List of covered drugs for Geisinger Kids Plans Member formulary

Transcription

1 List of covered drugs for Geisinger Kids Plans 208 Member formulary

2 Geisinger Health Plan Pharmacy Department Internal Mail Code North Academy Avenue Danville, PA 7822 CHIP Pharmacy Benefit The CHIP Pharmacy benefit assigns each prescription medication to one of two different tiers, each representing a set copayment amount. The copay amount will depend on your prescription medication rider. Additional medications, other than those included in this formulary, may be covered under the CHIP Pharmacy benefit. The definitions of the copay levels are listed below: Tier Includes most generic medications and has the lowest copayment. Prior authorization is usually not necessary for medications in this tier. Tier 2 Includes certain formulary brand name medications with no generic equivalent. Prior authorization may be necessary for medications in this tier. The Plan maintains sole discretion of assigning medications to tiers and moving medications from one tier to another. Several factors are considered when assigning medications to tiers. These factors include but are not limited to: Availability of a generic equivalent Absolute cost of a medication Cost of the medication relative to other medications in the same therapeutic class Availability of over-the-counter alternatives Clinical and economic factors Please note: A medication may change in tier status without notice due to immediate generic availability or changes in medication availability in the marketplace. A few things you should remember when using this formulary and your prescription benefit: All prescriptions must be filled at a participating pharmacy. You will pay the applicable copay, coinsurance or deductible when you receive the prescription. Coverage is for generic drugs when they have equivalent rating in the drug products list (Orange Book U.S. Department of Health and Human Services). Some medications on the formulary require prior authorization which your provider may request through our Pharmacy Service Team at (800) If you require medications not listed on this formulary, your provider may request an exception through our Pharmacy Customer Service Team, except for those items listed as I

3 specific exclusions. Non-formulary medications not requiring prior authorization will be available at the highest copay level. Some medications and diabetic supplies may be restricted to a specific manufacturer, vendor or supplier and may be subject to quantity limits. Quantity limits may apply to certain medications. Brand and generic Triptan medications for migraines have a quantity limit of 6 units per 28 days across all products (sumatriptan, rizatriptan, naratriptan, almotriptan, frovatriptan, eletriptan, zolmitriptan, and sumatriptan/naproxen). Insulin syringes, lancets, and inhaler spacers are covered at Tier 2. Non-prescription (over-the-counter) medications are not covered unless required by healthcare reform legislation. Note that if certain conditions are met some medications may be covered with no copay/coinsurance due to healthcare reform legislation. Please contact the pharmacy customer service team for more information. Many compounded prescriptions require prior authorization review, which your provider may request through our Pharmacy Customer Service Team. If an exception is approved, you will be charged at the Tier 2 copay level. If your request is denied, the medication will be excluded from coverage under your prescription medication benefits. Medications listed on Tier 0 are covered at $0 copay. All prescriptions for a total morphine equivalent dose (MED) of 90 or greater will require prior authorization. Short acting opioid prescriptions will require prior authorization if more than a 3 day supply is required for a member under 8 years of age. Using this formulary The medication Tier is listed in the Drug Tier Column. Medication names with QL in the Requirements/Limits column have quantity limits Medication names followed by PA in the Requirements/Limits column require prior authorization. Medication names followed by ST in the Requirements/Limits column have step therapy requirements. Medication names followed by SP in the Requirements/Limits column must be obtained from a network specialty vendor. This formulary is accurate as of October, 208 and is subject to change. Any additions or deletions to the formulary throughout the year may be found in the following publications: Member Update for members and Healthcare Provider Update for providers. The most up-to-date source for formulary information is the online formulary search available at Restrictions in medication availability may result from use of a formulary. II

4 Please be aware that if you choose to obtain a non-formulary drug, you may be required to pay the full price of that drug. For information about your specific prescription drug benefits, please contact the Pharmacy Service Team at (800) or (570) Quantity Limits Quantity limits are listed in the Requirements/Limits Column Note that non-formulary medications in the same class/category as formulary drugs with quantity limits will have the same quantity limits applied. If not listed above the maximum days supply for specialty vendor medications is 34 days or as otherwise defined in the prescription medication benefit documents. Step Therapy For details regarding step therapy requirements please contact the Pharmacy Service Team at (800) or (570) Specialty Vendor Drug Program Certain medications require the use of a contracted specialty pharmacy vendor for purchase. Please contact the Pharmacy Service Team at (800) for additional information on the program and a complete list of the medications included. What is a medication formulary? A medication formulary is a continually updated list of prescription medications. It represents the medications currently covered based upon the clinical judgment of the Pharmacy and Therapeutics Committee, which is made up of pharmacists and physicians. (The formulary is continually updated due to the high number of medications currently on the market, as well as the continuous introduction of new medications.) This committee thoroughly reviews medical literature to first determine which medications are likely to produce the best results for patients. Then, if two or more medications produce the same clinical results, elements like cost and ease of use are considered. A well-developed formulary enhances quality of patient care by encouraging physicians to prescribe medications that are safe, effective, and likely to achieve the best possible outcome for the patient. When you use a formulary medication, it is considered a covered medication and you pay your particular co-pay or coinsurance for that medication. The Plan recognizes that, in some situations, you may not respond well to a given formulary medication, or may have an allergy or other condition that warrants the use of a non-formulary medication. An exception process exists for these special instances. Your physician may initiate a request for a formulary exception by contacting our Pharmacy Service Team. Your request will be reviewed, including review of pertinent medical records, treatment and laboratory data. We respond to such requests within 48 hours of receiving all necessary information. If an exception is approved under the Triple Choice benefit, you will be charged at the highest applicable copay level. If your III

5 request is denied, the medication will be excluded from coverage under your prescription medication benefits. Formulary exclusions There are certain medications that your plan will not cover under any circumstance. These are called exclusions. Examples of exclusions include, but are not limited to, over-the-counter medications, medications used for experimental, investigational or unproven medication therapies, medications used for weight loss and weight management, life-style medications, medications used for cosmetic purposes, and medications for erectile dysfunction. Exclusions are subject to change so you should contact the Pharmacy Service Team when you are unsure whether a medication is covered. Formulary development When deciding whether or not a medication should be included in the formulary, the Pharmacy and Therapeutics Committee carefully considers each medication for coverage or non- coverage in order to ensure safety and effectiveness in the medications being prescribed. This information is then shared with participating providers for review and feedback. Based upon the gathered information and provider feedback, the Pharmacy and Therapeutics Committee will determine a medication s inclusion or exclusion in the formulary. For the specific criteria used to determine a medication s inclusion or exclusion in this formulary, please contact the Pharmacy Customer Service Team. Health Care Reform: The Affordable Care Act (ACA) was signed into law on March 23, 200. Under the ACA, the government created provisions, or laws, that health insurers must adapt to, which change health benefits for consumers. These changes include the expansion of preventive services, including vaccinations, prescription drugs, and more. In accordance with the ACA requirements, and subject to any applicable limitations of your pharmacy plan, the following preventive medications will be covered with no cost-sharing under the prescription drug benefit: Aspirin Products Low dose (8 mg) aspirin products for all females Contraceptives For females Breast Cancer Prevention Generic raloxifene and generic tamoxifen for females Folic Acid Supplements Generic folic acid 0.4 mg tablets for females Fluoride Supplements Fluoride drops and chewable tablets for members 6 months 6 years of age Iron Supplements Pediatric Iron supplements for members 6 2 months of age Smoking Cessation Products Two, 90 day treatment courses per benefit year Vaccinations Herpes Zoster and Influenza (Flu) Vaccine (Other preventive vaccinations may be covered under the medical benefit) Vitamins Generic over the counter vitamins IV

