PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

Transcription

1 HealthPartners UnityPoint Health Align (PPO) HealthPartners UnityPoint Health Symmetry (PPO) (Collectively known as HealthPartners UnityPoint Health) 017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on 10//017. For more recent information or other questions, please contact HealthPartners UnityPoint Health Member Services TTY users: Or visit healthpartnersunitypointhealth.com. From October 1 through February 1, we take calls from 8 a.m. to 8 p.m., seven days a week. You ll speak with a representative. From February 15 to September 0, call us 8 a.m. to 8 p.m. Monday through Friday to speak with a representative. On Saturdays, Sundays and Federal holidays, you can leave a message and we ll get back to you within one business day (11/17)

2 When this drug list (formulary) refers to we, us, or our, it means HealthPartners UnityPoint Health. When it refers to plan or our plan, it means HealthPartners UnityPoint Health. This document includes a list of the drugs (formulary) for our plan which is current as of October, 017. 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, 018, and from time to time during the year. What is the HealthPartners UnityPoint Health Formulary? A formulary is a list of covered drugs selected by HealthPartners UnityPoint Health 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. HealthPartners UnityPoint Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a HealthPartners UnityPoint Health 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 017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. 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. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 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 60 day supply of the drug. 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. The enclosed formulary is current as of October, 017. To get updated information about the drugs covered by HealthPartners UnityPoint Health, please contact us. Our contact information appears on the front and back cover pages. To find out what drugs might have changed, you can go to healthpartnersunitypointhealth.com. The formulary is updated monthly to include any changes. In the event of negative formulary changes, you ll get a Formulary Change Notice. This notice will be mailed with your monthly Explanation of Benefits and will also be posted on our website. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiac Drugs. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on I-

3 page 105. 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? HealthPartners UnityPoint Health 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: HealthPartners UnityPoint Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from HealthPartners UnityPoint Health before you fill your prescriptions. If you don't get approval, HealthPartners UnityPoint Health may not cover the drug. Quantity Limits: For certain drugs, HealthPartners UnityPoint Health limits the amount of the drug that HealthPartners UnityPoint Health will cover. For example, HealthPartners UnityPoint Health provides 1 tablets per prescription for Sumatriptan. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, HealthPartners UnityPoint Health 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, HealthPartners UnityPoint Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, HealthPartners UnityPoint Health will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask HealthPartners UnityPoint Health 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 HealthPartners UnityPoint Health formulary?" on page I- 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 HealthPartners UnityPoint Health does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by HealthPartners UnityPoint Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by HealthPartners UnityPoint Health. You can ask HealthPartners UnityPoint Health to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the HealthPartners UnityPoint Health Formulary? You can ask HealthPartners UnityPoint Health 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, I-

4 HealthPartners UnityPoint Health 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, HealthPartners UnityPoint Health will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s or prescribing physician 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 (unless you have a prescription written for fewer days) when you go to a network pharmacy. 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, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1- day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Transition process For existing members who change care level, such as entering a long-term care facility or being discharged from a hospital, we ll grant early refills when appropriate. Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can t be used to buy a non-part D drug or a drug out of network, unless you qualify for out of network access. See your Evidence of Coverage for information about non-part D drugs. For more information For more detailed information about your HealthPartners UnityPoint Health prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about HealthPartners UnityPoint Health, 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 I-

5 HealthPartners UnityPoint Health Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by HealthPartners UnityPoint Health. If you have trouble finding your drug in the list, turn to the Index that begins on page 105. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if HealthPartners UnityPoint Health has any special requirements for coverage of your drug. The second column of the chart lists the drug tier or coverage level. HealthPartners UnityPoint Health covers Medicare Part D prescription drugs at five levels of coverage: Tier 1 (Preferred Generic), Tier (Generic), Tier (Preferred Brand), Tier (Non-preferred Brand), and Tier 5 (Specialty). To determine the coverage level you will need to determine the tier level (1,,, or 5) of your drug. Once you have found your drug, look in the Tier column to determine whether your drug is Tier 1 (Preferred Generic), Tier (Generic), Tier (Preferred Brand), Tier (Non-preferred Brand), or Tier 5 (Specialty). Then use the key below to determine your costsharing during the initial coverage phase for a 0-day supply.* COST-SHARING LEVELS BY PLAN AND DRUG TIER KEY Tier 1 (Preferred Generic Drugs) Tier (Generic Drugs) Tier (Preferred Brand Drugs) Tier (Non-preferred Drugs) Tier 5 (Specialty Drugs) HealthPartners UnityPoint Health Align HealthPartners UnityPoint Health Symmetry $ $0 $7 $100 9% of cost $** $0** $7 $100 9% of cost * Coverage level shown does not reflect deductibles, gap coverage, or catastrophic benefit coverage. Please refer to your Evidence of Coverage for details. **We provide additional coverage in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. I-5

