2019 Sharp Direct Advantage SM Comprehensive Drug List

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1 019 Sharp Direct Advantage SM Comprehensive Drug List List of covered drugs for Sharp Direct Advantage (HMO) Medicare Plans

2 Sharp Direct Advantage (HMO) 019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 019 Part D Formulary Effective 01/01/019 Formulary ID: , Version: 7 This formulary was updated on 01/01/019. For more recent information or other questions, please contact Sharp Health Plan s Customer Care at (toll free), or, for TTY/TDD users, 711, Oct. 1 to March 1: 7 days per week 8 a.m. to 8 p.m., and from April 1 to Sept. 0: Monday through Friday, 8 a.m. to 8 p.m., or visit sharpmedicareadvantage.com. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Sharp Health Plan. When it refers to plan or our plan, it means Sharp Direct Advantage (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 01/01/019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January of each year and from time to time during the year. The formulary may change at any time. You will receive notice when necessary. H586_019 SDA Formulary Comp_C

3 What is the Sharp Direct Advantage (HMO) Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 019 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier.)] Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 0 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 0-day supply of the drug. The enclosed formulary is current as of 01/01/019. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. In the event of mid-year non-maintenance formulary changes, we will notify you in writing of the changes. We will post an updated version of the plan formulary on our website at sharpmedicareadvantage.com. If you would like a printed version of the corrections, we will mail it to you upon request. ii

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? We cover both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: We require you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, we provide 0 tablets for 0 days per prescription for simvastatin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to Sharp Direct Advantage (HMO) formulary? on page iv for information about how to request an exception. iii

5 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Care and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Care for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to Sharp Direct Advantage (HMO) Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if your drug is on Tier, Tier or Tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, we will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. iv

6 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 0-day supply of medication. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug while you pursue a formulary exception. If you are a member entering a long-term care (LTC) facility from other care settings and have a level of care change, we will cover one 1-day supply of a particular drug, or less if your prescription is written for fewer days. For more information For more detailed information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day/7 days a week. TTY/TDD users should call Or, visit v

7 Sharp Direct Advantage (HMO) Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BYETTA) and generic drugs are listed in lower-case italics (e.g., lisinopril). The second column, Drug Tier, will indicate what tier number the drug is in. The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. The amount you pay for a covered drug will depend on: Your drug payment stage. Your plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the coverage stage you are in. The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier has a copay and or co-insurance amount. The chart below shows the differences between the tiers. Drug Tier Tier 1 - Preferred Generic Drugs Includes Lower-cost generic drugs Tier - Generic Drugs Generic drugs Tier - Preferred Brand Name Drugs Commonly used preferred brand name drugs Tier - Non-Preferred Drugs Non-preferred generic and non-preferred brand name drugs Tier 5 - Specialty Drugs Unique and/or very high-cost drugs Tier 6 - Select Care Drugs Select generic drugs For more information about drug coverage and co-pay or co-insurance amounts for each tier, please review your Evidence of Coverage. vi

8 The following abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION LA Limited Access Drugs This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Care (TTY/TDD 711). For your convenience office hours from Oct. 1 through March 1 are 7 days per week, 8 a.m. to 8 p.m. April 1 to Sept. 0 our office hours are Monday through Friday, 8 a.m. to 8 p.m., and on weekends and holidays, your call will be handled by our voic system. A Customer Care Representative will return your phone call the next business day. NDS Non-Extended Days Supply This drug is limited to 0-days supply. NM No Mail Order This drug is not available through mail order. PA PA BvD Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination You (or your provider) are required to get prior authorization from us before you fill your prescription for this drug. Without prior approval, we may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your provider) are required to get authorization from us to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, we may not cover this drug. PA-HRM Prior Authorization Restrictions for members 65 years and older If you are 65 years or older, you (or your provider) are required to get prior authorization from us before you fill your prescription for this drug. Without prior authorization, we may not cover this drug. vii

9 ABBREVIATION DESCRIPTION EXPLANATION PA NSO Prior Authorization Restriction for New Starts Only If you are a new member or you have not taken this drug previously, you (or your provider) are required to get prior authorization from us before you fill your prescription for this drug. Without prior approval, we may not cover this drug. QL ST Quantity Limit Restrictions Step Therapy Restriction We limit the amount of this drug that is covered per prescription, or within a specific time frame. Before we will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. viii

