2019 Formulary (List of Covered Drugs)

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1 09 Formulary (List of Covered Drugs) UCare Individual & Family Plans UCare Individual & Family Plans with Fairview This formulary may change throughout the year. Please visit ucare.org or call UCare Customer Services for the most current information. PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THESE PLANS. UCare Customer Services UCare Individual & Family Plan members: toll free UCare Individual & Family Plans with Fairview members: toll free TTY: toll free 8 am 6 pm, Monday through Friday UC_FVC_38 IA (308)

2 What is the UCare Formulary? The UCare formulary is a list of generic and brand drugs that are covered by this plan(s). To be covered, the drug must be on our formulary. The most current list of covered drugs can be found on the UCare Individual & Family Plans formulary at ucare.org. To be covered, you must fill your prescription at a network pharmacy. The Provider Directory and Search Network tool at ucare.org includes in-network pharmacies. You can also visit ucare.org for the most current information. Over-the-counter (OTC) drugs are usually not covered. They must be prescribed and on our formulary to be covered. This applies to drugs covered as part of the Essential Health Benefits, such as emergency contraception, tobacco cessation and diabetic supplies. Can the formulary change? Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 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. How do I use the formulary? In the formulary, brand name drugs are capitalized (e.g. DILANTIN) and generic drugs are listed in lowercase italics (e.g. fenofibrate). UCare covers both brand name drugs and generic drugs. A generic drug is approved by the U.S. Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs, but work just as well and are equally as safe as the branded product. How to find prescription drugs in the formulary? There are two ways to find your prescription drugs in the formulary. You can search by category of drug or by alphabetical listing. Search by Drug Category Drugs listed by drug category begin on page. The drugs in this formulary are grouped into drug categories depending on the medical conditions they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovasuclar Agents, If you know what your drug is used for, look for the category name in the list that begins on page. Then look under the category name for your drug. ii UCare Comprehensive Formulary

3 Search by Alphabetical Listing If you are not sure what class to look under, you can look for your drug in the Index. The Index gives an alphabetical list of all of the drugs included in the formulary. Both brand name 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 within the formulary. Tiers and limitations for prescription drugs The numbers in the Tier column on the prescription drug formulary indicate the cost share for the medication. Tier indicates drugs that are preferred generic drugs and have a Tier copay. Tier indicates drugs that are primarily brand name, or specialty, or non-preferred generic drugs and have a Tier drug coinsurance. Tier 3 indicates drugs that may be eligible for a zero dollar copay if they are a preventive medication that is part of the Essential Health Benefits. For more detailed information about copays and coinsurance, please review your Member Contract. The abbreviations/symbols in the Limitations (Notes) column on the formulary tell you if UCare has any special requirements or limits on coverage for that drug. Use the key below to help understand the meaning of each abbreviation/symbol. PA = Prior authorization Some drugs require you or your provider to get UCare s approval before you fill your prescription. If you do not get approval, we may not cover the drug. The formulary states which drugs need approval or authorization. ST = Step therapy Even if a drug is on the formulary, we may require you to try one or more alternative drugs on the formulary before this drug will be covered. QL = Quantity limits We limit the amount of some covered drugs you can receive each time you fill a prescription. SP = Specialty drugs Fairview Specialty Pharmacy (Fairview) is the only network provider of specialty drugs for plan members. Specialty drugs are injectable or oral drugs that often require special handling or monitoring by a pharmacist or nurse. If you use a specialty drug, you or your doctor must contact the specialty pharmacy to order the prescription. Your drug and any needed supplies will be shipped to your home, work or doctor s office. Fairview also provides clinical support to you and your caregivers. A Fairview pharmacist is on call 4 hours a day if you have an urgent need related to your specialty drug. Call Fairview Specialty Pharmacy at toll free. TTY users may call the National Relay Center at 7 and ask for PV (Tier 3) = May be considered a Preventive Medication with a zero copay. UCare Comprehensive Formulary iii

4 Eligible Preventive Medication with no Copay Aspirin For prevention or cardiovascular events Aspirin (for pregnant women who are at risk for preeclampsia) Oral Fluoride Folic Acid Immunizations Tobacco Cessation Bowel Preps Breast Cancer Prevention Contraceptives Statins Low-to Moderate-Dose Statins Men: 45 to 79 years old Women: 55 to 79 years old Women under 55 years old Children ages 6 months to 6 years Women under 5 years old Recommended ages per the Advisory Committee on Immunization Practices Men and women age 8 and older who use tobacco products. Prescription products have $0 copay in pharmacy. OTC products available through smoking cessation program. Men and women between the ages of 49 and 76 - limit per 365 days High risk women age 35 and older with no previous diagnosis of breast cancer. Member must contact ESI for copay override. Women under 5 years old: Please see Member Contract/SBC Adults years What if my drug is not on the formulary? If your drug is not included in this formulary, you should first contact UCare Customer Services and confirm that your drug is not covered. If you learn that UCare does not cover your drug, you can: Ask your doctor to prescribe a similar drug that is covered by UCare. Ask UCare to make an exception to cover your drug iv UCare Comprehensive Formulary

5 Requesting a formulary, step therapy or drug restriction exception You or your doctor can ask UCare to make an exception and cover a non-formulary drug, or remove the step therapy requirements, drug restrictions or requirements. Contact Customer Services at the number listed on the front cover for information on how to request an exception. We generally require you to submit a statement from your doctor supporting your request. For more information For For more detailed information about your UCare prescription drug coverage, please review your Member Contract and other plan materials. If you have questions, please call the UCare Customer Services number on the front cover or visit ucare.org. This information is available in other forms to people with disabilities by calling: (voice) or toll free at (voice), (TTY) or toll free at UCare Comprehensive Formulary v

