Prominence Health Plan. NEVADA FORMULARY Commercial Membership. prominencehealthplan.com

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1 Prominence Health Plan NEVADA FORMULARY Commercial Membership prominencehealthplan.com

2 Get to Know Your Pharmacy Formulary Prominence Health Plan develops a medically sound formulary that supports patient health and is reviewed by a Pharmacy and Therapeutics Committee (P & T Committee), made up of practicing physicians, pharmacists, and nurses. The committee reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories. OUR PHARMACY PARTNERSHIPS MedImpact Prominence Health Plan partners with MedImpact to provide your pharmacy benefits. Once your group membership has been loaded into the MedImpact system, you can call the MedImpact Pharmacy Help Desk at (8) with questions regarding your prescription drug plan. Representatives are available hours a day, seven days a week to assist you. Or visit and enter the member information located on the back of your Prominence Health Plan member ID card. MedImpact Direct If you take prescribed medications regularly, you can have them delivered right to your door. MedImpact Direct offers custom delivery service for your maintenance medications the ones you take regularly for chronic or long-term conditions. This delivery option offers flexibility in payment options, how prescriptions are ordered and where they are delivered. Learn more at or call (855) Commcare Specialty Pharmacy For specialty pharmacy care, Prominence Health Plan partners with Commcare Specialty Pharmacy. Specialty pharmacy is designed to provide additional support and cost savings for patients dealing with chronic illnesses and complex medical conditions. The Commcare Pharmacy Team is comprised of pharmacists, nurses and patient care navigators that provide personalized support. These services are available to you at no charge. For additional information specific to your specialty pharmacy coverage, visit the Commcare website at or to speak with a member of the Commcare Pharmacy team you can call toll free at (8) If you have general questions regarding your prescription drug plan, please call the MedImpact Pharmacy Help Desk at (8) MedImpact Member Services representatives are available to assist you /7. FORMULARY DESIGN The Prominence Health Plan formulary design features different copayment amounts for medications in tiers: Tier Essential Health Benefits (includes certain vaccines, contraceptives, smoking cessation medications and more) Tier Generic Tier 3 Preferred Brand Tier Non-Preferred Brand Tier 5 Specialty Prominence Health Plan Formulary Reference Guide

3 The health plan formulary also uses utilization management functions to promote use of specific costeffective agents. These utilization management functions include step therapy, prior authorization, quantity and age limits and partial fills. Partial fill consists of a limit on the initial three months of selected medications to a or 5-day supply. These specific medications are targeted for partial fill due to high discontinuation rates, poor response, adverse effects and/or noncompliance. USING THE FORMULARY REFERENCE GUIDE TO HELP CONTAIN COSTS Prominence Health Plan uses this formulary to help manage the overall cost of providing prescription drug benefits. This formulary offers a wide range of medications from which to choose. This formulary reference guide may not include every drug from every manufacturer. However, choosing a preferred drug when it is appropriate can provide access to the necessary medications to stay healthy, at a cost that is more affordable. If a brand-name product is listed in the preferred brand-name section and its corresponding generic product is not listed in the generics section, then a generic version of the medication is not available. SAVING ON OUT-OF-POCKET COSTS Your prescription drug plan determines the cost for generic, preferred brand-name, non-preferred brand name and specialty medications. Choosing non-preferred drugs may mean paying higher out-of-pocket expenses (such as coinsurance, copayments, and deductible amounts) or not receiving coverage at all. Members may also pay less for generic drugs, or you may be asked to pay the cost difference between brand-name drugs and their generic alternatives, which are preferred by the plan. PRIOR AUTHORIZATION Certain medications require prior authorization. A prior authorization form should be completed by your provider that will request coverage for a specific drug within the formulary, a non-formulary drug for which there is no suitable alternative available, or any medication with restrictions. CONSULTING THE PRESCRIBER S OFFICE WHEN APPROPRIATE Your pharmacy benefit may provide coverage only for certain medications or for particular uses, time periods, doses, or quantities (e.g. they may exclude coverage for medications for unapproved, unproven, or cosmetic indications, as well as over-the-counter medications). When coverage for medications is provided based on use or quantity, MedImpact may contact your prescribing doctor s office for additional information to determine whether coverage is available under your plan. If you are unsure about whether these coverage rules apply for a particular medication, you can consult a MedImpact Member Services representative to determine specific coverage requirements. Formulary Disclaimer: Coverage for some drugs may be limited to specific dosage forms and/or strengths. The benefit design determines what is covered and the applicable copayment. The medications listed on this formulary are subject to change pursuant to the formulary management activities of Prominence Health Plan. The presence of a medication on this formulary list does not guarantee coverage. You may also call Customer Services at the number listed on your ID card to request a copy be mailed to you. Prominence Health Plan Formulary Reference Guide

4 Frequently used Abbreviations/Terminology QL ST PA LA LDD NDS AGE NSO Quantity Limit. For certain drugs, Prominence Health Plan limits the amount of the drug that we will cover. For example, Prominence Health Plan provides twelve tablets per prescription for Sumatriptan Succinate. This may be in addition to a standard one-month or three-month supply. Step Therapy. In some cases, Prominence Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B, subject to prior authorization and other requirements. Prior Authorization. Prominence Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you do not get approval, we may not cover the drug. Limited Availability. This prescription may be available only at certain pharmacies. For more information, consult your Provider and Pharmacy Directory or call Customer Services Monday through Friday, 8 a.m. to 5 p.m., PST/CST, at the phone number on the back of your member ID card. TTY/TDD users should call Limited Distribution Drugs. Used to treat conditions affecting only a small population of patients. Manufactures may limit the distribution of the medication to a few pharmacies or as recommended by the Food and Drug Administration (FDA) for the medication to be approved and distributed. Non-Extended Days Supply. Drugs not available for an extended days supply (i.e. more than a one-month supply) are noted with NDS in the Requirements/Limits column of your formulary. Age. There are age restrictions on certain medications. To have these age restrictions reconsidered, a prior authorization will need to be submitted by the prescribing provider. New Starts Only. If there is no evidence that you have taken this drug before, you (or your physician) are required to get prior authorization from our plan before you fill your prescription for this drug. Without prior approval, our plan may not cover this drug NV /9 Prominence Health Plan Formulary Reference Guide