10 Table of Contents Analgesics... Anesthetics... 9 Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials... 1 Anticancer Agents... Anticholinergic Agents... Anticonvulsants... Antidementia Agents... 6 Antidepressants... 6 Antidiabetic Agents... 9 Antifungals... Antigout Agents... Antihistamines... 5 Anti-Infectives (Skin And Mucous Membrane)... 5 Antimigraine Agents... 6 Antimycobacterials... 6 Antinausea Agents... 7 Antiparasite Agents... 8 Antiparkinsonian Agents... 9 Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents... 6 Cardiovascular Agents Central Nervous System Agents Contraceptives

11 Dental And Oral Agents Dermatological Agents Devices... 9 Enzyme Replacement/Modifiers... 9 Eye, Ear, Nose, Throat Agents... 9 Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations... 1 Respiratory Tract Agents... 1 Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals... 11

12 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet 00-0 acetaminophen-codeine oral tablet ascomp with codeine oral capsule QL (700 per 0 days) QL (60 per 0 days) (Tylenol-Codeine #) QL (60 per 0 days) (Tylenol-Codeine #) QL (180 per 0 days) PA-HRM; QL (180 per 0 days); AGE (Max 6 (Buprenex) buprenorphine hcl injection solution 0. /ml buprenorphine hcl injection syringe 0. /ml buprenorphine transdermal patch weekly (Butrans) QL ( per 8 days) 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral PA-HRM; QL (180 per capsule days); AGE (Max 6 butalbital-acetaminop-caf-cod oral PA-HRM; QL (180 per capsule , days); AGE (Max 6 butalbital-acetaminophen oral tablet 50-5 butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet butorphanol tartrate nasal spray,nonaerosol 10 /ml (Tencon) PA-HRM; QL (180 per 0 days); AGE (Max 6 (Capacet) PA-HRM; QL (180 per 0 days); AGE (Max 6 (Esgic) PA-HRM; QL (180 per 0 days); AGE (Max 6 (Fiorinal) PA-HRM; QL (180 per 0 days); AGE (Max 6 PA-HRM; QL (180 per 0 days); AGE (Max 6 QL (5 per 8 days)

13 capacet oral capsule PA-HRM; QL (180 per 0 days); AGE (Max 6 codeine sulfate oral tablet 15, 0, QL (180 per 0 days) 60 EMBEDA ORAL CAPSULE,ORAL QL (60 per 0 days) ONLY,EXT.REL PELL 100- MG, MG, 0-1. MG, 50- MG, 60-. MG, 80-. MG endocet oral tablet 10-5 QL (180 per 0 days) endocet oral tablet.5-5, 5-5 QL (60 per 0 days) endocet oral tablet QL (0 per 0 days) fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution /15 ml hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet 10-5 hydrocodone-acetaminophen oral tablet.5-5 hydrocodone-acetaminophen oral tablet 5-00 hydrocodone-acetaminophen oral tablet 5-5 hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-ibuprofen oral tablet 10-00, 5-00 hydrocodone-ibuprofen oral tablet hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml (Actiq) ; QL (10 per 0 days) (Duragesic) QL (10 per 0 days) (Hycet) QL (700 per 0 days) (Vicodin HP) QL (180 per 0 days) (Lorcet HD) QL (180 per 0 days) (Verdrocet) QL (0 per 0 days) (Vicodin) QL (0 per 0 days) (Lorcet (hydrocodone)) QL (0 per 0 days) (Vicodin ES) QL (180 per 0 days) (Lorcet Plus) QL (180 per 0 days) (Ibudone) QL (150 per 0 days) QL (150 per 0 days) hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 per 0 days) hydromorphone oral tablet,, 8 (Dilaudid) QL (180 per 0 days)

