HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2019 MSHO List of Covered Drugs (Formulary)

Transcription

1 HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2019 MSHO List of Covered Drugs (Formulary) This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter (OTC) drugs and items are covered by HealthPartners MSHO. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by HealthPartners MSHO. Key terms and their definitions appear in the last chapter of the Member Handbook. Table of Contents A. Disclaimers I-2 B. Frequently Asked Questions. I-3 B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) I-3 B2. Does the Drug List ever change?. I-3 B3. What happens when there is a change to the Drug List?. I-4 B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?.. I-5 B5. How will you know if the drug you want has limitations or if there are any actions required to get the drug? I-5 B6. What happens if we change our rules about how we cover some drugs (for example, prior authorization, quantity limits, and/or step therapy restrictions)? I-6 B7. How can you find a drug on the Drug List?... I-6 B8. What if the drug you want to take is not on the Drug List? I-6 B9. What if you are a new HealthPartners MSHO member and can t find your drug on the Drug List or have a problem getting your drug?. I-7 B10. Can you ask for an exception to cover your drug?... I-7 B11. How can you ask for an exception?.. I-8 B12. How long does it take to get an exception?.. I-8 B13. What are generic drugs? I-8 B14. What are over-the-counter (OTC) drugs?. I-8 B15. Does HealthPartners MSHO cover non-drug OTC products?.. I-8 B16. Can I get my drugs through Mail Order and Long-Term Supply? I-9 B17. What is your copay?. I-9 C. Overview of the List of Covered Drugs.. I-10 C1. List of Drugs by Drug Type I-10 D. Index of Covered Drugs Updated 10/2018 If you have questions, please call HealthPartners MSHO Member Services at or , TTY 711, Oct. 1 through March 31, 8 a.m. to 8 p.m. CT, seven days a week. April 1 through Sept. 30, 8 a.m. to 8 p.m. CT, Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_112300_01 Approved 10/3/2018

2 A. Disclaimers This is a list of drugs that members can get in HealthPartners MSHO. HealthPartners is a health plan that contracts with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in HealthPartners depends on contract renewal. 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 HealthPartners MSHO s up-to-date List of Covered Drugs online at healthpartners.com/medicarerx or call Member Services at the number listed at the bottom of this page. Limitations, copays, and restrictions may apply. For more information, call HealthPartners MSHO Member Services at the number listed at the bottom of this page or read the HealthPartners MSHO Member Handbook. Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. You can get this document for free in other formats, such as large print, braille or audio. Call Member Services at the number listed at the bottom of this page. You can make a standing request to get materials, now and in the future, in a language other than English or in an alternate format. Call Member Services at the number listed at the bottom of this page. American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older, this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your Primary Care Provider prior to the referral. Enrolling in this health plan does not guarantee you can see a particular provider on this list. If you want to make sure, call that provider to ask if he or she is still part of this health plan. Also ask if he or she is accepting new patients. This health plan may not cover all your health care costs. Read your contract or Member Handbook carefully to find out what is covered. If you have questions, please call HealthPartners MSHO Member Services at or , TTY 711, Oct. 1 through March 31, 8 a.m. to 8 p.m. CT, seven days a week. April 1 through Sept. 30, 8 a.m. to 8 p.m. CT, Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_112300_01 Approved 10/3/2018 I-2

3 B. Frequently Asked Questions (FAQ) Find answers 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. B1. 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 that starts on page 3 are the drugs covered by HealthPartners MSHO. These 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. HealthPartners MSHO will cover all medically necessary drugs on the Drug List if: o Your doctor or other prescriber says you need them to get better or stay healthy, and o You fill the prescription at a HealthPartners MSHO network pharmacy. HealthPartners MSHO may have additional steps to access certain drugs. See question B4 for more information. You can also see an up-to-date list of drugs we cover on our website at healthpartners.com/medicarerx or call Member Services at the number listed at the bottom of this page. B2. Does the Drug List ever change? Yes. HealthPartners MSHO may add or remove drugs on the Drug List during the year. We may also change our rules about drugs. For example, we could: Decide to require or not require prior authorization for a drug. (Prior authorization is permission from HealthPartners MSHO 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 question B4. If you have questions, please call HealthPartners MSHO Member Services at or , TTY 711, Oct. 1 through March 31, 8 a.m. to 8 p.m. CT, seven days a week. April 1 through Sept. 30, 8 a.m. to 8 p.m. CT, Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_112300_01 Approved 10/3/2018 I-3