5 Table of Contents Analgesics...3 Anesthetics... Anti-Addiction/Substance Abuse Treatment Agents... 3 Antianxiety Agents...5 Antibacterials... 6 Anticancer Agents... 6 Anticholinergic Agents Anticonvulsants...37 Antidementia Agents... Antidepressants... Antidiabetic Agents... Antifungals...9 Antigout Agents... 5 Antihistamines...5 Anti-Infectives (Skin And Mucous Membrane)...5 Antimigraine Agents...53 Antimycobacterials...5 Antinausea Agents...5 Antiparasite Agents...56 Antiparkinsonian Agents...57 Antipsychotic Agents...58 Antivirals (Systemic)...6 Blood Products/Modifiers/Volume Expanders Caloric Agents...7 Cardiovascular Agents... 7 Central Nervous System Agents Contraceptives...90 Cough And Cold Products Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents... Gastrointestinal Agents... 7 Genitourinary Agents... Heavy Metal Antagonists... 3

6 Hormonal Agents, Stimulant/Replacement/Modifying...3 Immunological Agents...3 Inflammatory Bowel Disease Agents... Irrigating Solutions...5 Metabolic Bone Disease Agents...5 Miscellaneous Therapeutic Agents...7 Ophthalmic Agents...50 Replacement Preparations... 5 Respiratory Tract Agents... 5 Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents...60 Vitamins And Minerals...6

7 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 0- /5 ml QL (90 per day); AGE (Min 8 Years) acetaminophen-codeine oral tablet QL ( per day) acetaminophen-codeine oral tablet (Tylenol-Codeine #3) QL ( per day) acetaminophen-codeine oral tablet (Tylenol-Codeine #) QL (6 per day) alfentanil injection solution 500 mcg/ml ascomp with codeine oral capsule QL (6 per day) 35-0 astramorph-pf injection solution 0.5 /ml, /ml buprenorphine hcl injection solution 0.3 (Buprenex) /ml buprenorphine hcl injection syringe 0.3 /ml buprenorphine transdermal patch weekly (Butrans) PA; QL ( per 7 days) 0 mcg/hour, 0 mcg/hour, 5 mcg/hour buprenorphine transdermal patch weekly (Butrans) PA NSO 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral QL (6 per day) capsule butalbital-acetaminop-caf-cod oral QL (6 per day) capsule , butalbital-acetaminophen oral tablet 50- (Tencon) 35 butalbital-acetaminophen-caff oral (Fioricet) capsule butalbital-acetaminophen-caff oral (Esgic) capsule butalbital-acetaminophen-caff oral tablet (Esgic) butalbital-aspirin-caffeine oral capsule (Fiorinal) butalbital-aspirin-caffeine oral tablet butorphanol tartrate injection solution /ml, /ml 3

8 butorphanol tartrate nasal spray,nonaerosol 0 /ml BUTRANS TRANSDERMAL PA; QL ( per 7 days) PATCH WEEKLY 0 MCG/HOUR, 0 MCG/HOUR, 5 MCG/HOUR BUTRANS TRANSDERMAL PATCH WEEKLY 5 MCG/HOUR, PA NSO; QL ( per 7 days) 7.5 MCG/HOUR capacet oral capsule codeine sulfate oral tablet 5, 30 QL ( per day) codeine sulfate oral tablet 60 QL (6 per day) DEMEROL (PF) INJECTION SOLUTION 00 MG/ ML, 5 MG/0.5 ML, 50 MG/ML, 75 MG/.5 ML DEMEROL (PF) INJECTION SYRINGE 75 MG/ML DEMEROL INJECTION SOLUTION 50 MG/ML DILAUDID-HP (PF) INJECTION RECON SOLN 50 MG endodan oral tablet QL ( per day) fentanyl citrate buccal lozenge on a (Actiq) PA; QL ( per day) handle,00 mcg,,600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 (Duragesic) PA; QL ( per 3 days) mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution 0-35 /5 ml(5 ml) QL (90 per day); AGE (Min 8 Years) hydrocodone-acetaminophen oral solution /5 ml QL (8 per day); AGE (Min 8 Years) hydrocodone-acetaminophen oral tablet (Vicodin HP) QL (6 per day) hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (6 per day) 0-35 hydrocodone-acetaminophen oral tablet (Verdrocet) QL ( per day).5-35 hydrocodone-acetaminophen oral tablet (Vicodin) QL (3 per day) hydrocodone-acetaminophen oral tablet 5-35 (Lorcet (hydrocodone)) QL ( per day)

9 hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (6 per day) hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (6 per day) hydrocodone-ibuprofen oral tablet 0-00 (Ibudone) QL (5 per day), 5-00 hydrocodone-ibuprofen oral tablet.5- QL (5 per day) 00, hydromorphone (pf) injection solution 0 /ml hydromorphone (pf)-0.9 % nacl intravenous solution /ml hydromorphone in 0.9 % nacl injection prefilled pump reservoir 00 /00 ml ( /ml) hydromorphone in 0.9 % nacl injection pt controlled analgesia syring 5 /5 ml, 55 /55 ml ( /ml) hydromorphone in 0.9 % nacl intravenous pt controlled analgesia syring 30 /30 ml ( /ml) hydromorphone injection solution /ml, /ml, /ml hydromorphone injection syringe 0.5 /0.5 ml, /ml, /ml, /ml hydromorphone oral liquid /ml (Dilaudid) hydromorphone oral tablet,, 8 (Dilaudid) hydromorphone oral tablet extended PA; QL ( per day) release hr, 6, 8 hydromorphone oral tablet extended PA; QL ( per day) release hr 3 ibuprofen-oxycodone oral tablet 00-5 QL ( per day) INFUMORPH P/F INJECTION SOLUTION 0 MG/ML, 5 MG/ML LAZANDA NASAL SPRAY,NON- 5 PA; QL ( per days) AEROSOL 300 MCG/SPRAY levorphanol tartrate oral tablet lorcet (hydrocodone) oral tablet 5-35 QL (8 per day) lorcet hd oral tablet 0-35 QL (6 per day) 5

10 lorcet plus oral tablet QL (6 per day) margesic oral capsule marten-tab oral tablet meperidine (pf) injection solution 00 (Demerol (PF)) /ml, 50 /ml meperidine (pf) injection solution 5 /ml meperidine injection cartridge 0 /ml meperidine oral solution 50 /5 ml QL (30 per day) meperidine oral tablet 00 (Demerol) QL (6 per day) meperidine oral tablet 50 QL (6 per day) methadone injection solution 0 /ml methadone oral concentrate 0 /ml (Methadone Intensol) methadone oral solution 0 /5 ml, 5 /5 ml methadone oral tablet 0, 5 (Dolophine) methadose oral tablet,soluble 0 morphine (pf) in 0.9 % nacl intravenous solution 5 /ml morphine (pf) in 0.9 % nacl intravenous syringe / ml ( /ml) morphine (pf) injection solution 0.5 (Astramorph-PF) /ml, /ml morphine (pf) intravenous patient control.analgesia soln 50 /30 ml, 30 /30 ml morphine concentrate oral solution 00 /5 ml (0 /ml) morphine in 0.9 % sodium chlor injection prefilled pump reservoir /ml morphine in 0.9 % sodium chlor injection pt controlled analgesia syring 5 /5 ml, 5 /5 ml, 55 /55 ml ( /ml) morphine in 0.9 % sodium chlor intravenous prefilled pump reservoir 50 /50 ml ( /ml) morphine in 0.9 % sodium chlor intravenous pt controlled analgesia syring 50 /30 ml (5 /ml), 75 /55 ml (5 /ml) morphine in 0.9 % sodium chlor intravenous solution /ml 6

