<2017> Formulary (List (List of of Covered Drugs)

Transcription

1 < Logo (flush upper left corner /8 x /8 margins)> BCBSHP <Mandatory MediBlue Plan Name> Prime Select (H) <017> Formulary (List (List of of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on on October <Last updated 1, 017. Month For more Day, recent Year>. For more information recent information other or questions, other questions, please contact please BCBSHP contact <Mandatory MediBlue Prime Plan Name> Select Customer (H) Service, Customer at <Customer Service, at Service Toll-free Number> or, for TTY or, users, for TTY 711, users, 8 a.m. <711>, to 8 <8 p.m., a.m. seven to 8 p.m., days seven a week days (except a week Thanksgiving (except Thanksgiving and and Christmas) from from October 1 through February 1, 1, and and Monday to to Friday (except (except holi holi from February from February 1 through 1 through September September 0>, or 0, visit or <Customer visit Service Web address>. <Contract> <Plan ID(s)> H_009 Y011_17_70_U<_XXX> <Material Status> <mm/dd/yyyy> Y011_17_70_U_10 CMS Accepted 08/1/01 CM_MAPD_1709_1_v0_1711_1 <HPMS Approved Formulary file submission ID, Version Number> 10 Y011_17_70_U 017 Comp Formulary template Anthem AGP

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us or our, it means Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.. When it refers to plan or our plan, it means BCBSHP MediBlue Prime Select (H). This document includes a list of the drugs (formulary) for our plan which is current as of November 1, 017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/ coinsurance may change on January 1, 018, and from time to time during the year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Effective Date November 1, 017 CM_MAPD_1709_1_v0_1711_1

3 What is the BCBSHP MediBlue Prime Select (H) formulary? A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary (drug list) change? Generally, if you are taking a drug on our 017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step-therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 0 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 0-day supply of the drug. If the Food and Administration (FDA) deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November 1, 017. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (nonmaintenance change) is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated 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 8. 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 Medications. If you know what your drug is used for, look for the category name in the list that begins on page 8. 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. 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? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 0 tablets per prescription for irbesartan 7mg tablets. This may be in addition to a standard one-month or three-month supply. Effective Date November 1, 017 CM_MAPD_1709_1_v0_1711_1

4 You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan 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 BCBSHP MediBlue Prime Select (H)'s formulary? on page for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan 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 BCBSHP MediBlue Prime Select (H)'s formulary? You can ask our plan 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 predetermined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan 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, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. Effective Date November 1, 017 CM_MAPD_1709_1_v0_1711_1

5 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term-care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or 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 -day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. During the time when you are getting a temporary supply of a drug, you should talk to your prescriber or prescribing physician to decide what to do when your supply runs out. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you while you pursue a formulary exception. Please refer to the Evidence of Coverage for more information about exceptions. For more information For more detailed information about our plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), hours a day/7 days a week. TTY users should call Or, visit Our plan s formulary The formulary on page 8 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., SPIRIVA) and generic drugs are listed in lowercase italics (e.g., atenolol). The information in the column tells you if our plan has any special requirements for coverage of your drug. QLL Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. B/D Part B vs. Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through Effective Date November 1, 017 CM_MAPD_1709_1_v0_1711_1

6 February 1, and Monday to Friday (except holi from February 1 through September 0. TTY/TDD users should call 711. INJ Injectable: The drug is available in injectable form. Mail Orders: Prescription drugs available through mail order. Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Effective Date November 1, 017 CM_MAPD_1709_1_v0_1711_1

7 Cost-sharing for a one-month supply of a covered Part D prescription drug during the Initial Coverage Stage: Cost-Sharing 1: Preferred Generic Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Generic Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Preferred Brand Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Nonpreferred Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Specialty * Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Select Care s Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Please refer to our Evidence of Coverage for more information on cost sharing. $0.00 $.00 $1.00 $17.00 $.00 $7.00 $9.00 $ Network Pharmacy with preferred cost-sharing A network pharmacy that offers covered drugs to members of our plan that may have lower cost-sharing levels than other network pharmacies with standard cost-sharing. * A long-term supply is not available for drugs in the : Specialty ** Mail-Order Pharmacy Mail-order service allows you to order a 0 90-day supply of drugs. The drugs available through our plan s mail-order service are marked as mail-order drugs in our drug list. % % $0.00 $0.00 Effective Date November 1, CM_MAPD_1709_1_v0_1711_1