6 Notice of Nondiscrimination UCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. UCare does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. We provide aids and services at no charge to people with disabilities to communicate effectively with us, such as TTY line, or written information in other formats, such as large print. If you need these services, contact us at (voice) or toll free at (voice), (TTY), or (TTY). We provide language services at no charge to people whose primary language is not English, such as qualified interpreters or information written in other languages. If you need these services, contact us at the number on the back of your membership card or or toll free at (voice); or toll free at (TTY). If you believe that UCare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file an oral or written grievance. Oral grievance If you are a current UCare member, please call the number on the back of your membership card. Otherwise please call or toll free at (voice); or toll free at (TTY). You can also use these numbers if you need assistance filing a grievance. Written grievance Mailing Address UCare Attn: Appeals and Grievances PO Box 5 Minneapolis, MN cag@ucare.org Fax: You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 00 Independence Avenue SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at

7 ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al / (TTY: / ). LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau / (TTY: / ). XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa / (TTY: / ). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số / (TTY: / ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 / (TTY: / ) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните / (телетайп: / ). ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ / (TTY: / ). ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ / (መስማት ለተሳናቸው: / ). ymol.ymo;=erh>uwdraundausdmtcd<aerrm>ausdmtw>rrpxrvxawvxmbl.vxmphraedwrhrb.ohm.vdria ud; / (TTY: / ). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: / (TTY: / ). របយ ក ប ស នជ អ កន យ ភ ស រ ខ រ, រសវ ជ ន យរ ផ កភ ស ដ យម នគ តឈ ល គ ឤចម នស រ ប ប ររ អ ក ច រ ទ រស ព / (TTY: / ) ملحوظة :إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان.اتصل برقم / (رقم ھاتف الصم والبكم: / ). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le / (ATS : / ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 / (TTY: / ) 번으로전화해주십시오. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa / (TTY: / ).

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9 UCare Individual & Family Plans Comprehensive Formulary (List of Covered Drugs) ANTIHISTAMINE DRUGS carbinoxamine maleate oral liquid 4 /5 ml carbinoxamine maleate oral tablet 4 cetirizine oral solution /ml clemastine oral tablet.68 cyproheptadine oral syrup /5 ml cyproheptadine oral tablet 4 desloratadine oral tablet 5 desloratadine oral tablet,disintegrating.5, 5 QL (30 EA per 30 days) diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl oral capsule 50 hydroxyzine hcl intramuscular solution 5 /ml hydroxyzine hcl oral solution 0 /5 ml hydroxyzine hcl oral tablet 0, 5, 50 hydroxyzine pamoate oral capsule 00, 5, 50 levocetirizine oral solution.5 /5 ml levocetirizine oral tablet 5 meclizine oral tablet.5, 5 promethazine injection solution 5 /ml, 50 /ml promethazine oral syrup 6.5 /5 ml promethazine oral tablet.5, 5, 50 promethazine rectal suppository.5, 5 ANTI-INFECTIVE AGENTS abacavir oral solution 0 /ml abacavir oral tablet 300 abacavir-lamivudine oral tablet abacavir-lamivudine-zidovudine oral tablet acyclovir oral capsule 00 acyclovir oral suspension 00 /5 ml acyclovir oral tablet 400, 800 acyclovir sodium intravenous recon soln,000, 500 adefovir oral tablet 0 SP albendazole oral tablet 00 ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML Effective: February, 09

10 amantadine hcl oral capsule 00 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 00 AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amikacin injection solution,000 /4 ml, 500 / ml amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet 50-5, 500-5, amoxicillin-pot clavulanate oral tablet extended release hr, amoxicillin-pot clavulanate oral tablet,chewable , amphotericin b injection recon soln 50 ampicillin oral capsule 50, 500 ampicillin sodium injection recon soln gram, 0 gram, 5, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln.5 gram, 5 gram ampicillin-sulbactam intravenous recon soln.5 gram, 3 gram APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLUTION 00 MG/ML atazanavir oral capsule 50, 00, 300 atovaquone oral suspension 750 /5 ml atovaquone-proguanil oral tablet 50-00, ATRIPLA ORAL TABLET MG azithromycin intravenous recon soln 500 azithromycin oral suspension for reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50, 500, 600 aztreonam injection recon soln gram, gram bacitracin intramuscular recon soln 50,000 unit Effective: February, 09

11 BARACLUDE ORAL SOLUTION 0.05 MG/ML SP benznidazole oral tablet 00,.5 BIKTARVY ORAL TABLET MG BILTRICIDE ORAL TABLET 600 MG CAPASTAT INJECTION RECON SOLN GRAM caspofungin intravenous recon soln 50, 70 CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML SP; QL (84 ML per 30 days) cefaclor oral capsule 50, 500 cefaclor oral tablet extended release hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, gram/50 ml cefazolin injection recon soln gram, 0 gram, 00 gram, 0 gram, 300 g, 500 cefazolin intravenous recon soln gram cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefepime injection recon soln gram, gram cefotaxime injection recon soln gram, 0 gram, gram, 500 cefotetan injection recon soln gram, gram cefotetan intravenous recon soln 0 gram cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml, gram/50 ml cefoxitin intravenous recon soln gram, 0 gram, gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram, gram, 6 gram Effective: February, 09 3

12 ceftriaxone in dextrose,iso-os intravenous piggyback gram/50 ml, gram/50 ml ceftriaxone injection recon soln gram, 0 gram, gram, 50, 500 ceftriaxone intravenous recon soln gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 50, 500 cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 chloramphenicol sod succinate intravenous recon soln gram chloroquine phosphate oral tablet 50, 500 cidofovir intravenous solution 75 /ml CIMDUO ORAL TABLET MG ciprofloxacin (mixture) oral tablet, er multiphase 4 hr,000, 500 ciprofloxacin hcl oral tablet 00, 50, 500, 750 ciprofloxacin lactate intravenous solution 400 /40 ml ciprofloxacin oral suspension,microcapsule recon 50 /5 ml, 500 /5 ml clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 clindamycin hcl oral capsule 50, 300, 75 clindamycin phosphate injection solution 50 /ml clindamycin phosphate intravenous solution 300 / ml, 600 /4 ml, 900 /6 ml COARTEM ORAL TABLET 0-0 MG colistin (colistimethate na) injection recon soln 50 COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 00 MG Effective: February, 09 4

