2019 FORMULARY. (List of Covered Drugs) Prominence Health Plan (HMO)

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1 Prominence Health Plan (HMO) 019 FORMULARY (List of Covered Drugs) Please read: This document contains information about the drugs we cover in this plan. HPMS Approved Formulary File Submission ID: 1915, Version Number 08 This formulary was updated on 01/01/019. For more recent information or other questions, please contact Prominence Health Plan Customer Service, at or, for TTY users, 711, 8 am to 8 pm, 7 days a week from October 1 March 1 and 8 am to 8 pm, Monday Friday from April 1 September 0 or visit ProminenceMedicare.com. Y0109_PHPCForm19_C

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Prominence Health Plan. When it refers to plan or our plan, it means Prominence Plus (HMO). This document includes list of the drugs (formulary) for our plan which is current as of 01/01/019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1 of each calendar year and from time to time during the year. What is the Prominence Health Plan Formulary? A formulary is a list of covered drugs selected by Prominence Health Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Prominence Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Prominence Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower costsharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Prominence Health Plan Formulary?

3 Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 0 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 0-day supply of the drug. The enclosed formulary is current as of 01/01/019. To get updated information about the drugs covered by Prominence Health Plan, please contact us. Our contact information appears on the front and back cover pages. If there is a mid-year, non-maintenance change to the formulary we will update printed formularies with an errata sheet. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page three (). The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page three. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Prominence Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

4 Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Prominence Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Prominence Health Plan before you fill your prescriptions. If you don t get approval, Prominence Health Plan may not cover the drug. Quantity Limits: For certain drugs, Prominence Health Plan limits the amount of the drug that Prominence Health Plan will cover. For example, Prominence Health Plan provides 60 tablets per prescription for Entresto oral tablets. This may be in addition to a standard onemonth or three-month supply. Step Therapy: In some cases, Prominence Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Prominence Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Prominence Health Plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page three (). You can also get more information about the restrictions applied to specific covered drugs by visiting our web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Prominence Health Plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Prominence Health Plan s formulary? on the next page for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Prominence Health Plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Prominence Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Prominence Health Plan. You can ask Prominence Health Plan to make an exception and cover your drug. See below for information about how to request an exception.

5 How do I request an exception to the Prominence Health Plan Formulary? You can ask Prominence Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Prominence Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Prominence Health Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 0-day supply of medication. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our

6 plan, we will cover a 90-day emergency supply of that drug while you pursue a formulary exception. Members who have a change in level of care (setting) will be allowed up to a one-time 1-day transition supply per drug. For example, members who: Enter long-term care (LTC) facilities from hospitals are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short term planning taken into account (often under 8 hours). Are discharged from a hospital to a home. End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary. End a long-term care facility stay and return to the community. If a member has more than one change in level of care in a month, the pharmacy will have to call us to request an extension of the transition policy. For more information For more detailed information about your Prominence Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Prominence Health Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day/7 days a week. TTY users should call Or, visit Prominence Health Plan s Formulary If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin ). The information in the Requirements/Limits column tells you if Prominence Health Plan has any special requirements for coverage of your drug. You can find information on what the symbols and abbreviations on this table mean by going to the next page.

7 List of Abbreviations: PA BvD: Prior Authorization Restriction for Part B vs Part D Determination. This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. QL: Quantity Limit: For certain drugs, Prominence Health Plan limits the amount of the drug that we will cover. For example, Prominence Health Plan provides twelve tablets per prescription for Sumatriptan Succinate. This may be in addition to a standard one month or three month supply. ST: Step Therapy: In some cases, Prominence Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. PA: Prior Authorization: Prominence Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don't get approval, we may not cover the drug. PA- HRM: Prior Authorization Restriction for High Risk Medications. This drug has been deemed to be potentially harmful and therefore, a High Risk Medication for individuals 65 years or older. Members age 65 years or older are required to get prior authorization from our plan before you fill your prescription for this drug. PA NSO: Prior Authorization Restriction for New Starts Only. If there is no evidence that you have taken this drug before, you (or your physician) are required to get prior authorization from our plan before you fill your prescription for this drug. Without prior approval, our plan may not cover this drug. NDS: Non-Extended Days Supply: Drugs not available for an extended days supply (i.e. more than a one-month supply) are noted with NDS in the Requirements/Limits column of your formulary. GC: Gap Coverage: We provide coverage of this prescription drug in the coverage gap, if your plan provides gap coverage. Please refer to our Evidence of Coverage for more information about this coverage. LA: Limited Availability: This prescription may be available only at certain pharmacies. For more information, consult your Provider and Pharmacy Directory or call Member Services at , 8 am to 8 pm, 7 days a week from October 1- March 1 and 8am to 8pm, Monday - Friday from April 1 - September 0. TTY/TDD users should call 711.

