2019 Comprehensive Formulary

Transcription

1 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) Centers Plan for Medicaid Advantage Plus (HMO SNP) 209 Comprehensive Formulary This formulary was updated on /209. For more recent information or other questions, please contact Centers Plan for Healthy Living at or, for TTY users, , seven days a week from 8 am 8 pm, or visit H6988_002_003_004_ENR085_C

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3 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) Centers Plan for Medicaid Advantage Plus (HMO SNP) 209 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN CPHL 209 Formulary ID: 902 Version: 8 This formulary was updated on /209. For more recent information or other questions, please contact us, Centers Plan for Healthy Living at or, for TTY users, , seven days a week, 8:00 AM to 8:00 PM, or visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Centers Plan for Healthy Living. When it refers to plan or our plan, it means Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP), or Centers Plan for Medicaid Advantage Plus (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of /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. H6988_002_003_004_ENR085_C i

4 What is the Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) or Centers Plan for Medicaid Advantage Plus (HMO SNP) Formulary? A formulary is a list of covered drugs selected by Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) 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 cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) or Centers Plan for Medicaid Advantage Plus (HMO SNP) Formulary? Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing H6988_002_003_004_ENR085_C ii

5 tier.). Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 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 0/0/209. To get updated information about the drugs covered by Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP), please contact us. Our contact information appears on the front and back cover pages. In the event of any mid-year non-maintenance formulary changes, Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) will mail you an errata sheet to update your printed formulary. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins 3. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) 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. H6988_002_003_004_ENR085_C iii

6 Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) before you fill your prescriptions. If you don t get approval, Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) may not cover the drug. Quantity Limits: For certain drugs Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) limits the amount of the drug that Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) will cover. For example, Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) provides 2 per prescription for sumatriptan. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) 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, Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explains our authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) formulary? on page vi for information about how to request an exception. H6988_002_003_004_ENR085_C iv

7 What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) pays for certain OTC drugs. Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) will provide these OTC drugs at no cost to you. The cost to Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) of these OTC drugs will not count toward your total Part D drug costs (that is, the cost of the OTC drugs does not count for the coverage gap.) What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you learn that Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP). You can ask Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) 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 Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) Formulary? You can ask Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) 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. H6988_002_003_004_ENR085_C v

8 You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) 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. 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 facilities from hospitals or enter an ambulatory setting from a hospital). H6988_002_003_004_ENR085_C vi

9 For more information For more detailed information about your Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) or Centers Plan for Medicaid Advantage Plus (HMO SNP) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) or Centers Plan for Medicaid Advantage Plus (HMO SNP), 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 day a week. TTY users should call Or, visit Centers Plan for Medicaid Advantage Plus (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) Formulary The formulary below provides coverage information about the drugs covered by Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP). If you have trouble finding your drug in the list, turn to the Index that begins on page I_. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR) and generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plus (HMO SNP) has any special requirements for coverage of your drug. H6988_002_003_004_ENR085_C vii

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11 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 Antidementia Agents Antidepressants Antidiabetic Agents... 3 Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders... 5 Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives... 68

12 Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents... 0 Irrigating Solutions... 0 Metabolic Bone Disease Agents... 0 Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants... 2 Sleep Disorder Agents... 2 Vasodilating Agents... 3 Vitamins And Minerals

13 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 20-2 /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet QL (2700 per 30 QL (360 per 30 (Tylenol-Codeine #3) QL (360 per 30 (Tylenol-Codeine #4) QL (80 per 30 (Buprenex) (Esgic) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Fiorinal) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) QL (80 per 30 codeine sulfate oral tablet 5, 30, 60 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 (Actiq) PA; QL (20 per 30 (Duragesic) QL (0 per 30 (Hycet) QL (2700 per 30 (Lorcet HD) QL (80 per 30 (Verdrocet) QL (240 per 30 (Lorcet (hydrocodone)) QL (240 per 30 3

14 hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (80 per hydrocodone-ibuprofen oral tablet QL (50 per 30 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 TABLET,ORAL QL (30 per 30 ONLY,EXT.REL.24 HR 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- PA; QL (30 per 30 AEROSOL 00 MCG/SPRAY, 300 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