6 The information in the Requirements/Limits column tells you if HealthPartners UnityPoint Health has any special requirements for coverage of your drug. The key below describes the abbreviations used in the Requirements/Limits column. Requirements/Limits Abbreviation Key ABBREVIATION PA QL BvD ST LA NM DESCRIPTION Prior Authorization Required Quantity Limit This drug could be covered as a Part B or a Part D Benefit. Step Therapy Required Limited Access Drug Some drugs may be available only at certain pharmacies. For more information consult your pharmacy directory or call Member Services. Non-Mail Order Drug Drugs not eligible for a 90-day mail order supply through your mail order benefit are noted with NM under Requirements/Limits. I-6

7 List of Drugs by Drug Type Table of Contents Analgesics... Anesthetics... 6 Anti-Addiction/Substance Abuse Treatment Agents... 7 Antianxiety Agents...8 Antibacterials... 9 Anticancer Agents...1 Anticholinergic Agents... Anticonvulsants... Antidementia Agents...6 Antidepressants... 7 Antidiabetic Agents...9 Antifungals... Antigout Agents... Antihistamines... Anti-Infectives (Skin And Mucous Membrane)... Antimigraine Agents... 5 Antimycobacterials...5 Antinausea Agents...6 Antiparasite Agents...7 Antiparkinsonian Agents...7 Antipsychotic Agents... 9 Antivirals (Systemic)...1 Blood Products/Modifiers/Volume Expanders... 7 Caloric Agents...9 Cardiovascular Agents Central Nervous System Agents Contraceptives...61 Dental And Oral Agents...67 Dermatological Agents...67 Devices...7 Enzyme Replacement/Modifiers...7 Eye, Ear, Nose, Throat Agents...7 Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists...80 Hormonal Agents, Stimulant/Replacement/Modifying...81 Immunological Agents Inflammatory Bowel Disease Agents...9 Irrigating Solutions...9 Metabolic Bone Disease Agents... 9 Miscellaneous Therapeutic Agents Ophthalmic Agents...97 Replacement Preparations...98 Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents...10 Vasodilating Agents Vitamins And Minerals

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9 List of Drugs by Drug Type Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml, 00-0 /1.5 ml acetaminophen-codeine oral tablet 00-15, 00-0, astramorph-pf injection solution 0.5 /ml, 1 /ml butalbital-acetaminophen oral tablet 50-00, 50-5 butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet butorphanol tartrate nasal spray,non-aerosol 10 /ml QL (10 ML per 1 day) QL (8 EA per 1 day) QL (0 ML per 0 days) QL (6 EA per 1 day) QL (6 EA per 1 day) QL (7.5 ML per 0 days) codeine sulfate oral tablet 15, 0, 60 QL (0 EA per 0 days) DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML endocet oral tablet 10-5,.5-5, 5-5, QL (0 ML per 0 days) QL (8 EA per 1 day) endodan oral tablet QL (0 EA per 0 days) fentanyl citrate buccal lozenge on a handle 00 mcg fentanyl citrate buccal lozenge on a handle 00 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, 7.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour ; QL (150 EA per 0 days) ; QL (90 EA per 0 days) QL (10 EA per 0 days) fentanyl transdermal patch 7 hour 1 mcg/hr QL (0 EA per 0 days) fentanyl transdermal patch 7 hour 5 mcg/hr QL (0 EA per 0 days) hydrocodone-acetaminophen oral solution /15 ml QL (10 ML per 1 day) 017 Medicare Drug Formulary Effective: November 1, 017

10 hydrocodone-acetaminophen oral tablet 10-00, 10-5,.5-5, 5-00, 5-5, , QL (8 EA per 1 day) hydrocodone-ibuprofen oral tablet QL (8 EA per 1 day) hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone (pf) injection solution /ml QL (0 ML per 0 days) hydromorphone injection solution /ml QL (0 ML per 0 days) hydromorphone injection syringe /ml, /ml QL (0 ML per 0 days) hydromorphone oral liquid 1 /ml QL (00 ML per 0 days) hydromorphone oral tablet, QL (0 EA per 0 days) hydromorphone oral tablet 8 QL (10 EA per 0 days) LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY, 00 MCG/SPRAY ; QL (0 EA per 0 days) ; QL (15 EA per 0 days) lorcet (hydrocodone) oral tablet 5-5 QL (8 EA per 1 day) lorcet hd oral tablet 10-5 QL (8 EA per 1 day) lorcet plus oral tablet QL (8 EA per 1 day) marten-tab oral tablet 50-5 methadone intensol oral concentrate 10 /ml QL (10 ML per 0 days) methadone oral solution 10 /5 ml QL (600 ML per 0 days) methadone oral solution 5 /5 ml QL (100 ML per 0 days) methadone oral tablet 10 QL (10 EA per 0 days) methadone oral tablet 5 QL (0 EA per 0 days) morphine (pf) injection solution 0.5 /ml QL (0 ML per 0 days) morphine concentrate oral solution 100 /5 ml (0 /ml) QL (180 ML per 0 days) morphine oral solution 10 /5 ml QL (1800 ML per 0 days) morphine oral solution 0 /5 ml ( /ml) QL (900 ML per 0 days) morphine oral tablet 15 QL (0 EA per 0 days) morphine oral tablet 0 QL (10 EA per 0 days) morphine oral tablet extended release 15, 0 QL ( EA per 1 day) morphine oral tablet extended release 60 QL ( EA per 1 day) 017 Medicare Drug Formulary Effective: November 1, 017