8 EX;CB: Excluded Part D Capped Benefit: Drugs covered by the plan that are excluded by Medicare law that are covered by your plan as a supplemental or bonus drug but do not count toward TrOOP.

9 Table of Contents Analgesics... Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents...8 Antianxiety Agents...9 Antibacterials Anticancer Agents Anticholinergic Agents... 8 Anticonvulsants...8 Antidementia Agents...1 Antidepressants... Antidiabetic Agents... Antifungals...8 Antigout Agents... 0 Antihistamines...0 Anti-Infectives (Skin And Mucous Membrane)...1 Antimigraine Agents...1 Antimycobacterials...1 Antinausea Agents... Antiparasite Agents... Antiparkinsonian Agents... Antipsychotic Agents...6 Antivirals (Systemic)...51 Blood Products/Modifiers/Volume Expanders Caloric Agents...60 Cardiovascular Agents... 6 Central Nervous System Agents... 7 Contraceptives...76 Dental And Oral Agents...8 Dermatological Agents...8 Devices Enzyme Replacement/Modifiers...87 Eye, Ear, Nose, Throat Agents...88 Gastrointestinal Agents... 9 Genitourinary Agents...95 Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying

10 Immunological Agents...10 Inflammatory Bowel Disease Agents Irrigating Solutions...11 Metabolic Bone Disease Agents...11 Miscellaneous Therapeutic Agents...11 Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants... 1 Sleep Disorder Agents... 1 Vasodilating Agents...15 Vitamins And Minerals...17

11 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet 00-0 acetaminophen-codeine oral tablet buprenorphine hcl injection solution 0. /ml buprenorphine hcl injection syringe 0. /ml butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet QL (700 per 0 QL (60 per 0 (Tylenol-Codeine #) QL (60 per 0 (Tylenol-Codeine #) QL (180 per 0 (Buprenex) (Esgic) PA-HRM; QL (180 per 0 ; AGE (Max 6 Years) (Fiorinal) PA-HRM; QL (180 per 0 ; AGE (Max 6 Years) PA-HRM; QL (180 per 0 ; AGE (Max 6 Years) QL (180 per 0 codeine sulfate oral tablet 15, 0, 60 endocet oral tablet 10-5 QL (180 per 0 endocet oral tablet.5-5, 5-5 QL (60 per 0 endocet oral tablet QL (0 per 0 fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution /15 ml hydrocodone-acetaminophen oral tablet 10-5 hydrocodone-acetaminophen oral tablet.5-5 (Actiq) ; QL (10 per 0 (Duragesic) QL (10 per 0 (Hycet) QL (700 per 0 (Lorcet HD) QL (180 per 0 (Verdrocet) QL (0 per 0

12 hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) QL (0 per hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (180 per hydrocodone-ibuprofen oral tablet 7.5- QL (150 per 0 00 hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 per 0 hydromorphone oral tablet,, 8 (Dilaudid) QL (180 per 0 HYSINGLA ER ORAL QL (0 per 0 TABLET,ORAL ONLY,EXT.REL. HR 100 MG, 10 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 00 ; QL (0 per 0 MCG/SPRAY, 00 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-5 QL (0 per 0 lorcet hd oral tablet 10-5 QL (180 per 0 lorcet plus oral tablet QL (180 per 0 methadone injection solution 10 /ml methadone oral solution 10 /5 ml QL (600 per 0 methadone oral solution 5 /5 ml QL (100 per 0 methadone oral tablet 10 (Dolophine) QL (10 per 0 methadone oral tablet 5 (Dolophine) QL (180 per 0 methadose oral tablet,soluble 0 QL (0 per 0 morphine 10 /ml isecure syrg l/f, p/f, suv, inner 10 /ml morphine concentrate oral solution 100 QL (180 per 0 /5 ml (0 /ml) morphine injection syringe 10 /ml morphine intravenous solution 10 /ml morphine oral solution 10 /5 ml QL (700 per 0 morphine oral solution 0 /5 ml ( QL (00 per 0 /ml) MORPHINE ORAL TABLET 15 MG QL (180 per 0 MORPHINE ORAL TABLET 0 MG QL (10 per 0