6 Depending on your specific benefits and in which state you reside, oral chemotherapy agents may have no cost sharing. Please note: For details about how these medications may be covered under your specific plan please contact the Pharmacy Customer Service Team. A prescription is required to process any claim for preventive care medications or products under the pharmacy plan, including over-thecounter medications. What are generics? When a company develops a new medication, it receives a patent that protects the medication company s right to be the only manufacturer of that medication for a certain period of time, which means that no generic can be manufactured. After that patent expires, other companies can then make the same medication and sell it in its generic form. The generic form of a medication has the same active ingredients, the same strength, and the same dosage as the brand name medication. The inactive ingredients (which provide texture, shape and color) may be different, which is why a generic typically looks different than its brand name counterpart. Generic medications are usually less expensive than brand name medications, but are just as safe and effective. This is because generic manufacturers have lower advertising costs and greater competition from other generic manufacturers. Additionally, the U.S. Food and Drug Administration regulates all pharmaceuticals, including generics, to assure quality, strength, purity and potency. Your prescription medication coverage is a generic-based plan and, whenever possible, you should use a cost-effective generic medication. V

7 Notes for Providers Formulary review process: Medications selected for inclusion in the formulary are chosen in consideration of effectiveness, safety and overall value. Evaluation for formulary inclusion is based on formalized selection criteria to determine the most optimal benefit to members. These criteria include but are not limited to: Medication name/dosage form Medication class/pharmacology FDA-approved indications Adverse reactions Clinical evidence of safety and efficacy Recommendations of national agencies and organizations Therapeutic equivalence Cost analysis The criteria are reviewed by the Health Plan Pharmacy and Therapeutics Committee, which is comprised of pharmacists and participating physicians in active clinical practice from various specialties. The medication is then reviewed and evaluated by clinicians in particular specialties for additional feedback. The feedback is discussed by the Pharmacy and Therapeutics Committee prior to finalizing a decision on formulary status. To be included, the medication must offer a distinct advantage over existing formulary medications in the same therapeutic class. Specifically, the medication must demonstrate such attributes as: A distinct or unique therapeutic feature Greater efficacy, proven in clinical trials, over other medications in the same therapeutic category An improved dosing schedule, safety profile or cost-effectiveness over existing formulary medications If there are comparable therapeutic agents, additional analysis may be considered. These factors include: Member satisfaction Cost analysis Contract terms and conditions Market share analysis Patent life assessment Utilization management Consumer advertising Per member per month costs VI

8 Generic substitution policy: The Health Plan prescription benefits are generically based. Generic substitution will occur for those medications included in the Approved Medication Products with Therapeutic Equivalence Evaluations, also known as The Orange Book, published by the U.S. Department of Health and Human Services. Generic medications, which have an equivalent rating by these standards, are generally provided under the member s prescription medication benefit. The Health Plan may also elect to include only one brand- name medication in the formulary even if the medication is marketed by more than one company, or if the brand name medication does not significantly differ from the generic medication. Prior authorization: To promote the most appropriate utilization, select medications may require prior authorization by the Health Plan to be eligible for coverage under the member s prescription benefit. The Pharmacy and Therapeutics Committee determines prior authorization criteria. In order for a member to receive coverage for a medication requiring prior authorization, the prescribing physician must obtain prior authorization by contacting the Health Plan Pharmacy Department at the address, telephone, or fax number above. Submission of medical documentation is required. Step Therapy: Some medications may require that other medications be tried prior to or concomitantly with the requested medication. The pharmacy claims system looks for a record of the required medications and if they are not found, medical documentation must be submitted showing use of these medications or rationale for skipping the step therapy medications. Non-formulary medications: The formulary is designed to meet most therapeutic needs of the population served by the Health Plan. Occasionally, because of allergy, therapeutic failure, or a specific diagnostic-related need, formulary medications may not meet the special needs of an individual member. In these special instances, the prescribing physician may make requests to the Health Plan Pharmacy Department for non-formulary or restricted medications. The prescribing physician will receive written documentation and/or a verbal response from the Health Plan Pharmacy Department regarding the request. Formulary addition requests: Requests for changes or additions, comments, and suggestions for the formulary are welcome and can be made by written request to the Health Plan Pharmacy Department. Sources: Academy of Managed Care Pharmacy (AMCP), Formulary Management, Formularies, November 200. Health Insurance Association of America (HIAA), Guide to Managed Care: Choosing and Using a Health Plan. November 200. National Consumers League (NCL), Consumer Guide to Generic Medications, November 200. From the Pharmacist, November 200. VII

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11 Table of Contents Analgesics... 3 Anesthetics... 6 Anti-Addiction/Substance Abuse Treatment Agents... 7 Antianxiety Agents... 7 Antibacterials... 8 Anticancer Agents... 2 Anticholinergic Agents... 7 Anticonvulsants... 7 Antidementia Agents... 8 Antidepressants... 9 Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents... 40

12 Contraceptives Cough And Cold Products Dental And Oral Agents Dermatological Agents Detergents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents... 6 Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents... 7 Metabolic Bone Disease Agents... 7 Miscellaneous Therapeutic Agents... 7 Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Urine And Feces Contents Vasodilating Agents Vitamins And Minerals

13 Analgesics Analgesics, Miscellaneous ABSTRAL 2 PA; QL (36 per 34 acetaminophen-caff-dihydrocod oral tablet mg acetaminophen-codeine oral solution 20-2 mg/5 ml acetaminophen-codeine oral tablet ascomp with codeine aspirin-caffeine-dihydrocodein belladonna alkaloids-opium belladonna-opium buprenorphine (Butrans) PA; QL (0.4 per day) butalbital compound w/codeine butalbital-acetaminop-caf-cod butalbital-acetaminophen oral capsule butalbital-acetaminophen oral tablet (Tencon) butalbital-acetaminophen-caff oral (Fioricet) capsule butalbital-acetaminophen-caff oral tablet (Esgic) mg butalbital-aspirin-caffeine oral capsule (Fiorinal) butorphanol tartrate nasal capacet codeine sulfate oral solution 5 mg/2.5 ml (2.5 ml) CODEINE SULFATE ORAL SOLUTION 30 MG/5 ML codeine sulfate oral tablet DISKETS PA endocet oral tablet mg, mg, mg, mg fentanyl (Duragesic) PA fentanyl citrate (Actiq) PA; QL (36 per 34 FENTORA 2 PA hydrocodone-acetaminophen oral solution mg/5 ml, 5-63 mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) mg/5 ml hydrocodone-acetaminophen oral tablet mg (Vicodin HP) 3