4 If you are taking a drug that is covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless: a new, 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, or a drug is removed from the market. Questions B3 and B6 have more information on what happens when the Drug List changes. You can always check HealthPartners MSHO s current Drug List online at healthpartners.com/medicarerx. You can also call Member Services at the number listed at the bottom of this page to check the current Drug List. B3. What happens when there is a change to the Drug List? Some changes to the Drug List will happen immediately. For example: A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. We will also send you a letter telling you that. Please follow the instructions in the letter and talk to your doctor. We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if: The FDA provides new guidance or there are new clinical guidelines about a drug. When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. 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. Then you can: Get a 30-day supply of the drug before the change to the Drug List is made, or Ask for an exception from these changes. Please see questions B10-B12 for more information about exceptions. If you have questions, please call HealthPartners MSHO Member Services at or , TTY 711, Oct. 1 through March 31, 8 a.m. to 8 p.m. CT, seven days a week. April 1 through Sept. 30, 8 a.m. to 8 p.m. CT, Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_112300_01 Approved 10/3/2018 I-4

5 B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you, your doctor, or other prescriber must do something before you can get the drug. For example: Prior authorization: For some drugs, you, your doctor, or other prescriber must get authorization from HealthPartners MSHO before you fill your prescription. Prior authorization means an approval from HealthPartners MSHO to seek services outside of our network or to get services not routinely covered by our network before you get the services. Prior authorization is different from a referral. HealthPartners MSHO may not cover the drug if you do not get authorization. Quantity limits: Sometimes HealthPartners MSHO limits the amount of a drug you can get. Step therapy: Sometimes HealthPartners MSHO requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn t work for you, then we will cover the second. 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 website at healthpartners.com/medicarerx. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception to these limits. 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 questions B10-B12 for more information about exceptions. B5. How will you know if the drug you want has limitations or if there are any actions required to get the drug? The Drug List on page 3 has a column labeled. If you have questions, please call HealthPartners MSHO Member Services at or , TTY 711, Oct. 1 through March 31, 8 a.m. to 8 p.m. CT, seven days a week. April 1 through Sept. 30, 8 a.m. to 8 p.m. CT, Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_112300_01 Approved 10/3/2018 I-5

6 B6. What happens if we change our rules about how we cover some drugs (for example, prior authorization, quantity limits, and/or step therapy restrictions)? In some cases, we will tell you in advance if we add or change prior authorization, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change. B7. 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 drug type. To search alphabetically, go to the Index of Covered Drugs section. You can find it in the back of this book. The Index of Covered Drugs is an alphabetical list of all of the drugs included in the Drug List. name drugs, generic drugs, and over-the-counter (OTC) drugs are listed in the index. To search by drug type, find the section labeled List of Drugs by Drug Type on page 1. The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the Antimigraine Agents category. That is where you will find drugs that treat migraines. B8. 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 the number listed at the bottom of this page and ask about it. If you learn that HealthPartners MSHO will not cover the drug, you can do one of these things: 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. See questions B10-B12 for more information about exceptions. If you have questions, please call HealthPartners MSHO Member Services at or , TTY 711, Oct. 1 through March 31, 8 a.m. to 8 p.m. CT, seven days a week. April 1 through Sept. 30, 8 a.m. to 8 p.m. CT, Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_112300_01 Approved 10/3/2018 I-6

7 B9. What if you are a new HealthPartners MSHO 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 HealthPartners MSHO. 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. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication. 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 authorization by HealthPartners MSHO, or you are taking a drug that is part of a step therapy restriction. 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. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away: We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new HealthPartners MSHO member. This is in addition to the temporary supply during the first 90 days you are a member of HealthPartners MSHO. For existing members who change care level, such as entering a long-term care facility or being discharged from a hospital, we ll grant early refills when appropriate. Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can t be used to buy a non-part D drug or a drug out of network, unless you qualify for out of network access. See your Member Handbook for information about non-part D drugs. B10. Can you ask for an exception to cover your drug? Yes. You can ask HealthPartners MSHO 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, HealthPartners MSHO 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 authorization requirements. If you have questions, please call HealthPartners MSHO Member Services at or , TTY 711, Oct. 1 through March 31, 8 a.m. to 8 p.m. CT, seven days a week. April 1 through Sept. 30, 8 a.m. to 8 p.m. CT, Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_112300_01 Approved 10/3/2018 I-7