11 morphine in dextrose 5 % injection prefilled pump reservoir /ml morphine in dextrose 5 % intravenous solution /ml morphine injection solution 0 /ml, 5 /ml, 5 /ml morphine injection syringe 5 /ml morphine intravenous solution 0 /ml, 8 /ml morphine intravenous syringe 0 /ml, 5 /ml, 8 /ml morphine oral capsule, er multiphase ST; QL ( per day) hr 0 morphine oral capsule, er multiphase ST; QL ( per day) hr 30, 5, 60, 75, 90 morphine oral capsule,extend.release (Kadian) ST; QL ( per day) pellets 0, 00, 0, 30, 50, 60, 80 morphine oral solution 0 /5 ml, 0 /5 ml ( /ml) morphine oral tablet extended release 00 (MS Contin) ST; QL (3 per day), 5, 00, 30, 60 nalbuphine injection solution 0 /ml, 0 /ml NUCYNTA ER ORAL TABLET PA EXTENDED RELEASE HR 00 MG, 50 MG, 00 MG, 50 MG, 50 MG OPANA INJECTION SOLUTION MG/ML oxycodone oral capsule 5 oxycodone oral concentrate 0 /ml oxycodone oral solution 5 /5 ml oxycodone oral tablet 0, 0 oxycodone oral tablet 5, 30, 5 (Roxicodone) oxycodone oral tablet,oral only,ext.rel. (OxyContin) ST; QL ( per day) hr 0, 5, 0, 30, 0, 60 oxycodone oral tablet,oral only,ext.rel. hr 80 (OxyContin) ST; QL ( per day) 7

12 oxycodone-acetaminophen oral solution PA; QL (60 per day) 5-35 /5 ml oxycodone-acetaminophen oral tablet 0- (Endocet) QL (6 per day) 35 oxycodone-acetaminophen oral tablet (Endocet) QL ( per day).5-35, 5-35, oxycodone-aspirin oral tablet QL ( per day) OXYCONTIN ORAL ST; QL ( per day) TABLET,ORAL ONLY,EXT.REL. HR 5 MG, 30 MG, 60 MG oxymorphone oral tablet 0, 5 (Opana) ST oxymorphone oral tablet extended release ST; QL ( per day) hr 0, 5, 0, 5, 7.5 oxymorphone oral tablet extended release ST; QL ( per day) hr 30, 0 pentazocine-naloxone oral tablet QL ( per day) reprexain oral tablet 0-00 QL (5 per day) roxicet oral solution 5-35 /5 ml QL (6 per day) tencon oral tablet tramadol oral capsule,er biphase hr (ConZip) ST; QL ( per day); AGE (Min 8 Years) tramadol oral capsule,er biphase hr , 00 (ConZip) ST; QL ( per day); AGE (Min 8 Years) tramadol oral capsule,er biphase hr ST; QL ( per day); AGE (Min 8 Years) tramadol oral tablet 50 (Ultram) QL (8 per day); AGE (Min 8 Years) tramadol oral tablet extended release hr 00, 00, 300 ST; QL ( per day); AGE (Min 8 Years) tramadol oral tablet, er multiphase hr 00, 00, 300 ST; QL ( per day); AGE (Min 8 Years) tramadol-acetaminophen oral tablet (Ultracet) QL (8 per day); AGE (Min 8 Years) xylon 0 oral tablet 0-00 QL (5 per day) ZAMICET ORAL SOLUTION 0-35 MG/5 ML QL (8 per day); AGE (Min 8 Years) zebutal oral capsule Nonsteroidal Anti-Inflammatory Agents aspirin low dose oral tablet,delayed release (dr/ec) 8 8

13 aspirin oral tablet 35 (Bayer Aspirin) aspirin oral tablet,chewable 8 (Aspirin Childrens) aspirin oral tablet,delayed release (dr/ec) (Aspir-Trin) 35 aspirin oral tablet,delayed release (dr/ec) (Adult Aspirin 8 Regimen) aspir-low oral tablet,delayed release (dr/ec) 8 aspir-trin oral tablet,delayed release (dr/ec) 35 CAMBIA ORAL POWDER IN PACKET 50 MG QL (3 per 0 days) celecoxib oral capsule 00, 00, (Celebrex) 00, 50 children's aspirin oral tablet,chewable 8 choline,magnesium salicylate oral liquid 500 /5 ml diclofenac epolamine transdermal patch (Flector) PA hour.3 % diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical gel % (Voltaren) diclofenac sodium topical gel 3 % (Solaraze) PA; QL (00 per day) diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 e.c. prin oral tablet,delayed release (dr/ec) 35 ecotrin oral tablet,delayed release (dr/ec) 35 etodolac oral capsule 00, 300 etodolac oral tablet 00 (Lodine) etodolac oral tablet 500 9

14 etodolac oral tablet extended release hr 00, 500, 600 fenoprofen oral capsule 00 (Nalfon) fenoprofen oral tablet 600 (Nalfon) FLECTOR TRANSDERMAL PA PATCH HOUR.3 % flurbiprofen oral tablet 00, 50 ibu oral tablet 00, 600, 800 ibuprofen oral suspension 00 /5 ml (Children's Advil) ibuprofen oral tablet 00, 600, (IBU) 800 INDOCIN ORAL SUSPENSION 5 3 MG/5 ML indomethacin oral capsule 5, 50 indomethacin oral capsule, extended release 75 indomethacin sodium intravenous recon soln ketoprofen oral capsule 5, 50, 75 ketoprofen oral capsule,ext rel. pellets hr 00 ketorolac injection cartridge 5 /ml, 30 /ml ketorolac injection solution 5 /ml, 30 /ml ( ml) ketorolac injection syringe 5 /ml, 30 /ml ketorolac intramuscular cartridge 60 / ml ketorolac intramuscular solution 60 / ml ketorolac intramuscular syringe 60 / ml ketorolac oral tablet 0 lo-dose aspirin oral tablet,delayed release (dr/ec) 8 meclofenamate oral capsule 00, 50 mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml 0