14 hydrocodone-acetaminophen oral tablet (Lorcet HD) mg hydrocodone-acetaminophen oral tablet (Verdrocet) mg hydrocodone-acetaminophen oral tablet 5- (Vicodin) 300 mg hydrocodone-acetaminophen oral tablet 5- (Lorcet (hydrocodone)) 325 mg hydrocodone-acetaminophen oral tablet (Vicodin ES) mg hydrocodone-acetaminophen oral tablet (Lorcet Plus) mg hydrocodone-ibuprofen hydromorphone oral liquid (Dilaudid) hydromorphone oral tablet (Dilaudid) ibuprofen-oxycodone levorphanol tartrate lorcet (hydrocodone) lorcet hd lorcet plus oral tablet mg margesic marten-tab meperidine oral solution meperidine oral tablet methadone oral concentrate (Methadone Intensol) PA methadone oral solution PA methadone oral tablet (Dolophine) PA methadone oral tablet,soluble (Diskets) PA methadose oral tablet,soluble PA morphine concentrate oral solution morphine oral capsule, er multiphase 24 PA hr morphine oral capsule,extend.release (Kadian) PA pellets morphine oral solution MORPHINE ORAL TABLET morphine oral tablet extended release (MS Contin) PA morphine rectal nalocet NUCYNTA 2 PA NUCYNTA ER 2 PA oxycodone oral capsule 4

15 oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet (Roxicodone) oxycodone oral tablet,oral only,ext.rel.2 (OxyContin) PA hr oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet 0- (Primlev) 300 mg, mg, mg oxycodone-acetaminophen oral tablet 0- (Endocet) 325 mg, mg, mg, mg oxycodone-aspirin OXYCONTIN ORAL TABLET,ORAL 2 PA ONLY,EXT.REL.2 HR oxymorphone oral tablet (Opana) panlor(acetam-caff-dihydrocod) pentazocine-naloxone phrenilin forte(with caffeine) reprexain ROXICODONE ORAL TABLET 5 MG SUBSYS 2 PA; QL (36 per 34 tencon oral tablet mg tramadol oral capsule,er biphase 24 hr (ConZip) PA tramadol oral tablet (Ultram) tramadol oral tablet extended release 24 PA hr tramadol oral tablet, er multiphase 24 hr PA tramadol-acetaminophen (Ultracet) xylon 0 zebutal oral capsule mg Nonsteroidal Anti-Inflammatory Agents celecoxib (Celebrex) choline,magnesium salicylate diclofenac potassium diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) diclofenac-misoprostol (Arthrotec 50) diflunisal etodolac oral capsule 5

16 etodolac oral tablet (Lodine) etodolac oral tablet extended release 24 hr fenoprofen oral capsule (Nalfon) fenoprofen oral tablet (ProFeno) flurbiprofen ibu ibuprofen oral suspension (Child Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 (IBU) mg INDOCIN ORAL 2 indomethacin oral ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac oral QL (20 per day) meclofenamate mefenamic acid meloxicam nabumetone naproxen oral suspension (Naprosyn) naproxen oral tablet naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) naproxen sodium oral tablet 275 mg naproxen sodium oral tablet 550 mg (Anaprox DS) oxaprozin (Daypro) piroxicam (Feldene) salsalate (Disalcid) sulindac tolmetin VIMOVO 2 PA; QL (2 per day) Anesthetics Local Anesthetics CIDALEAZE glydo LIDO BDK lidocaine hcl mucous membrane jelly lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine hcl topical cream 3 % (Lidopin) lidocaine hcl topical cream 3.88 % (Lidotral) 6

17 lidocaine hcl-hydrocortison ac rectal kit 3- % (7 gram) lidocaine hcl-hydrocortison ac topical lidocaine topical adhesive patch,medicated (Lidoderm) PA lidocaine topical ointment lidocaine viscous lidocaine-hydrocortisone-aloe rectal kit lidocaine-prilocaine topical cream lidocaine-prilocaine topical kit (AgonEaze) LIDO-K RELADOR PAK Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents buprenorphine hcl sublingual QL (34 days supply per fill) buprenorphine-naloxone sublingual tablet QL (34 days supply per fill) bupropion hcl (smoking deter) (Zyban) 0 CHANTIX 0 QL (2 per day) CHANTIX CONTINUING MONTH 0 QL (2 per day) BOX CHANTIX STARTING MONTH BOX 0 QL (53 per 80 disulfiram (Antabuse) LUCEMYRA 2 PA; QL (2 per 7 naloxone injection syringe naltrexone NARCAN 2 nicorelief 0 nicotine (polacrilex) buccal gum (Nicorelief) 0 nicotine (polacrilex) buccal lozenge (Nicorette) 0 nicotine transdermal patch 24 hour 0 NICOTINE TRANSDERMAL PATCH, TD DAILY, SEQUENTIAL NICOTROL 0 NICOTROL NS 0 stop smoking aid 0 SUBOXONE 2 PA; QL (34 days supply per fill) Antianxiety Agents 7 0

18 Benzodiazepines ALPRAZOLAM INTENSOL 2 alprazolam oral tablet (Xanax) alprazolam oral tablet extended release 24 (Xanax XR) hr alprazolam oral tablet,disintegrating buspirone chlordiazepoxide hcl clonazepam oral tablet (Klonopin) clonazepam oral tablet,disintegrating clorazepate dipotassium DIASTAT ACUDIAL 2 diazepam intensol diazepam oral solution 5 mg/5 ml ( mg/ml) diazepam oral tablet (Valium) diazepam rectal (Diastat) estazolam flurazepam lorazepam oral concentrate (Lorazepam Intensol) lorazepam oral tablet (Ativan) meprobamate midazolam oral syrup 2 mg/ml ONFI ORAL SUSPENSION 2 PA ONFI ORAL TABLET 0 MG, 20 MG 2 PA oxazepam quazepam (Doral) temazepam (Restoril) triazolam Antibacterials Aminoglycosides BETHKIS 2 PA; SP; QL (224 per 56 neomycin TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 2 PA; SP; QL (224 per 56 tobramycin in % nacl (Tobi) PA; SP; QL (280 per 56 Antibacterials, Miscellaneous clindamycin hcl (Cleocin HCl) clindamycin palmitate hcl (Cleocin Pediatric) FIRVANQ 2 8