13 dapsone oral tablet 00, 5 DAPTOMYCIN INTRAVENOUS RECON SOLN 500 MG demeclocycline oral tablet 50, 300 DESCOVY ORAL TABLET 00-5 MG dicloxacillin oral capsule 50, 500 didanosine oral capsule,delayed release(dr/ec) 5, 00, 50, 400 DIFICID ORAL TABLET 00 MG doxy-00 intravenous recon soln 00 doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00 doxycycline hyclate oral tablet,delayed release (dr/ec) 00, 50, 75 doxycycline monohydrate oral capsule 00, 50, 50, 75 doxycycline monohydrate oral tablet 50, 50, 75 E.E.S. 400 ORAL TABLET 400 MG EDURANT ORAL TABLET 5 MG efavirenz oral capsule 00, 50 efavirenz oral tablet 600 EMTRIVA ORAL CAPSULE 00 MG EMTRIVA ORAL SOLUTION 0 MG/ML entecavir oral tablet 0.5, SP ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 50 MG, 333 MG ERYTHROCIN (AS STEARATE) ORAL TABLET 50 MG ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG, 500 MG erythromycin ethylsuccinate oral tablet 400 erythromycin oral tablet 50, 500 ethambutol oral tablet 00, 400 EVOTAZ ORAL TABLET MG FACTIVE ORAL TABLET 30 MG famciclovir oral tablet 5, 500 QL ( EA per 30 days) famciclovir oral tablet 50 QL (60 EA per 30 days) fluconazole in dextrose(iso-o) intravenous piggyback 00 /00 ml, 400 /00 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 /00 ml Effective: February, 09 5

14 fluconazole oral suspension for reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 00, 50 fluconazole oral tablet 50 QL ( EA per 30 days) flucytosine oral capsule 50, 500 fosamprenavir oral tablet 700 foscarnet intravenous solution 4 /ml ganciclovir sodium intravenous recon soln 500 SP gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 0 /00 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin injection solution 0 / ml, 40 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 60 /6 ml GENVOYA ORAL TABLET MG griseofulvin microsize oral suspension 5 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 5, 50 HEPSERA ORAL TABLET 0 MG SP hydroxychloroquine oral tablet 00 imipenem-cilastatin intravenous recon soln 50, 500 INTELENCE ORAL TABLET 00 MG, 00 MG, 5 MG INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), SP 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML SP INVIRASE ORAL CAPSULE 00 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 5 MG isoniazid injection solution 00 /ml Effective: February, 09 6

15 isoniazid oral solution 50 /5 ml isoniazid oral tablet 00, 300 itraconazole oral capsule 00 QL (30 EA per 30 days) ivermectin oral tablet 3 JULUCA ORAL TABLET 50-5 MG KALETRA ORAL TABLET 00-5 MG, MG ketoconazole oral tablet 00 lamivudine oral solution 0 /ml lamivudine oral tablet 00, 50, 300 lamivudine-zidovudine oral tablet levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50, 500, 750 LEXIVA ORAL SUSPENSION 50 MG/ML linezolid in dextrose 5% intravenous piggyback 600 /300 ml linezolid oral suspension for reconstitution 00 /5 ml linezolid oral tablet 600 linezolid-0.9% sodium chloride intravenous parenteral solution 600 /300 ml lopinavir-ritonavir oral solution /5 ml MAVYRET ORAL TABLET MG PA; SP mefloquine oral tablet 50 meropenem intravenous recon soln gram, 500 methenamine hippurate oral tablet gram METRO I.V. INTRAVENOUS PIGGYBACK 500 MG/00 ML metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml metronidazole oral capsule 375 metronidazole oral tablet 50, 500 minocycline oral capsule 00, 50, 75 minocycline oral tablet 00, 50, 75 moxifloxacin oral tablet 400 MYCAMINE INTRAVENOUS RECON SOLN 00 MG, 50 MG Effective: February, 09 7

16 nafcillin injection recon soln gram, 0 gram, gram nafcillin intravenous recon soln gram, gram neomycin oral tablet 500 nevirapine oral suspension 50 /5 ml nevirapine oral tablet 00 nitrofurantoin macrocrystal oral capsule 00, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 nitrofurantoin oral suspension 5 /5 ml NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NOXAFIL ORAL SUSPENSION 00 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit ODEFSEY ORAL TABLET MG ofloxacin oral tablet 300, 400 oseltamivir oral capsule 30 QL (40 EA per 30 days) oseltamivir oral capsule 45, 75 QL (0 EA per 30 days) oseltamivir oral suspension for reconstitution 6 /ml QL (360 ML per 73 days) oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, gram/50 ml oxacillin injection recon soln gram, 0 gram, gram oxacillin intravenous recon soln gram, gram paromomycin oral capsule 50 PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 35 MCG/0.5 ML SP; QL (4 ML per 30 days) PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML SP; QL (4 ML per 30 days) PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML SP; QL (4 EA per 30 days) penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe. million unit/ ml penicillin g sodium injection recon soln 5 million unit Effective: February, 09 8

17 penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 piperacillin-tazobactam intravenous recon soln.5 gram, gram, 4.5 gram, 40.5 gram polymyxin b sulfate injection recon soln 500,000 unit praziquantel oral tablet 600 PREVYMIS INTRAVENOUS SOLUTION 40 MG/ ML, 480 MG/4 ML SP PREVYMIS ORAL TABLET 40 MG, 480 MG SP PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG PRIFTIN ORAL TABLET 50 MG PYLERA ORAL CAPSULE MG pyrazinamide oral tablet 500 quinidine gluconate injection solution 80 /ml quinidine gluconate oral tablet extended release 34 quinidine sulfate oral tablet 00, 300 quinine sulfate oral capsule 34 RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION QL (40 EA per 73 days) RESCRIPTOR ORAL TABLET 00 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML ribavirin oral capsule 00 SP ribavirin oral tablet 00 SP rifabutin oral capsule 50 rifampin intravenous recon soln 600 rifampin oral capsule 50, 300 RIFATER ORAL TABLET MG rimantadine oral tablet 00 ritonavir oral tablet 00 SELZENTRY ORAL SOLUTION 0 MG/ML SELZENTRY ORAL TABLET 50 MG, 5 MG, 300 MG, 75 MG Effective: February, 09 9