11 oxycodone oral capsule 5 QL (0 EA per 0 days) oxycodone oral concentrate 0 /ml QL (10 ML per 0 days) oxycodone oral solution 5 /5 ml QL (00 ML per 0 days) oxycodone oral tablet 10, 5 QL (0 EA per 0 days) oxycodone oral tablet 15 QL (180 EA per 0 days) oxycodone oral tablet 0 QL (10 EA per 0 days) oxycodone oral tablet,oral only,ext.rel.1 hr 10, 0 oxycodone oral tablet,oral only,ext.rel.1 hr 15 oxycodone oral tablet,oral only,ext.rel.1 hr 0 oxycodone oral tablet,oral only,ext.rel.1 hr 0 oxycodone oral tablet,oral only,ext.rel.1 hr 60 oxycodone oral tablet,oral only,ext.rel.1 hr 80 oxycodone-acetaminophen oral solution 5-5 /5 ml oxycodone-acetaminophen oral tablet 10-5,.5-5, 5-5, QL (10 EA per 0 days) QL (10 EA per 0 days) QL (60 EA per 0 days) QL (60 EA per 0 days) PA PA QL (0 ML per 1 day) QL (8 EA per 1 day) oxycodone-aspirin oral tablet QL (0 EA per 0 days) OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 0 MG, 0 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 60 MG, 80 MG tencon oral tablet 50-5 QL (10 EA per 0 days) QL (60 EA per 0 days) PA tramadol oral tablet 50 1 QL (8 EA per 1 day) vicodin es oral tablet QL (8 EA per 1 day) vicodin hp oral tablet QL (8 EA per 1 day) vicodin oral tablet 5-00 QL (8 EA per 1 day) Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule 100, 00, 00, Medicare Drug Formulary Effective: November 1, 017 5

12 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical gel 1 % etodolac oral capsule 00, 00 etodolac oral tablet 00, 500 etodolac oral tablet extended release hr 00, 500, 600 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5 ml ibuprofen oral tablet 00, 600, INDOCIN ORAL SUSPENSION 5 MG/5 ML indomethacin oral capsule 5, 50 1 ketorolac oral tablet 10 QL (0 EA per 0 days) meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml naproxen oral tablet 50, 75, naproxen oral tablet,delayed release (dr/ec) 75, 500 naproxen sodium oral tablet 75, 550 piroxicam oral capsule 10, 0 sulindac oral tablet 150, 00 tolmetin oral capsule 00 tolmetin oral tablet 00, 600 VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 10 /ml (1 %) 1 BvD lidocaine (pf) injection solution 5 /ml (0.5 %) BvD lidocaine hcl injection solution 5 /ml (0.5 %) BvD lidocaine hcl mucous membrane jelly % 017 Medicare Drug Formulary Effective: November 1, 017 6

13 lidocaine hcl mucous membrane solution % (0 /ml) lidocaine hcl(pf) in 0.9% nacl injection syringe 100 /10 ml (1 %) 1 1 BvD lidocaine topical adhesive patch,medicated 5 % PA; QL (90 EA per 0 days) lidocaine topical ointment 5 % BvD lidocaine viscous mucous membrane solution % 1 lidocaine-prilocaine topical cream.5-.5 % BvD Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) buprenorphine hcl sublingual tablet QL (60 EA per 0 days) buprenorphine hcl sublingual tablet 8 QL (90 EA per 0 days) buprenorphine-naloxone sublingual tablet -0.5 QL (60 EA per 0 days) buprenorphine-naloxone sublingual tablet 8- QL (90 EA per 0 days) buproban oral tablet extended release 1 hr 150 CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG QL ( EA per 1 day) CHANTIX ORAL TABLET 0.5 MG, 1 MG QL ( EA per 1 day) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG () disulfiram oral tablet 50, 500 naloxone injection solution 0. /ml naloxone injection syringe 0. /ml, 1 /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON-AEROSOL MG/ACTUATION, MG/ACTUATION NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 10 MG/ML QL (5 EA per 8 days) SUBOXONE SUBLINGUAL FILM 1- MG QL (60 EA per 0 days) 017 Medicare Drug Formulary Effective: November 1, 017 7