19 hyolev mb linezolid oral suspension for reconstitution (Zyvox) PA linezolid oral tablet (Zyvox) QL (2 per 80 methenamine hippurate (Hiprex) methenamine mandelate metronidazole oral (Flagyl) nitrofurantoin (Furadantin) nitrofurantoin macrocrystal (Macrodantin) nitrofurantoin monohyd/m-cryst (Macrobid) PHOSPHASAL 2 SIVEXTRO ORAL 2 PA; QL (6 per 365 trimethoprim ur n-c uretron d-s oral tablet mg 2 URETRON D-S ORAL TABLET MG urimar-t URIN DS 2 uro-458 uro-blue urogesic-blue urolet mb vancomycin in 0.9 % sodium chl intravenous solution.5 gram/500 ml vancomycin intravenous vancomycin oral capsule (Vancocin) XIFAXAN 2 PA Cephalosporins cefaclor oral capsule cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 2 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefdinir cefditoren pivoxil cefixime (Suprax) cefpodoxime cefprozil 9

20 CEFTIN ORAL SUSPENSION FOR 2 RECONSTITUTION cefuroxime axetil oral tablet cephalexin oral capsule 250 mg, 500 mg (Keflex) cephalexin oral suspension for reconstitution cephalexin oral tablet SUPRAX ORAL CAPSULE 2 SUPRAX ORAL SUSPENSION FOR 2 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 2 Macrolides azithromycin oral (Zithromax) clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr DIFICID 2 PA; QL (20 per day) e.e.s. 400 oral tablet E.E.S. GRANULES 2 ERYPED ERYPED ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 mg erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution erythromycin ethylsuccinate oral tablet (E.E.S. 400) erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet Penicillins amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution 0

21 amoxicillin-pot clavulanate oral tablet (Augmentin) amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 2 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin AUGMENTIN ORAL SUSPENSION 2 FOR RECONSTITUTION MG/5 ML dicloxacillin penicillin v potassium Quinolones BAXDELA ORAL 2 PA; QL (28 per 4 ciprofloxacin (Cipro) ciprofloxacin (mixture) (Cipro XR) ciprofloxacin hcl oral (Cipro) levofloxacin oral (Levaquin) moxifloxacin oral (Avelox) ofloxacin oral tablet 300 mg, 400 mg Sulfonamides sulfadiazine sulfamethoxazole-trimethoprim oral suspension (Sulfatrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfatrim Tetracyclines demeclocycline doxycycline hyclate oral capsule (Morgidox) doxycycline hyclate oral tablet doxycycline hyclate oral tablet,delayed release (dr/ec) 00 mg, 75 mg doxycycline hyclate oral tablet,delayed (Soloxide) release (dr/ec) 50 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension (Vibramycin) for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet minocycline oral tablet extended release (Solodyn) PA 24 hr 5 mg, 65 mg minocycline oral tablet extended release 24 hr 35 mg, 45 mg, 90 mg (CoreMino)

22 okebo tetracycline Anticancer Agents Anticancer Agents AFINITOR 2 PA; QL (28 per 28 AFINITOR DISPERZ 2 PA; QL (28 per 28 ALECENSA 2 PA; SP; QL (240 per 30 ALUNBRIG ORAL TABLET 80 MG, 90 MG 2 PA; SP; QL (30 per 30 ALUNBRIG ORAL TABLET 30 MG 2 PA; SP; QL (20 per 30 ALUNBRIG ORAL TABLETS,DOSE PACK 2 PA; SP; QL (30 per 30 anastrozole (Arimidex) bexarotene (Targretin) PA bicalutamide (Casodex) BOSULIF ORAL TABLET 00 MG 2 PA; SP; QL (90 per 30 BOSULIF ORAL TABLET 400 MG, 500 MG 2 PA; SP; QL (30 per 30 BRAFTOVI ORAL CAPSULE 50 MG 2 PA; SP; QL (20 per 30 BRAFTOVI ORAL CAPSULE 75 MG 2 PA; SP; QL (80 per 30 CABOMETYX 2 PA; SP; QL (30 per 30 CALQUENCE 2 PA; SP; QL (60 per 30 capecitabine (Xeloda) CAPRELSA ORAL TABLET 00 MG 2 PA; SP; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG 2 PA; SP; QL (30 per 30 COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-20 MG X) 2 PA; SP; QL (56 per 28 COMETRIQ ORAL CAPSULE 40 MG/DAY(80 MG X-20 MG X3) 2 PA; SP; QL (2 per 28 COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) 2 PA; SP; QL (84 per 28 COTELLIC 2 PA; SP; QL (90 per 30 2

23 CYCLOPHOSPHAMIDE ORAL CAPSULE EMCYT 2 ERIVEDGE 2 PA; SP; QL (28 per 28 ERLEADA 2 PA; SP; QL (20 per 30 etoposide oral exemestane (Aromasin) FARYDAK 2 PA; SP; QL (6 per 2 flutamide GILOTRIF 2 PA; SP; QL (30 per 30 GLEEVEC ORAL TABLET 00 MG 2 QL (90 per 30 GLEEVEC ORAL TABLET 400 MG 2 QL (60 per 30 GLEOSTINE 2 HEXALEN 2 HYCAMTIN ORAL 2 SP; QL (34 days supply per fill) hydroxyurea (Hydrea) IBRANCE 2 PA; SP; QL (2 per 28 ICLUSIG ORAL TABLET 5 MG 2 PA; SP; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG 2 PA; SP; QL (30 per 30 IDHIFA 2 PA; SP; QL (30 per 30 imatinib oral tablet 00 mg (Gleevec) QL (90 per 30 imatinib oral tablet 400 mg (Gleevec) QL (60 per 30 IMBRUVICA ORAL CAPSULE 40 MG 2 PA; SP; QL (20 per 30 IMBRUVICA ORAL CAPSULE 70 MG 2 PA; SP; QL (28 per 28 IMBRUVICA ORAL TABLET 2 PA; SP; QL (28 per 28 INLYTA ORAL TABLET MG 2 PA; SP; QL (80 per 30 INLYTA ORAL TABLET 5 MG 2 PA; SP; QL (20 per 30 IRESSA 2 PA; SP; QL (30 per 30 3

