2019 Comprehensive Formulary

Transcription

1 Centers Plan for Medicare Advantage Care (HMO) 09 Comprehensive Formulary This formulary was updated on /08. For more recent information or other questions, please contact Centers Plan for Healthy Living at or, for TTY users, , seven days a week from 8 am 8 pm, or visit H6988_ENR085_C

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3 Centers Plan for Medicare Advantage Care (HMO) 09 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN CPHL 09 Formulary ID: 9 Version: 7 This formulary was updated on /08. For more recent information or other questions, please contact us, Centers Plan for Healthy Living at or, for TTY users, , seven days a week, 8:00 AM to 8:00 PM, or visit 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 Centers Plan for Healthy Living. When it refers to plan or our plan, it means Centers Plan for Medicare Advantage Care (HMO. This document includes a list of the drugs (formulary) for our plan which is current as of /08. 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, 09, and from time to time during the year. What is the Centers Plan for Medicare Advantage Care (HMO) Formulary? A formulary is a list of covered drugs selected by Centers Plan for Medicare Advantage Care (HMO) 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. Centers Plan for Medicare Advantage Care (HMO) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Centers Plan for Medicare Advantage Care (HMO) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. H6988_ENR085_C i

4 Can the Formulary (drug list) change? Generally, if you are taking a drug on our 09 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 09 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 cost sharing 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 Centers Plan for Medicare Advantage Care (HMO) Formulary? 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 /08. To get updated information about the drugs covered by Centers Plan for Medicare Advantage Care (HMO), please contact us. Our contact information appears on the front and back cover pages. In the event of any mid-year non-maintenance formulary changes, Centers Plan for Medicare Advantage Care (HMO) will mail you an errata sheet to update your printed formulary. H6988_ENR085_C ii

5 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. 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. 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-. 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? Centers Plan for Medicare Advantage Care (HMO) 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. 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: Centers Plan for Medicare Advantage Care (HMO) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Centers Plan for Medicare Advantage Care (HMO) before you fill your prescriptions. If you don t get approval, Centers Plan for Medicare Advantage Care (HMO) may not cover the drug. Quantity Limits: For certain drugs, Centers Plan for Medicare Advantage Care (HMO) limits the amount of the drug that Centers Plan for Medicare Advantage Care (HMO) will cover. For example, Centers Plan for Medicare Advantage Care (HMO) provides per prescription for sumatriptan. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Centers Plan for Medicare Advantage Care (HMO) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that H6988_ENR085_C iii

6 condition. For example, if Drug A and Drug B both treat your medical condition, Centers Plan for Medicare Advantage Care (HMO) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Centers Plan for Medicare Advantage Care (HMO) 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. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explains our 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 Centers Plan for Medicare Advantage Care (HMO) 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 Centers Plan for Medicare Advantage Care (HMO) formulary? on page vi for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Centers Plan for Medicare Advantage Care (HMO) pays for certain OTC drugs. Centers Plan for Medicare Advantage Care (HMO) will provide these OTC drugs at no cost to you. The cost to Centers Plan for Medicare Advantage Care (HMO) of these OTC drugs will not count toward your total Part D drug costs (that is, the cost of the OTC drugs does not count for the coverage gap.) 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. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you learn that Centers Plan for Medicare Advantage Care (HMO) does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Centers Plan for Medicare Advantage Care (HMO). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Centers Plan for Medicare Advantage Care (HMO). You can ask Centers Plan for Medicare Advantage Care (HMO) to make an exception and cover your drug. See below for information about how to request an exception. H6988_ENR085_C iv

7 How do I request an exception to the Centers Plan for Medicare Advantage Care (HMO) Formulary? You can ask Centers Plan for Medicare Advantage Care (HMO) 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, Centers Plan for Medicare Advantage Care (HMO) 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, Centers Plan for Medicare Advantage Care (HMO) 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 4 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. H6988_ENR085_C v

8 If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a -day emergency supply of that drug while you pursue a formulary exception. Transition medications will be provided to members who change treatment settings due to changes in level of care (e.g. individuals who enter long term facilities from hospitals or enter an ambulatory setting from a hospital). For more information For more detailed information about your Centers Plan for Medicare Advantage Care (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Centers Plan for Medicare Advantage Care (HMO) 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 ( ) 4 hours a day/7 day a week. TTY users should call Or, visit Centers Plan for Medicare Advantage Care (HMO)Formulary The formulary below provides coverage information about the drugs covered by Centers Plan for Medicare Advantage Care (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on page I-. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR) and generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if Centers Plan for Medicare Advantage Care (HMO) has any special requirements for coverage of your drug. H6988_ENR085_C vi

