2017 Sharp Advantage® Comprehensive Formulary

triamcinolone acetonide .. 82, 87, U vicodin...................................... 7 93, 102 UCERIS ............................... 113 vicodin es ................................. 7 triamterene-hydrochlorothiazid u-cort ...................................... 87 vicodin hp................................. 7 ............................................ 70 ULORIC ................................ 42 VICTOZA 3-PAK .................. 38 trianex ..................................... 87 UNITUXIN ............................ 27 VIDEX 2 GRAM PEDIATRIC triazolam ................................. 11 UPTRAVI ............................ 127 ............................................ 54 TRIBENZOR ......................... 63 ursodiol .................................. 96 VIEKIRA PAK ...................... 55 tridesilon ................................. 87 V VIEKIRA XR......................... 55 tri-estarylla ............................. 81 VAGIFEM ........................... 101 vienva ..................................... 82 trifluoperazine ........................ 51 valacyclovir ........................... 56 VIGAMOX ............................ 92 trifluridine............................... 92 VALCHLOR ......................... 84 VIIBRYD ............................... 36 trihexyphenidyl....................... 47 VALCYTE............................. 56 VIMIZIM ............................... 89 tri-legest fe.............................. 81 valganciclovir ........................ 56 VIMPAT ................................ 32 tri-linyah ................................. 81 valproate sodium.................... 32 vinblastine .............................. 28 tri-lo-estarylla ......................... 81 valproic acid .......................... 32 vincasar pfs ............................ 28 tri-lo-marzia ............................ 81 valproic acid (as sodium salt) 32 vincristine ............................... 28 tri-lo-sprintec .......................... 81 valsartan ................................. 63 vinorelbine ............................. 28 trilyte with flavor packets ....... 97 valsartan-hydrochlorothiazide 63 viorele (28) ............................. 82 trimethoprim ........................... 13 VALSTAR ............................. 28 VIRACEPT ............................ 54 trimipramine ........................... 35 vancomycin ............................ 13 VIRAZOLE............................ 56 trinessa (28) ............................ 81 vancomycin in dextrose 5 % .. 13 VIREAD ................................ 54 TRINTELLIX......................... 35 VAQTA (PF) ....................... 112 VITEKTA .............................. 54 tri-previfem (28) ..................... 81 VARIVAX (PF) ................... 112 VOLTAREN ............................ 9 tri-sprintec (28) ....................... 82 VASCEPA ............................. 72 voriconazole ..................... 41, 42 TRIUMEQ .............................. 53 VECTIBIX............................. 28 VOTRIENT............................ 28 trivora (28).............................. 82 VELCADE............................. 28 VPRIV.................................... 89 TROKENDI XR ..................... 32 velivet triphasic regimen (28) 82 VRAYLAR ............................ 51 TROPHAMINE 10 % ............ 62 VELPHORO .......................... 97 vyfemla (28) ........................... 82 TROPHAMINE 6% ............... 62 VELTASSA ........................... 96 VYTORIN 10-10 ................... 72 trospium .................................. 98 VEMLIDY ............................. 56 VYTORIN 10-20 ................... 72 TRULICITY ........................... 38 VENCLEXTA ....................... 28 VYTORIN 10-40 ................... 72 TRUMENBA ....................... 112 VENCLEXTA STARTING VYTORIN 10-80 ................... 72 TRUVADA ............................ 53 PACK................................. 28 W TWINRIX (PF) .................... 112 venlafaxine ....................... 35, 36 warfarin .................................. 57 TYBOST .............................. 117 VENTOLIN HFA ................ 124 water for irrigation, sterile ... 113 TYGACIL .............................. 20 verapamil ............................... 67 WELCHOL ............................ 72 TYKERB ................................ 27 VEREGEN............................. 84 wera (28) ................................ 82 TYPHIM VI ......................... 112 VERSACLOZ ........................ 51 wymzya fe .............................. 82 TYSABRI ............................. 108 VESICARE ............................ 98 X TYVASO .............................. 127 vestura (28) ............................ 82 XALKORI.............................. 28 TYZEKA ................................ 56 VGO 40.................................. 88 XARELTO ............................. 57 TYZINE ........................... 90, 91 VIBERZI ............................... 96 XARTEMIS XR....................... 7 I-16