24 JAKAFI 2 PA; SP; QL (60 per 30 KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X )-2.5 MG 2 PA; SP; QL (49 per 28 KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X ) KISQALI ORAL TABLET 400 MG/DAY (200 MG X 2) KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3) LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 8 MG/DAY (4 MG X 2) LENVIMA ORAL CAPSULE 2 2 PA; SP; QL (70 per 28 2 PA; SP; QL (9 per 28 2 PA; SP; QL (2 per 28 2 PA; SP; QL (42 per 28 2 PA; SP; QL (63 per 28 2 PA; SP; QL (90 per 30 2 PA; SP; QL (90 per 30 MG/DAY (4 MG X 3), 4 MG letrozole (Femara) AGE (Min 45 Years) LEUKERAN 2 leuprolide subcutaneous kit lomustine (Gleostine) LONSURF ORAL TABLET MG 2 PA; SP; QL (00 per 28 LONSURF ORAL TABLET MG 2 PA; SP; QL (80 per 28 LYNPARZA ORAL CAPSULE 2 PA; SP; QL (448 per 28 LYNPARZA ORAL TABLET 2 PA; SP; QL (20 per 30 LYSODREN 2 MATULANE 2 SP; QL (34 days supply per fill) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG 2 PA; SP; QL (90 per 30 4

25 MEKINIST ORAL TABLET 2 MG 2 PA; SP; QL (30 per 30 MEKTOVI 2 PA; SP; QL (80 per 30 melphalan (Alkeran) mercaptopurine methotrexate sodium methotrexate sodium (pf) injection solution MYLERAN 2 NERLYNX 2 PA; SP; QL (80 per 30 NEXAVAR 2 PA; SP; QL (20 per 30 nilutamide (Nilandron) NINLARO 2 PA; SP; QL (3 per 28 ODOMZO 2 PA; SP; QL (30 per 30 POMALYST 2 PA; SP; QL (2 per 28 REVLIMID ORAL CAPSULE 0 MG, 2 PA; SP; QL (28 per MG, 5 MG REVLIMID ORAL CAPSULE 5 MG, 20 2 PA; SP; QL (2 per 28 MG, 25 MG RUBRACA 2 PA; SP; QL (20 per 30 RYDAPT 2 PA; SP; QL (2 per 28 SPRYCEL ORAL TABLET 00 MG, 40 2 PA; SP; QL (30 per 30 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG 2 PA; SP; QL (90 per 30 STIVARGA 2 PA; SP; QL (84 per 28 SUTENT 2 PA; SP; QL (28 per 28 TAFINLAR 2 PA; SP; QL (20 per 30 TAGRISSO 2 PA; SP; QL (30 per 30 tamoxifen $0 copay for women TARCEVA ORAL TABLET 00 MG, 2 PA NSO; SP; QL (30 per 50 MG 30 5

26 TARCEVA ORAL TABLET 25 MG 2 PA NSO; SP; QL (90 per 30 TARGRETIN TOPICAL 2 PA TASIGNA ORAL CAPSULE 50 MG, 200 MG 2 PA; SP; QL (2 per 28 TASIGNA ORAL CAPSULE 50 MG 2 PA; SP; QL (20 per 30 temozolomide (Temodar) TIBSOVO 2 PA; SP; QL (60 per 30 tretinoin (chemotherapy) TYKERB 2 PA; SP; QL (80 per 30 VENCLEXTA ORAL TABLET 0 MG 2 PA; SP; QL (56 per 28 VENCLEXTA ORAL TABLET 00 MG 2 PA; SP; QL (20 per 30 VENCLEXTA ORAL TABLET 50 MG 2 PA; SP; QL (28 per 28 VENCLEXTA STARTING PACK 2 PA; SP; QL (42 per 28 VERZENIO 2 PA; SP; QL (56 per 28 VOTRIENT 2 PA; SP; QL (20 per 30 XALKORI 2 PA; SP; QL (60 per 30 XTANDI 2 PA; SP; QL (20 per 30 YONSA 2 PA; SP; QL (20 per 30 ZEJULA 2 PA; SP; QL (90 per 30 ZELBORAF 2 PA; SP; QL (240 per 30 ZOLINZA 2 PA; SP; QL (20 per 30 ZYDELIG 2 PA; SP; QL (60 per 30 ZYKADIA 2 PA; SP; QL (84 per 28 ZYTIGA ORAL TABLET 250 MG 2 PA; SP; QL (20 per 30 6

27 ZYTIGA ORAL TABLET 500 MG 2 PA; SP; QL (60 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics chlordiazepoxide-clidinium (Librax (with clidinium)) ME-PB-HYOS ORAL ELIXIR me-pb-hyos oral tablet PHENOBARB-HYOSCY-ATROPINE- (Donnatal) SCOP ORAL ELIXIR phenobarb-hyoscy-atropine-scop oral tablet (Donnatal) propantheline Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, PA; QL ( per day) MG APTIOM ORAL TABLET 600 MG, PA; QL (2 per day) MG BANZEL 2 PA carbamazepine oral capsule, er (Carbatrol) multiphase 2 hr carbamazepine oral suspension 00 mg/5 (Tegretol) ml carbamazepine oral tablet (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 2 hr carbamazepine oral tablet,chewable DILANTIN 2 DILANTIN INFATABS 2 divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle divalproex oral tablet extended release 24 (Depakote ER) hr divalproex oral tablet,delayed release (Depakote) (dr/ec) epitol ethosuximide (Zarontin) felbamate (Felbatol) FYCOMPA ORAL SUSPENSION 2 PA; QL (24 per day) FYCOMPA ORAL TABLET 2 PA; QL ( per day) gabapentin oral capsule (Neurontin) gabapentin oral solution 250 mg/5 ml (Neurontin) 7

28 gabapentin oral tablet 600 mg, 800 mg (Neurontin) lamotrigine oral tablet (Lamictal) lamotrigine oral tablet extended release (Lamictal XR) 24hr lamotrigine oral tablet, chewable (Lamictal) dispersible lamotrigine oral tablets,dose pack 25 mg (Lamictal Starter (Blue) (35) Kit) levetiracetam oral solution 00 mg/ml (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release (Keppra XR) 24 hr LYRICA 2 oxcarbazepine (Trileptal) phenobarbital PHENYTEK 2 phenytoin oral suspension 25 mg/5 ml (Dilantin-25) phenytoin oral tablet,chewable (Dilantin Infatabs) phenytoin sodium extended (Dilantin Extended) primidone (Mysoline) SABRIL ORAL TABLET 2 PA; SP; QL (34 days supply per fill) subvenite tiagabine (Gabitril) topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) PA topiramate oral tablet (Topamax) TROKENDI XR 2 PA valproic acid (Depakene) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) vigabatrin (Sabril) PA vigadrone PA VIMPAT ORAL SOLUTION 2 PA VIMPAT ORAL TABLET 2 PA zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) donepezil oral tablet,disintegrating galantamine oral capsule,ext rel. pellets (Razadyne ER) 24 hr 8