13 morphine oral tablet extended release 100 (MS Contin) QL (60 per 0, 00, 60 morphine oral tablet extended release 15 (MS Contin) QL (90 per 0, 0 NUCYNTA ER ORAL TABLET QL (60 per 0 EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, QL (181 per 0 50 MG, 75 MG oxycodone oral solution 5 /5 ml QL (100 per 0 oxycodone oral tablet 10 QL (180 per 0 oxycodone oral tablet 15, 0 (Roxicodone) QL (10 per 0 oxycodone oral tablet 0 QL (10 per 0 oxycodone oral tablet 5 (Roxicodone) QL (180 per 0 oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 per 0 hr 10, 15, 0, 0, 0, 60, 80 oxycodone-acetaminophen oral solution QL (1800 per /5 ml oxycodone-acetaminophen oral tablet 10- (Endocet) QL (180 per 0 5 oxycodone-acetaminophen oral tablet (Endocet) QL (60 per 0.5-5, 5-5 oxycodone-acetaminophen oral tablet (Endocet) QL (0 per oxycodone-aspirin oral tablet QL (60 per 0 OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 00 MG/1.5 ML tramadol oral tablet 50 (Ultram) 1 QL (0 per 0 tramadol-acetaminophen oral tablet (Ultracet) QL (0 per 0 5

14 XTAMPZA ER ORAL QL (60 per 0 CAPSULE,SPRINKLE,ER 1HR TMPRR 1.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (10 per 0 CAPSULE,SPRINKLE,ER 1HR TMPRR 7 MG XTAMPZA ER ORAL QL (0 per 0 CAPSULE,SPRINKLE,ER 1HR TMPRR 6 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8 ML (100 MG/ML) celecoxib oral capsule 100, 00, (Celebrex) QL (60 per 0 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops 1.5 % QL (00 per 0 diclofenac sodium topical gel 1 % (Voltaren) diclofenac sodium topical gel % (Solaraze) PA; QL (100 per 8 etodolac oral capsule 00, 00 etodolac oral tablet 00 (Lodine) etodolac oral tablet 500 FLECTOR TRANSDERMAL PA PATCH 1 HOUR 1. % flurbiprofen oral tablet 100, 50 ibu oral tablet 00, 600, ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 00, 600, (IBU) indomethacin oral capsule 5 1 PA-HRM; QL (0 per 0 ; AGE (Max 6 Years) indomethacin oral capsule 50 1 PA-HRM; QL (10 per 0 ; AGE (Max 6 Years) 6

15 indomethacin sodium intravenous recon soln 1 ketorolac oral tablet 10 PA-HRM; QL (0 per 0 ; AGE (Max 6 Years) mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) 1 nabumetone oral tablet 500, 750 naproxen oral tablet 50, 75 1 naproxen oral tablet 500 (Naprosyn) 1 naproxen oral tablet,delayed release (dr/ec) 75, 500 (EC-Naprosyn) PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 0 ; QL ( per 8 MG/GRAM /ACTUATION( %) sulindac oral tablet 150, 00 VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in QL (0 per 0 applicator % lidocaine (pf) injection solution 10 /ml (Xylocaine-MPF) (1 %), 15 /ml (1.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 0 /ml ( %) lidocaine hcl injection solution 10 /ml (1 %), 0 /ml ( %), 5 /ml (0.5 %) (Xylocaine) lidocaine hcl mucous membrane jelly % QL (0 per 0 lidocaine hcl mucous membrane solution % (0 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 0 lidocaine topical ointment 5 % PA; QL (90 per 0 lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % PA; QL (0 per 0 7