8 Covered Medications by Therapeutic Category Legend Generic drugs are shown in lowercase italic (e.g., atenolol). Brand-name drugs are shown in capital letters (e.g., SPIRIVA). QLL Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. B/D Part B vs. Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 1, and Monday to Friday (except holi from February 1 through September 0. TTY/TDD users should call 711. INJ Injectable: The drug is available in injectable form. Mail Orders: Prescription drugs available through mail order. Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Anti - Infectives abacavir abacavir sulfate-lamivudine abacavir-lamivudinezidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 00 mg/ ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION per 0 ; QLL (0 per 0 ; per 0 B/D; PAR; HI; B/D; PAR; ; HI; PAR; ; QLL (180 per 0 ALINIA ORAL TABLET amantadine hcl oral capsule amantadine hcl oral tablet AMBISOME amikacin injection solution 1, 000 mg/ ml amikacin injection solution 00 mg/ ml amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 1 mg, 0 mg amoxicillin-pot clavulanate amphotericin b ampicillin ; QLL ( per 0 B/D; PAR; ; HI; B/D; PAR; CM_MAPD_1709_1_v0_1711_1 8 Effective Date November 1, 017

9 ampicillin sodium injection recon soln 1 gram, 10 gram, 1 mg ampicillin sodium injection recon soln gram, 0 mg, 00 mg ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1. gram ampicillin-sulbactam injection recon soln 1 gram ampicillin-sulbactam injection recon soln gram ampicillin-sulbactam intravenous recon soln 1. gram APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atovaquone atovaquone-proguanil oral tablet mg ATRIPLA AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) azithromycin intravenous azithromycin oral suspension for reconstitution azithromycin oral tablet 0 mg ( pack) azithromycin oral tablet 0 mg, 00 mg, 00 mg aztreonam for inj 1 GM baciim bacitracin intramuscular BARACLUDE ORAL SOLUTION BICILLIN C-R SYRINGE 1,00,000 UNIT/ ML(00K/00K) BILTRICIDE CANCIDAS CAPASTAT ; HI; HI; ; HI; HI; ; QLL (10 per 0 QLL (90 per 0 PAR; ; QLL (0 per 0 HI ; HI; HI PAR; QLL (00 per 0 ; B/D; PAR; CAYSTON cefaclor oral capsule cefaclor oral suspension for reconstitution 1 mg/ ml cefaclor oral suspension for reconstitution 0 mg/ ml, 7 mg/ ml cefaclor oral tablet extended release 1 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 0 mg/ ml, 00 mg/ ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/ 0 ml cefazolin injection recon soln 1 gram, 00 mg cefazolin injection recon soln 10 gram cefazolin injection recon soln 100 gram, 0 gram, 00 g cefazolin intravenous cefdinir cefepime cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram, gram cefpodoxime cefprozil ceftazidime ceftazidime injection recon soln 1 gram, gram ceftazidime injection recon soln gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, gram ceftriaxone injection recon soln 10 gram ceftriaxone injection recon soln 0 mg, 00 mg ceftriaxone intravenous PAR; LA; ; HI; HI; ; HI; ; HI; HI; ; ; HI; HI; HI; ; HI; ; HI; CM_MAPD_1709_1_v0_1711_1 9 Effective Date November 1, 017

10 cefuroxime axetil oral tablet cefuroxime sodium intravenous vial injection recon soln 1. gram, 70 mg cefuroxime sodium intravenous vial intravenous recon soln 7. gram cephalexin oral capsule 0 mg, 00 mg cephalexin oral suspension for reconstitution chloramphenicol sod succinate chloroquine phosphate oral ciprofloxacin (mixture) oral tablet, er multiphase hr 1, 000 mg ciprofloxacin (mixture) oral tablet, er multiphase hr 00 mg ciprofloxacin hcl oral tablet 0 mg, 00 mg, 70 mg ciprofloxacin lactate intravenous solution 00 mg/ 0 ml ciprofloxacin lactate intravenous solution 00 mg/ 0 ml clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release hr clindamycin hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 00 mg/ ml, 900 mg/ ml clindamycin phosphate intravenous solution 00 mg/ ml clotrimazole mucous membrane COARTEM colistin (colistimethate na) COMPLERA ; HI; HI; ; QLL (8 per 1 ; HI; ; HI; QLL (0 per 0 ; CRIXIVAN ORAL CAPSULE 00 MG CRIXIVAN ORAL CAPSULE 00 MG CUBICIN dapsone DARAPRIM demeclocycline DESCOVY dicloxacillin didanosine oral capsule,delayed release(dr/ec) 1 mg didanosine oral capsule,delayed release(dr/ec) 00 mg didanosine oral capsule,delayed release(dr/ec) 0 mg, 00 mg doxy-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline monohydrate oral capsule 100 mg, 0 mg, 7 mg EDURANT EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPCLUSA EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG ; QLL (0 per 0 ; QLL (180 per 0 QLL (0 per 0 ; ; QLL (90 per 0 per 0 ; QLL (0 per 0 HI; QLL (0 per 0 ; ; QLL (0 per 0 ; QLL (870 per 0 PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; ; QLL (90 per 0 ; QLL (0 per 0 PAR; ; HI CM_MAPD_1709_1_v0_1711_1 10 Effective Date November 1, 017

