2018 Formulary. (List of Covered Drugs) CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) Los Angeles County, CA

Transcription

1 2018 Formulary (List of Covered Drugs) CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) Los Angeles County, CA 2018 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on 10/23/18. If you have questions, please call CareMore Cal MediConnect Plan Member Services at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. For more information, visit duals.caremore.com. H6229_18_32077_T_011 CMS Approved 08/08/2017 Formulary ID: Version: 21 Issued 01/08/2018

2 H6229_18_32077_T_011 CMS Approved 08/08/2017 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 2018 List of Covered Drugs (Formulary) This is a list of drugs that members can get in CareMore Cal MediConnect Plan (Medicare-Medicaid Plan). CareMore Cal MediConnect Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. CareMore administers the contract on behalf of an affiliate of CareMore. CareMore is a registered trademark of CareMore Health System. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or copays may change on January 1 of each year. You can always check CareMore Cal MediConnect Plan s up-to-date List of Covered Drugs online at duals.caremore.com or by calling (TTY 711), Monday through Friday from 8:00 a.m. to 8:00 p.m.. Limitations and restrictions may apply. For more information, call CareMore Cal MediConnect Plan Member Services or read the CareMore Cal MediConnect Plan Member Handbook. duals.caremore.com. 1

3 You can get this document for free in other formats, such as large print, braille, or audio. Call (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. You can request to have health plan information sent to you in your language or in other formats. You can make a standing request at any time, call Member Services at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. The call is free. 2 duals.caremore.com.

4 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs (We call the List of Covered Drugs the Drug List for short.) The drugs on the Drug List are the drugs covered by CareMore Cal MediConnect Plan. The drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. CareMore Cal MediConnect Plan will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a CareMore Cal MediConnect Plan network pharmacy. In some cases, you have to do something before you can get a drug (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at duals.caremore.com or call Member Services at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. 2. Does the Drug List ever change Yes. CareMore Cal MediConnect Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now,or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from CareMore Cal MediConnect Plan before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page 4.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. duals.caremore.com. 3

5 You can always check CareMore Cal MediConnect Plan s up to date Drug List online at duals.caremore.com. You can also call Member Services to check the current Drug List at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the drug is removed from the drug list. We will send you a letter about any non-maintenance changes made to the drug list throughout the year. We ll also post a copy of the letter on our website. 4. What happens when we find out a drug is not safe If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you get a notice about an unsafe medicine, call your doctor right away. Your doctor can help you find another medicine that will work best for you. 5. Are there any restrictions or limits on drug coverage Or are there any required actions to take in order to get certain drugs Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from CareMore Cal MediConnect Plan before you fill your prescription. If you don t get approval, CareMore Cal MediConnect Plan may not cover the drug. Quantity limits: Sometimes CareMore Cal MediConnect Plan limits the amount of a drug you can get. You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our web site at duals.caremore.com. We have posted online a document that explains our prior authorization restriction. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see Question 11 for more information on exceptions. duals.caremore.com. 4

6 If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new CareMore Cal MediConnect Plan member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see Question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug The List of Covered Drugs on page 10 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some of the drugs For example, if we add prior authorization (approval) and/or quantity limits restrictions on a drug. We will tell you if we add prior approval or quantity limits restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask your pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the coverage rules is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it using the first letter of the name of the drug. To search by medical condition, find the section labeled List of drugs by medical condition on page 10. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, CARDIOVASCULAR, HYPERTENSION / LIPIDS. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List If you don t see your drug on the Drug List, call Member Services at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. and ask about it. If you learn that CareMore Cal MediConnect Plan will not cover the drug, you can do one of these things: duals.caremore.com. 5

7 Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new CareMore Cal MediConnect Plan member and can t find your drug on the Drug List or have a problem getting your drug We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of CareMore Cal MediConnect Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by CareMore Cal MediConnect Plan, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 to 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception. If you experience a change in the level of care you re getting that requires you to transition from one facility or treatment center to another, you may be eligible for a one-time temporary fill of the prescription you have now. For example, if you were discharged from the hospital and given a discharge list of medications based upon the hospital formulary, you may be able to get a one-time fill of the drug. You can get the temporary one-time fill exception, regardless of whether or not you re in your first 90 days of program enrollment. Have your prescriber call us for details. 11. Can you ask for an exception to cover your drug Yes. You can ask CareMore Cal MediConnect Plan to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, CareMore Cal MediConnect Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. duals.caremore.com. 6