18 stavudine oral capsule 5, 0, 30, 40 stavudine oral recon soln /ml streptomycin intramuscular recon soln gram STRIBILD ORAL TABLET MG STROMECTOL ORAL TABLET 3 MG sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral suspension /5 ml sulfamethoxazole-trimethoprim oral tablet , sulfasalazine oral tablet 500 sulfasalazine oral tablet,delayed release (dr/ec) 500 SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SP SYMFI LO ORAL TABLET MG SYMFI ORAL TABLET MG SYNAGIS INTRAMUSCULAR SOLUTION 00 MG/ML, 50 MG/0.5 ML SP SYNERCID INTRAVENOUS RECON SOLN 500 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML QL (360 ML per 73 days) tenofovir disoproxil fumarate oral tablet 300 terbinafine hcl oral tablet 50 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 tinidazole oral tablet 50, 500 TIVICAY ORAL TABLET 0 MG, 5 MG, 50 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 300 /5 ml SP; QL (80 ML per 30 days) tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 0 /ml, 40 /ml TRECATOR ORAL TABLET 50 MG trimethoprim oral tablet 00 TRIUMEQ ORAL TABLET MG TROGARZO INTRAVENOUS SOLUTION 00 MG/.33 ML (50 MG/ML) Effective: February, 09 0

19 TRUVADA ORAL TABLET MG valacyclovir oral tablet gram, 500 QL (30 EA per 30 days) VALGANCICLOVIR ORAL RECON SOLN 50 MG/ML valganciclovir oral tablet 450 vancomycin intravenous recon soln,000, 0 gram, 5 gram, 500, 750 vancomycin oral capsule 5, 50 VEMLIDY ORAL TABLET 5 MG SP VIRACEPT ORAL TABLET 50 MG, 65 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) SP VIREAD ORAL TABLET 50 MG, 00 MG, 50 MG SP voriconazole intravenous solution 00 voriconazole oral suspension for reconstitution 00 /5 ml (40 /ml) PA voriconazole oral tablet 00, 50 PA VOSEVI ORAL TABLET MG PA; SP zidovudine oral capsule 00 zidovudine oral syrup 0 /ml zidovudine oral tablet 300 ANTINEOPLASTIC AGENTS abiraterone oral tablet 50 PA; SP; QL (0 EA per 30 days) AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG, 7.5 MG PA; SP ALECENSA ORAL CAPSULE 50 MG PA; SP; QL (40 EA per 30 days) ALIMTA INTRAVENOUS RECON SOLN 00 MG, 500 MG SP ALIQOPA INTRAVENOUS RECON SOLN 60 MG SP ALUNBRIG ORAL TABLET 80 MG, 90 MG PA; SP ALUNBRIG ORAL TABLET 30 MG PA; QL (80 EA per 30 days) ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG (3) PA; SP anastrozole oral tablet AVASTIN INTRAVENOUS SOLUTION 5 MG/ML SP azacitidine injection recon soln 00 SP BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML Effective: February, 09

20 BELEODAQ INTRAVENOUS RECON SOLN 500 MG BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) SP bicalutamide oral tablet 50 BLINCYTO INTRAVENOUS KIT 35 MCG bortezomib intravenous recon soln 3.5 SP BOSULIF ORAL TABLET 00 MG PA; SP BOSULIF ORAL TABLET 400 MG PA BOSULIF ORAL TABLET 500 MG PA; SP; QL (30 EA per 30 days) BRAFTOVI ORAL CAPSULE 50 MG, 75 MG PA; SP CABOMETYX ORAL TABLET 0 MG, 40 MG, 60 MG PA; SP CALQUENCE ORAL CAPSULE 00 MG PA; SP capecitabine oral tablet 50, 500 SP CAPRELSA ORAL TABLET 00 MG PA; SP; QL (90 EA per 30 days) CAPRELSA ORAL TABLET 300 MG PA; SP; QL (30 EA per 30 days) COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 MG/DAY(80 MG X-0 PA; SP MG X3), 60 MG/DAY (0 MG X 3/DAY) COTELLIC ORAL TABLET 0 MG PA; SP; QL (63 EA per 8 days) CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML SP diclofenac sodium topical gel 3 % PA DOCETAXEL INTRAVENOUS SOLUTION 60 MG/6 ML (0 MG/ML), 60 MG/8 ML (0 MG/ML), 0 MG/ ML (0 MG/ML), 0 MG/ML ( ML), 80 MG/4 ML (0 MG/ML), 80 MG/8 ML (0 MG/ML) docetaxel intravenous solution 0 /ml doxorubicin intravenous recon soln 0, 50 doxorubicin intravenous solution 0 /5 ml, /ml, 0 /0 ml, 50 /5 ml EMCYT ORAL CAPSULE 40 MG ERIVEDGE ORAL CAPSULE 50 MG PA; SP; QL (30 EA per 30 days) ERLEADA ORAL TABLET 60 MG PA exemestane oral tablet 5 FARYDAK ORAL CAPSULE 0 MG PA; SP; QL ( EA per days) FARYDAK ORAL CAPSULE 5 MG, 0 MG PA; SP; QL (6 EA per days) FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML SP Effective: February, 09