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

17 Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 (Xanax) 1 QL (10 per 0 alprazolam oral tablet (Xanax) 1 QL (150 per 0 buspirone oral tablet 10, 15, 0, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 1 QL (10 per 0 5, 5 clobazam oral suspension.5 /ml (Onfi) PA NSO; QL (80 per 0 clobazam oral tablet 10, 0 (Onfi) PA NSO; QL (60 per 0 clonazepam oral tablet 0.5, 1 (Klonopin) 1 QL (90 per 0 clonazepam oral tablet (Klonopin) 1 QL (00 per 0 clonazepam oral tablet,disintegrating QL (90 per , 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 per 0 clorazepate dipotassium oral tablet 15 QL (180 per 0,.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (180 per 0 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG diazepam injection solution 5 /ml QL (10 per 8 diazepam injection syringe 5 /ml QL (10 per 8 diazepam intensol oral concentrate 5 QL (100 per 0 /ml diazepam oral solution 5 /5 ml (1 QL (100 per 0 /ml) diazepam oral tablet 10,, 5 (Valium) 1 QL (10 per 0 diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml (Ativan) 1 QL ( per 0 lorazepam injection solution /ml (Ativan) QL ( per 0 lorazepam injection syringe /ml, /ml QL ( per 0 9

18 lorazepam oral tablet 0.5, 1 (Ativan) 1 QL (90 per 0 lorazepam oral tablet (Ativan) 1 QL (150 per 0 ONFI ORAL SUSPENSION.5 MG/ML 5 PA NSO; NDS; QL (80 per 0 ONFI ORAL TABLET 10 MG, 0 MG 5 PA NSO; NDS; QL (60 per 0 temazepam oral capsule 15, 0 (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 ; AGE (Max 6 Years) Antibacterials Aminoglycosides BETHKIS INHALATION 5 PA BvD; NDS SOLUTION FOR NEBULIZATION 00 MG/ ML gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 10 /100 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 0 / ml, 0 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml, 60 /6 ml, 80 /8 ml neomycin oral tablet streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION ; QL ( per 8 DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 00 /5 ml (Tobi) 5 PA BvD; NDS 10

19 tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 0 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln (BACiiM) 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150, 00 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 150 /ml clindamycin phosphate intravenous (Cleocin) solution 600 / ml colistin (colistimethate na) injection (Coly-Mycin M 5 PA BvD; NDS recon soln 150 Parenteral) daptomycin intravenous recon soln 50 daptomycin intravenous recon soln 500 (Cubicin) FIRVANQ ORAL RECON SOLN 5 MG/ML, 50 MG/ML linezolid 600 /00 ml-0.9% nacl 600 /00 ml linezolid in dextrose 5% intravenous (Zyvox) piggyback 600 /00 ml linezolid oral suspension for (Zyvox) reconstitution 100 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) intravenous piggyback 500 /100 ml (Metro I.V.) metronidazole oral tablet 50, 500 (Flagyl) 11

20 nitrofurantoin macrocrystal oral capsule 100, 50 nitrofurantoin macrocrystal oral capsule 5 nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 0 ; AGE (Max 6 Years) (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 0 ; AGE (Max 6 Years) (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 0 ; AGE (Max 6 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet vancomycin intravenous recon soln 1,000 PA BvD, 10 gram, 50, 5 gram, 500, 750 vancomycin oral capsule 15 (Vancocin) vancomycin oral capsule 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG ; QL (9 per 0 XIFAXAN ORAL TABLET 550 MG Cephalosporins cefaclor oral capsule 50, 500 1

21 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 00 (Spectracef) cefepime injection recon soln 1 gram, (Maxipime) gram cefotaxime injection recon soln 1 gram, 500 cefotaxime injection recon soln 10 gram, (Claforan) gram cefoxitin intravenous recon soln 1 gram, 10 gram, gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln 1 gram (Fortaz) ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftibuten oral capsule 00 ceftibuten oral suspension for reconstitution 180 /5 ml ceftriaxone injection recon soln 1 gram, 10 gram, gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 1

22 cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex) 1 cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml SUPRAX ORAL CAPSULE 00 MG tazicef injection recon soln 1 gram, gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml azithromycin oral tablet 50 (6 1 pack), 500 ( pack) azithromycin oral tablet 50, 500 (Zithromax) 1 azithromycin oral tablet 600 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 DIFICID ORAL TABLET 00 MG 5 ST; NDS; QL (0 per 10 erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 LA; NDS ertapenem injection recon soln 1 gram (Invanz) imipenem-cilastatin intravenous recon soln 50 1

23 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, amoxicillin oral suspension for 1 reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, amoxicillin oral tablet,chewable 15, 1 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram 15