8 12. How long does it take to get an exception First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception To ask for an exception, call Member Services. Member Services will work with you and your provider to help you ask for an exception. 14. What are generic drugs Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and their names are less commonly known. Generic drugs are approved by the Food and Drug Administration (FDA). CareMore Cal MediConnect Plan covers both brand name drugs and generic drugs. 15. What are OTC drugs OTC stands for over-the-counter. CareMore Cal MediConnect Plan covers some OTC drugs when they are written as prescriptions by your provider. You pay nothing for OTC drugs that are covered on the drug list. You can read the CareMore Cal MediConnect Plan Drug List to see what OTC drugs are covered. 16. Does CareMore Cal MediConnect Plan cover OTC non-drug products CareMore Cal MediConnect Plan covers some OTC non-drug products when they are written as prescriptions by your provider. You pay nothing for OTC non-drug products that are covered on the drug list. You can read the CareMore Cal MediConnect Plan Drug List to see what OTC non-drug products are covered. 17. What is your copay As a CareMore Cal MediConnect Plan member, you have no copays for prescription and OTC drugs as long as you follow CareMore Cal MediConnect Plan s rules. duals.caremore.com. 7

9 CareMore Cal MediConnect Plan members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. 18. What are drug tiers Tiers are groups of drugs on our Drug List. All tiers have no copay. Tier 1 drugs are generic drugs. Tier 2 drugs are brand-name drugs. Tier 3 drugs are prescription drugs that are covered by Medi-Cal. Tier 4 drugs are over-the-counter (OTC) drugs that are covered by Medi-Cal. List of Covered Drugs The list of covered drugs below gives you information about the drugs covered by CareMore Cal MediConnect Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 132. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., enalapril). The information in the Necessary actions, restrictions, or limits on use column tells you if CareMore Cal MediConnect Plan has any rules for covering your drug. Here is a list of the abbreviations we use: List of Abbreviations Abbreviation B/D; PAR CG Description The next to a drug means the drug is not a Part D drug. Prior Authorization Required, Part D vs Part B determination only Coverage Gap Explanation The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. We provide coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. duals.caremore.com. 8

10 Abbreviation HI LA PAR QLL Description Home Infusion Limited Availability Mail-Order Drug Non-Extended Day Supply Prior Authorization Required Quantity Limit Explanation This prescription drug may be covered under our medical benefit. For more information, call Member Services at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. This prescription may be available only at certain pharmacies. For more information, call Member Services at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). This drug is not eligible for an extended days supply. You may have this prescription dispensed by your pharmacy for a maximum of 31 days supply at a time. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. For certain drugs, the Plan limits the amount of the drug that we will cover. Note: The asterisk (*) next to a drug means the drug is not a Part D drug. You will not be required to pay a copay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. You can also read the Member Handbook to learn how to appeal a decision. duals.caremore.com. 9

11 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, CARDIOVASCULAR, HYPERTENSION / LIPIDS. That is where you will find drugs that treat heart conditions. Name of Drug ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET AMBISOME amphotericin b CANCIDAS CASPOFUNGIN INTRAVENOUS RECON SOLN 50 MG CASPOFUNGIN INTRAVENOUS RECON SOLN 70 MG clotrimazole mucous membrane ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 400 mg/200 ml fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml flucytosine griseofulvin microsize oral suspension griseofulvin ultramicrosize itraconazole oral capsule ketoconazole oral NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet B/D PAR; ; B/D PAR; ; B/D PAR; B/D PAR; ; B/D PAR; B/D PAR PAR; ; ; QLL (600 per 30 days); You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 10

12 terbinafine hcl oral voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 200 mg voriconazole oral tablet 50 mg ANTIVIRALS abacavir oral solution abacavir oral tablet abacavir-lamivudine abacavir-lamivudine-zidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir amantadine hcl oral capsule amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 150 mg, 200 mg atazanavir oral capsule 300 mg ATRIPLA BARACLUDE ORAL SOLUTION BIKTARVY CIMDUO COMPLERA ; QLL (30 per 30 days) PAR; ; QLL (300 per 30 days); PAR; ; QLL (60 per 30 days); PAR; ; QLL (120 per 30 days); ; QLL (960 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) B/D PAR; PAR; ; ; QLL (120 per 30 days) QLL (390 per 30 days) ; QLL (60 per 30 days); ; QLL (30 per 30 days); ; QLL (30 per 30 days) PAR; ; ; QLL (30 per 30 days); ; QLL (30 per 30 days); ; QLL (30 per 30 days); duals.caremore.com. 11