8 B11. How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9 of the Member Handbook to learn more about exceptions. B12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get 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 getting your prescriber s supporting statement. B13. What are generic drugs? drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. drugs are approved by the Food and Drug Administration (FDA). HealthPartners MSHO covers both brand name drugs and generic drugs. B14. What are over-the-counter (OTC) drugs? OTC stands for over-the-counter. HealthPartners MSHO offers some OTC drugs through Medical Assistance (Medicaid) at no cost to you. You need a prescription for OTC drugs to be covered. These OTC drugs are listed in this Drug List. B15. Does HealthPartners MSHO cover non-drug OTC products? HealthPartners MSHO covers some non-drug OTC products through Medical Assistance (Medicaid). These nondrug OTC products are listed in this Drug List. Examples of OTC non-drug products include eye drops, laxatives and vitamins. If you have questions, please call HealthPartners MSHO Member Services at or , TTY 711, Oct. 1 through March 31, 8 a.m. to 8 p.m. CT, seven days a week. April 1 through Sept. 30, 8 a.m. to 8 p.m. CT, Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_112300_01 Approved 10/3/2018 I-8

9 B16. Can I get my drugs through Mail Order and Long-Term Supply? Mail Order Program. We offer a mail order program that allows you to get up to a 90-day supply of your prescription drugs sent directly to your home. A 90-day supply has the same copay as a one-month supply. Long-Term Supply. We offer a way to get a long-term supply of maintenance drugs on our plan s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.) For more information about getting drugs through mail order or long-term supply, please call Member Services at the number listed at the bottom of this page. B17. What is your copay? You can read the HealthPartners MSHO Drug List to learn about the copay for each drug. A copay is an amount you may be required to pay as your share of the cost of a prescription drug. A copay is usually a set amount, rather than a percentage. For example, you might pay $1.20 for a prescription drug. HealthPartners MSHO 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. The Drug List includes copays listed by tiers. Tier 1 drugs have the lowest copay. The copay is from $0 to $3.40, depending on your income and level of Medical Assistance (Medicaid) eligibility. Tier 1 drugs have a higher copay. The copay is from $0 to $8.50, depending on your income and level of Medical Assistance (Medicaid) eligibility. OTCs have a $0 copay. If you have questions, call Member Services at the number at the bottom of this page. We can help you understand what your copays will be. If you have questions, please call HealthPartners MSHO Member Services at or , TTY 711, Oct. 1 through March 31, 8 a.m. to 8 p.m. CT, seven days a week. April 1 through Sept. 30, 8 a.m. to 8 p.m. CT, Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_112300_01 Approved 10/3/2018 I-9

10 C. Overview of the List of Covered Drugs The List of Covered Drugs gives you information about the drugs covered by HealthPartners MSHO. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 143. The index alphabetically lists all drugs covered by HealthPartners MSHO. C1. List of Drugs by Drug Type The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the Antimigraine Agents category. That is where you will find drugs that treat migraines. The first column of the chart lists the name of the drug. drugs are listed in lowercase italics (e.g., atorvastatin), brand name drugs are capitalized (e.g., HUMALOG), and OTC drugs and products are listed in lowercase (e.g., guaifenesin). The information in the column tells you if HealthPartners MSHO has any rules for covering your drug. The key below describes the abbreviations used in the column. ABBREVIATION QL BvD ST LA DESCRIPTION Prior Authorization Required Quantity Limit This drug could be covered as a Part B or a Part D Benefit. Step Therapy Required Limited Access Drug Some drugs may be available only at certain pharmacies. For more information consult your pharmacy directory or call Member Services. Non-Mail Order Drug Drugs not eligible for a 90-day mail order supply through your mail order benefit are noted with under Requirements/Limits. If you have questions, please call HealthPartners MSHO Member Services at or , TTY 711, Oct. 1 through March 31, 8 a.m. to 8 p.m. CT, seven days a week. April 1 through Sept. 30, 8 a.m. to 8 p.m. CT, Monday Friday. The call is free. For more information, visit healthpartners.com/msho. H2422_112300_01 Approved 10/3/2018 I-10

