Erleada TABLET 60 MG Oral NF 5 + PA2 + LA Formulary Enhancement N/A Gentamicin Sulfate SOLUTION 10 1 NF CMS Required Deletion N/A MG/ML Intravenous Haloperidol Lactate SOLUTION 5 MG/ML Injection (1 ml Prefilled NF 2 Formulary Enhancement N/A Syringe) ISOtretinoin CAPSULE 10 MG Oral NF 2 Formulary Enhancement N/A ISOtretinoin CAPSULE 20 MG Oral NF 2 Formulary Enhancement N/A ISOtretinoin CAPSULE 30 MG Oral NF 2 Formulary Enhancement N/A ISOtretinoin CAPSULE 40 MG Oral NF 2 Formulary Enhancement N/A fosamprenavir Lexiva TABLET 700 MG Oral 5 NF Formulary Update 700 mg, 5 Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 14 NF 3 Formulary Enhancement N/A MG Oral Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 21 NF 3 Formulary Enhancement N/A MG Oral Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 28 NF 3 Formulary Enhancement N/A MG Oral Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 7 NF 3 Formulary Enhancement N/A MG Oral Methotrexate Sodium SOLUTION 250 NF 2 + BD Formulary Enhancement N/A MG/10ML INJECTION Naloxone HCl Solution Cartridge 0.4 NF 1 Formulary Enhancement N/A MG/ML Injection
Erleada TABLET 60 MG Oral NF 5 + PA2 + LA Formulary Enhancement N/A Gentamicin Sulfate SOLUTION 10 MG/ML Intravenous 1 NF CMS Required Deletion N/A Haloperidol Lactate SOLUTION 5 MG/ML Injection (1 ml Prefilled Syringe) NF 2 Formulary Enhancement N/A ISOtretinoin CAPSULE 10 MG Oral NF 2 Formulary Enhancement N/A ISOtretinoin CAPSULE 20 MG Oral NF 2 Formulary Enhancement N/A ISOtretinoin CAPSULE 30 MG Oral NF 2 Formulary Enhancement N/A ISOtretinoin CAPSULE 40 MG Oral NF 2 Formulary Enhancement N/A Lexiva TABLET 700 MG Oral 5 NF Formulary Update fosamprenavir 700 mg, 5 Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 14 MG Oral NF 3 Formulary Enhancement N/A Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 21 MG Oral NF 3 Formulary Enhancement N/A Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 28 MG Oral NF 3 Formulary Enhancement N/A Memantine HCl ER CAPSULE EXTENDED RELEASE 24 HOUR 7 MG Oral NF 3 Formulary Enhancement N/A Methotrexate Sodium SOLUTION 250 MG/10ML INJECTION NF 2 + BD Formulary Enhancement N/A Naloxone HCl Solution Cartridge 0.4 MG/ML Injection NF 1 Formulary Enhancement N/A
AgeWell-5-Tier_2018_Addendum_Eff_07012018.docx