15 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, 50 QL (8 per 30 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 5- QL (800 per /5 ml oxycodone-acetaminophen oral tablet 0- (Endocet) QL (80 per oxycodone-acetaminophen oral tablet 2.5- (Endocet) QL (360 per , oxycodone-acetaminophen oral tablet 7.5- (Endocet) QL (240 per oxycodone-aspirin oral tablet QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL QL (60 per 30 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 QL (20 per 30 CAPSULE,SPRINKLE,ER 2HR TMPRR 27 MG XTAMPZA ER ORAL QL (240 per 30 CAPSULE,SPRINKLE,ER 2HR TMPRR 36 MG Nonsteroidal Anti-Inflammatory Agents 5

16 CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8 ML (00 MG/ML) celecoxib oral capsule 00, 200, 50 (Celebrex) QL (60 per 30 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 PATCH 2 PA 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, 800 (IBU) indomethacin oral capsule 25 PA-HRM; QL (240 per 30 ; AGE (Max 64 Years) indomethacin oral capsule 50 PA-HRM; QL (20 per 30 ; AGE (Max 64 Years) indomethacin sodium intravenous recon soln ketorolac oral tablet 0 PA-HRM; QL (20 per 30 ; AGE (Max 64 Years) 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

17 PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 MG/GRAM /ACTUATION(2 %) sulindac oral tablet 50, 200 VOLTAREN TOPICAL GEL % Anesthetics PA; QL (224 per 28 Local Anesthetics glydo mucous membrane jelly in applicator 2 % QL (30 per 30 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 (Lidoderm) PA; QL (90 per 30 patch,medicated 5 % 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 CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG (Zyban) PA; QL (30 per 30 7 QL (90 per 30 QL (90 per 30 QL (336 per 365 QL (336 per 365

18 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 MG QL (228 per 4 naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL (4 per 30 AEROSOL 4 MG/ACTUATION NICOTROL INHALATION QL (008 per 90 CARTRIDGE 0 MG SUBOXONE SUBLINGUAL FILM 2-3 QL (60 per 30 MG, 8-2 MG SUBOXONE SUBLINGUAL FILM QL (30 per 30 MG, 4- MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, 2.9- QL (30 per MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25, 0.5, QL (60 per 30 (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 clonazepam oral tablet 2 (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating 0.25, 0.25, 0.5, clonazepam oral tablet,disintegrating 2 QL (90 per 30 QL (300 per 30 8

19 clorazepate dipotassium oral tablet 5, QL (80 per 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 ( /ml) QL (200 per 30 diazepam oral tablet 0, 2, 5 (Valium) QL (20 per 30 diazepam rectal kit , 5- (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) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML PA BvD 9

20 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 (Cleocin) solution 600 /4 ml colistin (colistimethate na) injection recon soln 50 daptomycin intravenous recon soln 350 (Coly-Mycin M Parenteral) PA BvD 0

21 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 piggyback 600 /300 ml (Zyvox) linezolid oral suspension for reconstitution (Zyvox) 00 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /00 ml metronidazole oral tablet 250, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 00, 25, 50 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 ; AGE (Max 64 Years) nitrofurantoin monohyd/m-cryst oral capsule 00 (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 ; AGE (Max 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 vancomycin intravenous recon soln,000 PA BvD, 0 gram, 250, 5 gram, 500, 750 vancomycin oral capsule 25, 250 (Vancocin) XIFAXAN ORAL TABLET 200 MG PA; QL (9 per 30

22 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 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, 2 (Claforan) 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 2

23 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 250, 500 (Keflex) 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 (Azactam) gram CAYSTON INHALATION SOLUTION LA FOR NEBULIZATION 75 MG/ML 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 3

24 amoxicillin oral capsule 250, 500 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 2 gm vial sterile, latex-free 2 gram nafcillin injection recon soln gram, 0 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

25 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 recon (Zosyn) PA BvD 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 sulfamethoxazole-trimethoprim oral suspension /5 ml (Sulfatrim) 5

26 sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) sulfatrim oral suspension /5 ml Tetracyclines doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon (Doxy-00) soln 00 doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 20 doxycycline monohydrate oral capsule 00 (Mondoxyne NL), 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 PA BvD ml, 500 /0 ml 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 6