15 bupivacaine-epinephrine (pf) injection solution 0.5 %-:00,000, 0.5 %- :00,000 bupivacaine-epinephrine bitart injection cartridge 0.5 %-:00,000 (Marcaine-Epinephrine (PF)) meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral suspension 5 /5 ml (Naprosyn) naproxen oral tablet 50, 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375, 500 naproxen sodium oral tablet 75 naproxen sodium oral tablet 550 (Anaprox DS) oxaprozin oral tablet 600 (Daypro) piroxicam oral capsule 0, 0 (Feldene) salsalate oral tablet 500, 750 (Disalcid) SPRIX NASAL SPRAY,NON- PA; QL ( per 6 days) AEROSOL 5.75 MG/SPRAY st joseph aspirin oral tablet,chewable 8 st. joseph aspirin oral tablet,delayed release (dr/ec) 8 sulindac oral tablet 50, 00 tolmetin oral capsule 00 tolmetin oral tablet 00, 600 tri-buffered aspirin oral tablet 35 Anesthetics Local Anesthetics ACCUCAINE KIT KIT 0 MG/ML ( %) ana-lex kit rectal kit - % bupivacaine (pf) injection solution 0.5 (Marcaine (PF)) % (.5 /ml) bupivacaine (pf) injection solution 0.5 % (Marcaine (PF)) (5 /ml) bupivacaine (pf) injection solution 0.75 (Marcaine (PF)) % (7.5 /ml) bupivacaine injection solution 0.5 % (.5 /ml), 0.5 % (5 /ml) (Marcaine) (Marcaine- Epinephrine)

16 bupivacaine-epinephrine injection solution (Marcaine- 0.5 %-:00,000, 0.5 %-:00,000 Epinephrine) chloroprocaine (pf) injection solution 0 (Nesacaine-MPF) /ml ( %) CIDALEAZE TOPICAL CREAM 3 % EXPAREL (PF) LOCAL INFILTRATION SUSPENSION.3 % (3.3 MG/ML) glydo mucous membrane jelly in applicator % LIDO BDK KIT GAUGE X "-.5 %-.5 % lidocaine (pf) injection solution 0 /ml (Xylocaine-MPF) ( %), 5 /ml (.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 0 /ml ( %) lidocaine (pf) injection syringe 00 /5 ml ( %) PA lidocaine hcl injection solution 0 /ml (Xylocaine) ( %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution % (0 /ml) lidocaine hcl topical cream 3 % (Lidopin) lidocaine hcl(pf) in 0.9% nacl injection syringe 00 /0 ml ( %) lidocaine hcl-hydrocortison ac rectal kit 3- % (7 gram) lidocaine hcl-hydrocortison ac topical cream % lidocaine topical adhesive (Lidoderm) ST patch,medicated 5 % lidocaine topical ointment 5 % ST lidocaine viscous mucous membrane solution % lidocaine-epinephrine bit injection (Xylocaine Dental- cartridge %-:00,000, %-:50,000 Epinephrine) lidocaine-epinephrine injection solution 0.5 %-:00,000, %-:00,000, %- :00,000 (Xylocaine with Epinephrine)

17 lidocaine-epinephrine injection solution.5 %-:00,000, %-:00,000 lidocaine-hydrocortisone-aloe rectal kit 3-.5 % (7 gram) lidocaine-prilocaine topical cream.5-.5 % polocaine-mpf injection solution 0 /ml ( %), 0 /ml ( %) ropivacaine (pf) in 0.9 % nacl local infiltration elastomeric pump,hi var rate 0. % 550 ml ropivacaine (pf) injection solution 0 (Naropin (PF)) /ml ( %), /ml (0. %), 5 /ml (0.5 %), 7.5 /ml (0.75 %) SENSORCAINE-MPF INJECTION SOLUTION 0.5 % (.5 MG/ML) sensorcaine-mpf injection solution 0.75 % (7.5 /ml) sensorcaine-mpf/epinephrine injection solution 0.5 %-:00,000 SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING MG XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION %- :00,000 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release PA (dr/ec) 333 buprenorphine hcl sublingual tablet, PA; QL (3 per day) 8 buprenorphine-naloxone sublingual film (Suboxone) QL ( per day) -3 buprenorphine-naloxone sublingual film (Suboxone) QL ( per day) -0.5, - buprenorphine-naloxone sublingual film (Suboxone) QL (3 per day) 8- buprenorphine-naloxone sublingual tablet -0.5, 8- QL (3 per day) 3

18 buproban oral tablet extended release hr 50 bupropion hcl (smoking deter) oral tablet extended release hr 50 CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG () max QL: 80 days/life (Zyban) max QL: 80 days/life max QL: 80 days/life; QL ( per day); AGE (Min 8 Years) max QL: 80 days/life; QL ( per day); AGE (Min 8 Years) max QL: 80 days/life; QL ( per day); AGE (Min 8 Years) disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0. /ml naloxone injection syringe 0. /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- AEROSOL MG/ACTUATION, MG/ACTUATION 3 QL ( per 30 days) NICODERM CQ TRANSDERMAL PATCH HOUR MG/ HR, MG/ HR, 7 MG/ HR max QL: 80 days/life; QL ( per day); AGE (Min 8 Years) nicorelief buccal gum, max QL: 80 days/life; QL (9 per day); AGE (Min 8 Years) NICORETTE BUCCAL GUM MG, MG NICORETTE BUCCAL MINI LOZENGE MG, MG nicotine (polacrilex) buccal gum, max QL: 80 days/life; QL (9 per day); AGE (Min 8 Years) max QL: 80 days/life; QL (9 per day); AGE (Min 8 Years) (Nicorelief) max QL: 80 days/life; QL (9 per day); AGE (Min 8 Years) nicotine (polacrilex) buccal lozenge (Nicorette) QL (9 per day); AGE (Min 8 Years) nicotine (polacrilex) buccal lozenge (Nicorette) max QL: 80 days/life; QL (9 per day); AGE (Min 8 Years)