11 ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 0 MG ery-tab oral tablet,delayed release (dr/ec) 0 mg, 00 mg ERYTHROCIN INTRAVENOUS RECON SOLN 00 MG ethambutol EVOTAZ famciclovir oral tablet 1 mg, 0 mg famciclovir oral tablet 00 mg fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/ 0 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/ 100 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/ 00 ml flucytosine foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium gentamicin injection solution 0 mg/ ml gentamicin injection solution 0 mg/ml gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/ 10 ml gentamicin sulfate (pf) intravenous solution 0 mg/ ml PAR; QLL (0 per 0 ; per 0 ; QLL (1 per 7 HI; HI; B/D; PAR; QLL (0 per 0 ; B/D; PAR; ; HI; gentamicin sulfate (pf) intravenous solution 80 mg/8 ml GENVOYA griseofulvin microsize oral suspension griseofulvin ultramicrosize HARVONI hydroxychloroquine oral imipenem-cilastatin INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 00 MG INTELENCE ORAL TABLET MG INVANZ INJECTION INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS HD 00MG ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE MG isoniazid oral itraconazole ivermectin mg tab KALETRA ORAL SOLUTION KALETRA ORAL TABLET 100- MG KALETRA ORAL TABLET 00-0 MG ketoconazole oral HI; QLL (0 per 0 ; PAR; QLL (8 per 8 ; ; HI; ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; HI ; QLL (00 per 0 ; QLL (10 per 0 QLL (0 per 0 ; QLL (10 per 0 ; QLL (180 per 0 ; ; QLL (70 per 0 ; QLL (80 per 0 ; QLL (00 per 0 ; QLL (10 per 0 CM_MAPD_1709_1_v0_1711_1 11 Effective Date November 1, 017

12 lamivudine oral solution lamivudine oral tablet 100 mg lamivudine oral tablet 10 mg lamivudine oral tablet 00 mg lamivudine-zidovudine levofloxacin intravenous levofloxacin oral solution levofloxacin oral tablet LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet lopinavir-ritonavir soln MACRODANTIN ORAL CAPSULE MG, 0 MG mefloquine meropenem intravenous recon soln 1 gram meropenem intravenous recon soln 00 mg methenamine hippurate methenamine mandelate oral tablet 1 gram metro i.v. metronidazole in nacl (iso-os) metronidazole oral minocycline oral capsule minocycline oral tablet moderiba morgidox oral capsule 100 mg MYCOBUTIN nafcillin injection recon soln 1 gram, 10 gram ; QLL (900 per 0 per 0 ; QLL (0 per 0 per 0 ; QLL (1800 per 0 ; QLL (10 per 0 PAR; HI; PAR; ; QLL (180 per 0 PAR; ; QLL ( per 0 ; QLL (80 per 0 ; ; HI; ; HI; ; HI; nafcillin injection recon soln gram nafcillin intravenous recon soln gram NEBUPENT neomycin nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release hr 100 mg nevirapine oral tablet extended release hr 00 mg nitrofurantoin NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet ODEFSEY ofloxacin oral tablet ofloxacin oral tablet 00 mg OLYSIO oxacillin injection recon soln 1 gram, gram oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 1 gram oxacillin intravenous recon soln gram paromomycin paser PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/0 ML B/D; PAR; ; QLL (100 per 0 per 0 ; QLL (0 per 0 ; ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (0 per 0 QLL (00 per 0 ; QLL (0 per 0 ; PAR; QLL (0 per 0 ; ; HI; HI; CM_MAPD_1709_1_v0_1711_1 1 Effective Date November 1, 017

13 PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK MILLION UNIT/0 ML, MILLION UNIT/0 ML penicillin g potassium injection recon soln 0 million unit penicillin g potassium injection recon soln million unit penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 00,000 unit/ml penicillin g sodium penicillin v potassium PENTAM piperacillin-tazobactam intravenous recon soln. gram piperacillin-tazobactam intravenous recon soln.7 gram,. gram, 0. gram PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 10 MG PREZISTA ORAL TABLET 00 MG, 800 MG PREZISTA ORAL TABLET 7 MG PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE HI ; HI; ; HI; ; HI; QLL (0 per 0 ; QLL (0 per 0 ; ; QLL (180 per 0 ; QLL (0 per 0 ; QLL (00 per 0 PAR; ; QLL (0 per 180 ; QLL (180 per 0 ; QLL (0 per 0 RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 10 MG, 00 MG REYATAZ ORAL CAPSULE 00 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg ribavirin oral capsule ribavirin oral tablet 00 mg rifampin intravenous rifampin oral RIFATER rimantadine SELZENTRY SELZENTRY ORAL SOL SELZENTRY TABLET MG SELZENTRY TABLET 7 MG SIRTURO SOVALDI stavudine oral capsule 1 mg, 0 mg stavudine oral capsule 0 mg, 0 mg stavudine oral recon soln STREPTOMYCIN STRIBILD STROMECTOL sulfadiazine oral sulfamethoxazole-trimethoprim SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 0 MG SUSTIVA ORAL TABLET ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; HI; QLL (10 per 0 ; QLL (180 per 0 ; QLL (10 per 0 QLL (0 per 0 PAR; LA; PAR; QLL (0 per 0 ; ; QLL (10 per 0 per 0 ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (0 per 0 CM_MAPD_1709_1_v0_1711_1 1 Effective Date November 1, 017

