FirstMedicare Direct HMO preferred Plus Advantage Formulary. (List of Covered Drugs)

Transcription

1 FirstMedicare Direct HMO preferred Plus 209 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 2/28/209. For more recent information or other questions, please contact FirstMedicare Direct Member Services at or, for TTY users 7, 24 hours a day, 7 days a week, or visit The 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 FirstMedicare Direct 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: 90, Version Number: Effective Date: 03/0/209 H6306_9852_C FMDApproved-0/0/208

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 03/0/209. 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, 209, and from time to time during the year. Formulary ID: 90, Version Number: Effective Date: 03/0/209 H6306_9852_C FMDApproved-0/0/208

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 209 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 209 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, we must notify affected members of the change at least 30 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 30-day supply of the drug. The enclosed formulary is current as of 03/0/209. 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: 90, Version Number: Effective Date: 03/0/209 H6306_9852_C FMDApproved-0/0/208

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 3. 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-. 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 30 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 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: 90, Version Number: Effective Date: 03/0/209 H6306_9852_C FMDApproved-0/0/208

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 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. For more information, 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 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 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 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. Formulary ID: 90, Version Number: Effective Date: 03/0/209 H6306_9852_C FMDApproved-0/0/208

6 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 30-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30 day supply of medication. After your first 30-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 3-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 ( ) 24 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-. 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: 90, Version Number: Effective Date: 03/0/209 H6306_9852_C FMDApproved-0/0/208

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 64 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 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 Formulary ID: 90, Version Number: Effective Date: 03/0/209 H6306_9852_C FMDApproved-0/0/208

8 ABBREVIATION DESCRIPTION EXPLANATION medical condition. This drug may only be covered if the other drug(s) does not work for you. OTHER SPECIAL REQUIREMENTS FOR COVERAGE 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 , 24 hours a day/7 days a week. TTY/TDD users should call 7. STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 2h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 2h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm DESCRIPTION adhesive patch aerosol, breath activated aerosol, powder aerosol powder, breath activated aerosol refill aerosol with adapter ampule bulk bag injection capsule, delayed release multiphasic capsule, dose pack capsule, 2 hour extended release capsule, 24 hour extended release capsule, extended release degradable capsule, extended release pellets capsule, multiphasic capsule, 24 hour sustained action capsule, 2 hour sustained release capsule, 24 hour sustained release capsule, 24 hour controlled-onset pellets capsule, 24 hour sustained release pellets capsule, sprinkle capsule sustained release pellets capsule with device capsule, delayed release capsule, extended release capsule, sustained action combination: capsule, pad combination: ointment, foam Formulary ID: 90, Version Number: Effective Date: 03/0/209 H6306_9852_C FMDApproved-0/0/208

9 ABBREVIATION DESCRIPTION cmb ont lt combination: ointment, lotion cmb tabpad combination: tablet, pad combo. pkg combination package cpmp 2hr capsule, 2 hour multiphasic cpmp 24hr capsule, 24 hour multiphasic cpmp capsule, multiphasic, 30%-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(2-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 Formulary ID: 90, Version Number: Effective Date: 03/0/209 H6306_9852_C FMDApproved-0/0/208

10 ABBREVIATION m.ht patch ma buc tab Mcg med. pad med. swab med. tape Mg Ml muc er 2h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 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 24h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew DESCRIPTION medicated heated patch mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram milliliter mucoadhesive system, 2 hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 24 hour transdermal patch, 72 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, 24 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable Formulary ID: 90, Version Number: Effective Date: 03/0/209 H6306_9852_C FMDApproved-0/0/208

11 ABBREVIATION tab er 2h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 2h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 2hr tbmp 24hr U vag ring DESCRIPTION tablet, 2 hour extended release tablet, 24 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 24 hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 2 hour sustained release tablet, 24 hour sustained release tablet, 24 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, 3-month dose pack tablet, 2 hour multiphasic tablet, 24 hour multiphasic unit vaginal ring Formulary ID: 90, Version Number: Effective Date: 03/0/209 H6306_9852_C FMDApproved-0/0/208

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 42 Memorial Drive Pinehurst, NC 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, 200 Independence Avenue SW., Room 509F, HHS Building, Washington, DC 2020, , (TDD). Complaint forms are available at Y0094_9027_C

13 MULTI-LANGUAGE INTERPRETER SERVICES Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY 7). 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 7) 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 7). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY 7) 번으로전화해주십시오. Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS 7). (Arabic) العر ية ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم -<< (رقم ھاتف الصم والبكم: 7 -TTY Hmoob (Hmong) Y0094_9027_C