14 SUBOXONE SUBLINGUAL FILM -0.5 MG QL (60 EA per 0 days) SUBOXONE SUBLINGUAL FILM -1 MG QL (180 EA per 0 days) SUBOXONE SUBLINGUAL FILM 8- MG QL (90 EA per 0 days) Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 1 QL (180 EA per 0 days) alprazolam oral tablet 1 QL (150 EA per 0 days) alprazolam oral tablet extended release hr 0.5, 1 alprazolam oral tablet extended release hr alprazolam oral tablet extended release hr QL (6 EA per 1 day) QL (5 EA per 1 day) QL ( EA per 1 day) chlordiazepoxide hcl oral capsule 10, 5 QL (180 EA per 0 days) chlordiazepoxide hcl oral capsule 5 QL (10 EA per 0 days) clonazepam oral tablet QL (180 EA per 0 days) clonazepam oral tablet 1 1 QL (10 EA per 0 days) clonazepam oral tablet 1 QL (00 EA per 0 days) clonazepam oral tablet,disintegrating 0.15, 0.5, 0.5 PA; QL (180 EA per 0 days) clonazepam oral tablet,disintegrating 1 PA; QL (10 EA per 0 days) clonazepam oral tablet,disintegrating PA; QL (00 EA per 0 days) clorazepate dipotassium oral tablet 15,.75, 7.5 DIASTAT ACUDIAL RECTAL KIT MG DIASTAT ACUDIAL RECTAL KIT MG QL (180 EA per 0 days) QL (0 EA per 0 days) QL (0 EA per 0 days) DIASTAT RECTAL KIT.5 MG QL (0 EA per 0 days) diazepam intensol oral concentrate 5 /ml QL (0 ML per 0 days) diazepam oral solution 5 /5 ml (1 /ml) QL (100 ML per 0 days) diazepam oral tablet 10 1 QL (10 EA per 0 days) diazepam oral tablet, 5 1 QL (180 EA per 0 days) diazepam rectal kit ,.5 QL (0 EA per 0 days) diazepam rectal kit QL (0 EA per 0 days) lorazepam oral concentrate /ml QL (150 ML per 0 days) 017 Medicare Drug Formulary Effective: November 1, 017 8

15 lorazepam oral tablet 0.5, 1, 1 QL (180 EA per 0 days) ONFI ORAL SUSPENSION.5 MG/ML QL (80 ML per 0 days) ONFI ORAL TABLET 10 MG QL (10 EA per 0 days) ONFI ORAL TABLET 0 MG QL (60 EA per 0 days) Antibacterials Aminoglycosides amikacin injection solution 1,000 / ml, 500 / ml BETHKIS INHALATION SOLUTION FOR NEBULIZATION 00 MG/ ML gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 0 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml neomycin oral tablet 500 streptomycin intramuscular recon soln 1 gram TOBI INHALATION SOLUTION FOR NEBULIZATION 00 MG/5 ML TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 00 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 0 /ml Antibacterials, Miscellaneous chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150, 00, 75 clindamycin palmitate hcl oral recon soln 75 /5 ml PA 5 5 PA; NM; BvD; QL ( ML per 0 days) PA; NM; LA; BvD; QL (80 ML per 0 days) ; QL ( EA per 0 days) 5 PA PA 1 PA; NM; BvD; QL (80 ML per 0 days) 017 Medicare Drug Formulary Effective: November 1, 017 9

16 clindamycin phosphate injection solution 150 (/ml) (6 ml), 150 /ml clindamycin phosphate intravenous solution 600 / ml colistin (colistimethate na) injection recon soln 150 CUBICIN INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 linezolid intravenous parenteral solution 600 /00 ml linezolid oral suspension for reconstitution 100 /5 ml linezolid oral tablet 600 metronidazole in nacl (iso-os) intravenous piggyback 500 /100 ml metronidazole oral tablet 50, 500 MONUROL ORAL PACKET GRAM nitrofurantoin macrocrystal oral capsule 100, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 100 nitrofurantoin oral suspension 5 /5 ml SIVEXTRO INTRAVENOUS RECON SOLN 00 MG SIVEXTRO ORAL TABLET 00 MG SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 vancomycin intravenous recon soln 1,000, 10 gram, 750 vancomycin oral capsule 15, 50 5 NM XIFAXAN ORAL TABLET 00 MG, 550 MG Cephalosporins cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram 017 Medicare Drug Formulary Effective: November 1,

17 cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefepime in dextrose 5 % intravenous piggyback gram/50 ml cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml cefepime injection recon soln 1 gram, gram cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml cefoxitin intravenous recon soln 1 gram, gram cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml cefprozil oral suspension for reconstitution 50 /5 ml cefprozil oral tablet 50, 500 CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 50 MG/5 ML ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml, gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 1.5 gram, 750 cefuroxime sodium intravenous recon soln 1.5 gram cefuroxime-dextrose (iso-osm) intravenous piggyback 750 /50 ml cephalexin oral capsule 50, cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml SUPRAX ORAL CAPSULE 00 MG TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG 017 Medicare Drug Formulary Effective: November 1,

18 Macrolides azithromycin intravenous recon soln 500 azithromycin oral suspension for reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50, 500, clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 DIFICID ORAL TABLET 00 MG e.e.s. 00 oral tablet 00 ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50,, 500 erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet 00 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 50, 500 INVANZ INJECTION RECON SOLN 1 GRAM MEROPENEM INTRAVENOUS RECON SOLN 1 GRAM, 500 MG Penicillins amoxicillin oral capsule 50, amoxicillin oral suspension for reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, amoxicillin oral tablet,chewable 15, PA; NM; LA; QL (8 ML per 0 days) 017 Medicare Drug Formulary Effective: November 1, 017 1

19 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet 50-15, , amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, ampicillin oral suspension for reconstitution 15 /5 ml, 50 /5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln 15 gram, gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) dicloxacillin oral capsule 50, 500 nafcillin injection recon soln 10 gram, gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln 0 million unit penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, piperacillin-tazobactam intravenous recon soln 1.5 gram,.5 gram,.75 gram,.5 gram, 0.5 gram Quinolones ciprofloxacin hcl oral tablet 100, 50, 500, 750 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml, 00 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 00 /0 ml Medicare Drug Formulary Effective: November 1, 017 1