14 SYNAGIS SYNERCID TAMIFLU TECHNIVIE TEFLARO INTRAVENOUS RECON SOLN 00 MG TEFLARO INTRAVENOUS RECON SOLN 00 MG terbinafine hcl oral tetracycline TIGECYCLINE TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET MG, 0 MG TOBI tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ TRIZIVIR TRUVADA ORAL TABLET MG, 1-00 MG, 17-0 MG TRUVADA ORAL TABLET MG TYBOST TYGACIL TYZEKA valacyclovir valganciclovir vancomycin in 0.9% sodium cl intravenous piggyback 00 mg/ 100 ml, 70 mg/10 ml PAR; LA; PAR; QLL ( per 8 ; ; QLL (0 per 0 QLL (0 per 0 QLL (0 per 0 ; PAR; QLL (80 per 8 ; ; HI; QLL (0 per 0 ; ; QLL (0 per 0 QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 HI; ; QLL (0 per 0 B/D; PAR; vancomycin in dextrose % intravenous piggyback 1 gram/ 00 ml vancomycin in dextrose % intravenous piggyback 00 mg/ 100 ml, 70 mg/10 ml vancomycin intravenous recon soln 1,000 mg, 10 gram, 00 mg vancomycin intravenous recon soln gram, 70 mg vancomycin oral capsule 1 mg vancomycin oral capsule 0 mg VIDEX GRAM PEDIATRIC VIDEX GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR VIRACEPT ORAL TABLET 0 MG VIRACEPT ORAL TABLET MG VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 00 mg voriconazole oral tablet 0 mg VOSEVI XIFAXAN ORAL TABLET 0 MG B/D; PAR; B/D; PAR; ; HI; B/D; PAR; PAR; QLL (0 per 10 ; PAR; QLL (80 per 10 ; ; QLL (100 per 0 ; QLL (100 per 0 PAR; QLL (11 per 8 ; PAR; QLL (8 per 8 ; ; QLL (00 per 0 ; QLL (10 per 0 PAR; ; QLL (0 per 0 ; QLL (0 per 0 QLL (0 per 0 ; PAR; QLL (00 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (10 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (8 per 8 ; CM_MAPD_1709_1_v0_1711_1 1 Effective Date November 1, 017

15 ZEPATIER ZERIT ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK. GRAM/ 0 ML,. GRAM/100 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK.7 GRAM/ 0 ML PAR; QLL (0 per 0 ; QLL (00 per 0 ; QLL (90 per 0 ; QLL (180 per 0 ; QLL (190 per 0 per 0 Antineoplastic / Immunosuppressant s ABRAXANE AFINITOR PAR; AFINITOR DISPERZ PAR; ALECENSA ALIMTA ALUNBRIG PAR; QLL (180 per 0 ; amifostine crystalline anastrozole ; QLL (0 per 0 ARRANON ARZERRA ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE HR 0. MG, 1 MG B/D; PAR; ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE HR MG AVASTIN azacitidine azasan azathioprine B/D; PAR; PAR; B/D; PAR; B/D; PAR; azathioprine sodium BAVENCIO BELEODAQ BENDEKA bexarotene bicalutamide BICNU bleomycin BLINCYTO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 00 MG busulfan BUSULFEX CABOMETYX ORAL TABLET 0 MG CABOMETYX ORAL TABLET 0 MG, 0 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 00 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine clofarabine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1) COMETRIQ ORAL CAPSULE 10 MG/DAY(80 MG X1-0 MG X) COMETRIQ ORAL CAPSULE 0 MG/DAY (0 MG X /DAY) COSMEGEN COTELLIC cyclophosphamide oral capsule cyclosporine intravenous B/D; PAR; PAR; PAR; PAR; ; QLL (0 per 0 B/D; PAR; PAR; PAR; QLL (10 per 0 ; PAR; QLL (0 per 0 ; B/D; PAR PAR; LA; QLL (90 per 0 ; PAR; LA; QLL (0 per 0 ; PAR; LA; QLL (90 per 0 ; PAR; LA; QLL (0 per 0 ; B/D; PAR; B/D; PAR; PAR; QLL ( per 8 ; PAR; QLL (11 per 8 ; PAR; QLL (8 per 8 ; PAR; LA; QLL (90 per 0 ; B/D; PAR; B/D; PAR; CM_MAPD_1709_1_v0_1711_1 1 Effective Date November 1, 017