27 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 RECON PA NSO SOLN 500 MG BENDEKA INTRAVENOUS PA NSO SOLUTION 25 MG/ML BESPONSA INTRAVENOUS RECON PA NSO 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 PA NSO MCG 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 7

28 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 ml (Clolar) 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 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) 8

29 EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON PA NSO 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 MG, 5 PA NSO 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 GAZYVA INTRAVENOUS SOLUTION PA NSO,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 RECON PA NSO 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 9

30 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 SOLUTION PA NSO 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 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 PA NSO; QL (49 per 28 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) PA NSO; QL (70 per 28 PA NSO; QL (9 per 28 PA NSO; QL (2 per 28 PA NSO; QL (42 per 28 20

31 KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3) PA NSO; QL (63 per 28 KYPROLIS INTRAVENOUS RECON PA NSO SOLN 0 MG, 30 MG, 60 MG LARTRUVO INTRAVENOUS PA NSO; LA 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) PA NSO letrozole oral tablet 2.5 (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit /0.2 ml LIBTAYO INTRAVENOUS SOLUTION 350 MG/7 ML (50 MG/ML) PA NSO; QL (7 per 2 LONSURF ORAL TABLET MG PA NSO; QL (00 per 28 LONSURF ORAL TABLET MG PA NSO; QL (80 per 28 LORBRENA ORAL TABLET 00 MG PA NSO; QL (30 per 30 LORBRENA ORAL TABLET 25 MG PA NSO; QL (90 per 30 LUMOXITI INTRAVENOUS RECON PA NSO SOLN MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG PA NSO; QL (448 per 28 LYNPARZA ORAL TABLET 00 MG, 50 MG PA NSO; QL (20 per 30 2

32 LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20, 40 PA NSO-HRM; AGE (Max 64 Years) MEKINIST ORAL TABLET 0.5 MG PA NSO; QL (90 per 30 MEKINIST ORAL TABLET 2 MG PA NSO; QL (30 per 30 MEKTOVI ORAL TABLET 5 MG PA NSO; QL (80 per 30 mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon PA BvD soln gram methotrexate sodium (pf) injection PA BvD solution 25 /ml methotrexate sodium injection solution 25 PA BvD /ml methotrexate sodium oral tablet 2.5 PA BvD; ST mitoxantrone intravenous concentrate 2 /ml MYLOTARG INTRAVENOUS RECON PA NSO SOLN 4.5 MG ( MG/ML INITIAL CONC) NERLYNX ORAL TABLET 40 MG PA NSO; QL (80 per 30 NEXAVAR ORAL TABLET 200 MG PA NSO; QL (20 per 30 nilutamide oral tablet 50 (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PA NSO; QL (3 per 28 ODOMZO ORAL CAPSULE 200 MG PA NSO; LA ONCASPAR INJECTION SOLUTION PA NSO 750 UNIT/ML ONIVYDE INTRAVENOUS PA BvD DISPERSION 4.3 MG/ML OPDIVO INTRAVENOUS SOLUTION PA NSO 00 MG/0 ML, 240 MG/24 ML, 40 MG/4 ML POMALYST ORAL CAPSULE MG, 2 PA NSO; QL (2 per 28 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (6 MG/ML) PA NSO; QL (00 per 2 22

33 POTELIGEO INTRAVENOUS PA NSO SOLUTION 4 MG/ML PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG PA NSO; LA; QL (28 per 28 RITUXAN HYCELA SUBCUTANEOUS PA NSO SOLUTION 400 MG/.7 ML (20 MG/ML), 600 MG/3.4 ML (20 MG/ML) RITUXAN INTRAVENOUS PA NSO CONCENTRATE 0 MG/ML RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PA NSO; QL (20 per 30 RYDAPT ORAL CAPSULE 25 MG PA NSO; QL (224 per 28 SOLTAMOX ORAL SOLUTION 0 MG/5 ML SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 20 MG PA NSO; QL (60 per 30 STIVARGA ORAL TABLET 40 MG PA NSO; QL (84 per 28 SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG PA NSO; QL (30 per 30 SYLVANT INTRAVENOUS RECON PA NSO SOLN 00 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG PA NSO; QL (28 per 28 TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA NSO; QL (20 per 30 TAGRISSO ORAL TABLET 40 MG, 80 MG PA NSO; LA; QL (30 per 30 TALZENNA ORAL CAPSULE 0.25 MG PA NSO; QL (90 per 30 TALZENNA ORAL CAPSULE MG PA NSO; QL (30 per 30 tamoxifen oral tablet 0, 20 23