21 fluorouracil topical cream 5 % fluorouracil topical solution %, 5 % flutamide oral capsule 5 GILOTRIF ORAL TABLET 0 MG PA; SP; QL (60 EA per 30 days) GILOTRIF ORAL TABLET 30 MG PA; SP; QL (40 EA per 30 days) GILOTRIF ORAL TABLET 40 MG PA; SP; QL (30 EA per 30 days) HALAVEN INTRAVENOUS SOLUTION MG/ ML (0.5 MG/ML) SP HEXALEN ORAL CAPSULE 50 MG HYCAMTIN ORAL CAPSULE 0.5 MG, MG SP hydroxyurea oral capsule 500 IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG PA; SP; QL ( EA per 8 days) IDHIFA ORAL TABLET 00 MG, 50 MG PA; SP imatinib oral tablet 00 PA; SP imatinib oral tablet 400 PA; SP; QL (60 EA per 30 days) IMBRUVICA ORAL CAPSULE 40 MG PA; SP; QL (0 EA per 30 days) IMBRUVICA ORAL CAPSULE 70 MG PA; QL (40 EA per 30 days) IMBRUVICA ORAL TABLET 40 MG PA; SP; QL (0 EA per 30 days) IMBRUVICA ORAL TABLET 80 MG PA; SP; QL (60 EA per 30 days) IMBRUVICA ORAL TABLET 40 MG, 560 MG PA; QL (30 EA per 30 days) IMFINZI INTRAVENOUS SOLUTION 50 MG/ML SP INLYTA ORAL TABLET MG, 5 MG PA; SP INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), SP 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML SP IRESSA ORAL TABLET 50 MG PA; SP; QL (30 EA per 30 days) irinotecan intravenous solution 00 /5 ml, 40 / ml, 500 /5 ml JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG PA; SP KADCYLA INTRAVENOUS RECON SOLN 00 MG, 60 MG PA; SP KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG, 400 MG/DAY(00 MG X )-.5 MG, 600 MG/DAY(00 MG X 3)-.5 MG PA; SP KISQALI ORAL TABLET 00 MG/DAY (00 MG X ), 400 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X 3) PA; SP Effective: February, 09 3

22 LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), MG/DAY (4 MG X 3), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X), 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 4 MG, 8 MG/DAY (4 MG X ) PA letrozole oral tablet.5 LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit /0. ml SP LONSURF ORAL TABLET MG, MG PA; SP LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG, PA; SP.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG PA; SP LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG PA; SP LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG PA; SP LUPRON DEPOT-PED INTRAMUSCULAR KIT.5 MG, 5 MG, 7.5 MG (PED) PA; SP LYNPARZA ORAL CAPSULE 50 MG PA; SP LYNPARZA ORAL TABLET 00 MG, 50 MG PA; SP LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG SP megestrol oral suspension 400 /0 ml (0 ml), 400 /0 ml (40 /ml) PA megestrol oral tablet 0, 40 PA MEKINIST ORAL TABLET 0.5 MG PA; SP; QL (0 EA per 30 days) MEKINIST ORAL TABLET MG PA; SP; QL (30 EA per 30 days) MEKTOVI ORAL TABLET 5 MG PA; SP melphalan oral tablet mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln gram methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 MYLERAN ORAL TABLET MG NERLYNX ORAL TABLET 40 MG PA; SP NEXAVAR ORAL TABLET 00 MG PA; SP; QL (0 EA per 30 days) nilutamide oral tablet 50 NINLARO ORAL CAPSULE.3 MG PA; SP; QL (6 EA per 8 days) Effective: February, 09 4

23 NINLARO ORAL CAPSULE 3 MG PA; SP; QL (4 EA per 8 days) NINLARO ORAL CAPSULE 4 MG PA; SP; QL (3 EA per 8 days) PANRETIN TOPICAL GEL 0. % PICATO TOPICAL GEL 0.05 %, 0.05 % POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG SP POTELIGEO INTRAVENOUS SOLUTION 4 MG/ML PA; SP PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT SP REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG PA; SP RITUXAN HYCELA SUBCUTANEOUS SOLUTION 400 MG/.7 ML (0 MG/ML), PA 600 MG/3.4 ML (0 MG/ML) RUBRACA ORAL TABLET 00 MG, 50 MG, 300 MG PA; SP RYDAPT ORAL CAPSULE 5 MG PA; SP SIKLOS ORAL TABLET,000 MG, 00 MG SPRYCEL ORAL TABLET 00 MG, 0 MG, 50 MG, 80 MG PA; SP SPRYCEL ORAL TABLET 40 MG PA; SP; QL (30 EA per 30 days) SPRYCEL ORAL TABLET 70 MG PA; SP; QL (60 EA per 30 days) STIVARGA ORAL TABLET 40 MG PA; SP SUTENT ORAL CAPSULE.5 MG, 5 MG, 37.5 MG, 50 MG PA; SP SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SP SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG SP TAFINLAR ORAL CAPSULE 50 MG PA; SP; QL (80 EA per 30 days) TAFINLAR ORAL CAPSULE 75 MG PA; SP; QL (0 EA per 30 days) TAGRISSO ORAL TABLET 40 MG PA; SP; QL (60 EA per 30 days) TAGRISSO ORAL TABLET 80 MG PA; SP; QL (30 EA per 30 days) tamoxifen oral tablet 0, 0 TARCEVA ORAL TABLET 00 MG, 5 MG PA; SP TARCEVA ORAL TABLET 50 MG PA; SP; QL (30 EA per 30 days) TARGRETIN TOPICAL GEL % TASIGNA ORAL CAPSULE 50 MG, 00 MG, 50 MG PA; SP TECENTRIQ INTRAVENOUS SOLUTION,00 MG/0 ML (60 MG/ML) SP Effective: February, 09 5

24 temozolomide oral capsule 00, 40, 80, 0, 50, 5 SP TIBSOVO ORAL TABLET 50 MG PA; SP topotecan intravenous recon soln 4 TOPOTECAN INTRAVENOUS SOLUTION 4 MG/4 ML ( MG/ML) TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 MG,.5 MG, 3.75 MG TRELSTAR INTRAMUSCULAR SYRINGE.5 MG/ ML,.5 MG/ ML SP TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/ ML tretinoin (chemotherapy) oral capsule 0 TYKERB ORAL TABLET 50 MG PA; SP; QL (80 EA per 30 days) UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VECTIBIX INTRAVENOUS SOLUTION 00 MG/5 ML (0 MG/ML), 400 MG/0 ML (0 SP MG/ML) VELCADE INJECTION RECON SOLN 3.5 MG SP VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG PA; SP VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG PA; SP; QL (4 EA per 80 days) VERZENIO ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG PA; SP VOTRIENT ORAL TABLET 00 MG PA; SP; QL (0 EA per 30 days) XALKORI ORAL CAPSULE 00 MG, 50 MG PA; SP XTANDI ORAL CAPSULE 40 MG PA; SP; QL (0 EA per 30 days) YONDELIS INTRAVENOUS RECON SOLN MG PA ZALTRAP INTRAVENOUS SOLUTION 00 MG/4 ML (5 MG/ML), 00 MG/8 ML (5 MG/ML) SP ZEJULA ORAL CAPSULE 00 MG PA; QL (90 EA per 30 days) ZELBORAF ORAL TABLET 40 MG PA; SP; QL (40 EA per 30 days) ZOLINZA ORAL CAPSULE 00 MG SP ZYDELIG ORAL TABLET 00 MG, 50 MG PA ZYKADIA ORAL CAPSULE 50 MG PA; SP; QL (50 EA per 30 days) ZYTIGA ORAL TABLET 500 MG PA; SP Effective: February, 09 6