16 cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine cytarabine (pf) injection solution 100 mg/ ml (0 mg/ ml), gram/0 ml (100 mg/ ml) cytarabine (pf) injection solution 0 mg/ml dacarbazine DACOGEN DARZALEX daunorubicin intravenous solution decitabine dexrazoxane hcl intravenous recon soln 0 mg dexrazoxane hcl intravenous recon soln 00 mg DOCEFREZ INTRAVENOUS RECON SOLN 0 MG docetaxel intravenous solution 10 mg/ml, 10 mg/1 ml (10 mg/ml), 10 mg/8 ml (0 mg/ ml), 0 mg/ ml (10 mg/ml), 0 mg/ml (1 ml), 80 mg/ ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) DOCETAXEL INTRAVENOUS SOLUTION 00 MG/10 ML doxorubicin intravenous recon soln doxorubicin intravenous solution doxorubicin, peg-liposomal DROXIA ELITEK EMCYT EMPLICITI epirubicin intravenous solution 00 mg/100 ml B/D; PAR; B/D; PAR; PAR; B/D; PAR; B/D; PAR; B/D; PAR; LA; B/D; PAR; PAR; B/D; PAR; epirubicin intravenous solution 0 mg/ ml ERBITUX ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 1 MG, 0 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN FUSILEV GAZYVA gemcitabine intravenous recon soln 1 gram, 00 mg gemcitabine intravenous recon soln gram gemcitabine intravenous solution 1 gram/. ml (8 mg/ml), 00 mg/. ml (8 mg/ml) gemcitabine intravenous solution gram/. ml (8 mg/ml) PAR; PAR; QLL (0 per 0 ; per 0 QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL ( per ; ; QLL (1 per 8 B/D; PAR; PAR; CM_MAPD_1709_1_v0_1711_1 1 Effective Date November 1, 017

17 gengraf oral capsule 100 mg, mg gengraf oral capsule 0 mg gengraf oral solution GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 00 MG GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyprogesterone caproate hydroxyurea IBRANCE ICLUSIG ORAL TABLET 1 MG ICLUSIG ORAL TABLET MG idarubicin IDHIFA ORAL TABLET 100 MG IDHIFA ORAL TABLET 0 MG ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg imatinib oral tablet 00 mg IMBRUVICA IMFINZI INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET MG IRESSA irinotecan intravenous solution 100 mg/ ml, 0 mg/ ml irinotecan intravenous solution 00 mg/ ml B/D; PAR; B/D; PAR; B/D; PAR; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (10 per 0 ; PAR; PAR; QLL (0 per 0 ; PAR; QLL (10 per 0 ; ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 1 MG JAKAFI ORAL TABLET 0 MG JAKAFI ORAL TABLET MG JAKAFI ORAL TABLET MG JEVTANA KADCYLA KEPIVANCE KEYTRUDA KISQALI 00 DOSE KISQALI 00 PAK FEMARA KISQALI 00 DOSE KISQALI 00 PAK FEMARA KISQALI 00 DOSE KISQALI 00 PAK FEMARA KYPROLIS LARTRUVO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) LENVIMA ORAL CAPSULE 1 MG/DAY(10 MG X 1- MG X 1), 0 MG/ DAY (10 MG X ), 8 MG/ DAY ( MG X ) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1- MG X), MG/ DAY(10 MG X - MG X 1) letrozole PAR; QLL (10 per 0 ; PAR; QLL (100 per 0 ; PAR; QLL (7 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (00 per 0 ; PAR; PAR; PAR; QLL (1 per 1 ; PAR; QLL (1 per 8 ; PAR; QLL ( per 1 ; PAR; QLL ( per 8 ; PAR; QLL ( per 1 ; PAR; QLL ( per 8 ; B/D; PAR; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (90 per 0 ; ; QLL (0 per 0 CM_MAPD_1709_1_v0_1711_1 17 Effective Date November 1, 017

