FirstMedicare Direct smarthmo Advantage Formulary. (List of Covered Drugs)

Transcription

1 FirstMedicare Direct smarthmo 019 Advantage Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on /8/019. For more recent information or other questions, please contact FirstMedicare Direct Member Services at or, for TTY users, 711, hours a day/7 days a week, or visit firstmedicare.com. This Formulary may change at any time. You will receive notice when necessary. FirstCarolinaCare Insurance Company is a HMO and PPO health plan with a Medicare contract. Enrollment in a FirstMedicareDirect plan depends on contract renewal. FirstCarolinaCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Formulary ID: 1916, Version Number: 11 Effective: 0/01/019 H606_195_C

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means FirstCarolinaCare Insurance Company. When it refers to plan or our plan, it means FirstMedicare Direct. This document includes a list of the drugs (formulary) for our plan which is current as of 0/01/019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 019, and from time to time during the year. Formulary ID: 1916, Version Number: 11 Effective: 0/01/019 H606_195_C

3 What is the FirstMedicare Direct Formulary? A formulary is a list of covered drugs selected by FirstMedicare Direct 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. FirstMedicare Direct will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a FirstMedicare Direct network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same costsharing 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 FirstMedicare Direct 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 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 0/01/019. To get updated information about the drugs covered by FirstMedicare Direct, please contact us. Our contact information appears on the front and back cover pages. Formulary ID: 1916, Version Number: 11 Effective: 0/01/019 H606_195_C

4 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 on page number. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? FirstMedicare Direct 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: FirstMedicare Direct requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from FirstMedicare Direct before you fill your prescriptions. If you don t get approval, FirstMedicare Direct may not cover the drug. Quantity Limits: For certain drugs, FirstMedicare Direct limits the amount of the drug that FirstMedicare Direct will cover. For example, FirstMedicare Direct provides 0 tablets per prescription for pioglitazone. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, FirstMedicare Direct 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, FirstMedicare Direct may not cover Drug B unless you try Drug A first. If Drug A does not work for you, FirstMedicare Direct 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 documents that explain our prior authorization restriction or step therapy restriction or 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. Formulary ID: 1916, Version Number: 11 Effective: 0/01/019 H606_195_C

5 You can ask FirstMedicare Direct 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 FirstMedicare Direct s formulary? on page 5 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 FirstMedicare Direct does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by FirstMedicare Direct. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by FirstMedicare Direct. You can ask FirstMedicare Direct 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 FirstMedicare Direct Formulary? You can ask FirstMedicare Direct 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, FirstMedicare Direct 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, FirstMedicare Direct 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) Formulary ID: 1916, Version Number: 11 Effective: 0/01/019 H606_195_C

6 exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 0 day supply of medication. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-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 care facilities from hospitals or enter an ambulatory setting from a hospital). For more information For more detailed information about your FirstMedicare Direct prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about FirstMedicare Direct, 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 FirstMedicare Direct s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by FirstMedicare Direct. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if FirstMedicare Direct has any special requirements for coverage of your drug. Formulary ID: 1916, Version Number: 11 Effective: 0/01/019 H606_195_C

7 The following abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION GENERAL generic(brand) UTILIZATION MANAGEMENT RESTRICTIONS AGE NDS PA PA B v D PA HRM PA NSO QL ST Restriction for members over 6 years of age Non-Extended Days Supply Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medication Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction OTHER SPECIAL REQUIREMENTS FOR COVERAGE The reference brand name in parentheses is provided for information only, to assist in identifying the generic medication and does NOT indicate formulary status or coverage A clinical review may be required for members 65 years of age and older. Without prior approval, FirstMedicare Direct may not cover this drug. This drug is not available for an extended day supply (example: 90 days supply) You (or your physician) are required to get prior authorization from FirstMedicare Direct before you fill your prescription for this drug. Without prior approval, FirstMedicare Direct may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from FirstMedicare Direct to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, FirstMedicare Direct may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 and older. Members age 65 years and older are required to get prior authorization from FirstMedicare Direct before you fill your prescription for this drug. Without prior approval, FirstMedicare Direct may not cover this drug. If you are a new member, you (or your physician) are required to get prior authorization from FirstMedicare Direct before you fill your prescription for this drug. Without prior approval, FirstMedicare Direct may not cover this drug. FirstMedicare Direct limits the amount of this drug that is covered per prescription, or within a specific time frame. Before FirstMedicare Direct will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. Formulary ID: 1916, Version Number: 11 Effective: 0/01/019 H606_195_C