19 nicotine transdermal patch hour / hr, / hr, 7 / hr nicotine transdermal patch hour / hr NICOTINE TRANSDERMAL PATCH, TD DAILY, SEQUENTIAL --7 MG/ HR NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON-AEROSOL 0 MG/ML stop smoking aid buccal lozenge, SUBOXONE SUBLINGUAL FILM -3 MG SUBOXONE SUBLINGUAL FILM MG, - MG VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL ORAL CONCENTRATE MG/ML alprazolam oral tablet 0.5, 0.5,, alprazolam oral tablet extended release hr 0.5,,, 3 alprazolam oral tablet,disintegrating 0.5, 0.5,, buspirone oral tablet 0, 5, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 0, 5, 5 (Nicoderm CQ) max QL: 80 days/life; QL ( per day); AGE (Min 8 Years) max QL: 80 days/life; QL ( per day); AGE (Min 8 Years) max QL: 80 days/life; QL ( per day); AGE (Min 8 Years) max QL: 80 days/life; QL (008 per 90 days); AGE (Min 8 Years) max QL: 80 days/life; QL (60 per 90 days); AGE (Min 8 Years) max QL: 80 days/life; QL (9 per day); AGE (Min 8 Years) QL ( per day) (Xanax) (Xanax XR) QL (3 per day) clobazam oral tablet 0, 0 (Onfi) PA; QL ( per day) clonazepam oral tablet 0.5,, (Klonopin) 3 5

20 clonazepam oral tablet,disintegrating 0.5, 0.5, 0.5,, clorazepate dipotassium oral tablet 5, 3.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) diazepam injection solution 5 /ml diazepam injection syringe 5 /ml diazepam intensol oral concentrate 5 /ml diazepam oral solution 5 /5 ml ( /ml) diazepam oral tablet 0,, 5 (Valium) diazepam rectal kit , (Diastat AcuDial) QL ( per day) diazepam rectal kit.5 (Diastat) QL ( per day) estazolam oral tablet, flurazepam oral capsule 5, 30 lorazepam injection solution /ml, (Ativan) /ml lorazepam injection syringe /ml, /ml lorazepam oral concentrate /ml (Lorazepam Intensol) lorazepam oral tablet 0.5,, (Ativan) meprobamate oral tablet 00, 00 ONFI ORAL TABLET 0 MG, 0 MG PA; QL ( per day) oxazepam oral capsule 0, 5, 30 quazepam oral tablet 5 (Doral) PA temazepam oral capsule 5,.5, (Restoril) 30, 7.5 triazolam oral tablet 0.5 triazolam oral tablet 0.5 (Halcion) Antibacterials Aminoglycosides amikacin injection solution,000 / ml, 500 / ml 6

21 gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 00 /50 ml, 0 /00 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin injection solution 0 / ml, 0 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 00 /0 ml, 60 /6 ml, 80 /8 ml KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION 300 MG/5 ML ; QL (0 per day) neomycin oral tablet 500 streptomycin intramuscular recon soln gram tobramycin in 0.5 % nacl inhalation solution for nebulization 300 /5 ml (Tobi) ; QL (5 per day) tobramycin sulfate injection solution 0 /ml, 0 /ml tobramycin with nebulizer inhalation solution for nebulization 300 /5 ml (Kitabis Pak) ; QL (5 per day) Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit 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 palmitate hcl oral recon soln (Cleocin Pediatric) 75 /5 ml clindamycin phosphate injection solution (Cleocin) 50 /ml clindamycin phosphate intravenous solution 600 / ml (Cleocin) 7

22 colistin (colistimethate na) injection (Coly-Mycin M recon soln 50 Parenteral) daptomycin intravenous recon soln daptomycin intravenous recon soln 500 (Cubicin) 5 FIRVANQ ORAL RECON SOLN 5 QL (300 per 30 days) MG/ML FIRVANQ ORAL RECON SOLN 50 QL (600 per 30 days) MG/ML linezolid oral suspension for (Zyvox) 5 PA reconstitution 00 /5 ml linezolid oral tablet 600 (Zyvox) PA; QL ( per day) linezolid-0.9% sodium chloride 5 intravenous parenteral solution 600 /300 ml methenamine hippurate oral tablet (Hiprex) gram metronidazole in nacl (iso-os) (Metro I.V.) intravenous piggyback 500 /00 ml metronidazole oral capsule 375 (Flagyl) metronidazole oral tablet 50, 500 (Flagyl) MONUROL ORAL PACKET 3 GRAM nitrofurantoin macrocrystal oral capsule (Macrodantin) 00, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 (Macrobid) nitrofurantoin oral suspension 5 /5 ml (Furadantin) PHOSPHASAL ORAL TABLET MG polymyxin b sulfate injection recon soln 500,000 unit PRIMSOL ORAL SOLUTION 50 MG/5 ML SIVEXTRO INTRAVENOUS PA RECON SOLN 00 MG SIVEXTRO ORAL TABLET 00 MG PA trimethoprim oral tablet 00 ur n-c oral tablet URETRON D-S ORAL TABLET MG 8

23 uro-58 oral tablet uro-blue oral tablet vancomycin in 0.9 % sodium chl intravenous solution.5 gram/500 ml, 750 /50 ml vancomycin in dextrose 5 % intravenous piggyback gram/00 ml, 500 /00 ml, 750 /50 ml vancomycin intravenous recon soln,000, 0 gram, 50, 5 gram, 500, 750 vancomycin oral capsule 5, 50 (Vancocin) PA; QL (0 per 30 days) XIFAXAN ORAL TABLET 00 MG PA XIFAXAN ORAL TABLET 550 MG PA; QL ( per day) Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 5 /5 ml, 50 /5 ml, 375 /5 ml cefaclor oral tablet extended release hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin in 0.9% sod chloride intravenous solution gram/00 ml cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln gram, 0 gram, 500 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 00 (Spectracef) cefixime oral suspension for (Suprax) reconstitution 00 /5 ml, 00 /5 ml cefotaxime injection recon soln gram, 500 cefotaxime injection recon soln 0 gram, gram (Claforan) 9

24 cefotetan in dextrose, iso-osm intravenous piggyback gram/50 ml, gram/50 ml cefotetan intravenous recon soln 0 gram cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml cefoxitin intravenous recon soln gram, 0 gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram (Fortaz) ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftibuten oral capsule 00 CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 50 MG/5 ML ceftriaxone in dextrose,iso-os intravenous piggyback gram/50 ml, gram/50 ml ceftriaxone injection recon soln 0 gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 50, 500, (Keflex) 750 cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 00 MG, 00 MG tazicef injection recon soln gram, gram, 6 gram 0

25 TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50, 500 (Zithromax) azithromycin oral tablet 600 clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release hr 500 DIFICID ORAL TABLET 00 MG QL (0 per 30 days) e.e.s. 00 oral tablet 00 E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ery-tab oral tablet,delayed release 3 (dr/ec) 50, 500 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet (E.E.S. 00) 00 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 KETEK ORAL TABLET 300 MG, 00 MG PA