18 leucovorin calcium injection recon soln 100 mg, 00 mg, 0 mg, 0 mg leucovorin calcium injection recon soln 00 mg leucovorin calcium oral LEUKERAN leuprolide subcutaneous kit levoleucovorin inj 0mg LONSURF LUPRON DEPOT SYRINGE KIT.7 MG, 7. MG LUPRON DEPOT ( NTH) SYRINGE KIT 11. MG LUPRON DEPOT ( NTH) SYRINGE KIT. MG LYNPARZA LYNPARZA ORAL TABLET 100 MG, 10 MG LYSODREN MARQIBO MATULANE megestrol oral suspension 00 mg/10 ml (10 ml), 800 mg/0 ml (0 ml) megestrol oral suspension 00 mg/10 ml (0 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0. MG MEKINIST ORAL TABLET MG melphalan hcl mercaptopurine mesna MESNEX ORAL methotrexate sodium methotrexate sodium (pf) injection recon soln PAR; PAR; QLL (1 per 8 ; PAR; QLL (1 per 8 ; PAR; QLL (1 per 8 ; PAR; QLL (80 per 0 ; PAR; QLL (10 per 0 ; PAR; QLL (90 per 0 ; PAR; QLL (0 per 0 ; methotrexate sodium (pf) injection solution mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium NERLYNX NEXAVAR NILANDRON NINLARO NIPENT NULOJIX octreotide acetate injection solution 1,000 mcg/ml, 00 mcg/ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ ml, 0 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 0 mcg/ml (1 ml) octreotide acetate injection syringe 00 mcg/ml (1 ml) ODOMZO OPDIVO oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 0 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG B/D; PAR; B/D; PAR; B/D; PAR; B/D; PAR; PAR; QLL (180 per 0 ; PAR; LA; QLL (10 per 0 ; QLL (0 per 0 ; PAR; QLL ( per 8 ; B/D; PAR; PAR; PAR; PAR; PAR; PAR; LA; QLL (0 per 0 ; PAR; PAR; QLL (10 per 0 ; CM_MAPD_1709_1_v0_1711_1 18 Effective Date November 1, 017

19 POMALYST ORAL CAPSULE MG POMALYST ORAL CAPSULE MG, MG PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 1 MG,. MG, 0 MG, MG REVLIMID ORAL CAPSULE MG RITUXAN RITUXAN HYCELA RUBRACA ORAL TABLET 00MG RUBRACA ORAL TABLET 0MG RUBRACA ORAL TABLET 00MG RYDAPT SANDIMMUNE ORAL SOLUTION SIGNIFOR SIMULECT sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 1. MG SUTENT ORAL CAPSULE MG, 7. MG, 0 MG SYNRIBO TABLOID tacrolimus oral PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; B/D; PAR; PAR; B/D; PAR; LA; QLL (0 per 0 ; LA; QLL (0 per 0 ; LA; QLL (10 per 0 ; B/D; PAR; PAR; QLL (180 per 0 ; PAR; QLL (10 per 0 ; PAR; QLL (10 per 0 ; PAR; QLL (0 per 0 ; B/D; PAR; B/D; PAR; B/D; PAR; QLL (0 per 0 ; PAR; QLL (10 per 0 ; QLL (90 per 0 ; QLL (0 per 0 ; B/D; PAR; TAFINLAR TAGRISSO ORAL TABLET 0 MG TAGRISSO ORAL TABLET 80 MG tamoxifen TARCEVA ORAL TABLET 100 MG, 10 MG TARCEVA ORAL TABLET MG TARGRETIN ORAL TARGRETIN TOPICAL TASIGNA TECENTRIQ TEPADINA THALOMID ORAL CAPSULE 100 MG, 0 MG THALOMID ORAL CAPSULE 10 MG, 00 MG thiotepa toposar topotecan TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR SUSPENSION FOR RECONSTITUTION TRELSTAR SYRINGE 11. MG/ ML TRELSTAR SYRINGE. MG/ ML TRELSTAR SYRINGE.7 MG/ ML tretinoin (chemotherapy) trexall TRISENOX PAR; QLL (10 per 0 ; PAR; LA; QLL (0 per 0 ; PAR; LA; QLL (0 per 0 ; QLL (0 per 0 ; QLL (90 per 0 ; PAR; PAR; QLL (0 per 0 ; QLL (11 per 8 ; LA; QLL (0 per 1 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (1 per 18 ; QLL (1 per 8 ; QLL (1 per 18 ; QLL (1 per 8 ; CM_MAPD_1709_1_v0_1711_1 19 Effective Date November 1, 017