8 ABBREVIATION DESCRIPTION EXPLANATION GC LA Gap Coverage Limited Access Drug We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at , hours a day/7 days a week. TTY/TDD users should call 711. STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION DESCRIPTION adh. patch adhesive patch aer br act aerosol, breath activated aer pow aerosol, powder aer pow ba aerosol powder, breath activated aer refill aerosol refill aer w/adap aerosol with adapter ampul ampule blkbaginj bulk bag injection cap dr mp capsule, delayed release multiphasic cap ds pk capsule, dose pack cap er 1h capsule, 1 hour extended release cap er h capsule, hour extended release cap er deg capsule, extended release degradable cap er pel capsule, extended release pellets cap mphase capsule, multiphasic cap.sa h capsule, hour sustained action cap.sr 1h capsule, 1 hour sustained release cap.sr h capsule, hour sustained release caph pct capsule, hour controlled-onset pellets caph pel capsule, hour sustained release pellets cap sprink capsule, sprinkle cap sr pel capsule sustained release pellets cap w/dev capsule with device capsule dr capsule, delayed release capsule er capsule, extended release capsule sa capsule, sustained action cmb cappad combination: capsule, pad cmb ont fm combination: ointment, foam cmb ont lt combination: ointment, lotion cmb tabpad combination: tablet, pad combo. pkg combination package cpmp 1hr capsule, 1 hour multiphasic cpmp hr capsule, hour multiphasic Formulary ID: 1916, Version Number: 11 Effective: 0/01/019 H606_195_C

9 ABBREVIATION DESCRIPTION cpmp 0-70 capsule, multiphasic, 0%-70% cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package dehp fr bg di(-ethylhexyl)phthalate free bag dis needle disposable needle disk w/dev disk with inhalation device disp syrin disposable syringe drops susp drops, suspension drps hpvis drops, hyperviscous emul adhes emulsion adhesive emul packt emulsion packet emulsn(g) emulsion (grams) foam/appl. foam with applicator froz.piggy frozen piggyback G gram gel/pf app gel with prefilled applicator gel (gm) gel (grams) gel (ml) gel (milliliters) gel md pmp gel in metered dose pump gel w/appl gel with applicator gel w/pump gel with pump gran pack granule pack hfa aer ad hfa aerosol adapter infus. btl infusion bottle insuln pen insulin pen ip soln intraperitoneal solution irrig soln irrigating solution iv soln. intravenous solution Jel jelly jelly/app jelly with applicator jel/pf app jelly with pre-filled applicator kit cl&crm kit: cleanser and cream kt crm le kit: cream, lotion emollient kt lotn ce kit: lotion, cream emollient kt oint le kit: ointment, lotion emollient lotion, er lotion, extended release lozenge hd lozenge handle m.ht patch medicated heated patch ma buc tab mucoadhesive buccal tablet Mcg microgram med. pad medicated pad med. swab medicated swab Formulary ID: 1916, Version Number: 11 Effective: 0/01/019 H606_195_C

10 ABBREVIATION med. tape Mg Ml muc er 1h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td patch td7 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 1h tab er h tab er prt tab er seq tab disper DESCRIPTION medicated tape milligram milliliter mucoadhesive system, 1 hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, hour transdermal patch, 7 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal suppository suspension, hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, 1 hour extended release tablet, hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible Formulary ID: 1916, Version Number: 11 Effective: 0/01/019 H606_195_C

11 ABBREVIATION tab ds pk tab er tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 1h tab.sr h tabergrhr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk mo tbmp 1hr tbmp hr U vag ring DESCRIPTION tablet, dose pack tablet, hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 1 hour sustained release tablet, hour sustained release tablet, hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack tablet, rapid disintegrating dose pack tablet, -month dose pack tablet, 1 hour multiphasic tablet, hour multiphasic unit vaginal ring Formulary ID: 1916, Version Number: 11 Effective: 0/01/019 H606_195_C