24 nafcillin intravenous recon soln gram oxacillin 1 gm add-vantage vl addvantage, inner 1 gram oxacillin injection recon soln 1 gram, 10 gram, gram penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous (Zosyn) PA BvD recon soln.5 gram,.75 gram,.5 gram, 0.5 gram Quinolones BAXDELA ORAL TABLET 50 MG ; QL (8 per 1 ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 ciprofloxacin hcl oral tablet ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 00 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 00 /0 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet

25 levofloxacin oral tablet 500, 750 (Levaquin) 1 moxifloxacin oral tablet 00 (Avelox) ofloxacin oral tablet 00, 00 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) 1 tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) 1 tablet sulfatrim oral suspension 00-0 /5 ml Tetracyclines doxy-100 intravenous recon soln 100 doxycycline hyclate intravenous recon (Doxy-100) soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline monohydrate oral capsule (Mondoxyne NL) 100, 50 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 50 minocycline oral capsule 100, 75 minocycline oral capsule 50 (Minocin) mondoxyne nl oral capsule 100, 50 okebo oral capsule 100 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) 17

26 Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 /5 ml, /ml, 0 /10 ml, 50 /5 ml adrucil intravenous solution.5 gram/50 ml, 500 /10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, 5 MG PA BvD PA BvD 5 PA NSO; NDS; QL (11 per 8 AFINITOR ORAL TABLET 10 MG 5 PA NSO; NDS; QL (56 per 8 AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA NSO; NDS; QL (8 per 8 ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (0 per 0 ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG 5 PA NSO; NDS; QL ( per 8 ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA NSO; NDS; QL (0 per 0 ALUNBRIG ORAL TABLET 0 MG 5 PA NSO; NDS; QL (10 per 0 ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG () 5 PA NSO; NDS; QL (0 per 0 anastrozole oral tablet 1 (Arimidex) 1 arsenic trioxide intravenous solution 1 /ml AVASTIN INTRAVENOUS 5 PA NSO; NDS SOLUTION 5 MG/ML azacitidine injection recon soln 100 (Vidaza) BAVENCIO INTRAVENOUS 5 PA NSO; NDS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS 5 PA NSO; NDS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 5 MG/ML 5 PA NSO; NDS 18

27 BESPONSA INTRAVENOUS 5 PA NSO; NDS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 5 PA NSO; NDS; QL (0 per 0 bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 15 unit, 0 PA BvD unit BLINCYTO INTRAVENOUS KIT 5 5 PA NSO; NDS MCG BORTEZOMIB INTRAVENOUS 5 PA NSO; NDS RECON SOLN.5 MG BOSULIF ORAL TABLET 100 MG 5 PA NSO; NDS; QL (90 per 0 BOSULIF ORAL TABLET 00 MG, 500 MG 5 PA NSO; NDS; QL (0 per 0 BRAFTOVI ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (10 per 0 BRAFTOVI ORAL CAPSULE 75 MG 5 PA NSO; NDS; QL (180 per 0 CABOMETYX ORAL TABLET 0 MG, 60 MG 5 PA NSO; NDS; QL (0 per 0 CABOMETYX ORAL TABLET 0 MG 5 PA NSO; NDS; QL (60 per 0 CALQUENCE ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (60 per 0 CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (60 per 0 CAPRELSA ORAL TABLET 00 MG 5 PA NSO; NDS; QL (0 per 0 clofarabine intravenous solution 0 /0 (Clolar) ml COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1), 10 MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) COPIKTRA ORAL CAPSULE 15 MG, 5 MG 5 PA NSO; NDS; QL (11 per 8 5 PA NSO; NDS; QL (56 per 8 COTELLIC ORAL TABLET 0 MG 5 PA NSO; LA; NDS; QL (6 per 8 19

28 cyclophosphamide intravenous recon soln 5 PA BvD; NDS 1 gram, gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 5 PA NSO; NDS SOLUTION 10 MG/ML DARZALEX INTRAVENOUS 5 PA NSO; LA; NDS SOLUTION 0 MG/ML decitabine intravenous recon soln 50 (Dacogen) doxorubicin intravenous solution 10 /5 (Adriamycin) PA BvD ml, /ml, 0 /10 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) 5 PA BvD; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE.5 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 5 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 10 MG EMPLICITI INTRAVENOUS 5 PA NSO; NDS RECON SOLN 00 MG, 00 MG ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (0 per 0 ERLEADA ORAL TABLET 60 MG 5 PA NSO; NDS; QL (10 per 0 ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 5 PA NSO; NDS MG, 15 MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD 0