20 TYKERB UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 0 MG VENCLEXTA STARTING PACK vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ml vincasar pfs intravenous solution mg/ ml vincristine vinorelbine VOTRIENT VYXEOS XALKORI XATMEP XGEVA XTANDI YERVOY YONDELIS ZALTRAP ZANOSAR ZEJULA ZELBORAF ZOLINZA ZORTRESS ORAL TABLET 0. MG ZORTRESS ORAL TABLET 0. MG, 0.7 MG LA; QLL (180 per 0 ; PAR; PAR; LA; QLL (0 per 0 PAR; LA; QLL (10 per 0 ; PAR; LA; QLL (0 per 0 PAR; LA; QLL (8 per ; B/D; PAR; B/D; PAR; B/D; PAR; QLL (10 per 0 ; B/D; PAR; PAR; QLL (0 per 0 ; PAR; QLL (1.7 per 8 ; PAR; QLL (10 per 0 ; B/D; PAR; PAR; PAR; QLL (90 per 0 ; PAR; QLL (0 per 0 ; QLL (10 per 0 ; B/D; PAR; B/D; PAR; ZYDELIG PAR; QLL (0 per 0 ; ZYKADIA PAR; QLL (10 per 0 ; ZYTIGA PAR; QLL (10 per 0 ; ZYTIGA 00 MG PAR; QLL (0 per 0 ; Autonomic / Cns s, Neurology / Psych ABILIFY MAINTENA QLL (1 per 8 ; ABSTRAL SUBLINGUAL TABLET 100 M PAR; ; QLL (10 per 0 ABSTRAL SUBLINGUAL TABLET 00 M, 00 M, 00 M, 00 PAR; QLL (10 per 0 ; M, 800 M acetaminophen-codeine oral solution 10 mg-1 mg / ml ( ml), 0 mg- mg /10 ml (10 ml), 00 mg-0 mg /1. ml acetaminophen-codeine oral solution 10-1 mg/ ml acetaminophen-codeine oral tablet 00-1 mg acetaminophen-codeine oral tablet 00-0 mg acetaminophen-codeine oral tablet 00-0 mg ADASUVE alprazolam oral tablet amitriptyline amoxapine AMPYRA AMRIX APOKYN APTIOM aripiprazole oral solution aripiprazole oral tablet 10 mg aripiprazole oral tablet 1 mg ; QLL (00 per 0 ; QLL (00 per 0 ; QLL (90 per 0 per 0 ; QLL (180 per 0 ; QLL (10 per 0 PAR; LA; QLL (0 per 0 ; PAR; PAR; LA; QLL (900 per 0 ; ; QLL (90 per 0 per 0 CM_MAPD_1709_1_v0_1711_1 0 Effective Date November 1, 017

21 aripiprazole oral tablet mg aripiprazole oral tablet 0 mg, 0 mg aripiprazole oral tablet mg aripiprazole oral tablet, disintegrating 10 mg aripiprazole oral tablet, disintegrating 1 mg ARISTADA SUSPENSION,EXTENDED REL SYRING 10 MG/.9 ML ARISTADA SUSPENSION,EXTENDED REL SYRING 1 MG/1. ML ARISTADA SUSPENSION,EXTENDED REL SYRING MG/. ML ARISTADA SUSPENSION,EXTENDED REL SYRING 88 MG/. ML AZILECT baclofen BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 00 MG BANZEL ORAL TABLET 00 MG benztropine oral BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (90 per 0 per 0 PAR; PAR; QLL (1. per 0 ; PAR; QLL (. per 0 ; PAR; QLL (. per 0 ; PAR; QLL (00 per 0 ; PAR; ; QLL (80 per 0 PAR; QLL (0 per 0 ; PAR PAR; QLL (00 per 0 PAR; QLL (00 per 0 ; BRIVIACT ORAL TABLET 100 MG, 7 MG BRIVIACT ORAL TABLET MG BRIVIACT ORAL TABLET 0 MG bromocriptine buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet mg buprenorphine hcl sublingual tablet 8 mg buprenorphine-naloxone sublingual tablet -0. mg buprenorphine-naloxone sublingual tablet 8- mg bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 7 mg bupropion hcl oral tablet extended release 100 mg bupropion hcl oral tablet extended release 10 mg, 00 mg bupropion hcl oral tablet extended release hr 10 mg bupropion hcl oral tablet extended release hr 00 mg buspirone butalbital-acetaminop-caf-cod oral capsule mg butorphanol tartrate injection butorphanol tartrate nasal carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 mg/ ml carbamazepine oral suspension 00 mg/10 ml carbamazepine oral tablet PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (10 per 0 ; ; QLL (90 per 0 ; QLL (10 per 0 ; QLL (0 per 0 per 0 per 0 ; QLL (90 per 0 ; QLL (1 per 0 ; QLL (180 per 0 ; QLL (10 per 0 per 0 ; QLL (90 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL ( per 8 CM_MAPD_1709_1_v0_1711_1 1 Effective Date November 1, 017