25 ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES ACTHIB (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE LF-( MCG)-5LF/0.5 ML AFLURIA (PF) INTRAMUSCULAR SYRINGE 45 MCG (5 MCG X 3)/0.5 ML 3 AFLURIA INTRAMUSCULAR SUSPENSION 45 MCG (5 MCG X 3)/0.5 ML 3 AFLURIA QUAD (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG 3 X 4)/0.5 ML AFLURIA QUAD INTRAMUSCULAR SUSPENSION 60 MCG (5 MCG X 4)/0.5 ML 3 BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG 3 SP; PV BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML 3 BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN GRAM, 6 PA; SP GRAM DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF- MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML EZ FLU 08-9(FLUCELVAX)(PF) INTRAMUSCULAR SYRINGE KIT 60 MCG (5 3 MCG X 4)/0.5 ML FLUAD (65 YR UP)(PF) INTRAMUSCULAR SYRINGE 45 MCG (5 MCG X 3)/0.5 ML 3 Effective: February, 09 7

26 FLUARIX QUAD (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG 3 X 4)/0.5 ML FLUBLOK QUAD (PF) INTRAMUSCULAR SYRINGE 80 MCG (45 3 MCG X 4)/0.5 ML FLUCELVAX QUAD (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG 3 X 4)/0.5 ML FLUCELVAX QUAD INTRAMUSCULAR SUSPENSION 60 MCG (5 3 MCG X 4)/0.5 ML FLULAVAL QUAD (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG 3 X 4)/0.5 ML FLULAVAL QUAD INTRAMUSCULAR SUSPENSION 60 MCG (5 3 MCG X 4)/0.5 ML FLUMIST QUAD NASAL NASAL SPRAY SYRINGE 0EXP FF UNIT/0. 3 ML FLUZONE HIGH-DOSE 08-9 (PF) INTRAMUSCULAR SYRINGE 80 MCG/0.5 ML 3 FLUZONE QUAD (PF) INTRAMUSCULAR SUSPENSION 60 MCG (5 3 MCG X 4)/0.5 ML FLUZONE QUAD (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG 3 X 4)/0.5 ML FLUZONE QUAD INTRAMUSCULAR SUSPENSION 60 MCG (5 MCG X 4)/0.5 ML 3 FLUZONE QUAD PEDI 08-9 (PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 3 MCG X 4)/0.5 ML GAMASTAN S/D INTRAMUSCULAR SOLUTION 5-8 % RANGE SP GAMMAGARD LIQUID INJECTION SOLUTION 0 % PA; SP HAVRIX (PF) INTRAMUSCULAR SUSPENSION,440 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE,440 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML HEPLISAV-B (PF) INTRAMUSCULAR SOLUTION 0 MCG/0.5 ML 3 HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML 3 Effective: February, 09 8

27 HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML HYQVIA SUBCUTANEOUS SOLUTION 0 GRAM /00 ML (0 %),.5 GRAM /5 ML (0 %), 0 GRAM /00 ML (0 %), 30 GRAM /300 ML (0 %), 5 GRAM /50 ML (0 %) PA; SP IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 5 LF-58 MCG-0 LF/0.5 ML PV MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENVEO A-C-Y-W-35-DIP (PF) INTRAMUSCULAR KIT 0-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN,000-,500 TCID50/0.5 ML ODACTRA SUBLINGUAL TABLET SQ-HDM PA PEDIARIX (PF) INTRAMUSCULAR SYRINGE 0 MCG-5LF-5 MCG-0LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 5 LF UNIT-0 MCG-5 LF/0.5 ML PNEUMOVAX 3 INJECTION SOLUTION 5 MCG/0.5 ML PNEUMOVAX 3 INJECTION SYRINGE 5 MCG/0.5 ML PREVNAR 3 (PF) INTRAMUSCULAR SYRINGE 0.5 ML PRIVIGEN INTRAVENOUS SOLUTION 0 % PA; SP PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML 3 RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 UNIT Effective: February, 09 9

28 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 0EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION ML SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 3 MCG/0.5 ML SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR 3 RECONSTITUTION 50 MCG STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,000 3 UNIT/0.5 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5- LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-5 LF UNIT/0.5 ML tetanus-diphtheria toxoids-td intramuscular suspension - lf unit/0.5 ml TRUMENBA INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 70 ELISA UNIT- 0 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 5 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 5 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 5 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,350 UNIT/0.5 ML VAXCHORA ACTIVE COMPONENT ORAL SUSPENSION FOR RECONSTITUTION 3 4X0EXP8 TO X 0EXP9 CF UNIT VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X0EXP8 TO X 3 0EXP9 CF UNIT VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC) BILLION UNIT 3 Effective: February, 09 0

29 YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 9,400 UNIT/0.65 ML AUTONOMIC DRUGS acebutolol oral capsule 00, 400 albuterol sulfate inhalation solution for nebulization 0.63 /3 ml,.5 /3 ml,.5 /3 ml (0.083 %), 5 /ml albuterol sulfate oral syrup /5 ml albuterol sulfate oral tablet, 4 albuterol sulfate oral tablet extended release hr 4, 8 alfuzosin oral tablet extended release 4 hr 0 ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION atenolol oral tablet 00, 5, 50 atenolol-chlorthalidone oral tablet 00-5, 50-5 atropine injection solution 0.4 /ml, /ml atropine injection syringe 0.05 /ml, 0. /ml ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION QL (6 GM per 30 days) baclofen oral tablet 0, 0 benztropine injection solution / ml benztropine oral tablet 0.5,, betaxolol oral tablet 0, 0 bethanechol chloride oral tablet 0, 5, 5, 50 bisoprolol fumarate oral tablet 0, 5 bisoprolol-hydrochlorothiazide oral tablet 0-6.5,.5-6.5, BROVANA INHALATION SOLUTION FOR NEBULIZATION 5 MCG/ ML carvedilol oral tablet.5, 5, 3.5, 6.5 cevimeline oral capsule 30 CHANTIX ORAL TABLET 0.5 MG chlorzoxazone oral tablet 50, 500 clonidine hcl oral tablet 0., 0., 0.3 Effective: February, 09

