oral Gocovri CAPSULE EXTENDED NF 2 + PA1 Formulary Enhancement N/A RELEASE 24 HOUR 68.5 MG Oral Haloperidol Decanoate SOLUTION 100 NF 1 Formulary Enhancement N/A MG/ML Intramuscular 1 ML Havrix SUSPENSION 1440 EL U/ML NF 2 Formulary Enhancement N/A Intramuscular (prefilled syringe) Havrix SUSPENSION 720 EL U/0.5ML NF 2 Formulary Enhancement N/A Intramuscular (prefilled syringe) Juluca TABLET 50-25 MG Oral NF 2 Formulary Enhancement N/A Kadcyla SOLUTION RECONSTITUTED 160 MG NF 2 Formulary Enhancement N/A Intravenous Klor-Con PACKET 20 MEQ Oral NF 1 Formulary Enhancement N/A Lartruvo SOLUTION 190 MG/19ML NF 2 + PA2 Formulary Enhancement N/A Intravenous Levonorgest-Eth Est & Eth Est NF 1 Formulary Enhancement N/A TABLET 42-21-21-7 DAYS Oral Levo-T TABLET 100 MCG ORAL NF 1 Formulary Enhancement N/A
Ethynodiol Diac-Eth Estradiol TABLET 1-35 MG-MCG Oral NF 1 Formulary Enhancement N/A Fosamprenavir Calcium TABLET 700 MG Oral NF 1 Formulary Enhancement N/A Glatiramer Acetate Solution Prefilled Syringe 20 MG/ML Subcutaneous NF 2 + PA1 Formulary Enhancement N/A Glatiramer Acetate Solution Prefilled Syringe 40 MG/ML Subcutaneous NF 2 + PA1 Formulary Enhancement N/A Gocovri CAPSULE EXTENDED RELEASE 24 HOUR 137 MG Oral NF 2 + PA1 Formulary Enhancement N/A Gocovri CAPSULE EXTENDED RELEASE 24 HOUR 68.5 MG Oral NF 2 + PA1 Formulary Enhancement N/A Haloperidol Decanoate SOLUTION 100 MG/ML Intramuscular 1 ML NF 1 Formulary Enhancement N/A Havrix SUSPENSION 1440 EL U/ML Intramuscular (prefilled syringe) NF 2 Formulary Enhancement N/A Havrix SUSPENSION 720 EL U/0.5ML Intramuscular (prefilled syringe) NF 2 Formulary Enhancement N/A Juluca TABLET 50-25 MG Oral NF 2 Formulary Enhancement N/A Kadcyla SOLUTION RECONSTITUTED 160 MG Intravenous NF 2 Formulary Enhancement N/A Klor-Con PACKET 20 MEQ Oral NF 1 Formulary Enhancement N/A Lartruvo SOLUTION 190 MG/19ML Intravenous NF 2 + PA2 Formulary Enhancement N/A Levonorgest-Eth Est & Eth Est TABLET 42-21-21-7 DAYS Oral NF 1 Formulary Enhancement N/A Levo-T TABLET 100 MCG ORAL NF 1 Formulary Enhancement N/A
AgeWell-MMP_2018_Addendum_Eff_07012018.docx