13 CRIXIVAN ORAL CAPSULE 200 MG CRIXIVAN ORAL CAPSULE 400 MG DESCOVY didanosine oral capsule,delayed release (dr/ec) 200 mg didanosine oral capsule,delayed release (dr/ec) 250 mg, 400 mg EDURANT efavirenz oral capsule 200 mg efavirenz oral capsule 50 mg efavirenz oral tablet EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPCLUSA EPIVIR HBV ORAL SOLUTION EVOTAZ famciclovir oral tablet 125 mg, 250 mg famciclovir oral tablet 500 mg fosamprenavir FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium intravenous recon soln GENVOYA HARVONI INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (30 per 30 days); ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days); ; QLL (120 per 30 days) ; QLL (360 per 30 days) ; QLL (30 per 30 days); ; QLL (30 per 30 days) ; QLL (870 per 30 days) PAR; ; PAR; ; QLL (30 per 30 days); ; QLL (30 per 30 days); ; QLL (60 per 30 days) ; QLL (21 per 7 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days); B/D PAR; ; QLL (30 per 30 days); PAR; ; QLL (28 per 28 days); ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) QLL (300 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 12

14 INVIRASE ORAL TABLET ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET, CHEWABLE 100 MG ISENTRESS ORAL TABLET, CHEWABLE 25 MG JULUCA KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine oral solution lamivudine oral tablet 100 mg lamivudine oral tablet 150 mg lamivudine oral tablet 300 mg lamivudine-zidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET lopinavir-ritonavir moderiba nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg NORVIR ORAL CAPSULE NORVIR ORAL POWDER IN PACKET NORVIR ORAL SOLUTION ; QLL (120 per 30 days) ; QLL (60 per 30 days); ; QLL (120 per 30 days); ; QLL (180 per 30 days); ; QLL (720 per 30 days) ; QLL (30 per 30 days); ; QLL (300 per 30 days) ; QLL (120 per 30 days) ; QLL (900 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (1800 per 30 days) ; QLL (120 per 30 days) ; QLL (480 per 30 days) QLL (1200 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) QLL (360 per 30 days) ; QLL (360 per 30 days) ; QLL (480 per 30 days) duals.caremore.com. 13

15 NORVIR ORAL TABLET ODEFSEY oseltamivir PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine ritonavir SELZENTRY ORAL SOLUTION SELZENTRY ORAL TABLET 150 MG, 300 MG SELZENTRY ORAL TABLET 25 MG SELZENTRY ORAL TABLET 75 MG stavudine oral capsule 15 mg, 20 mg stavudine oral capsule 30 mg, 40 mg ; QLL (360 per 30 days) ; QLL (30 per 30 days); ; QLL (30 per 30 days); ; QLL (420 per 30 days); ; QLL (180 per 30 days) ; QLL (60 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 180 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (240 per 30 days) ; QLL (360 per 30 days) ; QLL (1840 per 30 days); ; QLL (120 per 30 days); ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 14

16 STRIBILD SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SYMFI SYMFI LO synagis intramuscular solution 100 mg/ ml SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TECHNIVIE tenofovir disoproxil fumarate TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 25 MG, 50 MG TRIUMEQ TROGARZO TRUVADA TYBOST valacyclovir valganciclovir VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIDEX EC ORAL CAPSULE, DELAYED RELEASE(DR/EC) 125 MG VIRACEPT ORAL TABLET 250 MG ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (360 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days); ; QLL (30 per 30 days); PAR; ; LA; PAR; ; LA; ; PAR; ; QLL (56 per 28 days); ; QLL (30 per 30 days); ; QLL (60 per 30 days) ; QLL (60 per 30 days); ; QLL (30 per 30 days); ; QLL (10.64 per 28 days); ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (1200 per 30 days) ; QLL (1200 per 30 days) ; QLL (90 per 30 days) ; QLL (300 per 30 days) duals.caremore.com. 15