XELJANZ ............................ 108 ZARXIO ................................ 58 zoledronic acid-mannitol-water XELJANZ XR ...................... 108 ZAVESCA ............................. 89 .......................................... 114 XERMELO............................. 96 zebutal ...................................... 7 ZOLINZA .............................. 29 XGEVA ................................ 114 ZELBORAF........................... 28 zolmitriptan ............................ 43 XIFAXAN .............................. 13 ZEMPLAR........................... 114 zolpidem ............................... 126 XIIDRA .................................. 94 zenatane ................................. 84 ZOMACTON ....................... 104 XOLAIR ............................... 125 zenchent (28) ......................... 82 ZOMETA ............................. 115 XTAMPZA ER ........................ 7 zenchent fe ............................. 82 zonisamide ............................. 32 XTANDI................................. 28 ZENPEP................................. 89 ZORBTIVE .......................... 104 xulane ..................................... 82 ZEPATIER ............................ 55 ZORTRESS.......................... 109 xylon 10 .................................... 7 ZERIT .................................... 54 ZOSTAVAX (PF) ................ 112 XYREM ............................... 126 ZETIA .................................... 72 zovia 1/35e (28) ..................... 82 Y ZIAGEN ................................ 54 zovia 1/50e (28) ..................... 82 YERVOY ............................... 28 zidovudine ............................. 54 ZOVIRAX.............................. 84 YF-VAX (PF) ....................... 112 ZINBRYTA ........................... 76 ZUBSOLV ............................. 10 YONDELIS ............................ 28 ZIOPTAN (PF) .................... 118 ZURAMPIC ........................... 42 yuvafem ................................ 101 ziprasidone hcl ....................... 51 ZYDELIG .............................. 29 Z ZIRGAN ................................ 92 ZYKADIA ............................. 29 zafirlukast ............................. 123 ZOHYDRO ER........................ 7 ZYLET ................................... 92 zaleplon ................................ 126 ZOLADEX ...................... 28, 29 ZYPREXA RELPREVV ....... 51 ZALTRAP .............................. 28 zoledronic acid ..................... 114 ZYTIGA ................................. 29 zarah ....................................... 82 I-17

Non-discrimination Notice Sharp Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Sharp Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Sharp Health Plan:  Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)  Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Jamie Ryan, Director of Operations at (858) 499-8275. If you believe that Sharp Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Sharp Health Plan Appeal/Grievance Department Attn: Jamie Ryan, Director of Operations 8520 Tech Way, Suite 201 San Diego, CA 92123-1450 Toll-free: 1-855-562-8853 TTY: 711 Fax: (858) 636-2256 You can file a grievance in person or by mail or fax. If you need help filing a grievance, Sharp Health Plan’s Director of Operations is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

English If you, or someone who you are helping, has questions about Sharp Health Plan, you have the right to obtain help and information in your language without any cost to you. To speak with an interpreter, call (855) 562-8853. Español (Spanish) Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Sharp Health Plan, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al (855) 562-8853. 繁體中文 (Chinese) 如果您，或是您正在協助的對象，有關 Sharp Health Plan 代碼及範圍方面有疑問，您有權利免費以 您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話 (855) 562-8853。 Tiếng Việt (Vietnamese) Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Sharp Health Plan, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi (855) 562-8853. Tagalog (Tagalog – Filipino) Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Sharp Health Plan, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa (855) 562-8853. 한국어 (Korean) 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Sharp Health Plan 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 (855) 562-8853 로 전화하십시오. Հայ երեն (Armenian) Եթե Դու ք կամ Ձեր կողմից օգնու թյ ու ն ստացող անձը հարցեր ու նի Sharp Health Plan մասին, Դու ք իրավու նք ու նեք անվճար օգնու թյ ու ն և տեղեկու թյ ու ններ ստանալ ու Ձեր նախընտրած լ եզվով։ Թարգմանչ ի հետ խոսել ու համար զանգահարե՛ ք (855) 562-8853։