20 ciprofloxacin oral suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50, 500, moxifloxacin oral tablet 00 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral tablet 00-80, sulfasalazine oral tablet 500 sulfasalazine oral tablet,delayed release (dr/ec) 500 sulfatrim oral suspension 00-0 /5 ml Tetracyclines demeclocycline oral tablet 150, 00 doxy-100 intravenous recon soln 100 doxycycline hyclate intravenous recon soln 100 doxycycline hyclate oral tablet 0 doxycycline monohydrate oral capsule 100, 50 doxycycline monohydrate oral tablet 100, 50 minocycline oral capsule 100, 50, 75 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 5 NM TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG 1 5 NM 017 Medicare Drug Formulary Effective: November 1, 017 1

21 ADCETRIS INTRAVENOUS RECON SOLN 50 MG AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 MG, 5 MG, 7.5 MG ; LA 5 NM 5 NM ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG ALUNBRIG ORAL TABLET 0 MG anastrozole oral tablet 1 ARRANON INTRAVENOUS SOLUTION 50 MG/50 ML ARZERRA INTRAVENOUS SOLUTION 1,000 MG/50 ML, 100 MG/5 ML AVASTIN INTRAVENOUS SOLUTION 5 MG/ML, 5 MG/ML (16 ML) azacitidine injection recon soln 100 BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 5 MG/ML BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 5 NM bicalutamide oral tablet 50 BICNU INTRAVENOUS RECON SOLN 100 MG PA bleomycin injection recon soln 15 unit, 0 unit PA; BvD BLINCYTO INTRAVENOUS KIT 5 MCG BOSULIF ORAL TABLET 100 MG, 500 MG busulfan intravenous solution 60 /10 ml BUSULFEX INTRAVENOUS SOLUTION 60 MG/10 ML 017 Medicare Drug Formulary Effective: November 1,

22 CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG CAMPTOSAR INTRAVENOUS SOLUTION 00 MG/15 ML CAPRELSA ORAL TABLET 100 MG, 00 MG PA 5 NM; LA carboplatin intravenous solution 10 /ml PA cisplatin intravenous solution 1 /ml PA cladribine intravenous solution 10 /10 ml PA; BvD clofarabine intravenous solution 0 /0 ml CLOLAR INTRAVENOUS SOLUTION 0 MG/0 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) COSMEGEN INTRAVENOUS RECON SOLN 0.5 MG ; LA COTELLIC ORAL TABLET 0 MG cyclophosphamide oral capsule 5, 50 BvD CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) cytarabine (pf) injection solution gram/0 ml (100 /ml) PA; BvD cytarabine injection solution 0 /ml PA; BvD dacarbazine intravenous recon soln 100, 00 DARZALEX INTRAVENOUS SOLUTION 0 MG/ML PA daunorubicin intravenous solution 5 /ml PA decitabine intravenous recon soln 50 docetaxel intravenous solution 10 /7 ml (0 /ml), 160 /16 ml (10 /ml), 80 / ml (0 /ml) doxorubicin, peg-liposomal intravenous suspension /ml EMCYT ORAL CAPSULE 10 MG PA; BvD 017 Medicare Drug Formulary Effective: November 1,

23 EMPLICITI INTRAVENOUS RECON SOLN 00 MG, 00 MG epirubicin intravenous recon soln 50 PA epirubicin intravenous solution 00 /100 ml, 50 /5 ml ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML, 00 MG/100 ML PA ERIVEDGE ORAL CAPSULE 150 MG ; LA ERWINAZE INJECTION RECON SOLN 10,000 UNIT ETOPOSIDE INTRAVENOUS SOLUTION 0 MG/ML exemestane oral tablet 5 FARESTON ORAL TABLET 60 MG 5 NM FARYDAK ORAL CAPSULE 10 MG, 15 MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG, 80 MG fludarabine intravenous solution 50 / ml PA fluorouracil intravenous solution 1 gram/0 ml, 5 gram/100 ml, 500 /10 ml flutamide oral capsule 15 FOLOTYN INTRAVENOUS SOLUTION 0 MG/ML (1 ML) GAZYVA INTRAVENOUS SOLUTION 1,000 MG/0 ML gemcitabine intravenous recon soln 1 gram, gram, 00 gemcitabine intravenous solution 1 gram/6. ml (8 /ml), gram/5.6 ml (8 /ml), 00 /5.6 ml (8 /ml) GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 0 MG, 5 MG PA; BvD ; LA 017 Medicare Drug Formulary Effective: November 1,