17 VIRACEPT ORAL TABLET 625 MG VIRAMUNE ORAL SUSPENSION VIREAD ORAL POWDER VIREAD ORAL TABLET VOSEVI ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefaclor oral suspension for reconstitution 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g cefazolin intravenous cefdinir cefepime cefoxitin in dextrose, iso-osm ; QLL (120 per 30 days) ; QLL (1200 per 30 days) ; QLL (240 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days); ; QLL (2400 per 30 days) ; QLL (960 per 30 days) ; QLL (180 per 30 days) ; QLL (1920 per 30 days) ; QLL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 16

18 cefoxitin intravenous recon soln 1 gram, 2 gram cefoxitin intravenous recon soln 10 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram, 100 gram ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln 1.5 gram cefuroxime sodium intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution tazicef injection recon soln 1 gram tazicef injection recon soln 2 gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG TEFLARO INTRAVENOUS RECON SOLN 600 MG ; duals.caremore.com. 17

19 ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin ery-tab erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml atovaquone atovaquone-proguanil oral tablet mg AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) aztreonam injection recon soln 1 gram baciim bacitracin intramuscular BILTRICIDE CAPASTAT CAYSTON chloramphenicol sod succinate chloroquine phosphate clindamycin hcl clindamycin phosphate injection ; QLL (180 per 30 days) ; QLL (6 per 30 days) PAR; ; PAR; ; LA; You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 18

20 clindamycin phosphate intravenous COARTEM colistin (colistimethate na) dapsone oral daptomycin intravenous recon soln 500 mg DARAPRIM ertapenem ethambutol gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml gentamicin sulfate (pf) intravenous solution 60 mg/6 ml hydroxychloroquine imipenem-cilastatin INVANZ INJECTION INVANZ INTRAVENOUS isoniazid oral ivermectin linezolid in dextrose 5% linezolid oral suspension for reconstitution linezolid oral tablet linezolid-0.9% sodium chloride mefloquine meropenem metro i.v. metronidazole in nacl (iso-os) ; PAR PAR; ; QLL (1680 per 30 days) PAR; ; QLL (56 per 30 days) PAR duals.caremore.com. 19

21 metronidazole oral MYCOBUTIN NEBUPENT neomycin paromomycin PASER PENTAM praziquantel PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate reese's pinworm medicine rifampin RIFATER SIRTURO STREPTOMYCIN STROMECTOL SYNERCID tigecycline tobramycin in % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR XIFAXAN ORAL TABLET 550 MG PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution B/D PAR; PAR; ; PAR; ; LA; PAR; ; QLL (280 per 28 days); PAR; ; QLL (84 per 28 days); You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 20

22 amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate ampicillin oral capsule 500 mg ampicillin sodium injection ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/ 600K) dicloxacillin nafcillin injection nafcillin intravenous recon soln 2 gram oxacillin injection recon soln 1 gram, 10 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 3 MILLION UNIT/50 ML penicillin g potassium duals.caremore.com. 21

23 penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, 4.5 GRAM/100 ML QUINOLONES ciprofloxacin (mixture) ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg levofloxacin intravenous levofloxacin oral ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine sulfamethoxazole-trimethoprim TETRACYCLINES demeclocycline doxy-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 22

24 doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg minocycline oral capsule minocycline oral tablet morgidox tetracycline URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 25 MG, 50 MG methenamine hippurate methenamine mandelate oral tablet 1 gram nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/m-cryst trimethoprim VANCOMYCIN vancomycin in 0.9 % sodium chl intravenous piggyback vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml vancomycin in dextrose 5 % intravenous piggyback 500 mg/100 ml, 750 mg/150 ml vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg vancomycin intravenous recon soln 250 mg vancomycin oral capsule 125 mg vancomycin oral capsule 250 mg PAR; ; QLL (40 per 10 days); PAR; ; QLL (80 per 10 days); duals.caremore.com. 23

25 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane hcl intravenous recon soln 250 mg dexrazoxane hcl intravenous recon soln 500 mg ELITEK FUSILEV KEPIVANCE leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral levoleucovorin intravenous recon soln 50 mg levoleucovorin intravenous solution mesna MESNEX ORAL XGEVA PAR; ; ; ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE ADAGEN adriamycin intravenous recon soln 10 mg adriamycin intravenous solution 20 mg/ 10 ml adrucil intravenous solution 500 mg/10 ml AFINITOR AFINITOR DISPERZ ALECENSA ; PAR; ; QLL (1.7 per 28 days); ; ; LA; B/D PAR; PAR; ; PAR; ; ; LA; You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 24