12 Discrimination is Against the Law FirstCarolinaCare Insurance Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. FirstCarolinaCare Insurance Company does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. FirstCarolinaCare Insurance Company provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages. If you need these services, contact the Civil Rights Coordinator for FirstCarolinaCare Insurance Company. If you believe that FirstCarolinaCare Insurance Company has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: FCC Civil Rights Coordinator FirstCarolinaCare Insurance Company Memorial Drive Pinehurst, NC 87 Telephone: Fax number: fccfmd@firstcarolinacare.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the FCC Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 00 Independence Avenue SW., Room 509F, HHS Building, Washington, DC 001, , (TDD). Complaint forms are available at Y009_1907_C

13 MULTI-LANGUAGE INTERPRETER SERVICES Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY 711). 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY 711) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY 711) 번으로전화해주십시오. Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS 711). (Arabic) العر ية ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 1-<< (رقم ھاتف الصم والبكم: 711 -TTY Hmoob (Hmong) Y009_1907_C

14 LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY 711). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Tagalog (Tagalog Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY 711). જર ત (Gujarati) ચન : જ તમ જર ત બ લત હ, ત ન: લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY 711). ខ រ (Cambodian) របយ ត ប ស នជ អ កន យ យ ភ ស ខ រ, សវ ជ ន យ ផ កភ ស ដ យម នគ តឈ ល គ ឣ ចម នស រ ប ប រ អ ក ច រ ទ រស ព (TTY 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY 711). ह द (Hindi) ध य न द : य द आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY 711) पर क ल कर ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບລການຊ ວຍເຫ ອ ດ ານພາສາ, ໂດຍບ ເ ສ ຽ ຄ າ, ແ ມ ນ ມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY 711). 日本語 (Japanese) 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます ( TTY:711) まで お電話にてご連絡ください Y009_1907_C

15 Table of Contents Analgesics... Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents...7 Antianxiety Agents...8 Antibacterials Anticancer Agents Anticholinergic Agents... 7 Anticonvulsants...7 Antidementia Agents...0 Antidepressants... 1 Antidiabetic Agents... Antifungals...7 Antigout Agents... 9 Antihistamines...9 Anti-Infectives (Skin And Mucous Membrane)...0 Antimigraine Agents...0 Antimycobacterials...1 Antinausea Agents...1 Antiparasite Agents... Antiparkinsonian Agents... Antipsychotic Agents...5 Antivirals (Systemic)...50 Blood Products/Modifiers/Volume Expanders Caloric Agents...59 Cardiovascular Agents... 6 Central Nervous System Agents Contraceptives...7 Dental And Oral Agents...81 Dermatological Agents...81 Devices Enzyme Replacement/Modifiers...85 Eye, Ear, Nose, Throat Agents...87 Gastrointestinal Agents Genitourinary Agents...9 Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying

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

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

18 hydrocodone-ibuprofen oral tablet 7.5- QL (150 per 0 00 hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 per 0 hydromorphone oral tablet,, 8 (Dilaudid) QL (180 per 0 HYSINGLA ER ORAL QL (0 per 0 TABLET,ORAL ONLY,EXT.REL. HR 100 MG, 10 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 00 ; QL (0 per 0 MCG/SPRAY, 00 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-5 QL (0 per 0 lorcet hd oral tablet 10-5 QL (180 per 0 lorcet plus oral tablet QL (180 per 0 methadone injection solution 10 /ml methadone oral solution 10 /5 ml QL (600 per 0 methadone oral solution 5 /5 ml QL (100 per 0 methadone oral tablet 10 (Dolophine) QL (10 per 0 methadone oral tablet 5 (Dolophine) QL (180 per 0 methadose oral tablet,soluble 0 QL (0 per 0 morphine 10 /ml isecure syrg l/f, p/f, suv, inner 10 /ml morphine concentrate oral solution 100 QL (180 per 0 /5 ml (0 /ml) morphine injection syringe 10 /ml morphine intravenous solution 10 /ml morphine oral solution 10 /5 ml QL (700 per 0 morphine oral solution 0 /5 ml ( QL (00 per 0 /ml) MORPHINE ORAL TABLET 15 MG QL (180 per 0 MORPHINE ORAL TABLET 0 MG QL (10 per 0 morphine oral tablet extended release 100 (MS Contin) QL (60 per 0, 00, 60 morphine oral tablet extended release 15, 0 (MS Contin) QL (90 per 0

