Imbruvica TABLET 280 MG Oral NF 5 + PA2 Formulary Enhancement N/A Imbruvica TABLET 420 MG Oral NF 5 + PA2 Formulary Enhancement N/A Imbruvica TABLET 560 MG Oral NF 5 + PA2 Formulary Enhancement N/A Intron A SOLUTION 10000000 NF 5 Formulary Enhancement N/A UNIT/ML INJECTION Kelnor 1/50 Tablet 1-50 MG-MCG Oral NF 2 Formulary Enhancement N/A Keytruda SOLUTION 5 + PA2 NF CMS Required Deletion N/A RECONSTITUTED 50 MG Intravenous LamoTRIgine Starter Kit-Blue KIT 25 NF 4 Formulary Enhancement N/A (35) MG Oral LamoTRIgine Starter Kit-Green KIT 25 NF 4 Formulary Enhancement N/A (84)-100(14) MG Oral LamoTRIgine Starter Kit-Orange KIT NF 4 Formulary Enhancement N/A 25 (42)-100 (7) MG Oral LEVOleucovorin Calcium SOLUTION NF 3 + BD Formulary Enhancement N/A RECONSTITUTED 50 MG Intravenous Makena Solution Auto-injector 275 NF 5 Formulary Enhancement N/A MG/1.1ML Subcutaneous Nevirapine SUSPENSION 50 MG/5ML 3 NF CMS Required Deletion N/A Oral Oxycodone-Acetaminophen SOLUTION 2 + QL NF CMS Required Deletion N/A 5-325 MG/5ML ORAL 1800 atazanavir 150 Reyataz CAPSULE 150 MG Oral 5 NF Formulary Update mg, 4 atazanavir 200 Reyataz CAPSULE 200 MG Oral 5 NF Formulary Update mg, 4 atazanavir 300 Reyataz CAPSULE 300 MG Oral 5 NF Formulary Update mg, 5
Imbruvica TABLET 280 MG Oral NF 5 + PA2 Formulary Enhancement N/A Imbruvica TABLET 420 MG Oral NF 5 + PA2 Formulary Enhancement N/A Imbruvica TABLET 560 MG Oral NF 5 + PA2 Formulary Enhancement N/A Intron A SOLUTION 10000000 UNIT/ML INJECTION NF 5 Formulary Enhancement N/A Kelnor 1/50 Tablet 1-50 MG-MCG Oral NF 2 Formulary Enhancement N/A Keytruda SOLUTION RECONSTITUTED 50 MG Intravenous 5 + PA2 NF CMS Required Deletion N/A LamoTRIgine Starter Kit-Blue KIT 25 (35) MG Oral NF 4 Formulary Enhancement N/A LamoTRIgine Starter Kit-Green KIT 25 (84)-100(14) MG Oral NF 4 Formulary Enhancement N/A LamoTRIgine Starter Kit-Orange KIT 25 (42)-100 (7) MG Oral NF 4 Formulary Enhancement N/A LEVOleucovorin Calcium SOLUTION RECONSTITUTED 50 MG Intravenous NF 3 + BD Formulary Enhancement N/A Makena Solution Auto-injector 275 MG/1.1ML Subcutaneous NF 5 Formulary Enhancement N/A Nevirapine SUSPENSION 50 MG/5ML Oral 3 NF CMS Required Deletion N/A Oxycodone-Acetaminophen SOLUTION 5-325 MG/5ML ORAL 2 + QL 1800 NF CMS Required Deletion N/A Reyataz CAPSULE 150 MG Oral 5 NF Formulary Update atazanavir 150 mg, 4 Reyataz CAPSULE 200 MG Oral 5 NF Formulary Update atazanavir 200 mg, 4 Reyataz CAPSULE 300 MG Oral 5 NF Formulary Update atazanavir 300 mg, 5
AgeWell-5-Tier_2018_Addendum_Eff_07012018.docx