26 ALIMTA ALIQOPA ALUNBRIG ORAL TABLET 180 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLET 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK anastrozole ARRANON ARZERRA ASTAGRAF XL ORAL CAPSULE, EXTENDED RELEASE 24HR 0.5 MG, 1 MG ASTAGRAF XL ORAL CAPSULE, EXTENDED RELEASE 24HR 5 MG AVASTIN azacitidine AZASAN azathioprine azathioprine sodium BAVENCIO BELEODAQ BENDEKA BESPONSA bexarotene bicalutamide BICNU bleomycin BLINCYTO INTRAVENOUS KIT BORTEZOMIB ; PAR; ; LA; ; QLL (30 per 30 days); ; QLL (180 per 30 days); ; QLL (60 per 30 days); ; QLL (30 per 180 days); ; QLL (30 per 30 days) ; B/D PAR; B/D PAR; ; PAR; ; LA; ; B/D PAR; B/D PAR; B/D PAR PAR; ; LA; PAR; ; ; B/D PAR; ; PAR; ; ; QLL (30 per 30 days) B/D PAR; PAR; ; ; duals.caremore.com. 25

27 BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 400 MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG BRAFTOVI ORAL CAPSULE 75 MG BUSULFEX CABOMETYX ORAL TABLET 20 MG CABOMETYX ORAL TABLET 40 MG, 60 MG CALQUENCE CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine clofarabine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/ DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/ DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/ DAY (20 MG X 3/DAY) COSMEGEN COTELLIC cyclophosphamide oral capsule cyclosporine intravenous PAR; ; QLL (120 per 30 days); PAR; ; QLL (30 per 30 days); PAR; ; QLL (120 per 30 days) PAR; ; QLL (180 per 30 days) B/D PAR PAR; ; LA; QLL (90 per 30 days); PAR; ; LA; QLL (30 per 30 days); PAR; ; LA; PAR; ; LA; QLL (90 per 30 days); PAR; ; LA; QLL (30 per 30 days); B/D PAR; B/D PAR; ; PAR; ; LA; QLL (56 per 28 days); PAR; ; LA; QLL (112 per 28 days); PAR; ; LA; QLL (84 per 28 days); ; PAR; ; LA; QLL (90 per 30 days); B/D PAR; B/D PAR You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 26

28 cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine cytarabine (pf) injection solution 100 mg/ 5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ ml) cytarabine (pf) injection solution 20 mg/ ml dacarbazine DACOGEN dactinomycin DARZALEX daunorubicin intravenous solution decitabine docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 160 mg/8 ml (20 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ml doxorubicin intravenous recon soln 10 mg doxorubicin intravenous recon soln 50 mg doxorubicin intravenous solution doxorubicin, peg-liposomal DROXIA EMCYT EMPLICITI B/D PAR; B/D PAR; PAR; ; LA; B/D PAR; B/D PAR; B/D PAR ; B/D PAR; ; LA; ; ; B/D PAR; ; B/D PAR; ; duals.caremore.com. 27

29 epirubicin intravenous solution 200 mg/ 100 ml epirubicin intravenous solution 50 mg/25 ml ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML ERBITUX INTRAVENOUS SOLUTION 200 MG/100 ML ERIVEDGE ERLEADA ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN GAZYVA B/D PAR; PAR; ; PAR; PAR; ; LA; QLL (30 per 30 days); PAR; ; ; ; ; QLL (60 per 30 days) ; QLL (30 per 30 days); PAR; ; LA; QLL (60 per 30 days); PAR; ; LA; QLL (30 per 30 days); PAR; ; ; QLL (4 per 365 days); ; QLL (1 per 28 days) B/D PAR; ; PAR; ; You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 28