9 Table of Contents Analgesics... Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents... 7 Antianxiety Agents... 8 Antibacterials... 9 Anticancer Agents... 6 Anticholinergic Agents... 5 Anticonvulsants... 5 Antidementia Agents... 8 Antidepressants... 9 Antidiabetic Agents... Antifungals... 4 Antigout Agents... 6 Antihistamines... 6 Anti-Infectives (Skin And Mucous Membrane)... 6 Antimigraine Agents... 7 Antimycobacterials... 7 Antinausea Agents... 8 Antiparasite Agents... 9 Antiparkinsonian Agents Antipsychotic Agents... 4 Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders... 5 Caloric Agents... 5 Cardiovascular Agents Central Nervous System Agents Contraceptives... 68

10 Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents... 8 Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents... 9 Inflammatory Bowel Disease Agents Irrigating Solutions... 0 Metabolic Bone Disease Agents... 0 Miscellaneous Therapeutic Agents... 0 Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants... Sleep Disorder Agents... Vasodilating Agents... Vitamins And Minerals... 4

11 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 0- /5 ml acetaminophen-codeine oral tablet 00-5 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 #4) QL (80 per 0 (Buprenex) (Esgic) PA-HRM; QL (80 per 0 ; AGE (Max 64 Years) (Fiorinal) PA-HRM; QL (80 per 0 ; AGE (Max 64 Years) PA-HRM; QL (80 per 0 ; AGE (Max 64 Years) QL (80 per 0 codeine sulfate oral tablet 5, 0, 60 endocet oral tablet 0-5 QL (80 per 0 endocet oral tablet.5-5, 5-5 QL (60 per 0 endocet oral tablet QL (40 per 0 fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution /5 ml hydrocodone-acetaminophen oral tablet 0-5 hydrocodone-acetaminophen oral tablet.5-5 hydrocodone-acetaminophen oral tablet 5-5 (Actiq) ; QL (0 per 0 (Duragesic) QL (0 per 0 (Hycet) QL (700 per 0 (Lorcet HD) QL (80 per 0 (Verdrocet) QL (40 per 0 (Lorcet (hydrocodone)) QL (40 per 0

12 hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (80 per hydrocodone-ibuprofen oral tablet QL (50 per 0 hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone oral liquid /ml (Dilaudid) QL (00 per 0 hydromorphone oral tablet, 4, 8 (Dilaudid) QL (80 per 0 HYSINGLA ER ORAL TABLET,ORAL QL (0 per 0 ONLY,EXT.REL.4 HR 00 MG, 0 MG, 0 MG, 0 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 00 ; QL (0 per 0 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-5 QL (40 per 0 lorcet hd oral tablet 0-5 QL (80 per 0 lorcet plus oral tablet QL (80 per 0 methadone injection solution 0 /ml methadone oral solution 0 /5 ml QL (600 per 0 methadone oral solution 5 /5 ml QL (00 per 0 methadone oral tablet 0 (Dolophine) QL (0 per 0 methadone oral tablet 5 (Dolophine) QL (80 per 0 methadose oral tablet,soluble 40 QL (0 per 0 morphine 0 /ml isecure syrg l/f, p/f, suv, inner 0 /ml morphine concentrate oral solution 00 QL (80 per 0 /5 ml (0 /ml) morphine injection syringe 0 /ml morphine intravenous solution 0 /ml morphine oral solution 0 /5 ml QL (700 per 0 morphine oral solution 0 /5 ml (4 QL (00 per 0 /ml) MORPHINE ORAL TABLET 5 MG QL (80 per 0 MORPHINE ORAL TABLET 0 MG QL (0 per 0 morphine oral tablet extended release 00 (MS Contin) QL (60 per 0, 00, 60 morphine oral tablet extended release 5, 0 (MS Contin) QL (90 per 0 4

13 NUCYNTA ER ORAL TABLET QL (60 per 0 EXTENDED RELEASE HR 00 MG, 50 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 00 MG, 50 QL (8 per 0 MG, 75 MG oxycodone oral solution 5 /5 ml QL (00 per 0 oxycodone oral tablet 0 QL (80 per 0 oxycodone oral tablet 5, 0 (Roxicodone) QL (0 per 0 oxycodone oral tablet 0 QL (0 per 0 oxycodone oral tablet 5 (Roxicodone) QL (80 per 0 oxycodone oral tablet,oral only,ext.rel. (OxyContin) QL (60 per 0 hr 0, 5, 0, 0, 40, 60, 80 oxycodone-acetaminophen oral solution 5- QL (800 per 0 5 /5 ml oxycodone-acetaminophen oral tablet 0- (Endocet) QL (80 per 0 5 oxycodone-acetaminophen oral tablet.5- (Endocet) QL (60 per 0 5, 5-5 oxycodone-acetaminophen oral tablet 7.5- (Endocet) QL (40 per 0 5 oxycodone-aspirin oral tablet QL (60 per 0 OXYCONTIN ORAL TABLET,ORAL QL (60 per 0 ONLY,EXT.REL. HR 0 MG, 5 MG, 0 MG, 0 MG, 40 MG, 60 MG, 80 MG SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 00 MG/0.5 ML, 00 MG/.5 ML tramadol oral tablet 50 (Ultram) QL (40 per 0 tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (40 per 0 5 XTAMPZA ER ORAL QL (60 per 0 CAPSULE,SPRINKLE,ER HR TMPRR.5 MG, 8 MG, 9 MG XTAMPZA ER ORAL QL (0 per 0 CAPSULE,SPRINKLE,ER HR TMPRR 7 MG XTAMPZA ER ORAL QL (40 per 0 CAPSULE,SPRINKLE,ER HR TMPRR 6 MG Nonsteroidal Anti-Inflammatory Agents 5