19 NUCYNTA ER ORAL TABLET QL (60 per 0 EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, QL (181 per 0 50 MG, 75 MG oxycodone oral solution 5 /5 ml QL (100 per 0 oxycodone oral tablet 10 QL (180 per 0 oxycodone oral tablet 15, 0 (Roxicodone) QL (10 per 0 oxycodone oral tablet 0 QL (10 per 0 oxycodone oral tablet 5 (Roxicodone) QL (180 per 0 oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 per 0 hr 10, 15, 0, 0, 0, 60, 80 oxycodone-acetaminophen oral solution QL (1800 per /5 ml oxycodone-acetaminophen oral tablet 10- (Endocet) QL (180 per 0 5 oxycodone-acetaminophen oral tablet (Endocet) QL (60 per 0.5-5, 5-5 oxycodone-acetaminophen oral tablet (Endocet) QL (0 per oxycodone-aspirin oral tablet QL (60 per 0 OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 00 MG/1.5 ML tramadol oral tablet 50 (Ultram) 1 GC; QL (0 per 0 tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (0 per 0 5 XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 1HR TMPRR 1.5 MG, 18 MG, 9 MG QL (60 per 0 5

20 XTAMPZA ER ORAL QL (10 per 0 CAPSULE,SPRINKLE,ER 1HR TMPRR 7 MG XTAMPZA ER ORAL QL (0 per 0 CAPSULE,SPRINKLE,ER 1HR TMPRR 6 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8 ML (100 MG/ML) celecoxib oral capsule 100, 00, (Celebrex) QL (60 per 0 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops 1.5 % QL (00 per 0 diclofenac sodium topical gel % (Solaraze) PA; QL (100 per 8 etodolac oral capsule 00, 00 etodolac oral tablet 00 (Lodine) etodolac oral tablet 500 FLECTOR TRANSDERMAL PA PATCH 1 HOUR 1. % flurbiprofen oral tablet 100, 50 ibu oral tablet 00, 600, GC ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 00, 600, (IBU) 1 GC 800 indomethacin oral capsule 5 1 GC; QL (0 per 0 indomethacin oral capsule 50 1 GC; QL (10 per 0 indomethacin sodium intravenous recon soln 1 ketorolac oral tablet 10 QL (0 per 0 mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) 1 GC 6

21 nabumetone oral tablet 500, 750 naproxen oral tablet 50, 75 1 GC naproxen oral tablet 500 (Naprosyn) 1 GC naproxen oral tablet,delayed release (dr/ec) 75, 500 (EC-Naprosyn) PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 0 MG/GRAM /ACTUATION( %) ; QL ( per 8 sulindac oral tablet 150, 00 VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in QL (0 per 0 applicator % lidocaine (pf) injection solution 10 /ml (Xylocaine-MPF) (1 %), 15 /ml (1.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 0 /ml ( %) lidocaine hcl injection solution 10 /ml (1 %), 0 /ml ( %), 5 /ml (0.5 %) (Xylocaine) lidocaine hcl mucous membrane jelly % QL (0 per 0 lidocaine hcl mucous membrane solution % (0 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 0 lidocaine topical ointment 5 % PA; QL (90 per 0 lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) buprenorphine hcl sublingual tablet, 8 PA; QL (0 per 0 QL (90 per 0 7

22 buprenorphine-naloxone sublingual tablet QL (90 per 0-0.5, 8- bupropion hcl (smoking deter) oral tablet (Zyban) extended release 1 hr 150 CHANTIX CONTINUING MONTH QL (6 per 65 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 QL (6 per 65 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG () QL (106 per 65 disulfiram oral tablet 50, 500 (Antabuse) LUCEMYRA ORAL TABLET 0.18 MG ; QL (8 per 1 naloxone injection solution 0. /ml naloxone injection syringe 0. /ml, 1 /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL ( per 0 AEROSOL MG/ACTUATION NICOTROL INHALATION QL (1008 per 90 CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM QL (60 per 0 1- MG, 8- MG SUBOXONE SUBLINGUAL FILM - QL (0 per MG, -1 MG ZUBSOLV SUBLINGUAL TABLET QL (0 per MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG QL (60 per 0 Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 (Xanax) 1 GC; QL (10 per 0 alprazolam oral tablet (Xanax) 1 GC; QL (150 per 0 buspirone oral tablet 10, 15, 0, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 5, 5 1 GC; QL (10 per 0 8