26 PCE ORAL TABLET, PARTICLES/CRYSTALS 333 MG, 500 MG ZMAX ORAL SUSPENSION,EXTENDED REL RECON GRAM/60 ML Miscellaneous B-Lactam Antibiotics AZACTAM IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML aztreonam injection recon soln gram, gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML DORIBAX INTRAVENOUS RECON SOLN 500 MG (Azactam) doripenem intravenous recon soln 500 ertapenem injection recon soln gram (Invanz) imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 meropenem intravenous recon soln (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet, er multiphase (Moxatag) hr 775 amoxicillin oral tablet,chewable 5, 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml (Augmentin) ; QL (8 per 56 days)

27 amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet 50-5 amoxicillin-pot clavulanate oral tablet (Augmentin) 500-5, amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release hr, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, 500 ampicillin oral suspension for reconstitution 5 /5 ml, 50 /5 ml ampicillin sodium injection recon soln gram, 0 gram, 5, gram, 50, 500 ampicillin-sulbactam injection recon soln (Unasyn).5 gram, 5 gram, 3 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML BICILLIN C-R INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML(600K/600K),,00,000 UNIT/ ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML,,00,000 UNIT/ ML dicloxacillin oral capsule 50, 500 nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml nafcillin injection recon soln 0 gram nafcillin injection recon soln gram 3 nafcillin intravenous recon soln gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, gram/50 ml oxacillin injection recon soln 0 gram, gram oxacillin intravenous recon soln gram 3

28 penicillin g pot in dextrose intravenous piggyback million unit/50 ml, million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe. million unit/ ml, 600,000 unit/ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 piperacillin-tazobactam intravenous (Zosyn) recon soln.5 gram, gram,.5 gram, 0.5 gram Quinolones BAXDELA ORAL TABLET 50 MG PA ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase hr,000, 500 ciprofloxacin hcl oral tablet 50, 500 (Cipro) ciprofloxacin hcl oral tablet 750 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /00 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 00 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 00 /0 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml FACTIVE ORAL TABLET 30 MG levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50 levofloxacin oral tablet 500, 750 (Levaquin)

29 moxifloxacin oral tablet 00 (Avelox) moxifloxacin-sod.ace,sul-water intravenous piggyback 00 /50 ml ofloxacin oral tablet 300, 00 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml PA sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) tablet sulfatrim oral suspension 00-0 /5 ml Tetracyclines demeclocycline oral tablet 50, 300 doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon (Doxy-00) soln 00 doxycycline hyclate oral capsule 00 (Morgidox) doxycycline hyclate oral capsule 50 (Morgidox) ST doxycycline hyclate oral tablet 00, 0 doxycycline hyclate oral tablet 50, (Acticlate) 75 doxycycline hyclate oral tablet 50 (Targadox) doxycycline hyclate oral tablet,delayed ST; QL ( per day) release (dr/ec) 00, 75 doxycycline monohydrate oral capsule (Mondoxyne NL) 00, 50, 75 doxycycline monohydrate oral capsule,ir (Oracea) ST; QL ( per day) - delay rel,biphase 0 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 00 (Avidoxy) doxycycline monohydrate oral tablet 50, 75 minocycline oral capsule 00, 75 5

30 minocycline oral capsule 50 (Minocin) okebo oral capsule 00, 75 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) TYGACIL INTRAVENOUS RECON SOLN 50 MG VIBRAMYCIN ORAL SYRUP 50 MG/5 ML Anticancer Agents Anticancer Agents abiraterone oral tablet 50 (Zytiga) 5 PA ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG ADCETRIS INTRAVENOUS 5 PA RECON SOLN 50 MG adriamycin intravenous recon soln 0, PA 50 adriamycin intravenous solution 0 /5 PA ml, /ml, 0 /0 ml, 50 /5 ml adrucil intravenous solution.5 gram/50 PA ml, 500 /0 ml AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG ; QL ( per day) AFINITOR ORAL TABLET 7.5 MG ALECENSA ORAL CAPSULE 50 MG ALIMTA INTRAVENOUS RECON SOLN 00 MG ALIMTA INTRAVENOUS RECON 5 PA SOLN 500 MG ALIQOPA INTRAVENOUS RECON 5 PA SOLN 60 MG ALUNBRIG ORAL TABLET 80 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG (3) anastrozole oral tablet (Arimidex) ARRANON INTRAVENOUS SOLUTION 50 MG/50 ML 6

31 ARZERRA INTRAVENOUS SOLUTION,000 MG/50 ML, 00 MG/5 ML AVASTIN INTRAVENOUS 5 PA SOLUTION 5 MG/ML azacitidine injection recon soln 00 (Vidaza) BAVENCIO INTRAVENOUS 5 PA SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG BESPONSA INTRAVENOUS 5 PA RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) bicalutamide oral tablet 50 (Casodex) BICNU INTRAVENOUS RECON SOLN 00 MG bleomycin injection recon soln 5 unit, 30 PA; LA unit BLINCYTO INTRAVENOUS KIT 35 MCG BORTEZOMIB INTRAVENOUS RECON SOLN 3.5 MG BOSULIF ORAL TABLET 00 MG ; QL ( per day) BOSULIF ORAL TABLET 00 MG, 500 MG ; QL ( per day) CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG CALQUENCE ORAL CAPSULE 00 MG capecitabine oral tablet 50 (Xeloda) ; QL (8 per days) capecitabine oral tablet 500 (Xeloda) ; QL ( per days) CAPRELSA ORAL TABLET 00 MG ; QL ( per day) CAPRELSA ORAL TABLET 300 MG ; QL ( per day) carboplatin intravenous solution 0 /ml PA; LA carmustine intravenous recon soln 00 (BiCNU) 7