14 LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY 7). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 7). 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 7). 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 7). ខ រ (Cambodian) របយ ត ប ស នជ អ កន យ យ ភ ស 矄 ខ រ, សវ ជ ន យ ផ កភ ស ⱀ ដ យម នគ តឈ ល គ ឣ ចម នស រ ប ប រ អ ក ច រ ទ រស ព (TTY 7) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY 7). 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 7) 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 7). 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:7) まで お電話にてご連絡ください Y0094_9027_C

15 Table of Contents Analgesics...3 Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents...7 Antianxiety Agents...8 Antibacterials... 9 Anticancer Agents... 6 Anticholinergic Agents Anticonvulsants...27 Antidementia Agents...30 Antidepressants... 3 Antidiabetic Agents Antifungals...37 Antigout Agents Antihistamines...38 Anti-Infectives (Skin And Mucous Membrane)...39 Antimigraine Agents...39 Antimycobacterials...40 Antinausea Agents...4 Antiparasite Agents...42 Antiparkinsonian Agents...43 Antipsychotic Agents...44 Antivirals (Systemic)...49 Blood Products/Modifiers/Volume Expanders Caloric Agents...58 Cardiovascular Agents... 6 Central Nervous System Agents Contraceptives...73 Dental And Oral Agents...80 Dermatological Agents...80 Devices Enzyme Replacement/Modifiers...84 Eye, Ear, Nose, Throat Agents...86 Gastrointestinal Agents Genitourinary Agents...93 Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying... 94

16 Immunological Agents...00 Inflammatory Bowel Disease Agents Irrigating Solutions...0 Metabolic Bone Disease Agents...0 Miscellaneous Therapeutic Agents... Ophthalmic Agents...3 Replacement Preparations... 4 Respiratory Tract Agents... 7 Skeletal Muscle Relaxants... 2 Sleep Disorder Agents Vasodilating Agents...22 Vitamins And Minerals

17 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 20- QL (2700 per 30 2 /5 ml acetaminophen-codeine oral tablet QL (360 per 30 acetaminophen-codeine oral tablet (Tylenol-Codeine #3) QL (360 per 30 acetaminophen-codeine oral tablet (Tylenol-Codeine #4) QL (80 per 30 buprenorphine hcl injection solution 0.3 (Buprenex) /ml buprenorphine hcl injection syringe 0.3 /ml butalbital-acetaminophen-caff oral tablet (Esgic) QL (80 per butalbital-aspirin-caffeine oral capsule (Fiorinal) QL (80 per butalbital-aspirin-caffeine oral tablet 50- QL (80 per codeine sulfate oral tablet 5, 30, QL (80 per endocet oral tablet QL (80 per 30 endocet oral tablet , QL (360 per 30 endocet oral tablet QL (240 per 30 fentanyl citrate buccal lozenge on a handle,200 mcg,,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution /5 ml hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet (Actiq) PA; QL (20 per 30 (Duragesic) QL (0 per 30 QL (2700 per 30 (Lorcet HD) QL (80 per 30 (Verdrocet) QL (240 per 30 (Lorcet (hydrocodone)) QL (240 per 30 (Lorcet Plus) QL (80 per 30 3

18 hydrocodone-ibuprofen oral tablet 7.5- QL (50 per hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone oral liquid /ml (Dilaudid) QL (200 per 30 hydromorphone oral tablet 2, 4, 8 (Dilaudid) QL (80 per 30 HYSINGLA ER ORAL QL (30 per 30 TABLET,ORAL ONLY,EXT.REL.24 HR 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 300 PA; QL (30 per 30 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet QL (240 per 30 lorcet hd oral tablet QL (80 per 30 lorcet plus oral tablet QL (80 per 30 methadone injection solution 0 /ml methadone oral solution 0 /5 ml QL (600 per 30 methadone oral solution 5 /5 ml QL (200 per 30 methadone oral tablet 0 (Dolophine) QL (20 per 30 methadone oral tablet 5 (Dolophine) QL (80 per 30 methadose oral tablet,soluble 40 QL (30 per 30 morphine 0 /ml isecure syrg l/f, p/f, suv, inner 0 /ml morphine concentrate oral solution 00 QL (80 per 30 /5 ml (20 /ml) morphine injection syringe 0 /ml morphine intravenous solution 0 /ml morphine oral solution 0 /5 ml QL (700 per 30 morphine oral solution 20 /5 ml (4 QL (300 per 30 /ml) MORPHINE ORAL TABLET 5 MG QL (80 per 30 MORPHINE ORAL TABLET 30 MG QL (20 per 30 morphine oral tablet extended release 00 (MS Contin) QL (60 per 30, 200, 60 morphine oral tablet extended release 5, 30 (MS Contin) QL (90 per 30 4