11 List of Drugs by Drug Type Table of Contents Analgesics... 3 Anesthetics... 8 Anti-Addiction/Substance Abuse Treatment Agents... 9 Antianxiety Agents...10 Antibacterials Anticancer Agents...18 Anticholinergic Agents Anticonvulsants...30 Antidementia Agents...34 Antidepressants Antidiabetic Agents...37 Antifungals...41 Antigout Agents Antihistamines...44 Anti-Infectives (Skin And Mucous Membrane)...45 Antimigraine Agents Antimycobacterials...47 Antinausea Agents...48 Antiparasite Agents...49 Antiparkinsonian Agents...50 Antipsychotic Agents Antivirals (Systemic)...55 Blood Products/Modifiers/Volume Expanders Caloric Agents...66 Cardiovascular Agents Central Nervous System Agents Contraceptives...78 Dental And Oral Agents...86 Dermatological Agents...87 Devices...95 Enzyme Replacement/Modifiers...95 Eye, Ear, Nose, Throat Agents...97 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 Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents

12 Vasodilating Agents Vitamins And Minerals

13 List of Drugs by Drug Type The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the Antimigraine Agents category. That is where you will find drugs that treat migraines. Name of drug Analgesics Analgesics, Miscellaneous acetaminophen (bulk) powder 100 % acetaminophen oral drops 100 mg/ml acetaminophen oral elixir 160 mg/5 ml acetaminophen oral liquid 160 mg/5 ml, 500 mg/5 ml acetaminophen oral solution 160 mg/5 ml (5 ml) acetaminophen oral suspension 160 mg/5 ml acetaminophen oral tablet 325 mg acetaminophen oral tablet,disintegrating 80 mg acetaminophen rectal suppository 120 mg, 650 mg acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg, mg, mg arthritis pain relief (acetam) oral tablet extended release 650 mg astramorph-pf injection solution 0.5 mg/ml, 1 mg/ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital-acetaminophen oral tablet mg, mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg QL (120 ML per 1 day) QL (8 EA per 1 day) QL (8 ML per 1 day) ; QL (4 EA per 28 days) QL (12 EA per 1 day) QL (12 EA per 1 day) QL (6 EA per 1 day) 3

14 butalbital-aspirin-caffeine oral tablet mg capsaicin topical cream % children's pain reliever oral tablet,chewable 80 mg children's pain-fever relief oral tablet,disintegrating 160 mg codeine sulfate oral tablet 15 mg, 30 mg, 60 mg endocet oral tablet mg endocet oral tablet mg, mg endocet oral tablet mg extra strength muscle rub topical cream % fentanyl citrate buccal lozenge on a handle 200 mcg, 400 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr feverall rectal suppository 325 mg, 80 mg hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-ibuprofen oral tablet mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml hydromorphone injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml hydromorphone injection syringe 0.5 mg/0.5 ml, 1 mg/ml, 2 mg/ml, 4 mg/ml hydromorphone oral liquid 1 mg/ml hydromorphone oral tablet 2 mg QL (6 EA per 1 day) QL (8 EA per 1 day) QL (5 EA per 1 day) QL (8 EA per 1 day) QL (7 EA per 1 day) QL (120 ML per 1 day) QL (8 EA per 1 day) QL (8 EA per 1 day) QL (8 ML per 1 day) QL (8 ML per 1 day) QL (8 ML per 1 day) QL (20 ML per 1 day) QL (8 EA per 1 day) 4