32 cisplatin intravenous solution /ml PA; LA cladribine intravenous solution 0 /0 ml clofarabine intravenous solution 0 /0 (Clolar) ml CLOLAR INTRAVENOUS SOLUTION 0 MG/0 ML COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 0 ; QL ( per day) MG/DAY(80 MG X-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) COSMEGEN INTRAVENOUS RECON SOLN 0.5 MG COTELLIC ORAL TABLET 0 MG cyclophosphamide intravenous recon soln PA NSO; LA gram, gram, 500 CYCLOPHOSPHAMIDE ORAL 5 CAPSULE 5 MG CYCLOPHOSPHAMIDE ORAL 5 LA CAPSULE 50 MG CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML cytarabine (pf) injection solution 00 PA; LA /5 ml (0 /ml), gram/0 ml (00 /ml) cytarabine injection solution 0 /ml PA; LA dacarbazine intravenous recon soln 00 PA, 00 DARZALEX INTRAVENOUS 5 PA SOLUTION 0 MG/ML daunorubicin intravenous recon soln 0 daunorubicin intravenous solution 5 /ml DAUNOXOME INTRAVENOUS SOLUTION MG/ML decitabine intravenous recon soln 50 (Dacogen) docetaxel intravenous solution 0 /7 ml (0 /ml), 60 /8 ml (0 /ml) docetaxel intravenous solution 0 /ml ( ml), 80 / ml (0 /ml) (Taxotere) 8

33 doxorubicin intravenous recon soln 0 (Adriamycin) PA, 50 doxorubicin intravenous solution 0 /5 (Adriamycin) PA ml, /ml, 0 /0 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) suspension /ml DROXIA ORAL CAPSULE 00 MG, 300 MG, 00 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE.5 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 5 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) ELSPAR INJECTION RECON SOLN 0,000 UNIT EMCYT ORAL CAPSULE 0 MG LA EMPLICITI INTRAVENOUS 5 PA RECON SOLN 300 MG, 00 MG epirubicin intravenous recon soln 00, 50 epirubicin intravenous solution 00 (Ellence) /00 ml, 50 /5 ml ERBITUX INTRAVENOUS SOLUTION 00 MG/50 ML, 00 MG/00 ML ERIVEDGE ORAL CAPSULE 50 MG ; QL ( per day) ERLEADA ORAL TABLET 60 MG 5 PA etoposide intravenous solution 0 /ml (Toposar) PA exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG LA FARYDAK ORAL CAPSULE 0 MG, 5 MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 0 MG ; QL ( per 365 days) 9

34 FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG ; QL ( per 30 days) floxuridine injection recon soln 0.5 gram PA; LA fludarabine intravenous recon soln 50 PA; LA fludarabine intravenous solution 50 / PA; LA ml fluorouracil intravenous solution PA gram/0 ml fluorouracil intravenous solution 5 (Adrucil) PA gram/00 ml, 500 /0 ml flutamide oral capsule 5 FOLOTYN INTRAVENOUS SOLUTION 0 MG/ML ( ML), 0 MG/ ML (0 MG/ML) GAZYVA INTRAVENOUS SOLUTION,000 MG/0 ML gemcitabine intravenous recon soln gram, gram, 00 gemcitabine intravenous solution gram/6.3 ml (38 /ml), 00 /ml, gram/5.6 ml (38 /ml), 00 /5.6 ml (38 /ml) GILOTRIF ORAL TABLET 0 MG, 30 MG, 0 MG GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 0 MG, 5 MG HALAVEN INTRAVENOUS SOLUTION MG/ ML (0.5 MG/ML) HERCEPTIN INTRAVENOUS 5 PA RECON SOLN 50 MG, 0 MG HEXALEN ORAL CAPSULE 50 MG HYCAMTIN ORAL CAPSULE 0.5 MG, MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG ICLUSIG ORAL TABLET 5 MG ; QL ( per day) ICLUSIG ORAL TABLET 5 MG ; QL ( per day) idarubicin intravenous solution /ml (Idamycin PFS) 30

35 IDHIFA ORAL TABLET 00 MG, 50 MG ifosfamide intravenous recon soln gram, (Ifex) 3 gram ifosfamide intravenous solution gram/0 ml, 3 gram/60 ml imatinib oral tablet 00, 00 (Gleevec) IMBRUVICA ORAL CAPSULE 0 MG, 70 MG IMBRUVICA ORAL TABLET 0 MG, 80 MG, 0 MG, 560 MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML IMLYGIC INJECTION 5 PA SUSPENSION 0EXP6 ( MILLION) PFU/ML, 0EXP8 (00 MILLION) PFU/ML INLYTA ORAL TABLET MG ; QL (6 per day) INLYTA ORAL TABLET 5 MG ; QL ( per day) IRESSA ORAL TABLET 50 MG irinotecan intravenous solution 00 /5 (Camptosar) ml, 0 / ml irinotecan intravenous solution 500 /5 ml IXEMPRA INTRAVENOUS RECON SOLN 5 MG, 5 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG ; QL ( per day) JEVTANA INTRAVENOUS SOLUTION 0 MG/ML (FIRST DILUTION) KADCYLA INTRAVENOUS RECON SOLN 00 MG, 60 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML 3

36 KISQALI FEMARA CO-PACK 5 PA ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG, 00 MG/DAY(00 MG X )-.5 MG, 600 MG/DAY(00 MG X 3)-.5 MG KISQALI ORAL TABLET 00 5 PA MG/DAY (00 MG X ), 00 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X 3) KYPROLIS INTRAVENOUS 5 PA RECON SOLN 0 MG, 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 0 MG/ML LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), MG/DAY ( MG X 3), MG/DAY(0 MG X - MG X ), 8 MG/DAY (0 MG X - MG X), 0 MG/DAY (0 MG X ), MG/DAY(0 MG X - MG X ), MG, 8 MG/DAY ( MG X ) letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit /0. ml lipodox 50 intravenous suspension /ml lipodox intravenous suspension /ml lomustine oral capsule 0, 00, 0 (Gleostine) LONSURF ORAL TABLET 5-6. PA; LA MG LONSURF ORAL TABLET MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG,.5 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 5 MG 3

37 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYNPARZA ORAL TABLET 00 MG, 50 MG ; QL (0 per 30 days) LYSODREN ORAL TABLET 500 MG LA MARQIBO INTRAVENOUS KIT 5 MG/3 ML(0.6 MG/ML) FINAL MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 0 MEKINIST ORAL TABLET 0.5 MG, MG melphalan hcl intravenous recon soln 50 (Alkeran (as HCl)) mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln gram methotrexate sodium (pf) injection solution 5 /ml methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 mitomycin intravenous recon soln 0, (Mutamycin) PA; LA 0, 5 mitoxantrone intravenous concentrate PA; LA /ml MUSTARGEN INJECTION RECON SOLN 0 MG MYLOTARG INTRAVENOUS RECON SOLN.5 MG ( MG/ML INITIAL CONC) NERLYNX ORAL TABLET 0 MG NEXAVAR ORAL TABLET 00 MG ; QL ( per day) nilutamide oral tablet 50 (Nilandron) 5 PA NINLARO ORAL CAPSULE.3 MG, 3 MG, MG NIPENT INTRAVENOUS RECON SOLN 0 MG 33