14 CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8 ML (00 MG/ML) celecoxib oral capsule 00, 00, 50 (Celebrex) QL (60 per 0 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops.5 % QL (00 per 0 diclofenac sodium topical gel % (Solaraze) PA; QL (00 per 8 etodolac oral capsule 00, 00 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 FLECTOR TRANSDERMAL PATCH PA HOUR. % flurbiprofen oral tablet 00, 50 ibu oral tablet 400, 600, 800 ibuprofen oral suspension 00 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, 800 (IBU) indomethacin oral capsule 5 PA-HRM; QL (40 per 0 ; AGE (Max 64 Years) indomethacin oral capsule 50 PA-HRM; QL (0 per 0 ; AGE (Max 64 Years) indomethacin sodium intravenous recon soln ketorolac oral tablet 0 PA-HRM; QL (0 per 0 ; AGE (Max 64 Years) mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral tablet 50, 75 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (dr/ec) 75, 500 (EC-Naprosyn) 6

15 PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 0 MG/GRAM /ACTUATION( %) sulindac oral tablet 50, 00 VOLTAREN TOPICAL GEL % Anesthetics ; QL (4 per 8 Local Anesthetics glydo mucous membrane jelly in applicator % QL (0 per 0 lidocaine (pf) injection solution 0 /ml (Xylocaine-MPF) ( %), 5 /ml (.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl injection solution 0 /ml ( %), 0 /ml ( %), 5 /ml (0.5 %) (Xylocaine) lidocaine hcl mucous membrane jelly % QL (0 per 0 lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive (Lidoderm) PA; QL (90 per 0 patch,medicated 5 % lidocaine topical ointment 5 % PA; QL (90 per 0 lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual tablet -0.5, 8- bupropion hcl (smoking deter) oral tablet extended release hr 50 CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG (Zyban) PA; QL (0 per 0 7 QL (90 per 0 QL (90 per 0 QL (6 per 65 QL (6 per 65

16 CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) QL (06 per 65 disulfiram oral tablet 50, 500 (Antabuse) LUCEMYRA ORAL TABLET 0.8 MG ; QL (8 per 4 naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL (4 per 0 AEROSOL 4 MG/ACTUATION NICOTROL INHALATION QL (008 per 90 CARTRIDGE 0 MG SUBOXONE SUBLINGUAL FILM - QL (60 per 0 MG, 8- MG SUBOXONE SUBLINGUAL FILM -0.5 QL (0 per 0 MG, 4- MG ZUBSOLV SUBLINGUAL TABLET MG, MG,.4-.9 MG,.9- QL (0 per MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, QL (60 per 0 (Xanax) QL (0 per 0 alprazolam oral tablet (Xanax) QL (50 per 0 buspirone oral tablet 0, 5, 0, 5, 7.5 chlordiazepoxide hcl oral capsule 0, QL (0 per 0 5, 5 clonazepam oral tablet 0.5, (Klonopin) QL (90 per 0 clonazepam oral tablet (Klonopin) QL (00 per 0 clonazepam oral tablet,disintegrating QL (90 per 0 0.5, 0.5, 0.5, clonazepam oral tablet,disintegrating QL (00 per 0 clorazepate dipotassium oral tablet 5,.75 QL (80 per 0 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (80 per 0 8

17 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG diazepam injection solution 5 /ml QL (0 per 8 diazepam injection syringe 5 /ml QL (0 per 8 diazepam intensol oral concentrate 5 QL (00 per 0 /ml diazepam oral solution 5 /5 ml ( QL (00 per 0 /ml) diazepam oral tablet 0,, 5 (Valium) QL (0 per 0 diazepam rectal kit , 5- (Diastat AcuDial) diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml, 4 (Ativan) QL ( per 0 /ml lorazepam injection syringe /ml, 4 QL ( per 0 /ml lorazepam oral tablet 0.5, (Ativan) QL (90 per 0 lorazepam oral tablet (Ativan) QL (50 per 0 ONFI ORAL SUSPENSION.5 MG/ML 4 PA NSO; NDS; QL (480 per 0 ONFI ORAL TABLET 0 MG, 0 MG 4 PA NSO; NDS; QL (60 per 0 temazepam oral capsule 5, 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 64 Years) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION 4 PA BvD; NDS FOR NEBULIZATION 00 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 00 /50 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 9