29 galantamine oral solution galantamine oral tablet (Razadyne) memantine oral capsule,sprinkle,er 24hr (Namenda XR) PA memantine oral solution memantine oral tablet (Namenda) rivastigmine tartrate Antidepressants Antidepressants amitriptyline amitriptyline-chlordiazepoxide amoxapine APLENZIN 2 PA bupropion hcl oral tablet bupropion hcl oral tablet extended release (Wellbutrin XL) 24 hr bupropion hcl oral tablet sustainedrelease (Wellbutrin SR) 2 hr citalopram oral solution citalopram oral tablet (Celexa) clomipramine (Anafranil) desipramine (Norpramin) desvenlafaxine succinate (Pristiq) QL ( per day) doxepin oral duloxetine oral capsule,delayed (Cymbalta) release(dr/ec) 20 mg, 30 mg, 60 mg escitalopram oxalate (Lexapro) FETZIMA 2 PA fluoxetine oral capsule (Prozac) fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 0 mg, 20 mg (Sarafem) FLUOXETINE ORAL TABLET 60 MG fluvoxamine oral tablet FORFIVO XL 2 PA; QL ( per day) imipramine hcl (Tofranil) imipramine pamoate maprotiline mirtazapine nefazodone nortriptyline oral capsule (Pamelor) nortriptyline oral solution 9

30 olanzapine-fluoxetine (Symbyax) paroxetine hcl oral tablet (Paxil) paroxetine hcl oral tablet extended release (Paxil CR) 24 hr PAXIL ORAL SUSPENSION 2 perphenazine-amitriptyline phenelzine (Nardil) protriptyline sertraline (Zoloft) tranylcypromine (Parnate) trazodone trimipramine (Surmontil) TRINTELLIX 2 PA venlafaxine oral capsule,extended release (Effexor XR) 24hr venlafaxine oral tablet venlafaxine oral tablet extended release 24hr VIIBRYD ORAL TABLET 2 PA VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (23) 2 PA Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) BYDUREON 2 ST; QL (0.4 per day) BYDUREON BCISE 2 ST; QL (0.2 per day) GLUCAGEN HYPOKIT 2 QL (2 kits per fill) GLUCAGON EMERGENCY KIT 2 QL (2 kits per fill) (HUMAN) GLYXAMBI 2 QL ( per day) INVOKAMET 2 QL (2 per day) INVOKAMET XR 2 QL (2 per day) INVOKANA 2 QL ( per day) JARDIANCE 2 QL ( per day) JENTADUETO 2 QL (2 per day) JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-,000 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-,000 MG KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-,000 MG 2 QL (2 per day) 2 QL ( per day) 2 PA; QL (2 per day) 20

31 KOMBIGLYZE XR ORAL TABLET, ER 2 PA; QL ( per day) MULTIPHASE 24 HR 5-,000 MG, MG KORLYM 2 PA; SP; QL (2 per 28 metformin oral tablet (Glucophage) metformin oral tablet extended release 24 (Glucophage XR) hr miglitol (Glyset) nateglinide (Starlix) ONGLYZA 2 PA; QL ( per day) OZEMPIC SUBCUTANEOUS PEN 2 QL (0.06 per day) INJECTOR 0.25 MG OR 0.5 MG(2 MG/.5 ML) OZEMPIC SUBCUTANEOUS PEN INJECTOR MG/0.75 ML (2 MG/.5 ML) 2 QL (0. per day) pioglitazone (Actos) pioglitazone-glimepiride (DUETACT) pioglitazone-metformin (Actoplus MET) repaglinide (Prandin) SYMLINPEN 20 2 PA SYMLINPEN 60 2 PA SYNJARDY 2 QL (2 per day) SYNJARDY XR ORAL TABLET, IR - 2 QL ( per day) ER, BIPHASIC 24HR 0-,000 MG, 25-,000 MG SYNJARDY XR ORAL TABLET, IR - 2 QL (2 per day) ER, BIPHASIC 24HR 2.5-,000 MG, 5-,000 MG TANZEUM 2 PA NSO; QL (0.4 per day) TRADJENTA 2 QL ( per day) TRULICITY 2 ST; QL (0.07 per day) VICTOZA SUBCUTANEOUS PEN 2 QL (0.3 per day) INJECTOR 0.6 MG/0. ML (8 MG/3 ML) Insulins LANTUS SOLOSTAR U-00 INSULIN 2 LANTUS U-00 INSULIN 2 LEVEMIR FLEXTOUCH U-00 2 INSULN LEVEMIR U-00 INSULIN 2 2

32 NOVOLIN 70/30 U-00 INSULIN 2 NOVOLIN N NPH U-00 INSULIN 2 NOVOLIN R REGULAR U-00 INSULN 2 NOVOLOG FLEXPEN U-00 INSULIN 2 NOVOLOG MIX U-00 INSULN 2 NOVOLOG MIX 70-30FLEXPEN U-00 2 NOVOLOG PENFILL U-00 INSULIN 2 NOVOLOG U-00 INSULIN ASPART 2 TOUJEO MAX U-300 SOLOSTAR 2 AGE (Min 8 Years) TOUJEO SOLOSTAR U-300 INSULIN 2 AGE (Min 8 Years) TRESIBA FLEXTOUCH U-00 2 TRESIBA FLEXTOUCH U XULTOPHY 00/3.6 2 ST; QL (0.5 per day) Sulfonylureas chlorpropamide glimepiride (Amaryl) glipizide oral tablet (Glucotrol) glipizide oral tablet extended release 24hr (Glucotrol XL) glipizide-metformin glyburide glyburide micronized (Glynase) glyburide-metformin tolazamide tolbutamide Antifungals Antifungals ciclopirox topical cream (Ciclodan) ciclopirox topical gel ciclopirox topical shampoo (Loprox) ciclopirox topical suspension (Loprox (as olamine)) clotrimazole mucous membrane clotrimazole topical clotrimazole-betamethasone topical cream (Lotrisone) clotrimazole-betamethasone topical lotion econazole fluconazole (Diflucan) flucytosine (Ancobon) QL (34 days supply per fill) griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize itraconazole oral capsule (Sporanox) PA 22

33 ketoconazole oral ketoconazole topical cream ketoconazole topical foam (Extina) ketoconazole topical shampoo (Nizoral) luliconazole (Luzu) PA miconazole-3 vaginal suppository naftifine NAFTIN TOPICAL CREAM 2 % 2 NAFTIN TOPICAL GEL 2 NOXAFIL ORAL 2 PA; QL (34 days supply per fill) nyamyc NYSTATIN (BULK) POWDER BILLION UNIT nystatin oral powder 50 million unit nystatin oral suspension nystatin oral tablet nystatin topical (Nyamyc) nystatin-triamcinolone nystop SPORANOX ORAL SOLUTION 2 PA terbinafine hcl oral voriconazole oral (Vfend) PA; QL (34 days supply per fill) Antigout Agents Antigout Agents, Other allopurinol (Zyloprim) colchicine oral tablet (Colcrys) probenecid probenecid-colchicine ULORIC 2 PA; QL ( per day) Antihistamines Antihistamines arbinoxa oral liquid arbinoxa oral tablet carbinoxamine maleate oral liquid carbinoxamine maleate oral tablet centergy CLARINEX ORAL SYRUP 2 CLARINEX-D 2 HOUR 2 clemastine oral tablet 2.68 mg cyproheptadine 23