38 ODOMZO ORAL CAPSULE 00 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML OPDIVO INTRAVENOUS SOLUTION 00 MG/0 ML, 0 MG/ ML, 0 MG/ ML oxaliplatin intravenous recon soln 00 PA; LA, 50 oxaliplatin intravenous solution 00 PA; LA /0 ml, 50 /0 ml (5 /ml) paclitaxel intravenous concentrate 6 5 LA /ml PERJETA INTRAVENOUS SOLUTION 0 MG/ ML (30 MG/ML) PHOTOFRIN INTRAVENOUS RECON SOLN 75 MG POMALYST ORAL CAPSULE MG, MG, 3 MG, MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (6 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, ; QL ( per day) 5 MG RITUXAN HYCELA SUBCUTANEOUS SOLUTION 00 MG/.7 ML (0 MG/ML), 600 MG/3. ML (0 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 0 MG/ML romidepsin intravenous recon soln 0 (Istodax) / ml RUBRACA ORAL TABLET 00 MG, 50 MG, 300 MG RYDAPT ORAL CAPSULE 5 MG 5 PA SPRYCEL ORAL TABLET 00 MG, 0 MG, 50 MG, 70 MG, 80 MG ; QL ( per day) SPRYCEL ORAL TABLET 0 MG ; QL ( per day) 3

39 STIVARGA ORAL TABLET 0 MG ; QL (3 per day) SUTENT ORAL CAPSULE.5 MG, 5 MG, 50 MG ; QL ( per day) SUTENT ORAL CAPSULE 37.5 MG 5 PA SYLVANT INTRAVENOUS RECON SOLN 00 MG, 00 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 0 MG LA TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 0 MG, 80 MG tamoxifen oral tablet 0, 0 TARCEVA ORAL TABLET 00 MG, 50 MG, 5 MG ; QL ( per day) TARGRETIN TOPICAL GEL % TASIGNA ORAL CAPSULE 50 MG, 00 MG, 50 MG ; QL ( per day) TECENTRIQ INTRAVENOUS 5 PA SOLUTION,00 MG/0 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 00 MG temozolomide oral capsule 00, 0 (Temodar), 80, 0, 50, 5 temsirolimus intravenous recon soln 30 (Torisel) /3 ml (0 /ml) (first) teniposide intravenous solution 50 /5 5 PA ml thiotepa injection recon soln 5 (Tepadina) 5 PA toposar intravenous solution 0 /ml PA topotecan intravenous recon soln (Hycamtin) topotecan intravenous solution / ml ( /ml) toremifene oral tablet 60 (Fareston) 5 PA TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML (0 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON SOLN 00 MG, 5 MG 35

40 TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 MG,.5 MG, 3.75 MG tretinoin (chemotherapy) oral capsule 0 LA TYKERB ORAL TABLET 50 MG UNITUXIN INTRAVENOUS 5 PA SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL 5 PA SOLUTION 0 MG/ML VECTIBIX INTRAVENOUS SOLUTION 00 MG/5 ML (0 MG/ML), 00 MG/0 ML (0 MG/ML) VELCADE INJECTION RECON 5 PA SOLN 3.5 MG VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG VERZENIO ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG vinblastine intravenous solution /ml vincasar pfs intravenous solution PA /ml, / ml vincristine intravenous solution /ml, (Vincasar PFS) PA NSO / ml vinorelbine intravenous solution 0 (Navelbine) PA; LA /ml, 50 /5 ml VOTRIENT ORAL TABLET 00 MG ; QL ( per day) VYXEOS INTRAVENOUS RECON SOLN -00 MG XALKORI ORAL CAPSULE 00 MG, 50 MG ; QL ( per day) XATMEP ORAL SOLUTION.5 MG/ML QL (0 per 60 days); AGE (Max Years) XTANDI ORAL CAPSULE 0 MG ; QL ( per day) 36

41 YERVOY INTRAVENOUS SOLUTION 00 MG/0 ML (5 MG/ML), 50 MG/0 ML (5 MG/ML) YONDELIS INTRAVENOUS 5 PA RECON SOLN MG YONSA ORAL TABLET 5 MG 5 PA ZALTRAP INTRAVENOUS 5 PA SOLUTION 00 MG/ ML (5 MG/ML) ZALTRAP INTRAVENOUS SOLUTION 00 MG/8 ML (5 MG/ML) ZANOSAR INTRAVENOUS RECON SOLN GRAM ZEJULA ORAL CAPSULE 00 MG ZELBORAF ORAL TABLET 0 MG ; QL (8 per day) ZOLADEX SUBCUTANEOUS IMPLANT 0.8 MG, 3.6 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG ZYKADIA ORAL CAPSULE 50 MG ZYTIGA ORAL TABLET 50 MG, 500 MG Anticholinergic Agents Antimuscarinics/Antispasmodics ; QL ( per day) atropine injection solution 0. /ml atropine injection syringe 0.05 /ml, 0. /ml propantheline oral tablet 5 Anticonvulsants Anticonvulsants BANZEL ORAL SUSPENSION 0 3 PA; QL (80 per day) MG/ML BANZEL ORAL TABLET 00 MG 3 PA; QL (6 per day) BANZEL ORAL TABLET 00 MG 3 PA; QL (8 per day) carbamazepine oral capsule, er (Carbatrol) multiphase hr 00, 00, 300 carbamazepine oral suspension 00 /5 ml (Tegretol) 37

42 carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release hr 00, 00, 00 carbamazepine oral tablet,chewable 00 CELONTIN ORAL CAPSULE 300 MG DILANTIN EXTENDED ORAL CAPSULE 00 MG DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG DILANTIN ORAL CAPSULE 30 MG 3 DILANTIN-5 ORAL SUSPENSION 5 MG/5 ML divalproex oral capsule, delayed rel sprinkle 5 (Depakote Sprinkles) divalproex oral tablet extended release (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 5, 50, 500 epitol oral tablet 00 EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG, 00 MG, 300 MG ethosuximide oral capsule 50 (Zarontin) ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) ST; QL (30 per day) felbamate oral tablet 00 (Felbatol) ST; QL (9 per day) felbamate oral tablet 600 (Felbatol) ST; QL (6 per day) fosphenytoin injection solution 00 (Cerebyx) pe/ ml, 500 pe/0 ml gabapentin oral capsule 00, 300, (Neurontin) 00 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) GABITRIL ORAL TABLET MG QL ( per day) GABITRIL ORAL TABLET 6 MG QL (3 per day) LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 5 MG (8) -00 MG () 38