23 clobazam oral suspension.5 /ml (Onfi) PA NSO; QL (80 per 0 clobazam oral tablet 10, 0 (Onfi) PA NSO; QL (60 per 0 clonazepam oral tablet 0.5, 1 (Klonopin) 1 GC; QL (90 per 0 clonazepam oral tablet (Klonopin) 1 GC; QL (00 per 0 clonazepam oral tablet,disintegrating QL (90 per , 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 per 0 clorazepate dipotassium oral tablet 15 QL (180 per 0,.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (180 per 0 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG diazepam injection solution 5 /ml QL (10 per 8 diazepam injection syringe 5 /ml QL (10 per 8 diazepam intensol oral concentrate 5 QL (100 per 0 /ml diazepam oral solution 5 /5 ml (1 QL (100 per 0 /ml) diazepam oral tablet 10,, 5 (Valium) 1 GC; QL (10 per 0 diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml (Ativan) 1 GC; QL ( per 0 lorazepam injection solution /ml (Ativan) QL ( per 0 lorazepam injection syringe /ml, QL ( per 0 /ml lorazepam oral tablet 0.5, 1 (Ativan) 1 GC; QL (90 per 0 lorazepam oral tablet (Ativan) 1 GC; QL (150 per 0 ONFI ORAL SUSPENSION.5 MG/ML 5 PA NSO; NDS; QL (80 per 0 9

24 ONFI ORAL TABLET 10 MG, 0 MG 5 PA NSO; NDS; QL (60 per 0 temazepam oral capsule 15, 0 (Restoril) QL (0 per 0 Antibacterials Aminoglycosides BETHKIS INHALATION 5 PA BvD; NDS SOLUTION FOR NEBULIZATION 00 MG/ ML gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 10 /100 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 0 / ml, 0 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml, 60 /6 ml, 80 /8 ml neomycin oral tablet GC streptomycin intramuscular recon soln 1 gram 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 bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150, 00, 75 ; QL ( per 8 (Tobi) 5 PA BvD; NDS (BACiiM) (Cleocin HCl) 10

25 clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution 150 /ml clindamycin phosphate intravenous solution 600 / ml colistin (colistimethate na) injection recon soln 150 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 linezolid in dextrose 5% intravenous piggyback 600 /00 ml linezolid oral suspension for reconstitution 100 /5 ml (Cleocin) (Cleocin) (Coly-Mycin M Parenteral) 5 PA BvD; NDS (Cubicin) (Zyvox) (Zyvox) linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) intravenous piggyback 500 /100 ml (Metro I.V.) metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule (Macrodantin) QL (10 per 0 100, 50 nitrofurantoin macrocrystal oral capsule (Macrodantin) QL (10 per 0 5 nitrofurantoin monohyd/m-cryst oral (Macrobid) QL (60 per 0 capsule 100 polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet GC 11

26 vancomycin intravenous recon soln 1,000, 1.5 gram, 10 gram, 50, 5 gram, 500, 750 PA BvD vancomycin oral capsule 15 (Vancocin) vancomycin oral capsule 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG ; QL (9 per 0 XIFAXAN ORAL TABLET 550 MG Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 00 (Spectracef) cefepime injection recon soln 1 gram, (Maxipime) gram cefotaxime injection recon soln 1 gram, 500 cefotaxime injection recon soln 10 gram, (Claforan) gram cefoxitin intravenous recon soln 1 gram, 10 gram, gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln 1 gram (Fortaz) 1