19 NUCYNTA ER ORAL TABLET QL (60 per 30 EXTENDED RELEASE 2 HR 00 MG, 50 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 00 MG, QL (8 per MG, 75 MG oxycodone oral solution 5 /5 ml QL (300 per 30 oxycodone oral tablet 0 QL (80 per 30 oxycodone oral tablet 5, 30 (Roxicodone) QL (20 per 30 oxycodone oral tablet 20 QL (20 per 30 oxycodone oral tablet 5 (Roxicodone) QL (80 per 30 oxycodone oral tablet,oral only,ext.rel.2 (OxyContin) QL (60 per 30 hr 0, 5, 20, 30, 40, 60, 80 oxycodone-acetaminophen oral solution QL (800 per /5 ml oxycodone-acetaminophen oral tablet 0- (Endocet) QL (80 per oxycodone-acetaminophen oral tablet (Endocet) QL (360 per , oxycodone-acetaminophen oral tablet (Endocet) QL (240 per oxycodone-aspirin oral tablet QL (360 per 30 OXYCONTIN ORAL QL (60 per 30 TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 00 MG/0.5 ML, 300 MG/.5 ML tramadol oral tablet 50 (Ultram) QL (240 per 30 tramadol-acetaminophen oral tablet (Ultracet) QL (240 per XTAMPZA ER ORAL QL (60 per 30 CAPSULE,SPRINKLE,ER 2HR TMPRR 3.5 MG, 8 MG, 9 MG XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 2HR TMPRR 27 MG QL (20 per 30 5

20 XTAMPZA ER ORAL QL (240 per 30 CAPSULE,SPRINKLE,ER 2HR TMPRR 36 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8 ML (00 MG/ML) celecoxib oral capsule 00, 200, (Celebrex) QL (60 per diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 25, 50, 75 diclofenac sodium topical drops.5 % QL (300 per 30 diclofenac sodium topical gel 3 % (Solaraze) PA; QL (00 per 28 etodolac oral capsule 200, 300 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 FLECTOR TRANSDERMAL PA PATCH 2 HOUR.3 % flurbiprofen oral tablet 00, 50 ibu oral tablet 400, 600, 800 ibuprofen oral suspension 00 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, (IBU) 800 indomethacin oral capsule 25 QL (240 per 30 indomethacin oral capsule 50 QL (20 per 30 indomethacin sodium intravenous recon soln ketorolac oral tablet 0 QL (20 per 30 mefenamic acid oral capsule 250 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral tablet 250, 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (dr/ec) 375, 500 (EC-Naprosyn) 6

21 PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 MG/GRAM /ACTUATION(2 %) PA; QL (224 per 28 sulindac oral tablet 50, 200 VOLTAREN TOPICAL GEL % Anesthetics Local Anesthetics glydo mucous membrane jelly in QL (30 per 30 applicator 2 % lidocaine (pf) injection solution 0 /ml (Xylocaine-MPF) ( %), 5 /ml (.5 %), 20 /ml (2 %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl injection solution 0 /ml ( %), 20 /ml (2 %), 5 /ml (0.5 %) (Xylocaine) lidocaine hcl mucous membrane jelly 2 % QL (30 per 30 lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 30 lidocaine topical ointment 5 % PA; QL (90 per 30 lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 buprenorphine hcl sublingual tablet 2, 8 buprenorphine-naloxone sublingual tablet 2-0.5, 8-2 bupropion hcl (smoking deter) oral tablet extended release 2 hr 50 (Zyban) PA; QL (30 per 30 QL (90 per 30 QL (90 per 30 7