Persian کمک کە داريد را اين حق باشيد داشتە ،Sharp Health Plan مورد در سوال ، ميکنيد کمک او بە شما کە کسی يا ،شما اگر . نماييد حاصل تماس(855) 562-8853. نماييد دريافت رايگان طور بە را خود زبان بە اطالعات و (Russian) йикссуР Sharp Health удовоп оп ысорпов ястюеми, етеагомоп ыв умороток, ацил или сав у илсЕ мешав ан иицамрофни и ищомоп еинечулоп еонталпсеб ан оварп етееми ыв отPlan, (855) 562-8853. унофелет оп етиновзоп мокичдовереп с аровогзар ялД. екызя 日本語 (Japanese) ご本人様、またはお客様の身の回りの方でも、Sharp Health Plan についてご質問がございました ら、ご希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかり ません。通訳とお話される場合、(855) 562-8853 までお電話ください。 (Arabic) العربية والمعلومات المساعدة على الحصول في الحق فلديك ،Sharp Health Plan بخصوص أسئلة تساعده شخص لدى أو لديك كان إن ) (855) 562-8853. ب اتصل مترجم مع للتحدث. تكلفة اية دون من بلغتك الضرورية ਪੰ ਜਾਬੀ (Punjabi) ਜੇ ਤੁਹਾਨ ੂੰ , ਜਾਂ ਤੁਸੀ ਜਜਸ ਦੀ ਮਦਦ ਕਰ ਰਹੇ ਹੋ , Sharp Health Plan ਕੋਈ ਸਵਾਲ ਹੈ ਤਾਂ, ਤੁਹਾਨ ੂੰ ਜਿਨਾ ਜਕਸੇ ਕੀਮਤ 'ਤੇ ਆਪਣੀ ਭਾਸਾ ਜਵਿੱ ਚ ਮਦਦ ਅਤੇ ਜਾਣਕਾਰੀ ਪਰਾਪਤ ਕਰਨ ਦਾ ਅਜਿਕਾਰ ਹੈ . ਦੁਭਾਸੀਏ ਨਾਲ ਗਿੱ ਲ ਕਰਨ ਲਈ, (855) 562-8853 ਤੇ ਕਾਲ ਕਰੋ. ខ្មែរ (Mon Khmer, Cambodian) ប្រសិនររ ើអ្នក ឬន ណាម្ននក់ដែលអ្នកកំពុងដែជួយ ម្ននសំណួ អ្្ំំពី Sharp Health Plan ររ, អ្នកម្ននសិរំធិរំរំំួលជំនួយនិងព័ដំំ ម្នន រៅកនុងភាសា ស់អ្នក រោយម្ិនអ្ស់រ្ំ ក់ ។ ដររំ ម្រីនិយាយជាម្ួយអ្នក កែប្រ សូម្ (855) 562-8853។ Hmoob (Hmong) Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Sharp Health Plan, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau (855) 562-8853.

(Hindi) ीदंि ह ोत, ंैह न्शर्प ंेम ेराब ेकSharp Health Plan ेक तत्कय्व ीसकक ेहर ाज एकक ातयाहस ाराव्द पआ ाय, ेकपआ िदय ेस एषषाभुि ीसकक ।ैह राकिधअ ाक ेनरक त्पार्प ानचूस रऔ ातयाहस ंेम त्फुम ंेम ाषाभ ीनपअ साप ेकपआ ।ंेरक िॉक रप, (855) 562-8853 एिल ेक ेनरक ताब (Thai) ยทไาษาภ Sharp Health Plan บักวย่ีกเมาถาคีมอืลหเยว่ชงัลากณุค่ีทนคอืรห ณุคกาห (855) 562-8853 รทโ มา่ลบักยุคดูพ ยา่จ้ชใา่คีม่มไยดโ้ดไณุคงอขาษาภนใลูมอ้ขะลแอืลหเยว่ชมาวคบัร้ดไะจ่ีทิธทิสีมณุค