18 gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 00 /0 ml, 60 /6 ml, 80 /8 ml neomycin oral tablet 500 streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE ; QL (4 per 8 8 MG tobramycin in 0.5 % nacl inhalation (Tobi) 4 PA BvD; NDS solution for nebulization 00 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 0 /ml, 40 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln (BACiiM) 50,000 unit chloramphenicol sod succinate intravenous recon soln gram clindamycin hcl oral capsule 50, 00 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) clindamycin phosphate injection solution 50 /ml clindamycin phosphate intravenous solution 600 /4 ml colistin (colistimethate na) injection recon soln 50 daptomycin intravenous recon soln 50 daptomycin intravenous recon soln 500 FIRVANQ ORAL RECON SOLN 5 MG/ML, 50 MG/ML linezolid 600 /00 ml-0.9% nacl 600 /00 ml (Cleocin in 5 % dextrose) (Cleocin) (Cleocin) (Coly-Mycin M Parenteral) 0 4 PA BvD; NDS (Cubicin)

19 linezolid in dextrose 5% intravenous piggyback 600 /00 ml (Zyvox) linezolid oral suspension for reconstitution (Zyvox) 00 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /00 ml metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 00, 5, 50 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (0 per 0 ; AGE nitrofurantoin monohyd/m-cryst oral capsule 00 (Max 64 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 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 vancomycin intravenous recon soln,000, 0 gram, 50, 5 gram, 500, 750 PA BvD vancomycin oral capsule 5 (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

20 cefaclor oral suspension for reconstitution 5 /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 gram, 0 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 400 (Spectracef) cefepime injection recon soln gram, (Maxipime) gram cefotaxime injection recon soln gram, 500 cefotaxime injection recon soln 0 gram, (Claforan) gram 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 (Fortaz) ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftibuten oral capsule 400 ceftibuten oral suspension for reconstitution 80 /5 ml ceftriaxone injection recon soln gram, 0 gram, gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram

21 cephalexin oral capsule 50, 500 (Keflex) cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml SUPRAX ORAL CAPSULE 400 MG tazicef injection recon soln gram, gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 ( pack) azithromycin oral tablet 50, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 DIFICID ORAL TABLET 00 MG 4 ST; NDS; QL (0 per 0 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 gram, gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 4 LA; NDS ertapenem injection recon soln gram (Invanz) imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, 500

22 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 amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) 500-5, amoxicillin-pot clavulanate oral tablet,chewable , 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 (Unasyn).5 gram, 5 gram, gram BICILLIN L-A INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln gram nafcillin injection recon soln 0 gram nafcillin intravenous recon soln gram oxacillin gm add-vantage vl addvantage, inner gram oxacillin injection recon soln gram, 0 gram, gram penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe. million unit/ ml, 600,000 unit/ml 4

23 penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous recon (Zosyn) PA BvD soln.5 gram,.75 gram, 4.5 gram, 40.5 gram Quinolones BAXDELA ORAL TABLET 450 MG ; QL (8 per 4 ciprofloxacin hcl oral tablet 50, 500 (Cipro) ciprofloxacin hcl oral tablet 750 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /00 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml 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 levofloxacin oral tablet 500, 750 (Levaquin) moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 00, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) 5

24 sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) sulfatrim oral suspension /5 ml Tetracyclines doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon (Doxy-00) soln 00 doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 0 doxycycline monohydrate oral capsule 00 (Mondoxyne NL), 50 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 00 (Avidoxy) doxycycline monohydrate oral tablet 50 minocycline oral capsule 00, 75 minocycline oral capsule 50 (Minocin) mondoxyne nl oral capsule 00, 50 okebo oral capsule 00 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG adriamycin intravenous solution 0 /5 PA BvD ml, /ml, 0 /0 ml, 50 /5 ml adrucil intravenous solution.5 gram/50 PA BvD ml, 500 /0 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, 5 MG 4 PA NSO; NDS; QL ( per 8 AFINITOR ORAL TABLET 0 MG 4 PA NSO; NDS; QL (56 per 8 AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 4 PA NSO; NDS; QL (8 per 8 ALECENSA ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (40 per 0 6