29 fluorouracil intravenous solution 1 PA BvD gram/0 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/100 ml, 500 /10 ml flutamide oral capsule 15 GAZYVA INTRAVENOUS 5 PA NSO; NDS SOLUTION 1,000 MG/0 ML GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG 5 PA NSO; NDS; QL (0 per 0 GLEOSTINE ORAL CAPSULE 10 MG, 0 MG, 5 MG GLEOSTINE ORAL CAPSULE 100 MG HERCEPTIN INTRAVENOUS 5 PA NSO; NDS RECON SOLN 150 MG, 0 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG 5 PA NSO; NDS; QL (1 per 8 ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NDS; QL (60 per 0 ICLUSIG ORAL TABLET 5 MG 5 PA NSO; NDS; QL (0 per 0 IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA NSO; NDS; QL (0 per 0 ifosfamide intravenous recon soln 1 gram (Ifex) PA BvD ifosfamide intravenous solution 1 gram/0 PA BvD ml, gram/60 ml ifosfamide-mesna intravenous kit PA BvD; NDS gram,,000-1,000 imatinib oral tablet 100 (Gleevec) 5 PA NSO; NDS; QL (90 per 0 imatinib oral tablet 00 (Gleevec) 5 PA NSO; NDS; QL (60 per 0 IMBRUVICA ORAL CAPSULE 10 MG, 70 MG 5 PA NSO; NDS; QL (8 per 8 IMBRUVICA ORAL TABLET 10 MG, 80 MG, 0 MG, 560 MG 5 PA NSO; NDS; QL (8 per 8 IMFINZI INTRAVENOUS SOLUTION 50 MG/ML 5 PA NSO; NDS 1

30 IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML 5 PA NSO; NDS; QL ( per 65 5 PA NSO; NDS; QL (8 per 8 INLYTA ORAL TABLET 1 MG 5 PA NSO; NDS; QL (180 per 0 INLYTA ORAL TABLET 5 MG 5 PA NSO; NDS; QL (60 per 0 IRESSA ORAL TABLET 50 MG 5 PA NSO; NDS; QL (60 per 0 IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 5 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG 5 PA NSO; NDS; QL (60 per 0 KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML 5 PA NSO; NDS; QL (8 per 1 KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X )-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1) KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) KISQALI ORAL TABLET 600 MG/DAY (00 MG X ) KYPROLIS INTRAVENOUS RECON SOLN 10 MG, 0 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML 5 PA NSO; NDS; QL (9 per 8 5 PA NSO; NDS; QL (70 per 8 5 PA NSO; NDS; QL (91 per 8 5 PA NSO; NDS; QL (1 per 8 5 PA NSO; NDS; QL ( per 8 5 PA NSO; NDS; QL (6 per 8 5 PA NSO; NDS 5 PA NSO; LA; NDS

31 LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 1 MG/DAY ( MG X ), 1 MG/DAY(10 MG X 1- MG X 1), 18 MG/DAY (10 MG X 1- MG X), 0 MG/DAY (10 MG X ), MG/DAY(10 MG X - MG X 1), MG, 8 MG/DAY ( MG X ) 5 PA NSO; NDS letrozole oral tablet.5 (Femara) 1 LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit 1 /0. ml LIBTAYO INTRAVENOUS SOLUTION 50 MG/7 ML (50 MG/ML) LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG LORBRENA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (7 per 1 5 PA NSO; NDS; QL (100 per 8 5 PA NSO; NDS; QL (80 per 8 5 PA NSO; NDS; QL (0 per 0 LORBRENA ORAL TABLET 5 MG 5 PA NSO; NDS; QL (90 per 0 LUMOXITI INTRAVENOUS 5 PA NSO; NDS RECON SOLN 1 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 5 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (8 per 8 LYNPARZA ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (10 per 0 LYSODREN ORAL TABLET 500 MG