14 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL. HR 100 MG, 10 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY QL (0 per 0 days) ; QL (0 per 0 days) lorcet (hydrocodone) oral tablet 5-5 QL (0 per 0 days) lorcet hd oral tablet 10-5 QL (180 per 0 days) lorcet plus oral tablet QL (180 per 0 days) methadone injection solution 10 /ml methadone oral solution 10 /5 ml QL (600 per 0 days) methadone oral solution 5 /5 ml QL (100 per 0 days) methadone oral tablet 10 (Dolophine) QL (10 per 0 days) methadone oral tablet 5 (Dolophine) QL (180 per 0 days) methadose oral tablet,soluble 0 QL (0 per 0 days) morphine 10 /ml isecure syrg l/f, p/f, suv, inner 10 /ml morphine concentrate oral solution 100 QL (180 per 0 days) /5 ml (0 /ml) morphine injection syringe 10 /ml morphine intravenous solution 10 /ml morphine oral solution 10 /5 ml QL (700 per 0 days) morphine oral solution 0 /5 ml ( QL (00 per 0 days) /ml) MORPHINE ORAL TABLET 15 MG QL (180 per 0 days) MORPHINE ORAL TABLET 0 MG QL (10 per 0 days) morphine oral tablet extended release 100 (MS Contin) QL (60 per 0 days), 00, 60 morphine oral tablet extended release 15 (MS Contin) QL (90 per 0 days), 0 NUCYNTA ER ORAL TABLET QL (60 per 0 days) EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 QL (181 per 0 days) MG, 75 MG oxycodone oral capsule 5 QL (180 per 0 days) oxycodone oral concentrate 0 /ml QL (10 per 0 days) oxycodone oral solution 5 /5 ml QL (100 per 0 days) oxycodone oral tablet 10 QL (180 per 0 days) oxycodone oral tablet 15, 0 (Roxicodone) QL (10 per 0 days) oxycodone oral tablet 0 QL (10 per 0 days) 5

15 oxycodone oral tablet 5 (Roxicodone) QL (180 per 0 days) oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 per 0 days) hr 10, 15, 0, 0, 0, 60, 80 oxycodone-acetaminophen oral solution 5- QL (1800 per 0 days) 5 /5 ml oxycodone-acetaminophen oral tablet 10- (Endocet) QL (180 per 0 days) 5 oxycodone-acetaminophen oral tablet.5- (Endocet) QL (60 per 0 days) 5, 5-5 oxycodone-acetaminophen oral tablet 7.5- (Endocet) QL (0 per 0 days) 5 oxycodone-aspirin oral tablet QL (60 per 0 days) OXYCONTIN ORAL TABLET,ORAL QL (60 per 0 days) ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG oxymorphone oral tablet 10 (Opana) QL (10 per 0 days) oxymorphone oral tablet 5 (Opana) QL (180 per 0 days) oxymorphone oral tablet extended release QL (60 per 0 days) 1 hr 10, 15, 0, 0, 0, 5, 7.5 SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 00 MG/1.5 ML tencon oral tablet 50-5 PA-HRM; QL (180 per 0 days); AGE (Max 6 tramadol oral tablet 50 (Ultram) 1 QL (0 per 0 days) tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (0 per 0 days) 5 vicodin es oral tablet QL (180 per 0 days) vicodin hp oral tablet QL (180 per 0 days) vicodin oral tablet 5-00 QL (0 per 0 days) XTAMPZA ER ORAL QL (60 per 0 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 1.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 1HR TMPRR 7 MG QL (10 per 0 days) 6

16 XTAMPZA ER ORAL QL (0 per 0 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 6 MG xylon 10 oral tablet QL (150 per 0 days) zebutal oral capsule PA-HRM; QL (180 per 0 days); AGE (Max 6 ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 1HR 10 MG, 15 MG, 0 MG, 0 MG, 0 MG, 50 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8 ML (100 MG/ML) celecoxib oral capsule 100, 00, 50 QL (60 per 0 days) (Celebrex) QL (60 per 0 days) celecoxib oral capsule 00 (Celebrex) QL (60 per 0 days) diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops 1.5 % QL (00 per 0 days) diclofenac sodium topical gel % (Solaraze) PA; QL (100 per 8 days) diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 DUEXIS ORAL TABLET MG ; QL (90 per 0 days) etodolac oral capsule 00, 00 etodolac oral tablet 00 (Lodine) etodolac oral tablet 500 fenoprofen oral tablet 600 (Nalfon) FLECTOR TRANSDERMAL PATCH 1 PA HOUR 1. % flurbiprofen oral tablet 100, 50 ibu oral tablet 00, 600, ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) 7