22 CHANTIX CONTINUING MONTH QL (336 per 365 BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, QL (336 per 365 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) QL (06 per 365 disulfiram oral tablet 250, 500 (Antabuse) LUCEMYRA ORAL TABLET 0.8 QL (228 per 4 MG naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL (4 per 30 AEROSOL 4 MG/ACTUATION NICOTROL INHALATION QL (008 per 90 CARTRIDGE 0 MG SUBOXONE SUBLINGUAL FILM QL (60 per MG, 8-2 MG SUBOXONE SUBLINGUAL FILM 2- QL (30 per MG, 4- MG ZUBSOLV SUBLINGUAL TABLET QL (30 per MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET QL (60 per MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25, 0.5, (Xanax) QL (20 per 30 alprazolam oral tablet 2 (Xanax) QL (50 per 30 buspirone oral tablet 0, 5, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 0, QL (20 per 30 25, 5 clobazam oral suspension 2.5 /ml (Onfi) PA NSO; QL (480 per 30 clobazam oral tablet 0, 20 (Onfi) PA NSO; QL (60 per 30 clonazepam oral tablet 0.5, (Klonopin) QL (90 per 30 8

23 clonazepam oral tablet 2 (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating QL (90 per , 0.25, 0.5, clonazepam oral tablet,disintegrating 2 QL (300 per 30 clorazepate dipotassium oral tablet 5 QL (80 per 30, 3.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (80 per 30 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT 2.5 MG diazepam injection solution 5 /ml QL (0 per 28 diazepam injection syringe 5 /ml QL (0 per 28 diazepam intensol oral concentrate 5 QL (200 per 30 /ml diazepam oral solution 5 /5 ml ( QL (200 per 30 /ml) diazepam oral tablet 0, 2, 5 (Valium) QL (20 per 30 diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit 2.5 (Diastat) lorazepam injection solution 2 /ml, 4 (Ativan) QL (2 per 30 /ml lorazepam injection syringe 2 /ml, 4 QL (2 per 30 /ml lorazepam oral tablet 0.5, (Ativan) QL (90 per 30 lorazepam oral tablet 2 (Ativan) QL (50 per 30 ONFI ORAL SUSPENSION 2.5 MG/ML PA NSO; QL (480 per 30 ONFI ORAL TABLET 0 MG, 20 MG PA NSO; QL (60 per 30 temazepam oral capsule 5, 30 (Restoril) QL (30 per 30 Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML PA BvD 9

24 gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 00 /50 ml, 20 /00 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin injection solution 20 /2 ml, 40 /ml gentamicin sulfate (ped) (pf) injection solution 20 /2 ml gentamicin sulfate (pf) intravenous solution 00 /0 ml, 60 /6 ml, 80 /8 ml neomycin oral tablet 500 streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION QL (224 per 28 CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation (Tobi) PA BvD solution for nebulization 300 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 0 /ml, 40 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln (BACiiM) 50,000 unit chloramphenicol sod succinate intravenous recon soln gram clindamycin hcl oral capsule 50, 300 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 50 /ml clindamycin phosphate intravenous solution 600 /4 ml (Cleocin) 0

25 colistin (colistimethate na) injection (Coly-Mycin M PA BvD recon soln 50 Parenteral) daptomycin intravenous recon soln 350 daptomycin intravenous recon soln 500 (Cubicin) FIRVANQ ORAL RECON SOLN 25 MG/ML, 50 MG/ML linezolid 600 /300 ml-0.9% nacl 600 /300 ml linezolid in dextrose 5% intravenous (Zyvox) piggyback 600 /300 ml linezolid oral suspension for (Zyvox) reconstitution 00 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet (Hiprex) gram metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml (Metro I.V.) metronidazole oral tablet 250, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule (Macrodantin) QL (20 per 30 00, 25, 50 nitrofurantoin monohyd/m-cryst oral (Macrobid) QL (60 per 30 capsule 00 polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 vancomycin intravenous recon soln,000 PA BvD,.25 gram, 0 gram, 250, 5 gram, 500, 750 vancomycin oral capsule 25, 250 (Vancocin) XIFAXAN ORAL TABLET 200 MG PA; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG PA Cephalosporins cefaclor oral capsule 250, 500 cefaclor oral suspension for reconstitution 25 /5 ml, 250 /5 ml, 375 /5 ml cefadroxil oral capsule 500

26 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml cefazolin injection recon soln gram, 0 gram, 500 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefditoren pivoxil oral tablet 200 cefditoren pivoxil oral tablet 400 (Spectracef) cefepime injection recon soln gram, 2 (Maxipime) gram cefotaxime injection recon soln gram, 500 cefotaxime injection recon soln 0 gram, (Claforan) 2 gram cefoxitin intravenous recon soln gram, 0 gram, 2 gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 200 cefprozil oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 ceftazidime injection recon soln gram (Fortaz) ceftazidime injection recon soln 2 gram, 6 (TAZICEF) gram ceftibuten oral capsule 400 ceftibuten oral suspension for reconstitution 80 /5 ml ceftriaxone injection recon soln gram, 0 gram, 2 gram, 250, 500 cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 250, 500 (Keflex) 2