32 MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 0 PA NSO-HRM; AGE (Max 6 Years) MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NDS; QL (90 per 0 MEKINIST ORAL TABLET MG 5 PA NSO; NDS; QL (0 per 0 MEKTOVI ORAL TABLET 15 MG 5 PA NSO; NDS; QL (180 per 0 mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon PA BvD soln 1 gram methotrexate sodium (pf) injection PA BvD solution 5 /ml methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST mitoxantrone intravenous concentrate /ml MYLOTARG INTRAVENOUS 5 PA NSO; NDS RECON SOLN.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 0 MG 5 PA NSO; NDS; QL (180 per 0 NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NDS; QL (10 per 0 nilutamide oral tablet 150 (Nilandron) NINLARO ORAL CAPSULE. MG, MG, MG 5 PA NSO; NDS; QL ( per 8 ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; LA; NDS ONCASPAR INJECTION 5 PA NSO; NDS SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS 5 PA BvD; NDS DISPERSION. MG/ML OPDIVO INTRAVENOUS 5 PA NSO; NDS SOLUTION 100 MG/10 ML, 0 MG/ ML, 0 MG/ ML POMALYST ORAL CAPSULE 1 MG, MG, MG, MG 5 PA NSO; NDS; QL (1 per 8

33 PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) POTELIGEO INTRAVENOUS SOLUTION MG/ML PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG RITUXAN HYCELA SUBCUTANEOUS SOLUTION 100 MG/11.7 ML (10 MG/ML), 1600 MG/1. ML (10 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML RUBRACA ORAL TABLET 00 MG, 50 MG, 00 MG 5 PA NSO; NDS; QL (100 per 1 5 PA NSO; NDS 5 PA NSO; LA; NDS; QL (8 per 8 5 PA NSO; NDS 5 PA NSO; NDS 5 PA NSO; NDS; QL (10 per 0 RYDAPT ORAL CAPSULE 5 MG 5 PA NSO; NDS; QL ( per 8 SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 10 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; NDS; QL (0 per 0 SPRYCEL ORAL TABLET 0 MG 5 PA NSO; NDS; QL (60 per 0 STIVARGA ORAL TABLET 0 MG 5 PA NSO; NDS; QL (8 per 8 SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 7.5 MG, 50 MG 5 PA NSO; NDS; QL (0 per 0 SYLVANT INTRAVENOUS RECON 5 PA NSO; NDS SOLN 100 MG, 00 MG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG 5 PA NSO; NDS; QL (8 per 8 TABLOID ORAL TABLET 0 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA NSO; NDS; QL (10 per 0 TAGRISSO ORAL TABLET 0 MG, 80 MG 5 PA NSO; LA; NDS; QL (0 per 0 5

34 TALZENNA ORAL CAPSULE 0.5 MG 5 PA NSO; NDS; QL (90 per 0 TALZENNA ORAL CAPSULE 1 MG 5 PA NSO; NDS; QL (0 per 0 tamoxifen oral tablet 10, 0 TARCEVA ORAL TABLET 100 MG, 5 MG 5 PA NSO; NDS; QL (60 per 0 TARCEVA ORAL TABLET 150 MG 5 PA NSO; NDS; QL (90 per 0 TARGRETIN TOPICAL GEL 1 % 5 PA NSO; NDS; QL (60 per 8 TASIGNA ORAL CAPSULE 150 MG, 00 MG 5 PA NSO; NDS; QL (11 per 8 TASIGNA ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (10 per 0 TECENTRIQ INTRAVENOUS SOLUTION 1,00 MG/0 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG 5 PA NSO; NDS; QL (0 per 1 5 PA NSO; NDS thiotepa injection recon soln 15 (Tepadina) TIBSOVO ORAL TABLET 50 MG 5 PA NSO; NDS; QL (60 per 0 toposar intravenous solution 0 /ml TREANDA INTRAVENOUS RECON SOLN 100 MG, 5 MG TRELSTAR 11.5 MG VIAL OUTER, SDV 11.5 MG ; QL (1 per 8 TRELSTAR.5 MG VIAL OUTER, SDV.5 MG ; QL (1 per 168 TRELSTAR.75 MG VIAL INNER, SDV.75 MG TRELSTAR INTRAMUSCULAR SYRINGE 11.5 MG/ ML ; QL (1 per 8 TRELSTAR INTRAMUSCULAR SYRINGE.5 MG/ ML ; QL (1 per 168 TRELSTAR INTRAMUSCULAR SYRINGE.75 MG/ ML tretinoin (chemotherapy) oral capsule 10 TYKERB ORAL TABLET 50 MG 6