15 hydromorphone oral tablet 4 mg hydromorphone oral tablet 8 mg LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet mg lorcet hd oral tablet mg lorcet plus oral tablet mg mapap (acetaminophen) oral capsule 500 mg mapap (acetaminophen) oral liquid 500 mg/15 ml marten-tab oral tablet mg methadone oral concentrate 10 mg/ml methadone oral solution 10 mg/5 ml, 5 mg/5 ml methadone oral tablet 10 mg, 5 mg morphine (pf) injection solution 0.5 mg/ml morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) morphine oral solution 10 mg/5 ml morphine oral solution 20 mg/5 ml (4 mg/ml) morphine oral tablet 15 mg morphine oral tablet 30 mg morphine oral tablet extended release 15 mg, 30 mg, 60 mg QL (5 EA per 1 day) QL (2 EA per 1 day) QL (8 EA per 1 day) QL (8 EA per 1 day) QL (8 EA per 1 day) QL (12 EA per 1 day) QL (8 ML per 1 day) QL (4 ML per 1 day) QL (45 ML per 1 day) QL (20 ML per 1 day) QL (5 EA per 1 day) QL (2 EA per 1 day) 5

16 muscle relief topical cream % non-aspirin infants oral drops,suspension 100 mg/ml oxycodone oral capsule 5 mg oxycodone oral concentrate 20 mg/ml oxycodone oral solution 5 mg/5 ml oxycodone oral tablet 10 mg oxycodone oral tablet 15 mg oxycodone oral tablet 20 mg oxycodone oral tablet 5 mg oxycodone-acetaminophen oral solution mg/5 ml oxycodone-acetaminophen oral tablet mg oxycodone-acetaminophen oral tablet mg, mg oxycodone-acetaminophen oral tablet mg oxycodone-aspirin oral tablet mg pain relief (acetamin-asp-caf) oral tablet mg pain reliever extra strength oral tablet 500 mg sarna anti-itch topical lotion % tencon oral tablet mg tramadol oral tablet 50 mg QL (8 EA per 1 day) QL (4 ML per 1 day) QL (40 ML per 1 day) QL (5 EA per 1 day) QL (3 EA per 1 day) QL (4 EA per 1 day) QL (8 EA per 1 day) QL (40 ML per 1 day) QL (5 EA per 1 day) QL (8 EA per 1 day) QL (7 EA per 1 day) QL (8 EA per 1 day) QL (12 EA per 1 day) QL (8 EA per 1 day) 6

17 Nonsteroidal Anti-Inflammatory Agents aspirin oral tablet 325 mg aspirin oral tablet,chewable 81 mg aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg aspirin rectal suppository 300 mg bufferin oral tablet 325 mg celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac sodium topical gel 1 %, 3 % etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg flurbiprofen oral tablet 100 mg, 50 mg ibu oral tablet 400 mg, 600 mg, 800 mg ibuprofen oral capsule 200 mg ibuprofen oral suspension 100 mg/5 ml ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg ibuprofen oral tablet,chewable 100 mg indomethacin oral capsule 25 mg, 50 mg infant's ibuprofen oral drops,suspension 50 mg/1.25 ml 7

18 ketorolac oral tablet 10 mg meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 125 mg/5 ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 220 mg piroxicam oral capsule 10 mg, 20 mg sulindac oral tablet 150 mg, 200 mg Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % lidocaine (pf) injection solution 10 mg/ml (1 %), 5 mg/ml (0.5 %) lidocaine hcl injection solution 10 mg/ml (1 %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % QL (20 EA per 30 days) ; QL (90 EA per 30 days) 8

19 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg buprenorphine-naloxone sublingual tablet mg buprenorphine-naloxone sublingual tablet 8-2 mg bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE CK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 mg naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, 1 mg/ml naltrexone oral tablet 50 mg NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION nicotine (polacrilex) buccal gum 2 mg, 4 mg nicotine (polacrilex) buccal lozenge 2 mg, 4 mg nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr QL (360 EA per 30 days) QL (90 EA per 30 days) QL (360 EA per 30 days) QL (90 EA per 30 days) QL (2 EA per 1 day) QL (2 EA per 1 day) QL (53 EA per 28 days) 9

20 NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 10 MG/ML SUBOXONE SUBLINGUAL FILM 12-3 MG SUBOXONE SUBLINGUAL FILM MG SUBOXONE SUBLINGUAL FILM 4-1 MG SUBOXONE SUBLINGUAL FILM 8-2 MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg alprazolam oral tablet 2 mg alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg alprazolam oral tablet extended release 24 hr 2 mg alprazolam oral tablet extended release 24 hr 3 mg buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg chlordiazepoxide hcl oral capsule 10 mg, 5 mg chlordiazepoxide hcl oral capsule 25 mg clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg QL (60 EA per 30 days) QL (360 EA per 30 days) QL (180 EA per 30 days) QL (90 EA per 30 days) QL (180 EA per 30 days) QL (150 EA per 30 days) QL (6 EA per 1 day) QL (5 EA per 1 day) QL (3 EA per 1 day) QL (180 EA per 30 days) QL (120 EA per 30 days) QL (180 EA per 30 days) QL (120 EA per 30 days) QL (300 EA per 30 days) 10