25 ALIMTA INTRAVENOUS RECON SOLN 00 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG 4 PA NSO; NDS; QL ( per 8 ALUNBRIG ORAL TABLET 80 MG, 90 MG 4 PA NSO; NDS; QL (0 per 0 ALUNBRIG ORAL TABLET 0 MG 4 PA NSO; NDS; QL (0 per 0 ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG () 4 PA NSO; NDS; QL (0 per 0 anastrozole oral tablet (Arimidex) AVASTIN INTRAVENOUS SOLUTION 4 PA NSO; NDS 5 MG/ML azacitidine injection recon soln 00 (Vidaza) BAVENCIO INTRAVENOUS 4 PA NSO; NDS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON 4 PA NSO; NDS SOLN 500 MG BENDEKA INTRAVENOUS 4 PA NSO; NDS SOLUTION 5 MG/ML BESPONSA INTRAVENOUS RECON 4 PA NSO; NDS SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 4 PA NSO; NDS; QL (40 per 0 bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 5 unit, 0 PA BvD unit BLINCYTO INTRAVENOUS KIT 5 4 PA NSO; NDS MCG BORTEZOMIB INTRAVENOUS 4 PA NSO; NDS RECON SOLN.5 MG BOSULIF ORAL TABLET 00 MG 4 PA NSO; NDS; QL (90 per 0 BOSULIF ORAL TABLET 400 MG, 500 MG 4 PA NSO; NDS; QL (0 per 0 BRAFTOVI ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (0 per 0 BRAFTOVI ORAL CAPSULE 75 MG 4 PA NSO; NDS; QL (80 per 0 CABOMETYX ORAL TABLET 0 MG, 60 MG 4 PA NSO; NDS; QL (0 per 0 CABOMETYX ORAL TABLET 40 MG 4 PA NSO; NDS; QL (60 per 0 7

26 CALQUENCE ORAL CAPSULE 00 MG 4 PA NSO; NDS; QL (60 per 0 CAPRELSA ORAL TABLET 00 MG 4 PA NSO; NDS; QL (60 per 0 CAPRELSA ORAL TABLET 00 MG 4 PA NSO; NDS; QL (0 per 0 clofarabine intravenous solution 0 /0 ml (Clolar) COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 MG/DAY(80 MG X-0 MG X), 60 MG/DAY (0 MG X /DAY) 4 PA NSO; NDS; QL ( per 8 COTELLIC ORAL TABLET 0 MG 4 PA NSO; LA; NDS; QL (6 per 8 cyclophosphamide intravenous recon soln 4 PA BvD; NDS gram, gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 4 PA NSO; NDS SOLUTION 0 MG/ML DARZALEX INTRAVENOUS 4 PA NSO; LA; NDS SOLUTION 0 MG/ML decitabine intravenous recon soln 50 (Dacogen) doxorubicin intravenous solution 0 /5 (Adriamycin) PA BvD ml, /ml, 0 /0 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) 4 PA BvD; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 400 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON 4 PA NSO; NDS SOLN 00 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (0 per 0 8

27 ERLEADA ORAL TABLET 60 MG 4 PA NSO; NDS; QL (0 per 0 ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 4 PA NSO; NDS MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil intravenous solution PA BvD gram/0 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/00 ml, 500 /0 ml flutamide oral capsule 5 GAZYVA INTRAVENOUS SOLUTION 4 PA NSO; NDS,000 MG/40 ML GILOTRIF ORAL TABLET 0 MG, 0 MG, 40 MG 4 PA NSO; NDS; QL (0 per 0 GLEOSTINE ORAL CAPSULE 0 MG, 40 MG, 5 MG GLEOSTINE ORAL CAPSULE 00 MG HERCEPTIN INTRAVENOUS RECON 4 PA NSO; NDS SOLN 50 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG 4 PA NSO; NDS; QL ( per 8 ICLUSIG ORAL TABLET 5 MG 4 PA NSO; NDS; QL (60 per 0 ICLUSIG ORAL TABLET 45 MG 4 PA NSO; NDS; QL (0 per 0 IDHIFA ORAL TABLET 00 MG, 50 MG 4 PA NSO; NDS; QL (0 per 0 ifosfamide intravenous recon soln gram (Ifex) PA BvD ifosfamide intravenous solution gram/0 PA BvD ml, gram/60 ml ifosfamide-mesna intravenous kit - gram,,000-,000 4 PA BvD; NDS 9