27 cephalexin oral suspension for reconstitution 25 /5 ml, 250 /5 ml SUPRAX ORAL CAPSULE 400 MG tazicef injection recon soln gram, 2 gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 200 /5 ml azithromycin oral tablet 250 (6 pack), 500 (3 pack), 600 azithromycin oral tablet 250, 500 (Zithromax) clarithromycin oral suspension for reconstitution 25 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 DIFICID ORAL TABLET 200 MG ST; QL (20 per 0 erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 200 /5 ml erythromycin oral tablet 250, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram, 2 gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML LA ertapenem injection recon soln gram (Invanz) imipenem-cilastatin intravenous recon soln 250 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln (Merrem) gram, 500 Penicillins amoxicillin oral capsule 250, 500 3

28 amoxicillin oral suspension for reconstitution 25 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 25, 250 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 250, 500 ampicillin sodium injection recon soln gram, 0 gram, 25, 2 gram, 250, 500 ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln (Unasyn).5 gram, 5 gram, 3 gram BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250, 500 nafcillin gm/ 50 ml inj gram/50 ml nafcillin injection recon soln gram nafcillin injection recon soln 0 gram, 2 gram nafcillin intravenous recon soln 2 gram oxacillin gm add-vantage vl addvantage, inner gram oxacillin injection recon soln gram, 0 gram, 2 gram penicillin g potassium injection recon soln 20 million unit (Pfizerpen-G) 4

29 penicillin g procaine intramuscular syringe.2 million unit/2 ml, 600,000 unit/ml penicillin v potassium oral recon soln 25 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous (Zosyn) PA BvD recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones BAXDELA ORAL TABLET 450 MG PA; QL (28 per 4 ciprofloxacin hcl oral tablet 250, 500 (Cipro) ciprofloxacin hcl oral tablet 750 ciprofloxacin in 5 % dextrose intravenous piggyback 200 /00 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /200 ml ciprofloxacin lactate intravenous solution 200 /20 ml, 400 /40 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 250 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 25 /ml levofloxacin oral solution 250 /0 ml levofloxacin oral tablet 250 levofloxacin oral tablet 500, 750 (Levaquin) moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 300, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml 5

30 sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) tablet sulfatrim oral suspension /5 ml Tetracyclines doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon (Doxy-00) soln 00 doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 20 doxycycline monohydrate oral capsule (Mondoxyne NL) 00, 50 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 25 /5 ml doxycycline monohydrate oral tablet 00 (Avidoxy) doxycycline monohydrate oral tablet 50 minocycline oral capsule 00, 75 minocycline oral capsule 50 (Minocin) mondoxyne nl oral capsule 00, 50 okebo oral capsule 00 tetracycline oral capsule 250, 500 tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG adriamycin intravenous solution 0 /5 PA BvD ml, 2 /ml, 20 /0 ml, 50 /25 ml adrucil intravenous solution 2.5 gram/50 ml, 500 /0 ml PA BvD 6

31 AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG PA NSO; QL (2 per 28 AFINITOR ORAL TABLET 0 MG PA NSO; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG PA NSO; QL (28 per 28 ALECENSA ORAL CAPSULE 50 MG PA NSO; QL (240 per 30 ALIMTA INTRAVENOUS RECON SOLN 00 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG PA NSO; QL (3 per 28 ALUNBRIG ORAL TABLET 80 MG, 90 MG PA NSO; QL (30 per 30 ALUNBRIG ORAL TABLET 30 MG PA NSO; QL (20 per 30 ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG (23) PA NSO; QL (30 per 30 anastrozole oral tablet (Arimidex) arsenic trioxide intravenous solution /ml AVASTIN INTRAVENOUS SOLUTION 25 MG/ML PA NSO azacitidine injection recon soln 00 (Vidaza) BAVENCIO INTRAVENOUS PA NSO SOLUTION 20 MG/ML BELEODAQ INTRAVENOUS PA NSO RECON SOLN 500 MG BENDEKA INTRAVENOUS PA NSO SOLUTION 25 MG/ML BESPONSA INTRAVENOUS PA NSO RECON SOLN 0.9 MG (0.25 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) PA NSO; QL (420 per 30 bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 5 unit, 30 PA BvD unit BLINCYTO INTRAVENOUS KIT 35 MCG PA NSO 7