21 clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg clonazepam oral tablet,disintegrating 1 mg clonazepam oral tablet,disintegrating 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT MG DIASTAT ACUDIAL RECTAL KIT MG DIASTAT RECTAL KIT 2.5 MG diazepam intensol oral concentrate 5 mg/ml diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet 10 mg diazepam oral tablet 2 mg, 5 mg diazepam rectal kit mg, 2.5 mg diazepam rectal kit mg lorazepam oral concentrate 2 mg/ml lorazepam oral tablet 0.5 mg, 1 mg, 2 mg ONFI ORAL SUSPENSION 2.5 MG/ML ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG QL (180 EA per 30 days) QL (120 EA per 30 days) QL (300 EA per 30 days) QL (180 EA per 30 days) QL (40 EA per 30 days) QL (20 EA per 30 days) QL (40 EA per 30 days) QL (240 ML per 30 days) QL (1200 ML per 30 days) QL (120 EA per 30 days) QL (180 EA per 30 days) QL (40 EA per 30 days) QL (20 EA per 30 days) QL (150 ML per 30 days) QL (180 EA per 30 days) ; QL (480 ML per 30 days) ; QL (120 EA per 30 days) ; QL (60 EA per 30 days) 11

22 temazepam oral capsule 15 mg, 30 mg Antibacterials Aminoglycosides amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 120 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 20 mg/2 ml, 40 mg/ml gentamicin sulfate (ped) (pf) injection solution 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 100 mg/10 ml, 60 mg/6 ml, 80 mg/8 ml neomycin oral tablet 500 mg streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin palmitate hcl oral recon soln 75 mg/5 ml QL (30 EA per 30 days) ; BvD; QL (224 ML per 30 days) ; QL (224 EA per 30 days) ; BvD; QL (280 ML per 30 days) 12

23 clindamycin phosphate injection solution 150 (mg/ml) (6 ml), 150 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml daptomycin intravenous recon soln 350 mg, 500 mg FIRVANQ ORAL RECON SOLN 25 MG/ML, 50 MG/ML linezolid in dextrose 5% intravenous piggyback 600 mg/300 ml linezolid oral suspension for reconstitution 100 mg/5 ml linezolid oral tablet 600 mg metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml metronidazole oral tablet 250 mg, 500 mg MONUROL ORAL CKET 3 GRAM nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin oral suspension 25 mg/5 ml polymyxin b sulfate injection recon soln 500,000 unit SIVEXTRO INTRAVENOUS RECON SOLN 200 MG SIVEXTRO ORAL TABLET 200 MG SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg 13

24 vancomycin intravenous recon soln 1,000 mg, 10 gram, 250 mg, 5 gram, 500 mg, 750 mg vancomycin oral capsule 125 mg, 250 mg XIFAXAN ORAL TABLET 200 MG, 550 MG Cephalosporins cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefepime injection recon soln 1 gram, 2 gram cefoxitin intravenous recon soln 1 gram, 2 gram cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection recon soln 1 gram, 2 gram, 6 gram ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 750 mg 14

25 cefuroxime sodium intravenous recon soln 1.5 gram cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml SUPRAX ORAL CAPSULE 400 MG TEFLARO INTRAVENOUS RECON SOLN 400 MG TEFLARO INTRAVENOUS RECON SOLN 600 MG Macrolides azithromycin intravenous recon soln 500 mg azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg DIFICID ORAL TABLET 200 MG ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin oral capsule,delayed release(dr/ec) 250 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, 2 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML ertapenem injection recon soln 1 gram ; LA; QL (84 ML per 30 days) 15

26 imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 mg Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) dicloxacillin oral capsule 250 mg, 500 mg nafcillin injection recon soln 1 gram 16