34 desloratadine oral tablet (Clarinex) diphenhydramine hcl oral elixir (Children's Allergy (diphenhyd)) hydroxyzine hcl oral solution 0 mg/5 ml hydroxyzine hcl oral tablet levocetirizine (Xyzal) promethazine oral syrup promethazine vc Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL 2 CLEOCIN VAGINAL SUPPOSITORY 2 clindamycin phosphate vaginal (Cleocin) CLINDESSE 2 metronidazole vaginal (Metrogel Vaginal) terconazole vaginal cream terconazole vaginal suppository Antimigraine Agents Antimigraine Agents AIMOVIG AUTOINJECTOR 2 PA; QL (2 per 30 almotriptan malate PA NSO; QL (6 per 28 CAFERGOT 2 dihydroergotamine injection (D.H.E.45) dihydroergotamine nasal (Migranal) eletriptan (Relpax) PA NSO; QL (6 per 28 ergotamine-caffeine (Cafergot) frovatriptan (Frova) PA NSO; QL (6 per 28 isometh-dichloral-acetaminophn isomethepten-caf-acetaminophen oral (Prodrin) tablet mg MIGERGOT naratriptan (Amerge) QL (6 per 28 prodrin oral tablet mg rizatriptan oral tablet QL (6 per 28 rizatriptan oral tablet,disintegrating (Maxalt-MLT) QL (6 per 28 sumatriptan (Imitrex) QL (6 per 28 sumatriptan succinate oral (Imitrex) QL (6 per 28 24

35 sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml (Imitrex STATdose Kit Refill) QL (8 per 28 (Imitrex STATdose Kit QL (6 per 28 Refill) (Imitrex STATdose Pen) QL (8 per 28 (Imitrex STATdose Pen) QL (6 per 28 (Imitrex) QL (8 per 28 QL (6 per 28 sumatriptan-naproxen (Treximet) PA; QL (6 per 28 TREXIMET ORAL TABLET 0-60 MG 2 PA; QL (6 per 28 ZEMBRACE SYMTOUCH 2 PA; QL (8 per 28 zolmitriptan oral tablet (Zomig) QL (6 per 28 zolmitriptan oral tablet,disintegrating (Zomig ZMT) QL (6 per 28 ZOMIG NASAL 2 PA NSO; QL (6 per 28 Antimycobacterials Antimycobacterials dapsone oral ethambutol isoniazid oral pyrazinamide rifabutin (Mycobutin) rifampin oral (Rifadin) RIFATER 2 SIRTURO 2 PA Antinausea Agents Antinausea Agents AKYNZEO (NETUPITANT) 2 QL (2 per 28 aprepitant (Emend) BONJESTA 2 QL (2 per day) compro DICLEGIS 2 QL (4 per day) dronabinol (Marinol) EMEND ORAL SUSPENSION FOR RECONSTITUTION 2 granisetron hcl oral QL (2 tablets per fill) meclizine oral tablet 2.5 mg 25

36 meclizine oral tablet 25 mg Drug Name Drug Tier Requirements/Limits (Dramamine Less Drowsy) ondansetron (Zofran ODT) ondansetron hcl oral (Zofran) phenadoz prochlorperazine (Compazine) prochlorperazine maleate (Compazine) promethazine oral tablet promethazine rectal (Phenergan) promethegan SANCUSO 2 PA; QL (4 per 28 scopolamine base (Transderm-Scop) TRANSDERM-SCOP 2 trimethobenzamide oral (Tigan) VARUBI ORAL 2 QL (2 per 4 Antiparasite Agents Antiparasite Agents ALBENZA 2 QL (4 per day) ALINIA 2 atovaquone (Mepron) atovaquone-proguanil (Malarone Pediatric) chloroquine phosphate DARAPRIM 2 SP; QL (34 days supply per fill) EMVERM 2 PA hydroxychloroquine (Plaquenil) ivermectin (Stromectol) mefloquine NEBUPENT 2 paromomycin quinine sulfate (Qualaquin) PA tinidazole YODOXIN 2 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl APOKYN 2 SP; QL (34 days supply per fill) benztropine oral bromocriptine (Parlodel) cabergoline carbidopa-levodopa oral tablet (Sinemet) 26

37 carbidopa-levodopa oral tablet extended (Sinemet CR) release carbidopa-levodopa oral tablet,disintegrating carbidopa-levodopa-entacapone (Stalevo 00) entacapone (Comtan) pramipexole oral tablet (Mirapex) pramipexole oral tablet extended release (Mirapex ER) PA 24 hr rasagiline (Azilect) ropinirole oral tablet (Requip) ropinirole oral tablet extended release 24 hr (Requip XL) selegiline hcl oral capsule selegiline hcl oral tablet tolcapone (Tasmar) trihexyphenidyl Antipsychotic Agents Antipsychotic Agents aripiprazole oral solution aripiprazole oral tablet (Abilify) aripiprazole oral tablet,disintegrating chlorpromazine oral clozapine oral tablet (Clozaril) clozapine oral tablet,disintegrating (FazaClo) FANAPT 2 PA fluphenazine decanoate fluphenazine hcl oral haloperidol haloperidol decanoate (Haldol Decanoate) haloperidol lactate LATUDA 2 PA loxapine succinate NUPLAZID ORAL CAPSULE 2 PA; SP; QL (30 per 30 NUPLAZID ORAL TABLET 0 MG 2 PA; SP; QL (30 per 30 NUPLAZID ORAL TABLET 7 MG 2 PA; SP; QL (60 per 30 olanzapine intramuscular (Zyprexa) olanzapine oral tablet (Zyprexa) olanzapine oral tablet,disintegrating (Zyprexa Zydis) 27

38 paliperidone (Invega) PA perphenazine pimozide (Orap) quetiapine oral tablet (Seroquel) quetiapine oral tablet extended release 24 (Seroquel XR) hr risperidone oral solution (Risperdal) risperidone oral tablet (Risperdal) risperidone oral tablet,disintegrating SAPHRIS 2 PA thioridazine thiothixene trifluoperazine VRAYLAR 2 PA; QL ( per day) ziprasidone hcl (Geodon) Antivirals (Systemic) Antiretrovirals abacavir oral solution (Ziagen) QL (30 per day) abacavir oral tablet (Ziagen) QL (2 per day) abacavir-lamivudine (Epzicom) QL ( per day) abacavir-lamivudine-zidovudine (Trizivir) QL (2 per day) APTIVUS ORAL CAPSULE 2 QL (4 per day) APTIVUS ORAL SOLUTION 2 QL (0 per day) atazanavir oral capsule 50 mg, 200 mg (Reyataz) QL (2 per day) atazanavir oral capsule 300 mg (Reyataz) QL ( per day) ATRIPLA 2 QL ( per day) BIKTARVY 2 QL ( per day) CIMDUO 2 QL ( per day) COMPLERA 2 QL ( per day) CRIXIVAN ORAL CAPSULE 200 MG 2 QL (3 per day) CRIXIVAN ORAL CAPSULE 400 MG 2 QL (6 per day) DESCOVY 2 QL ( per day) didanosine (Videx EC) QL ( per day) EDURANT 2 QL (2 per day) efavirenz oral capsule 200 mg (Sustiva) QL (2 per day) efavirenz oral capsule 50 mg (Sustiva) QL (3 per day) efavirenz oral tablet (Sustiva) QL ( per day) EMTRIVA ORAL CAPSULE 2 QL ( per day) EMTRIVA ORAL SOLUTION 2 QL (24 per day) EPIVIR HBV ORAL SOLUTION 2 QL (20 per day) EVOTAZ 2 QL ( per day) fosamprenavir (Lexiva) QL (4 per day) 28