28 imatinib oral tablet 00 (Gleevec) 4 PA NSO; NDS; QL (90 per 0 imatinib oral tablet 400 (Gleevec) 4 PA NSO; NDS; QL (60 per 0 IMBRUVICA ORAL CAPSULE 40 MG, 70 MG 4 PA NSO; NDS; QL (8 per 8 IMBRUVICA ORAL TABLET 40 MG, 80 MG, 40 MG, 560 MG 4 PA NSO; NDS; QL (8 per 8 IMFINZI INTRAVENOUS SOLUTION 4 PA NSO; NDS 50 MG/ML IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML 4 PA NSO; NDS; QL (4 per 65 IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML 4 PA NSO; NDS; QL (8 per 8 INLYTA ORAL TABLET MG 4 PA NSO; NDS; QL (80 per 0 INLYTA ORAL TABLET 5 MG 4 PA NSO; NDS; QL (60 per 0 IRESSA ORAL TABLET 50 MG 4 PA NSO; NDS; QL (60 per 0 IXEMPRA INTRAVENOUS RECON SOLN 5 MG, 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG 4 PA NSO; NDS; QL (60 per 0 KEYTRUDA INTRAVENOUS 4 PA NSO; NDS; QL (8 SOLUTION 5 MG/ML KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 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 ) KISQALI ORAL TABLET 400 MG/DAY (00 MG X ) KISQALI ORAL TABLET 600 MG/DAY (00 MG X ) KYPROLIS INTRAVENOUS RECON SOLN 0 MG, 0 MG, 60 MG per 4 PA NSO; NDS; QL (49 per 8 4 PA NSO; NDS; QL (70 per 8 4 PA NSO; NDS; QL (9 per 8 4 PA NSO; NDS; QL ( per 8 4 PA NSO; NDS; QL (4 per 8 4 PA NSO; NDS; QL (6 per 8 4 PA NSO; NDS 0

29 LARTRUVO INTRAVENOUS 4 PA NSO; LA; NDS SOLUTION 0 MG/ML LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), MG/DAY (4 MG X ), 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 ) 4 PA NSO; NDS letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit /0. ml LONSURF ORAL TABLET MG 4 PA NSO; NDS; QL (00 per 8 LONSURF ORAL TABLET MG 4 PA NSO; NDS; QL (80 per 8 LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG,.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (448 per 8 LYNPARZA ORAL TABLET 00 MG, 50 MG 4 PA NSO; NDS; QL (0 per 0 LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 40 PA NSO-HRM; AGE (Max 64 Years) MEKINIST ORAL TABLET 0.5 MG 4 PA NSO; NDS; QL (90 per 0 MEKINIST ORAL TABLET MG 4 PA NSO; NDS; QL (0 per 0 MEKTOVI ORAL TABLET 5 MG 4 PA NSO; NDS; QL (80 per 0 mercaptopurine oral tablet 50

30 methotrexate sodium (pf) injection recon PA BvD soln gram methotrexate sodium (pf) injection PA BvD solution 5 /ml methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST mitoxantrone intravenous concentrate /ml MYLOTARG INTRAVENOUS RECON 4 PA NSO; NDS SOLN 4.5 MG ( MG/ML INITIAL CONC) NERLYNX ORAL TABLET 40 MG 4 PA NSO; NDS; QL (80 per 0 NEXAVAR ORAL TABLET 00 MG 4 PA NSO; NDS; QL (0 per 0 nilutamide oral tablet 50 (Nilandron) NINLARO ORAL CAPSULE. MG, MG, 4 MG 4 PA NSO; NDS; QL ( per 8 ODOMZO ORAL CAPSULE 00 MG 4 PA NSO; LA; NDS ONCASPAR INJECTION SOLUTION 4 PA NSO; NDS 750 UNIT/ML ONIVYDE INTRAVENOUS 4 PA BvD; NDS DISPERSION 4. MG/ML OPDIVO INTRAVENOUS SOLUTION 4 PA NSO; NDS 00 MG/0 ML, 40 MG/4 ML, 40 MG/4 ML POMALYST ORAL CAPSULE MG, MG, MG, 4 MG 4 PA NSO; NDS; QL ( per 8 PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (6 MG/ML) 4 PA NSO; NDS; QL (00 per POTELIGEO INTRAVENOUS 4 PA NSO; NDS SOLUTION 4 MG/ML PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG 4 PA NSO; LA; NDS; QL (8 per 8 RITUXAN HYCELA SUBCUTANEOUS SOLUTION 400 MG/.7 ML (0 MG/ML), 600 MG/.4 ML (0 MG/ML) 4 PA NSO; NDS

31 RITUXAN INTRAVENOUS 4 PA NSO; NDS CONCENTRATE 0 MG/ML RUBRACA ORAL TABLET 00 MG, 50 MG, 00 MG 4 PA NSO; NDS; QL (0 per 0 RYDAPT ORAL CAPSULE 5 MG 4 PA NSO; NDS; QL (4 per 8 SOLTAMOX ORAL SOLUTION 0 MG/5 ML SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG 4 PA NSO; NDS; QL (0 per 0 SPRYCEL ORAL TABLET 0 MG 4 PA NSO; NDS; QL (60 per 0 STIVARGA ORAL TABLET 40 MG 4 PA NSO; NDS; QL (84 per 8 SUTENT ORAL CAPSULE.5 MG, 5 MG, 7.5 MG, 50 MG 4 PA NSO; NDS; QL (0 per 0 SYLVANT INTRAVENOUS RECON 4 PA NSO; NDS SOLN 00 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG 4 PA NSO; NDS; QL (8 per 8 TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG 4 PA NSO; NDS; QL (0 per 0 TAGRISSO ORAL TABLET 40 MG, 80 MG 4 PA NSO; LA; NDS; QL (0 per 0 tamoxifen oral tablet 0, 0 TARCEVA ORAL TABLET 00 MG, 5 MG 4 PA NSO; NDS; QL (60 per 0 TARCEVA ORAL TABLET 50 MG 4 PA NSO; NDS; QL (90 per 0 TARGRETIN TOPICAL GEL % 4 PA NSO; NDS; QL (60 per 8 TASIGNA ORAL CAPSULE 50 MG, 00 MG 4 PA NSO; NDS; QL ( per 8 TASIGNA ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (0 per 0 TECENTRIQ INTRAVENOUS SOLUTION,00 MG/0 ML (60 4 PA NSO; NDS; QL (0 per MG/ML) TEMODAR INTRAVENOUS RECON 4 PA NSO; NDS SOLN 00 MG thiotepa injection recon soln 5 (Tepadina)