17 ibuprofen oral tablet 00, 600, 800 (IBU) 1 indomethacin oral capsule 5 1 PA-HRM; QL (0 per 0 days); AGE (Max 6 indomethacin oral capsule 50 1 PA-HRM; QL (10 per 0 days); AGE (Max 6 indomethacin oral capsule, extended release 75 PA-HRM; QL (60 per 0 days); AGE (Max 6 indomethacin sodium intravenous recon soln 1 ketoprofen oral capsule 5, 50, 75 ketoprofen oral capsule,ext rel. pellets hr 00 ketorolac injection cartridge 15 /ml PA-HRM; QL (0 per 0 days); AGE (Max 6 ketorolac injection cartridge 0 /ml PA-HRM; QL (0 per 0 days); AGE (Max 6 ketorolac injection solution 15 /ml PA-HRM; QL (0 per 0 days); AGE (Max 6 ketorolac injection solution 0 /ml (1 ml) PA-HRM; QL (0 per 0 days); AGE (Max 6 ketorolac injection syringe 15 /ml PA-HRM; QL (0 per 0 days); AGE (Max 6 ketorolac injection syringe 0 /ml PA-HRM; QL (0 per 0 days); AGE (Max 6 ketorolac intramuscular cartridge 60 / ml ketorolac intramuscular solution 60 / ml ketorolac intramuscular syringe 60 / ml PA-HRM; QL (0 per 0 days); AGE (Max 6 PA-HRM; QL (0 per 0 days); AGE (Max 6 PA-HRM; QL (0 per 0 days); AGE (Max 6 8

18 ketorolac oral tablet 10 PA-HRM; QL (0 per 0 days); AGE (Max 6 mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) 1 nabumetone oral tablet 500, 750 naproxen oral tablet 50, 75 1 naproxen oral tablet 500 (Naprosyn) 1 naproxen oral tablet,delayed release (dr/ec) 75, 500 (EC-Naprosyn) PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 0 MG/GRAM /ACTUATION( %) piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet 150, 00 tolmetin oral capsule 00 tolmetin oral tablet 00, 600 VIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC 75-0 MG, MG ; QL ( per 8 days) ; QL (60 per 0 days) VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % QL (0 per 0 days) lidocaine (pf) injection solution 10 /ml (Xylocaine-MPF) (1 %), 15 /ml (1.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 0 /ml ( %) lidocaine hcl injection solution 10 /ml (1 %), 0 /ml ( %), 5 /ml (0.5 %) (Xylocaine) lidocaine hcl mucous membrane jelly % QL (0 per 0 days) lidocaine hcl mucous membrane solution % (0 /ml) lidocaine topical adhesive (Lidoderm) PA; QL (90 per 0 days) patch,medicated 5 % lidocaine topical ointment 5 % PA; QL (90 per 0 days) lidocaine viscous mucous membrane solution % 9

19 lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual tablet -0.5, 8- bupropion hcl (smoking deter) oral tablet extended release 1 hr 150 CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG () (Zyban) PA; QL (0 per 0 days) 10 QL (90 per 0 days) QL (90 per 0 days) QL (6 per 65 days) QL (6 per 65 days) QL (106 per 65 days) disulfiram oral tablet 50, 500 (Antabuse) LUCEMYRA ORAL TABLET 0.18 MG ; QL (8 per 1 days) naloxone injection solution 0. /ml naloxone injection syringe 0. /ml, 1 /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL ( per 0 days) AEROSOL MG/ACTUATION NICOTROL INHALATION QL (1008 per 90 days) CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM 1- QL (60 per 0 days) MG, 8- MG SUBOXONE SUBLINGUAL FILM -0.5 QL (0 per 0 days) MG, -1 MG ZUBSOLV SUBLINGUAL TABLET 0.7- QL (0 per 0 days) 0.18 MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG QL (60 per 0 days) Antianxiety Agents

20 Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 (Xanax) 1 QL (10 per 0 days) alprazolam oral tablet (Xanax) 1 QL (150 per 0 days) alprazolam oral tablet extended release (Xanax XR) QL (10 per 0 days) hr 0.5, 1, alprazolam oral tablet extended release (Xanax XR) QL (90 per 0 days) hr buspirone oral tablet 10, 15, 0, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 5, 5 1 QL (10 per 0 days) clobazam oral suspension.5 /ml (Onfi) PA NSO; QL (80 per 0 days) clobazam oral tablet 10, 0 (Onfi) PA NSO; QL (60 per 0 days) clonazepam oral tablet 0.5, 1 (Klonopin) 1 QL (90 per 0 days) clonazepam oral tablet (Klonopin) 1 QL (00 per 0 days) clonazepam oral tablet,disintegrating QL (90 per 0 days) 0.15, 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 per 0 days) clorazepate dipotassium oral tablet 15,.75 QL (180 per 0 days) clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (180 per 0 days) DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG diazepam injection solution 5 /ml QL (10 per 8 days) diazepam injection syringe 5 /ml QL (10 per 8 days) diazepam intensol oral concentrate 5 QL (100 per 0 days) /ml diazepam oral solution 5 /5 ml (1 /ml) QL (100 per 0 days) diazepam oral tablet 10,, 5 (Valium) 1 QL (10 per 0 days) diazepam rectal kit , 5- (Diastat AcuDial) diazepam rectal kit.5 (Diastat) 11