34 TARCEVA ORAL TABLET 00 MG, 25 MG PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 50 MG PA NSO; QL (90 per 30 TARGRETIN TOPICAL GEL % PA NSO; QL (60 per 28 TASIGNA ORAL CAPSULE 50 MG, 200 MG PA NSO; QL (2 per 28 TASIGNA ORAL CAPSULE 50 MG PA NSO; QL (20 per 30 TECENTRIQ INTRAVENOUS SOLUTION,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON PA NSO; QL (20 per 2 PA NSO SOLN 00 MG thiotepa injection recon soln 5 (Tepadina) TIBSOVO ORAL TABLET 250 MG PA NSO; QL (60 per 30 toposar intravenous solution 20 /ml TREANDA INTRAVENOUS RECON SOLN 00 MG, 25 MG TRELSTAR.25 MG VIAL OUTER, QL ( per 84 SDV.25 MG TRELSTAR 22.5 MG VIAL OUTER, QL ( per 68 SDV 22.5 MG TRELSTAR 3.75 MG VIAL INNER, SDV 3.75 MG TRELSTAR INTRAMUSCULAR QL ( per 84 SYRINGE.25 MG/2 ML TRELSTAR INTRAMUSCULAR QL ( per 68 SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 0 TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS PA NSO SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG PA NSO 24

35 VENCLEXTA ORAL TABLET 0 MG PA NSO; LA; QL (60 per 30 VENCLEXTA ORAL TABLET 00 MG PA NSO; LA; QL (20 per 30 VENCLEXTA ORAL TABLET 50 MG PA NSO; LA; QL (30 per 30 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG PA NSO; LA; QL (42 per 28 VERZENIO ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG PA NSO; QL (56 per 28 vinorelbine intravenous solution 0 /ml, (Navelbine) 50 /5 ml VIZIMPRO ORAL TABLET 5 MG, 30 MG, 45 MG PA NSO; QL (30 per 30 VOTRIENT ORAL TABLET 200 MG PA NSO; QL (20 per 30 VYXEOS INTRAVENOUS RECON PA BvD SOLN MG XALKORI ORAL CAPSULE 200 MG, 250 MG PA NSO; QL (60 per 30 XATMEP ORAL SOLUTION 2.5 PA BvD; ST MG/ML XTANDI ORAL CAPSULE 40 MG PA NSO; QL (20 per 30 YERVOY INTRAVENOUS SOLUTION PA NSO 200 MG/40 ML (5 MG/ML), 50 MG/0 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON PA NSO SOLN MG YONSA ORAL TABLET 25 MG PA NSO; QL (20 per 30 ZEJULA ORAL CAPSULE 00 MG PA NSO; QL (90 per 30 ZELBORAF ORAL TABLET 240 MG PA NSO; QL (240 per 30 ZOLADEX SUBCUTANEOUS QL ( per 84 IMPLANT 0.8 MG ZOLADEX SUBCUTANEOUS QL ( per 28 IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG PA NSO; QL (60 per 30 25

36 ZYKADIA ORAL CAPSULE 50 MG PA NSO; QL (90 per 30 ZYTIGA ORAL TABLET 250 MG, 500 MG PA NSO; QL (20 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0. /ml propantheline oral tablet 5 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 ST MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 ST MG/ML BANZEL ORAL TABLET 200 MG, 400 ST MG BRIVIACT INTRAVENOUS QL (80 per 30 SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 QL (600 per 30 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG QL (60 per 30 carbamazepine oral capsule, er (Carbatrol) multiphase 2 hr 00, 200, 300 carbamazepine oral suspension 00 /5 (Tegretol) ml carbamazepine oral tablet 200 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 2 hr 00, 200, 400 carbamazepine oral tablet,chewable 00 CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 25 divalproex oral tablet extended release 24 (Depakote ER) hr 250, 500 divalproex oral tablet,delayed release (dr/ec) 25, 250, 500 (Depakote) EPIDIOLEX ORAL SOLUTION 00 MG/ML PA NSO 26