32 TIBSOVO ORAL TABLET 50 MG 4 PA NSO; NDS; QL (60 per 0 toposar intravenous solution 0 /ml TREANDA INTRAVENOUS RECON SOLN 00 MG, 5 MG TRELSTAR.75 MG VIAL INNER, SDV.75 MG TRELSTAR INTRAMUSCULAR ; QL ( per 84 SYRINGE.5 MG/ ML TRELSTAR INTRAMUSCULAR SYRINGE.5 MG/ ML ; QL ( per 68 TRELSTAR INTRAMUSCULAR SYRINGE.75 MG/ ML tretinoin (chemotherapy) oral capsule 0 TYKERB ORAL TABLET 50 MG UNITUXIN INTRAVENOUS 4 PA NSO; NDS SOLUTION.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 4 PA NSO; NDS.5 MG VENCLEXTA ORAL TABLET 0 MG PA NSO; LA; QL (60 per 0 VENCLEXTA ORAL TABLET 00 MG 4 PA NSO; LA; NDS; QL (0 per 0 VENCLEXTA ORAL TABLET 50 MG PA NSO; LA; QL (0 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG VERZENIO ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG vinorelbine intravenous solution 0 /ml, 50 /5 ml per 0 4 PA NSO; LA; NDS; QL (4 per 8 4 PA NSO; NDS; QL (56 per 8 (Navelbine) VOTRIENT ORAL TABLET 00 MG 4 PA NSO; NDS; QL (0 per 0 VYXEOS INTRAVENOUS RECON 4 PA BvD; NDS SOLN MG XALKORI ORAL CAPSULE 00 MG, 50 MG 4 PA NSO; NDS; QL (60 per 0 XATMEP ORAL SOLUTION.5 MG/ML PA BvD; ST 4

33 XTANDI ORAL CAPSULE 40 MG 4 PA NSO; NDS; QL (0 per 0 YERVOY INTRAVENOUS SOLUTION 4 PA NSO; NDS 00 MG/40 ML (5 MG/ML), 50 MG/0 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON 4 PA NSO; NDS SOLN MG YONSA ORAL TABLET 5 MG 4 PA NSO; NDS; QL (0 per 0 ZEJULA ORAL CAPSULE 00 MG 4 PA NSO; NDS; QL (90 per 0 ZELBORAF ORAL TABLET 40 MG 4 PA NSO; NDS; QL (40 per 0 ZOLADEX SUBCUTANEOUS QL ( per 84 IMPLANT 0.8 MG ZOLADEX SUBCUTANEOUS QL ( per 8 IMPLANT.6 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG 4 PA NSO; NDS; QL (60 per 0 ZYKADIA ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (90 per 0 ZYTIGA ORAL TABLET 50 MG, 500 MG 4 PA NSO; NDS; QL (0 per 0 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0. /ml propantheline oral tablet 5 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 00 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 MG/ML 4 ST; NDS 4 ST; NDS 4 ST; NDS QL (80 per 0 ; QL (600 per 0 5

34 BRIVIACT ORAL TABLET 0 MG, 00 MG, 5 MG, 50 MG, 75 MG ; QL (60 per 0 carbamazepine oral capsule, er (Carbatrol) multiphase hr 00, 00, 00 carbamazepine oral suspension 00 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release hr 00, 00, 400 carbamazepine oral tablet,chewable 00 CELONTIN ORAL CAPSULE 00 MG DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 5 divalproex oral tablet extended release 4 (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 5, 50, 500 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 400, 600 (Felbatol) fosphenytoin injection solution 00 pe/ ml, 500 pe/0 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 ST MG/ML FYCOMPA ORAL TABLET 0 MG, 4 ST; NDS MG, 4 MG, 6 MG, 8 MG FYCOMPA ORAL TABLET MG ST gabapentin oral capsule 00, 00, (Neurontin) 400 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) lamotrigine oral tablet 00, 50, (Lamictal) 00, 5 lamotrigine oral tablet, chewable (Lamictal) dispersible 5, 5 levetiracetam intravenous solution 500 (Keppra) /5 ml levetiracetam oral solution 00 /ml (Keppra) 6