21 estazolam oral tablet 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 days); AGE (Max 6 estazolam oral tablet PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 days); AGE (Max 6 flurazepam oral capsule 15 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 days); AGE (Max 6 flurazepam oral capsule 0 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 days); AGE (Max 6 lorazepam injection solution /ml (Ativan) 1 QL ( per 0 days) lorazepam injection solution /ml (Ativan) QL ( per 0 days) lorazepam injection syringe /ml, /ml QL ( per 0 days) 1

22 lorazepam oral concentrate /ml (Lorazepam Intensol) QL (150 per 0 days) lorazepam oral tablet 0.5, 1 (Ativan) 1 QL (90 per 0 days) lorazepam oral tablet (Ativan) 1 QL (150 per 0 days) midazolam oral syrup /ml QL (10 per 0 days) ONFI ORAL SUSPENSION.5 MG/ML 5 PA NSO; NDS; NM; QL (80 per 0 days) ONFI ORAL TABLET 10 MG, 0 MG 5 PA NSO; NDS; NM; QL (60 per 0 days) oxazepam oral capsule 10, 15, 0 QL (10 per 0 days) temazepam oral capsule 15, 0 (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 days); AGE (Max 6 triazolam oral tablet 0.15 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (10 per 0 days); AGE (Max 6 triazolam oral tablet 0.5 (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 days); AGE (Max 6 Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 00 MG/ ML 5 PA BvD; NDS; NM 1

23 gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 10 /100 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 0 / ml, 0 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml, 60 /6 ml, 80 /8 ml neomycin oral tablet streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 00 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 0 /ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150, 00, 75 clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution 150 /ml clindamycin phosphate intravenous solution 600 / ml ; QL ( per 8 days) (Tobi) 5 PA BvD; NDS; NM (BACiiM) (Cleocin HCl) (Cleocin Pediatric) (Cleocin) (Cleocin) 1

24 colistin (colistimethate na) injection recon (Coly-Mycin M 5 PA BvD; NDS; NM soln 150 Parenteral) daptomycin intravenous recon soln 50 daptomycin intravenous recon soln 500 (Cubicin) FIRVANQ ORAL RECON SOLN 5 MG/ML, 50 MG/ML linezolid 600 /00 ml-0.9% nacl 600 /00 ml linezolid in dextrose 5% intravenous piggyback 600 /00 ml (Zyvox) linezolid oral suspension for reconstitution (Zyvox) 100 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /100 ml metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 100, 50 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 0 days); AGE (Max 6 nitrofurantoin macrocrystal oral capsule 5 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 0 days); AGE (Max 6 15

25 nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 0 days); AGE (Max 6 polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet vancomycin intravenous recon soln 1,000 PA BvD, 10 gram, 50, 5 gram, 500, 750 vancomycin oral capsule 15 (Vancocin) vancomycin oral capsule 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG ; QL (9 per 0 days) XIFAXAN ORAL TABLET 550 MG Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefaclor oral tablet extended release 1 hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 00 (Spectracef) cefepime injection recon soln 1 gram, gram (Maxipime) 16

26 cefixime oral suspension for reconstitution (Suprax) 100 /5 ml, 00 /5 ml cefotaxime injection recon soln 1 gram, 500 cefotaxime injection recon soln 10 gram, (Claforan) gram cefoxitin intravenous recon soln 1 gram, 10 gram, gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln 1 gram (Fortaz) ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftibuten oral capsule 00 ceftibuten oral suspension for reconstitution 180 /5 ml ceftriaxone injection recon soln 1 gram, 10 gram, gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex) 1 cephalexin oral capsule 750 (Keflex) cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 SUPRAX ORAL CAPSULE 00 MG SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML tazicef injection recon soln 1 gram, gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) 17