30 clonidine transdermal patch weekly 0. /4 hr, 0. /4 hr, 0.3 /4 hr QL (4 EA per 30 days) CLORPRES ORAL TABLET 0.-5 MG, 0.-5 MG COMBIVENT RESPIMAT INHALATION MIST 0-00 MCG/ACTUATION QL (8 GM per 30 days) cyclobenzaprine oral tablet 0, 5, 7.5 dantrolene oral capsule 00, 5, 50 dicyclomine oral capsule 0 dicyclomine oral solution 0 /5 ml dicyclomine oral tablet 0 dihydroergotamine injection solution /ml diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet donepezil oral tablet 0, 5 donepezil oral tablet,disintegrating 0, 5 doxazosin oral tablet,, 4 QL (30 EA per 30 days) doxazosin oral tablet 8 QL (60 EA per 30 days) DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION, 00-5 QL (3 GM per 30 days) MCG/ACTUATION DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT, 500 UNIT PA; SP EPINEPHRINE INJECTION AUTO-INJECTOR 0.5 MG/0.5 ML, 0.5 MG/0.3 ML, 0.3 MG/0.3 QL ( EA per 30 days) ML epinephrine injection solution /ml, /ml ( ml) epinephrine injection syringe 0. /ml EPIPEN -PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML QL ( EA per 30 days) EPIPEN INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML QL ( EA per 30 days) EPIPEN JR -PAK INJECTION AUTO- INJECTOR 0.5 MG/0.3 ML QL ( EA per 30 days) EPIPEN JR INJECTION AUTO-INJECTOR 0.5 MG/0.3 ML ergoloid oral tablet fluticasone-salmeterol inhalation aerosol powdr breath activated 3-4 mcg/actuation, 3-4 mcg/actuation, 55-4 mcg/actuation galantamine oral capsule,ext rel. pellets 4 hr 6, 4, 8 Effective: February, 09

31 galantamine oral solution 4 /ml galantamine oral tablet, 4, 8 glycopyrrolate oral tablet, guanidine oral tablet 5 ipratropium bromide inhalation solution 0.0 % ipratropium-albuterol inhalation solution for nebulization (.5 base)/3 ml labetalol intravenous solution 5 /ml labetalol oral tablet 00, 00, 300 metaproterenol oral syrup 0 /5 ml metaproterenol oral tablet 0, 0 methocarbamol oral tablet 500, 750 methscopolamine oral tablet.5, 5 methyldopa oral tablet 50, 500 methyldopa-hydrochlorothiazide oral tablet 50-5, 50-5 methyldopate intravenous solution 50 /5 ml metoprolol succinate oral tablet extended release 4 hr 00, 00, 5, 50 metoprolol ta-hydrochlorothiaz oral tablet 00-5, 00-50, 50-5 metoprolol tartrate intravenous solution 5 /5 ml metoprolol tartrate oral tablet 00, 5, 50 midodrine oral tablet 0,.5, 5 NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON-AEROSOL 0 MG/ML orphenadrine citrate injection solution 30 /ml pilocarpine hcl oral tablet 5, 7.5 pindolol oral tablet 0, 5 prazosin oral capsule,, 5 propranolol intravenous solution /ml propranolol oral capsule,extended release 4 hr 0, 60, 60, 80 propranolol oral solution 0 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 0, 0, 40, 60, 80 propranolol-hydrochlorothiazid oral tablet 40-5, 80-5 pyridostigmine bromide oral tablet 60 Effective: February, 09 3

32 REGONOL INJECTION SOLUTION 5 MG/ML rivastigmine tartrate oral capsule.5, 3, 4.5, 6 rivastigmine transdermal patch 4 hour 3.3 /4 hour, 4.6 /4 hr, 9.5 /4 hr sotalol oral tablet 0, 60, 40, 80 SPIRIVA RESPIMAT INHALATION MIST.5 MCG/ACTUATION,.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MCG QL (30 EA per 30 days) SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, QL ( GM per 30 days) MCG/ACTUATION tamsulosin oral capsule 0.4 terazosin oral capsule,, 5 QL (30 EA per 30 days) terazosin oral capsule 0 QL (60 EA per 30 days) terbutaline oral tablet.5, 5 terbutaline subcutaneous solution /ml timolol maleate oral tablet 0, 0, 5 tizanidine oral capsule, 4, 6 tizanidine oral tablet, 4 TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE MCG trihexyphenidyl oral elixir 0.4 /ml trihexyphenidyl oral tablet, 5 VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION QL (7 GM per 30 days) XEOMIN INTRAMUSCULAR RECON SOLN 00 UNIT, 00 UNIT, 50 UNIT PA; SP BLOOD FORMATION, COAGULATION, THROMBOSIS anagrelide oral capsule 0.5, ARANESP (IN POLYSORBATE) INJECTION SOLUTION 00 MCG/ML, 50 MCG/0.75 ML, 00 MCG/ML, 5 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML PA; SP ARANESP (IN POLYSORBATE) INJECTION SYRINGE 0 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 00 MCG/0.5 ML, 50 MCG/0.3 ML, 00 MCG/0.4 ML, 5 MCG/0.4 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML Effective: February, 09 4 SP PA; SP