35 UNITUXIN INTRAVENOUS 5 PA NSO; NDS SOLUTION.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 0 MG/ML VELCADE INJECTION RECON 5 PA NSO; NDS SOLN.5 MG VENCLEXTA ORAL TABLET 10 MG PA NSO; LA; QL (60 per 0 VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; LA; NDS; QL (10 per 0 VENCLEXTA ORAL TABLET 50 MG PA NSO; LA; QL (0 per 0 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 5 PA NSO; LA; NDS; QL ( per 8 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG 5 PA NSO; NDS; QL (56 per 8 vinorelbine intravenous solution 10 /ml, 50 /5 ml (Navelbine) VIZIMPRO ORAL TABLET 15 MG, 0 MG, 5 MG 5 PA NSO; NDS; QL (0 per 0 VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NDS; QL (10 per 0 VYXEOS INTRAVENOUS RECON 5 PA BvD; NDS SOLN -100 MG XALKORI ORAL CAPSULE 00 MG, 50 MG 5 PA NSO; NDS; QL (60 per 0 XATMEP ORAL SOLUTION.5 PA BvD; ST MG/ML XTANDI ORAL CAPSULE 0 MG 5 PA NSO; NDS; QL (10 per 0 YERVOY INTRAVENOUS 5 PA NSO; NDS SOLUTION 00 MG/0 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS 5 PA NSO; NDS RECON SOLN 1 MG YONSA ORAL TABLET 15 MG 5 PA NSO; NDS; QL (10 per 0 ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (90 per 0 7

36 ZELBORAF ORAL TABLET 0 MG 5 PA NSO; NDS; QL (0 per 0 ZOLADEX SUBCUTANEOUS QL (1 per 8 IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS QL (1 per 8 IMPLANT.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (60 per 0 ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (90 per 0 ZYTIGA ORAL TABLET 50 MG, 500 MG 5 PA NSO; NDS; QL (10 per 0 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0.1 /ml propantheline oral tablet 15 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, 5 ST; NDS 00 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 0 5 ST; NDS MG/ML BANZEL ORAL TABLET 00 MG, 5 ST; NDS 00 MG BRIVIACT INTRAVENOUS QL (80 per 0 SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML ; QL (600 per 0 BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 MG, 50 MG, 75 MG ; QL (60 per 0 carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr 100, 00, 00 carbamazepine oral suspension 100 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended release 1 hr 100, 00, 00 (Tegretol XR) 8

37 carbamazepine oral tablet,chewable 100 CELONTIN ORAL CAPSULE 00 MG DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, delayed rel sprinkle 15 (Depakote Sprinkles) divalproex oral tablet extended release (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (dr/ec) 15, 50, 500 (Depakote) EPIDIOLEX ORAL SOLUTION PA NSO; NDS MG/ML epitol oral tablet 00 ethosuximide oral capsule 50 (Zarontin) ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 00, 600 (Felbatol) fosphenytoin injection solution 100 pe/ ml, 500 pe/10 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 ST MG/ML FYCOMPA ORAL TABLET 10 MG, 5 ST; NDS 1 MG, MG, 6 MG, 8 MG FYCOMPA ORAL TABLET MG ST gabapentin oral capsule 100, 00, (Neurontin) 1 00 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) lamotrigine oral tablet 100, 150, (Lamictal) 1 00, 5 lamotrigine oral tablet, chewable (Lamictal) dispersible 5, 5 levetiracetam intravenous solution 500 (Keppra) /5 ml levetiracetam oral solution 100 /ml (Keppra) levetiracetam oral tablet 1,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release hr 500, 750 (Keppra XR) 9

38 LYRICA ORAL CAPSULE 100 MG, 150 MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML oxcarbazepine oral suspension 00 /5 ml (60 /ml) oxcarbazepine oral tablet 150, 00, 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE HR 150 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5 ml ( /ml) phenobarbital oral tablet 100, 15, 16., 0,., 60, 6.8, 97. (Trileptal) (Trileptal) QL (90 per 0 QL (900 per 0 ST PA NSO-HRM; AGE (Max 6 Years) PA NSO-HRM; AGE (Max 6 Years) phenytoin oral suspension 15 /5 ml (Dilantin-15) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 100 phenytoin sodium extended oral capsule (Phenytek) 00, 00 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml primidone oral tablet 50, 50 (Mysoline) ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR ST; QL (60 per 0 SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 50 MG, 500 MG, 750 ST; QL (10 per 0 MG subvenite oral tablet 100, 150, 00, 5 1 0

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