27 azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml azithromycin oral tablet 50 (6 pack), ( pack) azithromycin oral tablet 50, 500 (Zithromax) 1 azithromycin oral tablet 600 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release hr 500 DIFICID ORAL TABLET 00 MG 5 ST; NDS; NM; QL (0 per 10 days) erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 LA; NDS; NM ertapenem injection recon soln 1 gram (Invanz) imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, amoxicillin oral suspension for 1 reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, amoxicillin oral tablet,chewable 15,

28 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram nafcillin intravenous recon soln gram oxacillin 1 gm add-vantage vl addvantage, inner 1 gram oxacillin injection recon soln 1 gram, 10 gram, gram penicillin g potassium injection recon soln 0 million unit (Pfizerpen-G) 19

29 penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous recon (Zosyn) PA BvD soln.5 gram,.75 gram,.5 gram, 0.5 gram Quinolones BAXDELA ORAL TABLET 50 MG ; QL (8 per 1 days) ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase hr 1,000, 500 ciprofloxacin hcl oral tablet 100 ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 ciprofloxacin hcl oral tablet ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 00 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 00 /0 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50 1 levofloxacin oral tablet 500, 750 (Levaquin) 1 moxifloxacin oral tablet 00 (Avelox) ofloxacin oral tablet 00, 00 Sulfonamides sulfadiazine oral tablet 500 0

30 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) sulfatrim oral suspension 00-0 /5 ml Tetracyclines demeclocycline oral tablet 150, 00 doxy-100 intravenous recon soln 100 doxycycline hyclate intravenous recon (Doxy-100) soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline hyclate oral tablet,delayed release (dr/ec) 100, 75 doxycycline hyclate oral tablet,delayed (Soloxide) release (dr/ec) 150 doxycycline hyclate oral tablet,delayed release (dr/ec) 00, 50 (Doryx) doxycycline monohydrate oral capsule 100 (Mondoxyne NL), 50 doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral capsule 75 (Mondoxyne NL) doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 150, 75 doxycycline monohydrate oral tablet 50 MINOCIN INTRAVENOUS RECON SOLN 100 MG minocycline oral capsule 100, 75 minocycline oral capsule 50 (Minocin) 1

31 minocycline oral tablet 100, 50, 75 mondoxyne nl oral capsule 100, 50 mondoxyne nl oral capsule 75 okebo oral capsule 100 okebo oral capsule 75 soloxide oral tablet,delayed release (dr/ec) 150 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 /5 PA BvD ml, /ml, 0 /10 ml, 50 /5 ml adrucil intravenous solution.5 gram/50 PA BvD ml, 500 /10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, 5 MG 5 PA NSO; NDS; NM; QL (11 per 8 days) AFINITOR ORAL TABLET 10 MG 5 PA NSO; NDS; NM; QL (56 per 8 days) AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA NSO; NDS; NM; QL (8 per 8 days) ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NDS; NM; QL (0 per 0 days) ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG 5 PA NSO; NDS; NM; QL ( per 8 days) ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA NSO; NDS; NM; QL (0 per 0 days) ALUNBRIG ORAL TABLET 0 MG 5 PA NSO; NDS; NM; QL (10 per 0 days) ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG () 5 PA NSO; NDS; NM; QL (0 per 0 days) anastrozole oral tablet 1 (Arimidex) 1 arsenic trioxide intravenous solution 1 /ml AVASTIN INTRAVENOUS SOLUTION 5 MG/ML 5 PA NSO; NDS; NM

32 azacitidine injection recon soln 100 (Vidaza) BAVENCIO INTRAVENOUS 5 PA NSO; NDS; NM SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON 5 PA NSO; NDS; NM SOLN 500 MG BENDEKA INTRAVENOUS 5 PA NSO; NDS; NM SOLUTION 5 MG/ML BESPONSA INTRAVENOUS RECON 5 PA NSO; NDS; NM SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 5 PA NSO; NDS; NM; QL (0 per 0 days) bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 15 unit, 0 PA BvD unit BLINCYTO INTRAVENOUS KIT 5 5 PA NSO; NDS; NM MCG BORTEZOMIB INTRAVENOUS 5 PA NSO; NDS; NM RECON SOLN.5 MG BOSULIF ORAL TABLET 100 MG 5 PA NSO; NDS; NM; QL (90 per 0 days) BOSULIF ORAL TABLET 00 MG, 500 MG 5 PA NSO; NDS; NM; QL (0 per 0 days) BRAFTOVI ORAL CAPSULE 50 MG 5 PA NSO; NDS; NM; QL (10 per 0 days) BRAFTOVI ORAL CAPSULE 75 MG 5 PA NSO; NDS; NM; QL (180 per 0 days) CABOMETYX ORAL TABLET 0 MG, 60 MG 5 PA NSO; NDS; NM; QL (0 per 0 days) CABOMETYX ORAL TABLET 0 MG 5 PA NSO; NDS; NM; QL (60 per 0 days) CALQUENCE ORAL CAPSULE 100 MG 5 PA NSO; NDS; NM; QL (60 per 0 days) CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NDS; NM; QL (60 per 0 days) CAPRELSA ORAL TABLET 00 MG 5 PA NSO; NDS; NM; QL (0 per 0 days) carboplatin intravenous solution 10 /ml cladribine intravenous solution 10 /10 PA BvD ml clofarabine intravenous solution 0 /0 ml (Clolar)