This formulary was updated on 04/26/2017. For more recent information or other questions, please contact Sharp Advantage Customer Care at 1-855-562-8853 (toll free), or, for TTY users, 711, October 1 to February 14: 7 days per week 8 a.m. to 8 p.m. From February 15 to September 30: Monday through Friday, 8 a.m. to 8 p.m. Or visit sharpmedicareadvantage.com. Sharp Advantage is an HMO plan with a Medicare contract. Enrollment in Sharp Advantage depends on contract renewal. Sharp Advantage is offered by Sharp Health Plan. This information is available for free in other languages. Please call our Customer Care number at 1-855-562-8853 (toll free) for additional information. (TTY users should call 711.) For your convenience, our office hours are: from October 1 to February 14: 7 days per week 8 a.m. to 8 p.m. From February 15 to September 30: Monday through Friday, 8 a.m. to 8 p.m. and on weekends and holidays, your call will be handled by our voicemail system and a Customer Care Representative will return your phone call the next business day. Customer Care also has free language interpreter services available for non-English speakers. Please contact Sharp Advantage if you need information in another format. Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de Servicios de Miembros al 1-855-562-8853 (número gratuito) para obtener información adicional. (Los usuarios de TTY deben llamar al 711.) Para su conveniencia, nuestras horas de oficina son: 1 de octubre al 14 de febrero, los 7 días de la semana de 8 de la mañana a 8 de la tarde. El 15 de febrero al 30 de septiembre, lunes a viernes de 8 de la mañana a 8 de la tarde, y los fines de semana y festivos, su llamada será atendida por nuestro sistema de correo de voz. Un Representante de Servicios de Miembros le devolverá su llamada el día hábil siguiente. Servicios de Miembros también tiene servicios de intérprete de idiomas gratis, para personas que no hablan inglés. Por favor, póngase en contacto con Sharp Advantage si usted necesita información en otro forma. The formulary may change at any time. You will receive notice when necessary.

Consider us your personal health care assistant 1-855-562-8853, TTY users call 711 sharpmedicareadvantage.com Sharp Advantage is offered by Sharp Health Plan. Sharp Advantage is an HMO plan with a Medicare contract. Enrollment in Sharp Advantage depends on contract renewal. This information is available for free in other languages. Please call our Customer Care number at 1-855-562-8853 (toll free) or 1-858-499-8050 (local) for additional information. (TTY users should call 711.) For your convenience, our office hours are: from October 1 to February 14: 7 days per week 8 a.m. to 8 p.m. From February 15 to September 30: Monday through Friday, 8 a.m. to 8 p.m. and on weekends and holidays, your call will be handled by our voicemail system. A Customer Care Representative will return your phone call the next business day. Customer Care also has free language interpreter services available for non-English speakers. Please contact Sharp Advantage if you need information in another format. Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de Servicios de Miembros al 1-855-562-8853 (número gratuito) o 1-858-499-8050 (local) para obtener información adicional. (Los usuarios de TTY deben llamar al 711.) Para su conveniencia, nuestras horas de oficina son: 1 de octubre al 14 de febrero, los 7 días de la semana de 8 de la mañana a 8 de la tarde. El 15 de febrero al 30 de septiembre, lunes a viernes de 8 de la mañana a 8 de la tarde, y los fines de semana y festivos, su llamada será atendida por nuestro sistema de correo de voz. Un Representante de Servicios de Miembros le devolverá su llamada el día hábil siguiente. Servicios de Miembros también tiene servicios de intérprete de idiomas gratis, para personas que no hablan inglés. Por favor, póngase en contacto con Sharp Advantage si usted necesita información en otro forma. SHP107.5.5 © 2017 SHC H5386_2017 Formulary Comp INDV Accepted