30 gemcitabine intravenous recon soln 1 gram, 200 mg gemcitabine intravenous recon soln 2 gram gemcitabine intravenous solution 1 gram/ 26.3 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gemcitabine intravenous solution 100 mg/ ml, 2 gram/52.6 ml (38 mg/ml) gengraf oral capsule 100 mg, 25 mg gengraf oral solution GILOTRIF GLEOSTINE HALAVEN HERCEPTIN INTRAVENOUS RECON SOLN 150 MG HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN hydroxyprogesterone caproate hydroxyurea IBRANCE ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin IDHIFA ORAL TABLET 100 MG B/D PAR; B/D PAR; PAR; ; LA; QLL (30 per 30 days); ; ; ; LA; ; ; PAR; ; LA; QLL (30 per 30 days); PAR; ; LA; QLL (60 per 30 days); PAR; ; LA; QLL (30 per 30 days); PAR; ; LA; QLL (30 per 30 days); duals.caremore.com. 29

31 IDHIFA ORAL TABLET 50 MG ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA ORAL CAPSULE 140 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET IMFINZI INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA irinotecan intravenous solution 100 mg/ 5 ml, 40 mg/2 ml irinotecan intravenous solution 500 mg/ 25 ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 15 MG JAKAFI ORAL TABLET 20 MG JAKAFI ORAL TABLET 25 MG PAR; ; LA; QLL (60 per 30 days); PAR; ; QLL (240 per 30 days); PAR; ; QLL (60 per 30 days); PAR; ; LA; QLL (120 per 30 days); PAR; ; QLL (30 per 30 days); PAR; ; QLL (30 per 30 days); PAR; ; PAR; ; LA; QLL (240 per 30 days); PAR; ; LA; QLL (120 per 30 days); ; LA; ; PAR; ; LA; QLL (150 per 30 days); PAR; ; LA; QLL (100 per 30 days); PAR; ; LA; QLL (75 per 30 days); PAR; ; LA; QLL (60 per 30 days); You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 30

32 JAKAFI ORAL TABLET 5 MG JEVTANA KADCYLA INTRAVENOUS RECON SOLN 100 MG KADCYLA INTRAVENOUS RECON SOLN 160 MG KEYTRUDA INTRAVENOUS SOLUTION KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)- 2.5 MG 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 1) KISQALI ORAL TABLET 400 MG/ DAY (200 MG X 2) KISQALI ORAL TABLET 600 MG/ DAY (200 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 10 MG KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LARTRUVO LENVIMA ORAL CAPSULE 10 MG/ DAY (10 MG X 1) PAR; ; LA; QLL (300 per 30 days); ; PAR; ; LA; PAR; ; PAR; ; PAR; ; QLL (49 per 28 days); PAR; ; QLL (70 per 28 days); PAR; ; QLL (91 per 28 days); PAR; ; QLL (21 per 21 days); PAR; ; QLL (42 per 21 days); PAR; ; QLL (63 per 21 days); ; LA; B/D PAR; ; LA; ; LA; PAR; ; LA; QLL (30 per 30 days); duals.caremore.com. 31

33 LENVIMA ORAL CAPSULE 12 MG/ DAY (4 MG X 3), 4 MG LENVIMA ORAL CAPSULE 14 MG/ DAY(10 MG X 1-4 MG X 1), 20 MG/ DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) LENVIMA ORAL CAPSULE 18 MG/ DAY (10 MG X 1-4 MG X2), 24 MG/ DAY(10 MG X 2-4 MG X 1) letrozole LEUKERAN leuprolide subcutaneous kit LONSURF LUPRON DEPOT LUPRON DEPOT (3 NTH) LUPRON DEPOT-PED (3 NTH) INTRAMUSCULAR SYRINGE KIT MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) LYNPARZA ORAL CAPSULE LYNPARZA ORAL TABLET LYSODREN MARQIBO MATULANE megestrol oral suspension 400 mg/10 ml (10 ml), 800 mg/20 ml (20 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG PAR; ; QLL (30 per 30 days) PAR; ; LA; QLL (60 per 30 days); PAR; ; LA; QLL (90 per 30 days); ; QLL (30 per 30 days) PAR; ; PAR; ; QLL (1 per 28 days); PAR; ; QLL (1 per 84 days); PAR; ; QLL (1 per 28 days); PAR; ; QLL (1 per 28 days) PAR; ; LA; QLL (480 per 30 days); PAR; ; QLL (120 per 30 days); ; ; LA; PAR; ; QLL (90 per 30 days); You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 32