27 nafcillin injection recon soln 10 gram penicillin g pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 20 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml, 400 mg/200 ml ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml levofloxacin intravenous solution 25 mg/ml levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg moxifloxacin oral tablet 400 mg Sulfonamides sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg 17

28 sulfatrim oral suspension mg/5 ml Tetracyclines demeclocycline oral tablet 150 mg, 300 mg doxy-100 intravenous recon soln 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg minocycline oral capsule 100 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg tigecycline intravenous recon soln 50 mg Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQO INTRAVENOUS RECON SOLN 60 MG 18

29 ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE CK 90 MG (7)- 180 MG (23) anastrozole oral tablet 1 mg ARRANON INTRAVENOUS SOLUTION 250 MG/50 ML ARZERRA INTRAVENOUS SOLUTION 1,000 MG/50 ML, 100 MG/5 ML AVASTIN INTRAVENOUS SOLUTION 25 MG/ML azacitidine injection recon soln 100 mg BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 MG/ML BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.25 MG/ML INITIAL) bexarotene oral capsule 75 mg bicalutamide oral tablet 50 mg BICNU INTRAVENOUS RECON SOLN 100 MG bleomycin injection recon soln 15 unit, 30 unit BLINCYTO INTRAVENOUS KIT 35 MCG BORTEZOMIB INTRAVENOUS RECON SOLN 3.5 MG BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG ; BvD 19

30 BRAFTOVI ORAL CAPSULE 50 MG, 75 MG busulfan intravenous solution 60 mg/10 ml CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG CALQUENCE ORAL CAPSULE 100 MG CAMPTOSAR INTRAVENOUS SOLUTION 300 MG/15 ML CAPRELSA ORAL TABLET 100 MG, 300 MG carboplatin intravenous solution 10 mg/ml cisplatin intravenous solution 1 mg/ml cladribine intravenous solution 10 mg/10 ml clofarabine intravenous solution 20 mg/20 ml COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide oral capsule 25 mg, 50 mg CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) cytarabine injection solution 20 mg/ml dacarbazine intravenous recon soln 100 mg, 200 mg ; LA ; BvD ; LA BvD ; BvD ; BvD 20

31 dactinomycin intravenous recon soln 0.5 mg DARZALEX INTRAVENOUS SOLUTION 20 MG/ML daunorubicin intravenous recon soln 20 mg daunorubicin intravenous solution 5 mg/ml decitabine intravenous recon soln 50 mg docetaxel intravenous solution 160 mg/8 ml (20 mg/ml), 20 mg/2 ml (10 mg/ml), 20 mg/ml, 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous solution 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml doxorubicin, peg-liposomal intravenous suspension 2 mg/ml EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG epirubicin intravenous recon soln 50 mg epirubicin intravenous solution 200 mg/100 ml, 50 mg/25 ml ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML, 200 MG/100 ML ERIVEDGE ORAL CAPSULE 150 MG ERLEADA ORAL TABLET 60 MG ERWINAZE INJECTION RECON SOLN 10,000 UNIT etoposide intravenous solution 20 mg/ml ; BvD ; BvD ; LA 21

32 exemestane oral tablet 25 mg FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG, 80 MG fludarabine intravenous recon soln 50 mg fludarabine intravenous solution 50 mg/2 ml fluorouracil intravenous solution 1 gram/20 ml, 5 gram/100 ml, 500 mg/10 ml flutamide oral capsule 125 mg FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML (1 ML), 40 MG/2 ML (20 MG/ML) GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML gemcitabine intravenous recon soln 1 gram, 2 gram, 200 mg gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 100 mg/ml, 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 10 MG, 40 MG, 5 MG GLEOSTINE ORAL CAPSULE 100 MG HALAVEN INTRAVENOUS SOLUTION 1 MG/2 ML (0.5 MG/ML) ; BvD ; LA 22

33 HERCEPTIN INTRAVENOUS RECON SOLN 150 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG, 45 MG idarubicin intravenous solution 1 mg/ml IDHIFA ORAL TABLET 100 MG, 50 MG ifosfamide intravenous recon soln 1 gram, 3 gram ifosfamide intravenous solution 1 gram/20 ml, 3 gram/60 ml imatinib oral tablet 100 mg, 400 mg IMBRUVICA ORAL CAPSULE 140 MG, 70 MG IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML, 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG, 5 MG IRESSA ORAL TABLET 250 MG irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml, 500 mg/25 ml IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 45 MG ; LA ; BvD ; LA 23