35 levetiracetam oral tablet,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 (Keppra XR) LYRICA ORAL CAPSULE 00 MG, 50 QL (90 per 0 MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML QL (900 per 0 oxcarbazepine oral suspension 00 /5 ml (60 /ml) (Trileptal) oxcarbazepine oral tablet 50, 00, (Trileptal) 600 OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 4 HR 50 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5 ml (4 /ml) PA NSO-HRM; AGE (Max 64 Years) phenobarbital oral tablet 00, 5, 6., 0,.4, 60, 64.8, 97. PA NSO-HRM; AGE (Max 64 Years) phenytoin oral suspension 5 /5 ml (Dilantin-5) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 00 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,000 MG, 500 MG, 750 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR ST; QL (60 per 0 SUSPENSION,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 50 MG, 500 MG, 750 MG subvenite oral tablet 00, 50, 00, 5 ST; QL (0 per 0 7

36 tiagabine oral tablet, 6,, (Gabitril) 4 topiramate oral capsule, sprinkle 5, (Topamax) 5 topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) 00, 50, 00, 5, 50 topiramate oral tablet 00, 00, 5, 50 (Topamax) TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 4HR 00 MG 4 ST; NDS; QL (60 per 0 valproate sodium intravenous solution 500 (Depacon) /5 ml (00 /ml) valproic acid (as sodium salt) oral (Depakene) solution 50 /5 ml valproic acid oral capsule 50 (Depakene) vigabatrin oral powder in packet 500 (Sabril) vigadrone oral powder in packet 500 VIMPAT INTRAVENOUS SOLUTION ST; QL (00 per 5 00 MG/0 ML VIMPAT ORAL SOLUTION 0 MG/ML ST; QL (00 per 0 VIMPAT ORAL TABLET 00 MG, 50 ST; QL (60 per 0 MG, 00 MG, 50 MG zonisamide oral capsule 00, 5 (Zonegran) zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 0, 5 (Aricept) QL (0 per 0 donepezil oral tablet,disintegrating 0, QL (0 per 0 5 galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (0 per 0 4 hr 6, 4, 8 galantamine oral solution 4 /ml QL (00 per 0 galantamine oral tablet, 4, 8 (Razadyne) QL (60 per 0 memantine oral capsule,sprinkle,er 4hr (Namenda XR) QL (0 per 0 4,, 8, 7 memantine oral solution /ml QL (60 per 0 memantine oral tablet 0, 5 (Namenda) QL (60 per 0 NAMZARIC ORAL CAP,SPRINKLE,ER 4HR DOSE PACK 7/4//8 MG-0 MG QL (56 per 65 8

37 NAMZARIC ORAL QL (0 per 0 CAPSULE,SPRINKLE,ER 4HR 4-0 MG, -0 MG, 8-0 MG, 7-0 MG rivastigmine tartrate oral capsule.5, QL (60 per 0, 4.5, 6 rivastigmine transdermal patch 4 hour (Exelon) QL (0 per 0. /4 hour, 4.6 /4 hr, 9.5 /4 hr Antidepressants Antidepressants amitriptyline oral tablet 0, 00, 50, 5, 50, 75 PA NSO-HRM; AGE (Max 64 Years) amoxapine oral tablet 00, 50, 5, 50 PA NSO-HRM; AGE (Max 64 Years) bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr 50, 00 bupropion hcl oral tablet sustainedrelease (Wellbutrin SR) hr 00, 50, 00 citalopram oral solution 0 /5 ml QL (600 per 0 citalopram oral tablet 0, 0, 40 (Celexa) QL (0 per 0 clomipramine oral capsule 5, 50, 75 (Anafranil) PA NSO-HRM; AGE (Max 64 Years) desipramine oral tablet 0, 5 (Norpramin) PA NSO-HRM; AGE (Max 64 Years) desipramine oral tablet 00, 50, 50, 75 PA NSO-HRM; AGE (Max 64 Years) desvenlafaxine succinate oral tablet (Pristiq) QL (0 per 0 extended release 4 hr 00, 5, 50 doxepin oral capsule 0, 00, 50, 5, 50, 75 PA NSO-HRM; AGE (Max 64 Years) doxepin oral concentrate 0 /ml PA NSO-HRM; AGE (Max 64 Years) duloxetine oral capsule,delayed (Cymbalta) QL (60 per 0 release(dr/ec) 0, 60 duloxetine oral capsule,delayed (Cymbalta) QL (0 per 0 release(dr/ec) 0 EMSAM TRANSDERMAL PATCH 4 HOUR MG/4 HR, 6 MG/4 HR, 9 MG/4 HR ; QL (0 per 0 9