39 FUZEON SUBCUTANEOUS RECON 2 SP; QL (2 per day) SOLN GENVOYA 2 QL ( per day) INTELENCE ORAL TABLET 00 MG, 2 QL (2 per day) 200 MG INTELENCE ORAL TABLET 25 MG 2 QL (4 per day) INVIRASE ORAL CAPSULE 2 QL (0 per day) INVIRASE ORAL TABLET 2 QL (4 per day) ISENTRESS ORAL POWDER IN 2 QL (2 per day) PACKET ISENTRESS ORAL TABLET 2 QL (4 per day) ISENTRESS ORAL 2 QL (6 per day) TABLET,CHEWABLE JULUCA 2 QL ( per day) KALETRA ORAL TABLET MG 2 QL ( per day) KALETRA ORAL TABLET MG 2 QL (4 per day) lamivudine oral solution (Epivir) QL (30 per day) lamivudine oral tablet 00 mg (Epivir HBV) QL ( per day) lamivudine oral tablet 50 mg (Epivir) QL (2 per day) lamivudine oral tablet 300 mg (Epivir) QL ( per day) lamivudine-zidovudine (Combivir) QL (2 per day) LEXIVA ORAL SUSPENSION 2 QL (56 per day) lopinavir-ritonavir (Kaletra) QL (4 per day) nevirapine oral suspension (Viramune) QL (40 per day) nevirapine oral tablet (Viramune) QL (2 per day) nevirapine oral tablet extended release 24 (Viramune XR) QL (3 per day) hr 00 mg nevirapine oral tablet extended release 24 (Viramune XR) QL ( per day) hr 400 mg NORVIR ORAL CAPSULE 2 QL (2 per day) NORVIR ORAL POWDER IN PACKET 2 QL (2 per day) NORVIR ORAL SOLUTION 2 QL (6 per day) ODEFSEY 2 QL ( per day) PREZCOBIX 2 QL ( per day) PREZISTA ORAL SUSPENSION 2 QL (3.34 per day) PREZISTA ORAL TABLET 50 MG 2 QL (6 per day) PREZISTA ORAL TABLET 600 MG, 75 2 QL (2 per day) MG PREZISTA ORAL TABLET 800 MG 2 QL ( per day) RESCRIPTOR ORAL TABLET 2 QL (6 per day) RESCRIPTOR ORAL TABLET, DISPERSIBLE 2 QL (2 per day) 29

40 REYATAZ ORAL POWDER IN 2 QL (6 per day) PACKET ritonavir (Norvir) QL (2 per day) SELZENTRY ORAL SOLUTION 2 QL (60 per day) SELZENTRY ORAL TABLET 50 MG, 2 QL (2 per day) 75 MG SELZENTRY ORAL TABLET 25 MG 2 QL (8 per day) SELZENTRY ORAL TABLET 300 MG 2 QL (4 per day) stavudine oral capsule (Zerit) QL (2 per day) stavudine oral recon soln (Zerit) QL (80 per day) STRIBILD 2 QL ( per day) SYMFI 2 QL ( per day) SYMFI LO 2 QL ( per day) tenofovir disoproxil fumarate (Viread) QL ( per day) TIVICAY 2 QL (2 per day) TRIUMEQ 2 QL ( per day) TRUVADA 2 QL ( per day) VEMLIDY 2 QL ( per day) VIDEX 2 GRAM PEDIATRIC 2 QL (40 per day) VIRACEPT ORAL TABLET 250 MG 2 QL (9 per day) VIRACEPT ORAL TABLET 625 MG 2 QL (4 per day) VIRAMUNE XR ORAL TABLET 2 QL (3 per day) EXTENDED RELEASE 24 HR 00 MG VIREAD ORAL POWDER 2 QL (8 per day) VIREAD ORAL TABLET 50 MG, QL ( per day) MG, 250 MG VITEKTA 2 QL ( per day) zidovudine oral capsule (Retrovir) QL (6 per day) zidovudine oral syrup (Retrovir) QL (6 per day) zidovudine oral tablet QL (2 per day) Antivirals, Miscellaneous oseltamivir oral capsule (Tamiflu) fill of Tamiflu or Relenza per season; QL (20 per 80 oseltamivir oral suspension for reconstitution (Tamiflu) fill of Tamiflu or Relenza per season; QL (250 per 80 PREVYMIS ORAL 2 PA; QL ( per day) RELENZA DISKHALER 2 fill of Tamiflu or Relenza per season rimantadine (Flumadine) 30

41 TAMIFLU ORAL CAPSULE 2 fill of Tamiflu or Relenza per season; QL (20 per 80 TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 2 fill of Tamiflu or Relenza per season; QL (250 per 80 Hcv Antivirals MAVYRET 2 PA; SP; QL (84 per 28 Interferons INTRON A INJECTION 2 SP; QL (34 days supply per fill) PEGASYS PROCLICK 2 SP; QL (2 per 28 PEGASYS SUBCUTANEOUS 2 SP; QL (4 per 28 SOLUTION PEGASYS SUBCUTANEOUS 2 SP; QL (2 per 28 SYRINGE PEGINTRON 2 SP; QL (2 per 28 PEGINTRON REDIPEN 2 SP; QL (2 per 28 SYLATRON 2 PA; SP; QL (4 per 28 Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet (Zovirax) adefovir (Hepsera) BARACLUDE ORAL SOLUTION 2 entecavir (Baraclude) famciclovir ribasphere oral capsule ribasphere oral tablet ribasphere ribapak oral tablets,dose pack 200 mg (7)- 400 mg (7), mg (28)- mg (28), mg (28)-mg (28), mg (28)-mg (28) ribavirin inhalation (Virazole) ribavirin oral capsule (Ribasphere) ribavirin oral tablet 200 mg (Moderiba) TYZEKA 2 valacyclovir (Valtrex) VALCYTE ORAL RECON SOLN 2 QL (34 days supply per fill) 3