32 BORTEZOMIB INTRAVENOUS PA NSO RECON SOLN 3.5 MG BOSULIF ORAL TABLET 00 MG PA NSO; QL (90 per 30 BOSULIF ORAL TABLET 400 MG, 500 MG PA NSO; QL (30 per 30 BRAFTOVI ORAL CAPSULE 50 MG PA NSO; QL (20 per 30 BRAFTOVI ORAL CAPSULE 75 MG PA NSO; QL (80 per 30 CABOMETYX ORAL TABLET 20 MG, 60 MG PA NSO; QL (30 per 30 CABOMETYX ORAL TABLET 40 MG PA NSO; QL (60 per 30 CALQUENCE ORAL CAPSULE 00 MG PA NSO; QL (60 per 30 CAPRELSA ORAL TABLET 00 MG PA NSO; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG PA NSO; QL (30 per 30 clofarabine intravenous solution 20 /20 (Clolar) ml COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-20 MG X), 40 PA NSO; QL (2 per 28 MG/DAY(80 MG X-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COPIKTRA ORAL CAPSULE 5 MG, 25 MG PA NSO; QL (56 per 28 COTELLIC ORAL TABLET 20 MG PA NSO; LA; QL (63 per 28 cyclophosphamide intravenous recon soln PA BvD gram, 2 gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 25 MG, 50 MG CYRAMZA INTRAVENOUS PA NSO SOLUTION 0 MG/ML DARZALEX INTRAVENOUS SOLUTION 20 MG/ML PA NSO; LA DAURISMO ORAL TABLET 00 MG PA NSO; QL (30 per 30 8

33 DAURISMO ORAL TABLET 25 MG PA NSO; QL (60 per 30 decitabine intravenous recon soln 50 (Dacogen) doxorubicin intravenous solution 0 /5 (Adriamycin) PA BvD ml, 2 /ml, 20 /0 ml, 50 /25 ml doxorubicin, peg-liposomal intravenous (Doxil) PA BvD suspension 2 /ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS PA NSO RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG PA NSO; QL (30 per 30 ERLEADA ORAL TABLET 60 MG PA NSO; QL (20 per 30 ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG etoposide intravenous solution 20 /ml (Toposar) exemestane oral tablet 25 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 PA NSO MG, 5 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil intravenous solution PA BvD gram/20 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/00 ml, 500 /0 ml flutamide oral capsule 25 9

34 GAZYVA INTRAVENOUS PA NSO SOLUTION,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG PA NSO; QL (30 per 30 GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS PA NSO RECON SOLN 50 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG PA NSO; QL (2 per 28 ICLUSIG ORAL TABLET 5 MG PA NSO; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG PA NSO; QL (30 per 30 IDHIFA ORAL TABLET 00 MG, 50 MG PA NSO; QL (30 per 30 ifosfamide intravenous recon soln gram (Ifex) PA BvD ifosfamide intravenous solution gram/20 PA BvD ml, 3 gram/60 ml ifosfamide-mesna intravenous kit - PA BvD gram, 3,000-,000 imatinib oral tablet 00 (Gleevec) PA NSO; QL (90 per 30 imatinib oral tablet 400 (Gleevec) PA NSO; QL (60 per 30 IMBRUVICA ORAL CAPSULE 40 MG, 70 MG PA NSO; QL (28 per 28 IMBRUVICA ORAL TABLET 40 MG, 280 MG, 420 MG, 560 MG PA NSO; QL (28 per 28 IMFINZI INTRAVENOUS PA NSO SOLUTION 50 MG/ML IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML PA NSO; QL (4 per 365 IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML PA NSO; QL (8 per 28 INLYTA ORAL TABLET MG PA NSO; QL (80 per 30 20

35 INLYTA ORAL TABLET 5 MG PA NSO; QL (60 per 30 IRESSA ORAL TABLET 250 MG PA NSO; QL (60 per 30 IXEMPRA INTRAVENOUS RECON SOLN 5 MG, 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG PA NSO; QL (60 per 30 KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML PA NSO; QL (8 per 2 KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X )-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X ) KISQALI ORAL TABLET 400 MG/DAY (200 MG X 2) KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 0 MG, 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 0 MG/ML LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), 2 MG/DAY (4 MG X 3), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 4 MG, 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit /0.2 ml PA NSO; QL (49 per 28 PA NSO; QL (70 per 28 PA NSO; QL (9 per 28 PA NSO; QL (2 per 28 PA NSO; QL (42 per 28 PA NSO; QL (63 per 28 PA NSO PA NSO; LA PA NSO 2