34 MEKINIST ORAL TABLET 2 MG MEKTOVI melphalan hcl mercaptopurine methotrexate sodium methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin intravenous mitoxantrone MUSTARGEN mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium MYLOTARG NERLYNX NEXAVAR NILANDRON NINLARO NIPENT NULOJIX octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml PAR; ; QLL (30 per 30 days); PAR; ; QLL (180 per 30 days) B/D PAR; B/D PAR; ; B/D PAR; B/D PAR; PAR; ; LA; PAR; ; LA; QLL (180 per 30 days); PAR; ; LA; QLL (120 per 30 days); ; QLL (30 per 30 days); PAR; ; QLL (3 per 28 days); ; ; PAR; ; PAR; duals.caremore.com. 33

35 octreotide acetate injection syringe ODOMZO OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML OPDIVO INTRAVENOUS SOLUTION 240 MG/24 ML oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE 2 MG POMALYST ORAL CAPSULE 3 MG, 4 MG PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 5 MG RITUXAN HYCELA RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML (10 ML) ROMIDEPSIN PAR; PAR; ; LA; QLL (30 per 30 days); PAR; ; PAR; ; LA; PAR; ; LA; QLL (120 per 30 days); PAR; ; LA; QLL (60 per 30 days); PAR; ; LA; QLL (30 per 30 days); ; B/D PAR; PAR; ; LA; B/D PAR; ; LA; QLL (60 per 30 days); ; LA; QLL (30 per 30 days); ; LA; QLL (150 per 30 days); B/D PAR; ; ; LA; B/D PAR; ; You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 34

36 RUBRACA ORAL TABLET 200 MG RUBRACA ORAL TABLET 250 MG RUBRACA ORAL TABLET 300 MG RYDAPT SANDIMMUNE ORAL SOLUTION SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG SYNRIBO TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG PAR; ; LA; QLL (180 per 30 days); PAR; ; LA; QLL (120 per 1 day); PAR; ; LA; QLL (120 per 30 days); PAR; ; QLL (240 per 30 days); B/D PAR; ; LA; B/D PAR; B/D PAR; ; B/D PAR; ; ; QLL (30 per 30 days); PAR; ; LA; QLL (120 per 30 days); ; QLL (90 per 30 days); ; QLL (30 per 30 days); ; B/D PAR; PAR; ; QLL (120 per 30 days); PAR; ; LA; QLL (60 per 30 days); PAR; ; LA; QLL (30 per 30 days); duals.caremore.com. 35

37 tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 25 MG TARGRETIN ORAL TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 150 MG, 200 MG TASIGNA ORAL CAPSULE 50 MG TECENTRIQ temsirolimus THALOMID ORAL CAPSULE 100 MG, 50 MG THALOMID ORAL CAPSULE 150 MG, 200 MG thiotepa toposar topotecan intravenous recon soln topotecan intravenous solution TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) TREXALL TRISENOX INTRAVENOUS SOLUTION 2 MG/ML ; LA; QLL (30 per 30 days); ; LA; QLL (90 per 30 days); PAR; ; PAR; ; QLL (60 per 30 days); ; QLL (112 per 28 days); ; QLL (56 per 28 days); ; LA; QLL (20 per 21 days); ; QLL (30 per 30 days); ; QLL (60 per 30 days); ; ; ; ; QLL (1 per 84 days); ; QLL (1 per 168 days); ; QLL (1 per 28 days); ; ; You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 36

38 TYKERB UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK VERZENIO vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ ml vincasar pfs intravenous solution 2 mg/2 ml vincristine vinorelbine VOTRIENT VYXEOS XALKORI XATMEP XTANDI YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML) YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) ; LA; QLL (180 per 30 days); ; PAR; ; PAR; ; LA; QLL (60 per 30 days) PAR; ; LA; QLL (120 per 30 days); PAR; ; LA; QLL (30 per 30 days) PAR; ; LA; QLL (84 per 365 days); PAR; ; LA; QLL (60 per 30 days); B/D PAR; B/D PAR B/D PAR; B/D PAR; ; QLL (120 per 30 days); B/D PAR; ; PAR; ; LA; QLL (60 per 30 days); PAR; ; LA; QLL (120 per 30 days); ; ; LA; duals.caremore.com. 37