24 HALAVEN INTRAVENOUS SOLUTION 1 MG/ ML (0.5 MG/ML) HERCEPTIN INTRAVENOUS RECON SOLN 150 MG, 0 MG HEXALEN ORAL CAPSULE 50 MG 5 NM hydroxyurea oral capsule 500 IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG ICLUSIG ORAL TABLET 15 MG, 5 MG ; LA idarubicin intravenous solution 1 /ml PA IDHIFA ORAL TABLET 100 MG, 50 MG ifosfamide intravenous solution 1 gram/0 ml PA imatinib oral tablet 100, 00 5 NM IMBRUVICA ORAL CAPSULE 10 MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML, 10EXP8 (100 MILLION) PFU/ML ; BvD INLYTA ORAL TABLET 1 MG, 5 MG ; LA IRESSA ORAL TABLET 50 MG irinotecan intravenous solution 100 /5 ml, 0 / ml, 500 /5 ml ISTODAX INTRAVENOUS RECON SOLN 10 MG/ ML IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 5 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG JEVTANA INTRAVENOUS SOLUTION 10 MG/ML (FIRST DILUTION) KADCYLA INTRAVENOUS RECON SOLN 100 MG, 160 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML PA ; LA ; LA 017 Medicare Drug Formulary Effective: November 1,

25 KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG, 00 MG/DAY(00 MG X )-.5 MG, 600 MG/DAY(00 MG X )-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1), 00 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X ) KYPROLIS INTRAVENOUS RECON SOLN 0 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 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), 8 MG/DAY ( MG X ) letrozole oral tablet.5 LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit 1 /0. ml LONSURF ORAL TABLET MG, 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 ; LA LYNPARZA ORAL CAPSULE 50 MG LYNPARZA ORAL TABLET 100 MG, 150 MG LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 MG/1 ML(0.16 MG/ML) FINAL MATULANE ORAL CAPSULE 50 MG ; LA megestrol oral tablet 0, 0 MEKINIST ORAL TABLET 0.5 MG, MG 017 Medicare Drug Formulary Effective: November 1,

26 melphalan hcl intravenous recon soln 50 mercaptopurine oral tablet 50 methotrexate sodium (pf) injection solution 5 /ml BvD methotrexate sodium oral tablet.5 BvD mitomycin intravenous recon soln 0, 0, 5 MITOXANTRONE INTRAVENOUS CONCENTRATE MG/ML MUSTARGEN INJECTION RECON SOLN 10 MG MYLOTARG INTRAVENOUS RECON SOLN.5 MG (1 MG/ML INITIAL CONC) PA PA PA NERLYNX ORAL TABLET 0 MG NEXAVAR ORAL TABLET 00 MG 5 NM; LA nilutamide oral tablet 150 NINLARO ORAL CAPSULE. MG, MG, MG ODOMZO ORAL CAPSULE 00 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS DISPERSION. MG/ML OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 0 MG/ ML oxaliplatin intravenous recon soln 100, 50 PA oxaliplatin intravenous solution 100 /0 ml, 50 /10 ml (5 /ml) PA paclitaxel intravenous concentrate 6 /ml PA PERJETA INTRAVENOUS SOLUTION 0 MG/1 ML (0 MG/ML) PHOTOFRIN INTRAVENOUS RECON SOLN 75 MG POMALYST ORAL CAPSULE 1 MG, MG, MG, MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) ; LA ; LA ; LA 017 Medicare Drug Formulary Effective: November 1, 017 0

27 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 NM; LA ; BvD RYDAPT ORAL CAPSULE 5 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 10 MG, 0 MG, 50 MG, 70 MG, 80 MG 5 NM STIVARGA ORAL TABLET 0 MG ; LA SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 7.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 00 MG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG TABLOID ORAL TABLET 0 MG 5 NM TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 0 MG, 80 MG tamoxifen oral tablet 10, 0 TARCEVA ORAL TABLET 100 MG, 150 MG, 5 MG 5 NM TARGRETIN TOPICAL GEL 1 % 5 NM TASIGNA ORAL CAPSULE 150 MG, 00 MG TECENTRIQ INTRAVENOUS SOLUTION 1,00 MG/0 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG 5 NM PA teniposide intravenous solution 50 /5 ml 017 Medicare Drug Formulary Effective: November 1, 017 1

28 thiotepa injection recon soln 15 PA topotecan intravenous solution / ml (1 /ml) TORISEL INTRAVENOUS RECON SOLN 0 MG/ ML (10 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON SOLN 100 MG TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 MG TRELSTAR INTRAMUSCULAR SYRINGE 11.5 MG/ ML,.5 MG/ ML,.75 MG/ ML 5 NM tretinoin (chemotherapy) oral capsule 10 5 NM TRISENOX INTRAVENOUS SOLUTION 10 MG/10 ML TYKERB ORAL TABLET 50 MG 5 NM; LA UNITUXIN INTRAVENOUS SOLUTION.5 MG/ML VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (0 MG/ML), 00 MG/0 ML (0 MG/ML) VELCADE INJECTION RECON SOLN.5 MG VENCLEXTA ORAL TABLET 10 MG, 50 MG PA VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG vinblastine intravenous solution 1 /ml PA; BvD vincasar pfs intravenous solution 1 /ml PA vincristine intravenous solution 1 /ml PA vinorelbine intravenous solution 10 /ml, 50 /5 ml PA VOTRIENT ORAL TABLET 00 MG 5 NM 017 Medicare Drug Formulary Effective: November 1, 017