33 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1), 10 MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) COPIKTRA ORAL CAPSULE 15 MG, 5 MG 5 PA NSO; NDS; NM; QL (11 per 8 days) 5 PA NSO; NDS; NM; QL (56 per 8 days) COTELLIC ORAL TABLET 0 MG 5 PA NSO; LA; NDS; NM; QL (6 per 8 days) cyclophosphamide intravenous recon soln 5 PA BvD; NDS; NM 1 gram, gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 5 PA NSO; NDS; NM SOLUTION 10 MG/ML DARZALEX INTRAVENOUS 5 PA NSO; LA; NDS; NM SOLUTION 0 MG/ML decitabine intravenous recon soln 50 (Dacogen) docetaxel intravenous solution 0 / ml (10 /ml), 0 /ml, 80 /8 ml (10 /ml) docetaxel intravenous solution 0 /ml (Taxotere) (1 ml), 80 / ml (0 /ml) doxorubicin intravenous solution 10 /5 (Adriamycin) PA BvD ml, /ml, 0 /10 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) 5 PA BvD; NDS; NM suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE.5 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 5 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 10 MG EMPLICITI INTRAVENOUS RECON 5 PA NSO; NDS; NM SOLN 00 MG, 00 MG ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NDS; NM; QL (0 per 0 days) ERLEADA ORAL TABLET 60 MG 5 PA NSO; NDS; NM; QL (10 per 0 days)

34 ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 5 PA NSO; NDS; NM MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil intravenous solution 1 PA BvD gram/0 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/100 ml, 500 /10 ml flutamide oral capsule 15 GAZYVA INTRAVENOUS SOLUTION 5 PA NSO; NDS; NM 1,000 MG/0 ML gemcitabine intravenous recon soln 1 (Gemzar) gram, 00 gemcitabine intravenous recon soln gram gemcitabine intravenous solution 1 gram/6. ml (8 /ml), 100 /ml, gram/5.6 ml (8 /ml), 00 /5.6 ml (8 /ml) GILOTRIF ORAL TABLET 0 MG, 0 5 PA NSO; NDS; NM; QL MG, 0 MG (0 per 0 days) GLEOSTINE ORAL CAPSULE 10 MG, 0 MG, 5 MG GLEOSTINE ORAL CAPSULE 100 MG HERCEPTIN INTRAVENOUS RECON 5 PA NSO; NDS; NM SOLN 150 MG, 0 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 5 PA NSO; NDS; NM; QL 15 MG, 75 MG (1 per 8 days) ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NDS; NM; QL (60 per 0 days) ICLUSIG ORAL TABLET 5 MG 5 PA NSO; NDS; NM; QL (0 per 0 days) IDHIFA ORAL TABLET 100 MG, 50 5 PA NSO; NDS; NM; QL MG (0 per 0 days) ifosfamide intravenous recon soln 1 gram (Ifex) PA BvD 5