34 JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG JEVTANA INTRAVENOUS SOLUTION 10 MG/ML (FIRST DILUTION) KADCYLA INTRAVENOUS RECON SOLN 100 MG, 160 MG KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML KISQALI FEMARA CO-CK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 10 MG, 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 12 MG/DAY (4 MG X 3), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 4 MG, 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 mg/0.2 ml LONSURF ORAL TABLET MG, MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG ; LA ; LA ; LA 24

35 LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNRZA ORAL CAPSULE 50 MG LYNRZA ORAL TABLET 100 MG, 150 MG LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 MG/31 ML(0.16 MG/ML) FINAL MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG, 2 MG MEKTOVI ORAL TABLET 15 MG melphalan hcl intravenous recon soln 50 mg mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection solution 25 mg/ml methotrexate sodium injection solution 25 mg/ml methotrexate sodium oral tablet 2.5 mg mitomycin intravenous recon soln 20 mg, 40 mg, 5 mg mitoxantrone intravenous concentrate 2 mg/ml MUSTARGEN INJECTION RECON SOLN 10 MG ; LA BvD BvD BvD 25

36 mutamycin intravenous recon soln 20 mg, 40 mg, 5 mg MYLOTARG INTRAVENOUS RECON SOLN 4.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 40 MG NEXAVAR ORAL TABLET 200 MG nilutamide oral tablet 150 mg NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG ONCASR INJECTION SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS DISPERSION 4.3 MG/ML OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 240 MG/24 ML, 40 MG/4 ML oxaliplatin intravenous recon soln 100 mg, 50 mg oxaliplatin intravenous solution 100 mg/20 ml, 50 mg/10 ml (5 mg/ml) paclitaxel intravenous concentrate 6 mg/ml PERJETA INTRAVENOUS SOLUTION 420 MG/14 ML (30 MG/ML) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) POTELIGEO INTRAVENOUS SOLUTION 4 MG/ML PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT ; LA ; LA ; LA 26

37 PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG/11.7 ML (120 MG/ML), 1600 MG/13.4 ML (120 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML romidepsin intravenous recon soln 10 mg/2 ml RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG RYDAPT ORAL CAPSULE 25 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 10 mg, 20 mg TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG ; LA ; BvD ; LA 27

38 TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG temsirolimus intravenous recon soln 30 mg/3 ml (10 mg/ml) (first) thiotepa injection recon soln 15 mg TIBSOVO ORAL TABLET 250 MG topotecan intravenous recon soln 4 mg topotecan intravenous solution 4 mg/4 ml (1 mg/ml) TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML (10 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON SOLN 100 MG, 25 MG TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML, 22.5 MG/2 ML, 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 10 mg TRISENOX INTRAVENOUS SOLUTION 2 MG/ML TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML) VELCADE INJECTION RECON SOLN 3.5 MG ; LA 28

39 VENCLEXTA ORAL TABLET 10 MG, 50 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING CK ORAL TABLETS,DOSE CK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG vinblastine intravenous solution 1 mg/ml vincasar pfs intravenous solution 1 mg/ml, 2 mg/2 ml vincristine intravenous solution 1 mg/ml, 2 mg/2 ml vinorelbine intravenous solution 10 mg/ml, 50 mg/5 ml VOTRIENT ORAL TABLET 200 MG VYXEOS INTRAVENOUS RECON SOLN MG XALKORI ORAL CAPSULE 200 MG, 250 MG XATMEP ORAL SOLUTION 2.5 MG/ML XTANDI ORAL CAPSULE 40 MG YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG YONSA ORAL TABLET 125 MG ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML), 200 MG/8 ML (25 MG/ML) ; BvD ; LA ; BvD ; LA ; BvD 29

40 ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM ZEJULA ORAL CAPSULE 100 MG ZELBORAF ORAL TABLET 240 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG, 500 MG Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline oral tablet 15 mg Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG ; LA ; LA ; QL (80 ML per 1 day) ; QL (16 EA per 1 day) ; QL (8 EA per 1 day) 30