29 VYXEOS INTRAVENOUS RECON SOLN -100 MG XALKORI ORAL CAPSULE 00 MG, 50 MG ; LA XATMEP ORAL SOLUTION.5 MG/ML PA XTANDI ORAL CAPSULE 0 MG ; LA YERVOY INTRAVENOUS SOLUTION 00 MG/0 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG ZALTRAP INTRAVENOUS SOLUTION 100 MG/ ML (5 MG/ML), 00 MG/8 ML (5 MG/ML) ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM ; BvD PA ZEJULA ORAL CAPSULE 100 MG ZELBORAF ORAL TABLET 0 MG ; LA ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 50 MG, 500 MG ; LA Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0.1 /ml propantheline oral tablet 15 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG PA APTIOM ORAL TABLET 00 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 0 MG/ML 5 NM BANZEL ORAL TABLET 00 MG, 00 MG 5 NM BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML 017 Medicare Drug Formulary Effective: November 1, 017

30 BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 1 hr 100, 00, 00 carbamazepine oral suspension 100 /5 ml carbamazepine oral tablet 00 carbamazepine oral tablet extended release 1 hr 100, 00, 00 carbamazepine oral tablet,chewable 100 CELONTIN ORAL CAPSULE 00 MG DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, delayed rel sprinkle 15 divalproex oral tablet extended release hr 50, 500 divalproex oral tablet,delayed release (dr/ec) 15, 50, 500 epitol oral tablet 00 ethosuximide oral capsule 50 ethosuximide oral solution 50 /5 ml 5 NM felbamate oral suspension 600 /5 ml 5 NM felbamate oral tablet 00, 600 FYCOMPA ORAL SUSPENSION 0.5 MG/ML PA FYCOMPA ORAL TABLET 10 MG, 1 MG, MG, MG, 6 MG, 8 MG gabapentin oral capsule 100, 00, 00 gabapentin oral solution 50 /5 ml gabapentin oral tablet 600, 800 GABITRIL ORAL TABLET 1 MG, 16 MG lamotrigine oral tablet 100, 150, 00, 5 lamotrigine oral tablet, chewable dispersible 5, 5 lamotrigine oral tablet,disintegrating 100, 00, 5, 50 lamotrigine oral tablets,dose pack 5 (5) PA 017 Medicare Drug Formulary Effective: November 1, 017

31 levetiracetam in nacl (iso-os) intravenous piggyback 1,000 /100 ml, 1,500 /100 ml, 500 /100 ml levetiracetam intravenous solution 500 /5 ml levetiracetam oral solution 100 /ml levetiracetam oral tablet 1,000, 50, 500, 750 LEVETIRACETAM ORAL TABLET EXTENDED RELEASE HR 500 MG, 750 MG LYRICA ORAL CAPSULE 100 MG, 150 MG, 00 MG, 5 MG, 50 MG, 75 MG QL ( EA per 1 day) LYRICA ORAL CAPSULE 5 MG, 00 MG QL ( EA per 1 day) LYRICA ORAL SOLUTION 0 MG/ML QL (0 ML per 1 day) 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 phenobarbital oral tablet., 6.8, 97. phenytoin oral suspension 15 /5 ml phenytoin oral syringe 100 / ml phenytoin oral tablet,chewable 50 phenytoin sodium extended oral capsule 100, 00, 00 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml PA POTIGA ORAL TABLET 00 MG, 50 MG QL (6 EA per 1 day) POTIGA ORAL TABLET 00 MG, 00 MG QL ( EA per 1 day) primidone oral tablet 50, Medicare Drug Formulary Effective: November 1, 017 5

32 SABRIL ORAL POWDER IN PACKET 500 MG ; LA SABRIL ORAL TABLET 500 MG ; LA SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 50 MG, 500 MG, 750 MG tiagabine oral tablet, topiramate oral capsule, sprinkle 15, 5 topiramate oral tablet 100, 00, 5, 50 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE HR 100 MG, 00 MG, 5 MG, 50 MG valproate sodium intravenous solution 500 /5 ml (100 /ml) valproic acid (as sodium salt) oral solution 50 /5 ml valproic acid oral capsule 50 PA PA vigabatrin oral powder in packet 500 ; LA VIMPAT INTRAVENOUS SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 10 MG/ML QL (0 ML per 1 day) VIMPAT ORAL TABLET 100 MG QL ( EA per 1 day) VIMPAT ORAL TABLET 150 MG, 00 MG QL ( EA per 1 day) VIMPAT ORAL TABLET 50 MG QL (8 EA per 1 day) zonisamide oral capsule 100, 5, 50 Antidementia Agents Antidementia Agents donepezil oral tablet 10, 5 donepezil oral tablet,disintegrating 10, 5 galantamine oral capsule,ext rel. pellets hr 16,, 8 galantamine oral solution /ml galantamine oral tablet 1,, 8 memantine oral solution /ml memantine oral tablet 10, 5 memantine oral tablets,dose pack Medicare Drug Formulary Effective: November 1, 017 6