35 ifosfamide intravenous solution 1 gram/0 PA BvD ml, gram/60 ml ifosfamide-mesna intravenous kit PA BvD; NDS; NM gram,,000-1,000 imatinib oral tablet 100 (Gleevec) 5 PA NSO; NDS; NM; QL (90 per 0 days) imatinib oral tablet 00 (Gleevec) 5 PA NSO; NDS; NM; QL (60 per 0 days) IMBRUVICA ORAL CAPSULE 10 MG, 70 MG 5 PA NSO; NDS; NM; QL (8 per 8 days) IMBRUVICA ORAL TABLET 10 MG, 80 MG, 0 MG, 560 MG 5 PA NSO; NDS; NM; QL (8 per 8 days) IMFINZI INTRAVENOUS SOLUTION 5 PA NSO; NDS; NM 50 MG/ML IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML 5 PA NSO; NDS; NM; QL ( per 65 days) IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML 5 PA NSO; NDS; NM; QL (8 per 8 days) INLYTA ORAL TABLET 1 MG 5 PA NSO; NDS; NM; QL (180 per 0 days) INLYTA ORAL TABLET 5 MG 5 PA NSO; NDS; NM; QL (60 per 0 days) IRESSA ORAL TABLET 50 MG 5 PA NSO; NDS; NM; QL (60 per 0 days) irinotecan intravenous solution 100 /5 (Camptosar) ml, 0 / ml irinotecan intravenous solution 500 /5 ml IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 5 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG 5 PA NSO; NDS; NM; QL (60 per 0 days) KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML 5 PA NSO; NDS; NM; QL (8 per 1 days) KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG 5 PA NSO; NDS; NM; QL (9 per 8 days) KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X )-.5 MG 5 PA NSO; NDS; NM; QL (70 per 8 days) 5 PA NSO; NDS; NM; QL (91 per 8 days) 6

36 KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1) 5 PA NSO; NDS; NM; QL (1 per 8 days) KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) 5 PA NSO; NDS; NM; QL ( per 8 days) KISQALI ORAL TABLET 600 MG/DAY (00 MG X ) 5 PA NSO; NDS; NM; QL (6 per 8 days) KYPROLIS INTRAVENOUS RECON 5 PA NSO; NDS; NM SOLN 10 MG, 0 MG, 60 MG LARTRUVO INTRAVENOUS 5 PA NSO; LA; NDS; NM SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 1 MG/DAY ( MG X ), 1 MG/DAY(10 MG X 1- MG X 1), 18 MG/DAY (10 MG X 1- MG X), 0 MG/DAY (10 MG X ), MG/DAY(10 MG X - MG X 1), MG, 8 MG/DAY ( MG X ) 5 PA NSO; NDS; NM letrozole oral tablet.5 (Femara) 1 LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit 1 /0. ml LIBTAYO INTRAVENOUS SOLUTION 50 MG/7 ML (50 MG/ML) 5 PA NSO; NDS; NM; QL (7 per 1 days) LONSURF ORAL TABLET MG 5 PA NSO; NDS; NM; QL (100 per 8 days) LONSURF ORAL TABLET MG 5 PA NSO; NDS; NM; QL (80 per 8 days) LORBRENA ORAL TABLET 100 MG 5 PA NSO; NDS; NM; QL (0 per 0 days) LORBRENA ORAL TABLET 5 MG 5 PA NSO; NDS; NM; QL (90 per 0 days) LUMOXITI INTRAVENOUS RECON 5 PA NSO; NDS; NM SOLN 1 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 5 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG 7

37 LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; NDS; NM; QL (8 per 8 days) LYNPARZA ORAL TABLET 100 MG, 5 PA NSO; NDS; NM; QL 150 MG (10 per 0 days) LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 5 PA NSO; NDS; NM; QL MG/1 ML(0.16 MG/ML) FINAL ( per 8 days) MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 0 PA NSO-HRM; AGE (Max 6 MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NDS; NM; QL (90 per 0 days) MEKINIST ORAL TABLET MG 5 PA NSO; NDS; NM; QL (0 per 0 days) MEKTOVI ORAL TABLET 15 MG 5 PA NSO; NDS; NM; QL (180 per 0 days) melphalan hcl intravenous recon soln 50 (Alkeran (as HCl)) mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon PA BvD soln 1 gram methotrexate sodium (pf) injection PA BvD solution 5 /ml methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST mitoxantrone intravenous concentrate /ml MYLOTARG INTRAVENOUS RECON 5 PA NSO; NDS; NM SOLN.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 0 MG 5 PA NSO; NDS; NM; QL (180 per 0 days) NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NDS; NM; QL (10 per 0 days) nilutamide oral tablet 150 (Nilandron) NINLARO ORAL CAPSULE. MG, 5 PA NSO; NDS; NM; QL MG, MG ( per 8 days) ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; LA; NDS; NM ONCASPAR INJECTION SOLUTION 5 PA NSO; NDS; NM 750 UNIT/ML ONIVYDE INTRAVENOUS 5 PA BvD; NDS; NM DISPERSION. MG/ML 8

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