27 ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftibuten oral capsule 00 ceftibuten oral suspension for reconstitution 180 /5 ml ceftriaxone injection recon soln 1 gram, 10 gram, gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex) 1 GC cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml SUPRAX ORAL CAPSULE 00 MG tazicef injection recon soln 1 gram, gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml azithromycin oral tablet 50 (6 1 GC pack), 500 ( pack) azithromycin oral tablet 50, 500 (Zithromax) 1 GC azithromycin oral tablet 600 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 DIFICID ORAL TABLET 00 MG 5 ST; NDS; QL (0 per 10 erythromycin ethylsuccinate oral suspension for reconstitution 00 /5 ml (E.E.S. Granules) 1

28 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 LA; NDS ertapenem injection recon soln 1 gram (Invanz) imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, GC amoxicillin oral suspension for 1 GC reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, GC amoxicillin oral tablet,chewable 15, 1 GC 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, GC ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram 1

29 ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin 1 gm/ 50 ml inj 1 gram/50 ml nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram nafcillin injection recon soln gram nafcillin intravenous recon soln gram oxacillin 1 gm add-vantage vl addvantage, inner 1 gram oxacillin injection recon soln 1 gram, 10 gram, gram penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 1 GC 500 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous (Zosyn) PA BvD recon soln.5 gram,.75 gram,.5 gram, 0.5 gram Quinolones BAXDELA ORAL TABLET 50 MG ; QL (8 per 1 ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 GC ciprofloxacin hcl oral tablet GC ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous piggyback 00 /00 ml (Cipro in D5W) 15

30 ciprofloxacin lactate intravenous solution 00 /0 ml, 00 /0 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50 1 GC levofloxacin oral tablet 500, 750 (Levaquin) 1 GC moxifloxacin oral tablet 00 (Avelox) ofloxacin oral tablet 00, 00 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) 1 GC tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) 1 GC tablet sulfatrim oral suspension 00-0 /5 ml Tetracyclines doxy-100 intravenous recon soln 100 doxycycline hyclate intravenous recon (Doxy-100) soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline monohydrate oral capsule (Mondoxyne NL) 100, 50 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) 16

31 doxycycline monohydrate oral tablet 50 minocycline oral capsule 100, 75 minocycline oral capsule 50 (Minocin) mondoxyne nl oral capsule 100, 50 okebo oral capsule 100 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 /5 PA BvD ml, /ml, 0 /10 ml, 50 /5 ml adrucil intravenous solution.5 gram/50 PA BvD ml, 500 /10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 5 PA NSO; NDS; QL (11 per 8 MG, 5 MG AFINITOR ORAL TABLET 10 MG 5 PA NSO; NDS; QL (56 per 8 AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA NSO; NDS; QL (8 per 8 ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (0 per 0 ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG 5 PA NSO; NDS; QL ( per 8 ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA NSO; NDS; QL (0 per 0 ALUNBRIG ORAL TABLET 0 MG 5 PA NSO; NDS; QL (10 per 0 ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG () 5 PA NSO; NDS; QL (0 per 0 anastrozole oral tablet 1 (Arimidex) 1 GC arsenic trioxide intravenous solution 1 /ml 17

32 AVASTIN INTRAVENOUS 5 PA NSO; NDS SOLUTION 5 MG/ML azacitidine injection recon soln 100 (Vidaza) BAVENCIO INTRAVENOUS 5 PA NSO; NDS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS 5 PA NSO; NDS RECON SOLN 500 MG BENDEKA INTRAVENOUS 5 PA NSO; NDS SOLUTION 5 MG/ML BESPONSA INTRAVENOUS 5 PA NSO; NDS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 5 PA NSO; NDS; QL (0 per 0 bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 15 unit, 0 PA BvD unit BLINCYTO INTRAVENOUS KIT 5 5 PA NSO; NDS MCG BORTEZOMIB INTRAVENOUS 5 PA NSO; NDS RECON SOLN.5 MG BOSULIF ORAL TABLET 100 MG 5 PA NSO; NDS; QL (90 per 0 BOSULIF ORAL TABLET 00 MG, 500 MG 5 PA NSO; NDS; QL (0 per 0 BRAFTOVI ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (10 per 0 BRAFTOVI ORAL CAPSULE 75 MG 5 PA NSO; NDS; QL (180 per 0 CABOMETYX ORAL TABLET 0 MG, 60 MG 5 PA NSO; NDS; QL (0 per 0 CABOMETYX ORAL TABLET 0 MG 5 PA NSO; NDS; QL (60 per 0 CALQUENCE ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (60 per 0 CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (60 per 0 CAPRELSA ORAL TABLET 00 MG 5 PA NSO; NDS; QL (0 per 0 clofarabine intravenous solution 0 /0 (Clolar) ml 18