33 rivastigmine tartrate oral capsule 1.5,,.5, 6 rivastigmine transdermal patch hour 1. / hour,.6 / hr, 9.5 / hr Antidepressants Antidepressants amitriptyline oral tablet 10, 100, 150, 5, 50, 75 amoxapine oral tablet 100, 150, 5, 50 BRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG bupropion hcl (smoking deter) oral tablet extended release 1 hr 150 bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release 1 hr 100, 150, 00 bupropion hcl oral tablet extended release hr 150, 00 citalopram oral solution 10 /5 ml citalopram oral tablet 10, 0, 0 1 PA PA clomipramine oral capsule 5, 50, 75 PA desipramine oral tablet 10, 100, 150, 5, 50, 75 DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE HR 100 MG, 50 MG desvenlafaxine oral tablet extended release hr 100, 50 desvenlafaxine oral tablet extended release hr 100, 50 desvenlafaxine succinate oral tablet extended release hr 100, 50 desvenlafaxine succinate oral tablet extended release hr 5 doxepin oral capsule 10, 100, 150, 5, 50, 75 PA PA PA PA PA doxepin oral concentrate 10 /ml PA 017 Medicare Drug Formulary Effective: November 1, 017 7

34 duloxetine oral capsule,delayed release(dr/ec) 0, 0, 60 EMSAM TRANSDERMAL PATCH HOUR 1 MG/ HR, 6 MG/ HR, 9 MG/ HR escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 0, 5 FETZIMA ORAL CAPSULE,EXT REL HR DOSE PACK 0 MG ()- 0 MG (6) FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 10 MG, 0 MG, 0 MG, 80 MG fluoxetine oral capsule 10, 0, 0 1 fluoxetine oral solution 0 /5 ml ( /ml) 1 fluvoxamine oral tablet 100, 5, 50 1 PA PA imipramine hcl oral tablet 10, 5, 50 PA maprotiline oral tablet 5, 50, 75 MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15, 0, 5 mirtazapine oral tablet 7.5 mirtazapine oral tablet,disintegrating 15, 0, 5 nefazodone oral tablet 100, 150, 00, 50, 50 nortriptyline oral capsule 10, 5, 50, 75 nortriptyline oral solution 10 /5 ml paroxetine hcl oral tablet 10, 0, 0, 0 PAXIL ORAL SUSPENSION 10 MG/5 ML phenelzine oral tablet 15 PRISTIQ ORAL TABLET EXTENDED RELEASE HR 100 MG, 50 MG PRISTIQ ORAL TABLET EXTENDED RELEASE HR 5 MG protriptyline oral tablet 10, 5 sertraline oral concentrate 0 /ml 1 1 PA 017 Medicare Drug Formulary Effective: November 1, 017 8

35 sertraline oral tablet 100, 5, 50 1 tranylcypromine oral tablet 10 trazodone oral tablet 100, 150, 00, 50 trimipramine oral capsule 100, 5, 50 PA TRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG venlafaxine oral capsule,extended release hr 150, 7.5, 75 venlafaxine oral tablet 100, 5, 7.5, 50, 75 VIIBRYD ORAL TABLET 10 MG, 0 MG, 0 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG () Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100, 5, 50 BYDUREON SUBCUTANEOUS PEN INJECTOR MG/0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON MG BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(50 MCG/ML). ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (50 MCG/ML) 1. ML 1 PA PA PA CYCLOSET ORAL TABLET 0.8 MG PA INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG, MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 MG, 00 MG QL ( EA per 8 days) QL ( EA per 8 days) QL (. ML per 0 days) QL (1. ML per 0 days) ST; QL (60 EA per 0 days) ST; QL (60 EA per 0 days) ST JARDIANCE ORAL TABLET 10 MG, 5 MG ST 017 Medicare Drug Formulary Effective: November 1, 017 9

36 JENTADUETO ORAL TABLET.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC HR.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC HR 5-1,000 MG QL (60 EA per 0 days) QL (60 EA per 0 days) QL (0 EA per 0 days) KORLYM ORAL TABLET 00 MG metformin oral tablet 1,000 1 QL (75 EA per 0 days) metformin oral tablet QL (150 EA per 0 days) metformin oral tablet QL (90 EA per 0 days) metformin oral tablet extended release hr 500 metformin oral tablet extended release hr 750 metformin oral tablet extended release hr 1,000 metformin oral tablet extended release hr 500 miglitol oral tablet 100, 5, 50 nateglinide oral tablet 10, 60 1 QL (10 EA per 0 days) 1 QL (60 EA per 0 days) QL (10 EA per 0 days) pioglitazone oral tablet 15 QL (90 EA per 0 days) pioglitazone oral tablet 0, 5 QL (0 EA per 0 days) pioglitazone-glimepiride oral tablet 0-, 0- pioglitazone-metformin oral tablet , repaglinide oral tablet 0.5, 1, SYMLINPEN 10 SUBCUTANEOUS PEN INJECTOR,700 MCG/.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET 1.5-1,000 MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC HR 10-1,000 MG, 1.5-1,000 MG, 5-1,000 MG, 5-1,000 MG TRADJENTA ORAL TABLET 5 MG QL (0 EA per 0 days) QL (90 EA per 0 days) ST ST 017 Medicare Drug Formulary Effective: November 1, 017 0