39 YONDELIS YONSA ZALTRAP ZANOSAR ZEJULA ZELBORAF ZOLINZA ZORTRESS ORAL TABLET 0.25 MG ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG ZYDELIG ZYKADIA ZYTIGA ORAL TABLET 250 MG ZYTIGA ORAL TABLET 500 MG B/D PAR; ; LA; PAR; ; QLL (120 per 30 days); PAR; ; AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG PAR; ; QLL (90 per 30 days); PAR; ; LA; QLL (240 per 30 days); ; QLL (120 per 30 days); B/D PAR; B/D PAR; ; PAR; ; LA; QLL (60 per 30 days); PAR; ; LA; QLL (150 per 30 days); PAR; ; LA; QLL (120 per 30 days); PAR; ; QLL (60 per 30 days); PAR; ; QLL (2400 per 30 days); PAR; ; QLL (480 per 30 days); PAR; ; QLL (240 per 30 days); PAR PAR; ; QLL (600 per 30 days) PAR; ; QLL (600 per 30 days); You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 38

40 BRIVIACT ORAL TABLET 100 MG, 75 MG BRIVIACT ORAL TABLET 25 MG BRIVIACT ORAL TABLET 50 MG carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/ 5 ml carbamazepine oral suspension 200 mg/ 10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating mg clonazepam oral tablet,disintegrating 0.25 mg clonazepam oral tablet,disintegrating 0.5 mg clonazepam oral tablet,disintegrating 1 mg clonazepam oral tablet,disintegrating 2 mg DIASTAT PAR; ; QLL (60 per 30 days); PAR; ; QLL (240 per 30 days); PAR; ; QLL (120 per 30 days); ; QLL (1200 per 30 days) ; QLL (600 per 30 days) ; QLL (300 per 30 days) ; QLL (4800 per 30 days) ; QLL (2400 per 30 days) ; QLL (1200 per 30 days) ; QLL (600 per 30 days) ; QLL (300 per 30 days) duals.caremore.com. 39

41 diastat acudial rectal kit mg DIASTAT ACUDIAL RECTAL KIT MG diazepam rectal kit 2.5 mg, mg DILANTIN DILANTIN EXTENDED DILANTIN INFATABS divalproex epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ethosuximide felbamate fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 12 MG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (180 per 30 days) ; QLL (720 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (45 per 30 days) ; QLL (1080 per 30 days) ; QLL (360 per 30 days) ; QLL (270 per 30 days) ; QLL (2160 per 30 days) QLL (2160 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 40

42 gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/ 100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 150 MG LYRICA ORAL CAPSULE 200 MG LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL CAPSULE 25 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (720 per 30 days) ; QLL (360 per 30 days) ; QLL (240 per 30 days) ; QLL (900 per 30 days) PAR; ; QLL (480 per 30 days) duals.caremore.com. 41

43 ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG oxcarbazepine oral tablet OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG PEGANONE phenobarbital oral elixir phenobarbital oral tablet 100 mg phenobarbital oral tablet 15 mg phenobarbital oral tablet 16.2 mg phenobarbital oral tablet 30 mg phenobarbital oral tablet 32.4 mg phenobarbital oral tablet 60 mg phenobarbital oral tablet 64.8 mg phenobarbital oral tablet 97.2 mg phenytek phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution primidone roweepra oral tablet 500 mg SABRIL ORAL POWDER IN PACKET SABRIL ORAL TABLET PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) ; QLL (3000 per 30 days) ; QLL (120 per 30 days) ; QLL (800 per 30 days) ; QLL (741 per 30 days) ; QLL (400 per 30 days) ; QLL (370 per 30 days) ; QLL (200 per 30 days) ; QLL (185 per 30 days) ; QLL (123 per 30 days) ; LA; QLL (180 per 30 days) ; LA; QLL (180 per 30 days); You can find information on what the symbols and abbreviations in this table mean by going to page. Updated 10/23/18 42

44 SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG tiagabine topiramate oral capsule, sprinkle topiramate oral tablet 100 mg topiramate oral tablet 200 mg topiramate oral tablet 25 mg topiramate oral tablet 50 mg TRILEPTAL ORAL SUSPENSION valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) vigabatrin VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 100 MG VIMPAT ORAL TABLET 150 MG, 200 MG VIMPAT ORAL TABLET 50 MG zonisamide ANTIPARKINSONISM AGENTS APOKYN benztropine oral PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (1920 per 30 days) ; QLL (960 per 30 days) PAR; ; LA; QLL (180 per 30 days); QLL (1200 per 30 days) ; QLL (1200 per 30 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) PAR; ; LA; duals.caremore.com. 43