33 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1), 10 MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) COPIKTRA ORAL CAPSULE 15 MG, 5 MG 5 PA NSO; NDS; QL (11 per 8 5 PA NSO; NDS; QL (56 per 8 COTELLIC ORAL TABLET 0 MG 5 PA NSO; LA; NDS; QL (6 per 8 5 PA BvD; NDS cyclophosphamide intravenous recon soln 1 gram, gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 5 PA NSO; NDS SOLUTION 10 MG/ML DARZALEX INTRAVENOUS 5 PA NSO; LA; NDS SOLUTION 0 MG/ML DAURISMO ORAL TABLET PA NSO; NDS; QL (0 MG per 0 DAURISMO ORAL TABLET 5 MG 5 PA NSO; NDS; QL (60 per 0 decitabine intravenous recon soln 50 (Dacogen) doxorubicin intravenous solution 10 /5 (Adriamycin) PA BvD ml, /ml, 0 /10 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) 5 PA BvD; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE.5 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 5 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 10 MG EMPLICITI INTRAVENOUS 5 PA NSO; NDS RECON SOLN 00 MG, 00 MG ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (0 per 0 19

34 ERLEADA ORAL TABLET 60 MG 5 PA NSO; NDS; QL (10 per 0 ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 5 PA NSO; NDS MG, 15 MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil intravenous solution 1 PA BvD gram/0 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/100 ml, 500 /10 ml flutamide oral capsule 15 GAZYVA INTRAVENOUS 5 PA NSO; NDS SOLUTION 1,000 MG/0 ML GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG 5 PA NSO; NDS; QL (0 per 0 GLEOSTINE ORAL CAPSULE 10 MG, 0 MG, 5 MG GLEOSTINE ORAL CAPSULE 100 MG HERCEPTIN INTRAVENOUS 5 PA NSO; NDS RECON SOLN 150 MG, 0 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG 5 PA NSO; NDS; QL (1 per 8 ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NDS; QL (60 per 0 ICLUSIG ORAL TABLET 5 MG 5 PA NSO; NDS; QL (0 per 0 IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA NSO; NDS; QL (0 per 0 ifosfamide intravenous recon soln 1 gram (Ifex) PA BvD ifosfamide intravenous solution 1 gram/0 ml, gram/60 ml PA BvD 0

35 ifosfamide-mesna intravenous kit PA BvD; NDS gram,,000-1,000 imatinib oral tablet 100 (Gleevec) 5 PA NSO; NDS; QL (90 per 0 imatinib oral tablet 00 (Gleevec) 5 PA NSO; NDS; QL (60 per 0 IMBRUVICA ORAL CAPSULE 10 MG, 70 MG 5 PA NSO; NDS; QL (8 per 8 IMBRUVICA ORAL TABLET 10 MG, 80 MG, 0 MG, 560 MG 5 PA NSO; NDS; QL (8 per 8 IMFINZI INTRAVENOUS 5 PA NSO; NDS SOLUTION 50 MG/ML IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML 5 PA NSO; NDS; QL ( per 65 IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML 5 PA NSO; NDS; QL (8 per 8 INLYTA ORAL TABLET 1 MG 5 PA NSO; NDS; QL (180 per 0 INLYTA ORAL TABLET 5 MG 5 PA NSO; NDS; QL (60 per 0 IRESSA ORAL TABLET 50 MG 5 PA NSO; NDS; QL (60 per 0 IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 5 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG 5 PA NSO; NDS; QL (60 per 0 KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML 5 PA NSO; NDS; QL (8 per 1 KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X )-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1) 5 PA NSO; NDS; QL (9 per 8 5 PA NSO; NDS; QL (70 per 8 5 PA NSO; NDS; QL (91 per 8 5 PA NSO; NDS; QL (1 per 8 1