33 argatroban in 0.9 % sod chlor intravenous parenteral solution 50 /50 ml ( /ml) argatroban in 0.9 % sod chlor intravenous solution /ml argatroban in nacl (iso-os) intravenous solution 50 /50 ml ( /ml) argatroban intravenous solution 00 /ml aspirin oral tablet 35 aspirin oral tablet,delayed release (dr/ec) 35 aspirin-dipyridamole oral capsule, er multiphase hr 5-00 BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00, 50 clopidogrel oral tablet 300, 75 desmopressin injection solution 4 mcg/ml desmopressin nasal spray,non-aerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0., 0. dipyridamole oral tablet 5, 50, 75 enoxaparin subcutaneous solution 300 /3 ml SP enoxaparin subcutaneous syringe 00 /ml, 0 /0.8 ml, 50 /ml, 30 /0.3 ml, 40 SP /0.4 ml, 60 /0.6 ml, 80 /0.8 ml enteric coated aspirin oral tablet,delayed release (dr/ec) 8 EPOGEN INJECTION SOLUTION 0,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PA; SP fondaparinux subcutaneous syringe 0 /0.8 ml,.5 /0.5 ml, 5 /0.4 ml, 7.5 /0.6 ml FRAGMIN SUBCUTANEOUS SOLUTION 5,000 ANTI-XA UNIT/ML FRAGMIN SUBCUTANEOUS SYRINGE 0,000 ANTI-XA UNIT/ML,,500 ANTI-XA UNIT/0.5 ML, 5,000 ANTI-XA UNIT/0.6 ML, 8,000 ANTI- XA UNIT/0.7 ML,,500 ANTI-XA UNIT/0. ML, 5,000 ANTI-XA UNIT/0. ML, 7,500 ANTI-XA UNIT/0.3 ML FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML, 480 MCG/.6 ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML SP SP SP PA; SP Effective: February, 09 5

34 HEMLIBRA SUBCUTANEOUS SOLUTION 05 MG/0.7 ML, 50 MG/ML, 30 MG/ML, 60 MG/0.4 PA; SP ML heparin (porcine) in 5 % dex intravenous parenteral solution 0,000 unit/500 ml (40 unit/ml), 5,000 unit/50 ml(00 unit/ml), 5,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/,000 ml heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 0,000 unit/ml heparin, porcine (pf) injection solution,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml IXINITY INTRAVENOUS RECON SOLN,000 UNIT,,500 UNIT,,000 UNIT, 50 UNIT, 3,000 SP UNIT, 500 UNIT JANTOVEN ORAL TABLET MG, 0 MG, MG,.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG LEUKINE INJECTION RECON SOLN 50 MCG SP MOZOBIL SUBCUTANEOUS SOLUTION 4 MG/. ML (0 MG/ML) SP multi-vit with fluoride-iron oral drops 0.5 fluoride -0 iron/ml NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML PA; SP; QL ( ML per 30 days) NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML PA; SP; QL ( ML per 30 days) NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6 ML PA; SP NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PA; SP NOVOEIGHT INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,500 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT OBIZUR INTRAVENOUS RECON SOLN 500 (+/- ) UNIT RANGE pentoxifylline oral tablet extended release 400 PRENATAL VITAMIN WITH MINERALS ORAL TABLET 8 MG IRON- 800 MCG Effective: February, 09 6

35 PROCRIT INJECTION SOLUTION 0,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML PA; SP PROMACTA ORAL POWDER IN PACKET.5 MG PA; SP PROMACTA ORAL TABLET.5 MG, 5 MG, 50 MG, 75 MG PA; SP REBINYN INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,000 (+/-) UNIT, 500 (+/-) UNIT SP tranexamic acid intravenous solution,000 /0 ml (00 /ml) tranexamic acid oral tablet 650 TRI-VIT WITH FLUORIDE AND IRON ORAL DROPS MG/ML PV warfarin oral tablet, 0,,.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 0 MG, 5 MG,.5 MG, 0 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (4)- 0 MG (9) ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PA; SP CARDIOVASCULAR DRUGS acebutolol oral capsule 00, 400 acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 5, 50 acetazolamide sodium injection recon soln 500 amiloride oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 amiodarone intravenous solution 50 /ml amiodarone oral tablet 00, 400 amlodipine oral tablet 0,.5, 5 amlodipine-benazepril oral capsule 0-0, 0-40,.5-0, 5-0, 5-0, 5-40 aspirin-dipyridamole oral capsule, er multiphase hr 5-00 atenolol oral tablet 00, 5, 50 atenolol-chlorthalidone oral tablet 00-5, 50-5 atorvastatin oral tablet 0, 0 ; QL (60 EA per 30 days) atorvastatin oral tablet 40, 80 QL (60 EA per 30 days) Effective: February, 09 7

36 benazepril oral tablet 0, 0, 40, 5 benazepril-hydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5, betaxolol oral tablet 0, 0 bisoprolol fumarate oral tablet 0, 5 bisoprolol-hydrochlorothiazide oral tablet 0-6.5,.5-6.5, bumetanide injection solution 0.5 /ml bumetanide oral tablet 0.5,, captopril oral tablet 00,.5, 5, 50 captopril-hydrochlorothiazide oral tablet 5-5, 5-5, 50-5, 50-5 carvedilol oral tablet.5, 5, 3.5, 6.5 chlorothiazide oral tablet 50, 500 chlorothiazide sodium intravenous recon soln 500 chlorthalidone oral tablet 5, 50 CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM cilostazol oral tablet 00, 50 clonidine hcl oral tablet 0., 0., 0.3 clonidine transdermal patch weekly 0. /4 hr, 0. /4 hr, 0.3 /4 hr QL (4 EA per 30 days) CLORPRES ORAL TABLET 0.-5 MG, 0.-5 MG colestipol oral packet 5 gram colestipol oral tablet gram CORLANOR ORAL TABLET 5 MG, 7.5 MG PA digoxin injection solution 50 mcg/ml digoxin injection syringe 50 mcg/ml digoxin oral solution 50 mcg/ml digoxin oral tablet 5 mcg, 50 mcg DILANTIN ORAL CAPSULE 30 MG diltiazem hcl intravenous recon soln 00 diltiazem hcl intravenous solution 5 /ml diltiazem hcl oral capsule,ext.rel 4h degradable 0, 80, 40 Effective: February, 09 8

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