22 carbamazepine oral tablet extended release 1 hr 100 mg carbamazepine oral tablet extended release 1 hr 00 mg, 00 mg carbamazepine oral tablet, chewable carbidopa-levodopa celecoxib oral capsule 100 mg, 00 mg, 0 mg celecoxib oral capsule 00 mg CELONTIN ORAL CAPSULE 00 MG chlorpromazine citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 0 mg citalopram oral tablet 0 mg clomipramine clonazepam oral tablet 0. mg clonazepam oral tablet 1 mg clonazepam oral tablet mg clonazepam oral tablet, disintegrating 0.1 mg clonazepam oral tablet, disintegrating 0. mg clonazepam oral tablet, disintegrating 0. mg clonazepam oral tablet, disintegrating 1 mg clonazepam oral tablet, disintegrating mg clorazepate dipotassium clozapine oral tablet 100 mg clozapine oral tablet 00 mg PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 0 per 0 ; QLL (10 per 0 per 0 ; QLL (0 per 0 ; QLL (100 per 0 0 per 0 ; QLL (00 per 0 ; QLL (800 per 0 ; QLL (00 per 0 ; QLL (100 per 0 0 per 0 ; QLL (00 per 0 ; QLL (70 per 0 ; QLL (10 per 0 clozapine oral tablet mg clozapine oral tablet 0 mg clozapine oral tablet, disintegrating 100 mg clozapine oral tablet, disintegrating 1. mg CLOZAPINE ORAL TABLET, DISINTEGRATING 10 MG CLOZAPINE ORAL TABLET, DISINTEGRATING 00 MG clozapine oral tablet, disintegrating mg COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML dantrolene desipramine oral desvenlafaxine fumarate oral tablet extended release hr 100 mg desvenlafaxine fumarate oral tablet extended release hr 0 mg DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG desvenlafaxine succinate oral tablet extended release hr 100 mg desvenlafaxine succinate oral tablet extended release hr mg ; QLL (1080 per 0 ; QLL (0 per 0 ; QLL (70 per 0 ; QLL (10 per 0 QLL (180 per 0 QLL (10 per 0 ; QLL (1080 per 0 PAR; QLL (0 per 0 ; PAR; QLL (1 per 8 ; ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (80 per 0 CM_MAPD_1709_1_v0_1711_1 Effective Date November 1, 017

23 desvenlafaxine succinate oral tablet extended release hr 0 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet mg dextroamphetamineamphetamine oral tablet 10 mg, 1. mg, 1 mg, 0 mg, mg, 7. mg dextroamphetamineamphetamine oral tablet 0 mg DIASTAT RECTAL GEL. MG, 10 MG diazepam injection solution diazepam injection syringe diazepam intensol diazepam oral concentrate diazepam oral solution mg/ ml (1 mg/ml) diazepam oral solution mg/ ml (1 mg/ml, ml) diazepam oral tablet 10 mg diazepam oral tablet mg diazepam oral tablet mg DIAZEPAM RECTAL diazepam rectal diclofenac potassium diclofenac sodium oral diflunisal DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 MG DILANTIN INFATABS divalproex donepezil oral tablet 10 mg donepezil oral tablet mg ; QLL (0 per 0 PAR; ; QLL (180 per 0 PAR; ; QLL (90 per 0 ; QLL (90 per 0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (100 per 0 ; QLL (100 per 0 ; QLL (10 per 0 0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 doxepin oral duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg duramorph (pf) injection solution 0. mg/ml duramorph (pf) injection solution 1 mg/ml EMSAM endocet oral tablet 10- mg, - mg, 7.- mg entacapone epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 00 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 00 MG ergoloid ergomar escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet mg ethosuximide FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG ; QLL (180 per 0 ; QLL (10 per 0 ; QLL (90 per 0 per 0 ; QLL (180 per 0 ; QLL (180 per 0 QLL (0 per 0 ; per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (180 per 0 0 per 0 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (70 per 0 QLL (0 per 0 CM_MAPD_1709_1_v0_1711_1 Effective Date November 1, 017

24 FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS, DOSE PACK FAZACLO ORAL TABLET, DISINTEGRATING 100 MG FAZACLO ORAL TABLET, DISINTEGRATING 1. MG FAZACLO ORAL TABLET, DISINTEGRATING MG felbamate fenoprofen oral tablet fentanyl citrate fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, mcg/hr, 0 mcg/hr, 7 mcg/ hr FENTORA FETZIMA ORAL CAPSULE,EXT REL HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 10 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG fluoxetine oral capsule 10 mg ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (10 per 0 ; QLL (90 per 0 ; QLL (1 per QLL (70 per 0 QLL (10 per 0 QLL (1080 per 0 PAR; QLL (10 per 0 ; ; QLL (1 per 0 PAR; QLL (10 per 0 ; PAR; ; QLL ( per PAR; ; QLL (0 per 0 PAR; ; QLL (180 per 0 PAR; ; QLL (90 per 0 ; QLL (0 per 0 fluoxetine oral capsule 0 mg fluoxetine oral capsule 0 mg fluoxetine oral solution fluphenazine decanoate fluphenazine hcl flurbiprofen fluvoxamine oral tablet 100 mg fluvoxamine oral tablet mg fluvoxamine oral tablet 0 mg fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 1 MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 100 mg gabapentin oral capsule 00 mg gabapentin oral capsule 00 mg gabapentin oral solution 0 mg/ ml gabapentin oral solution 0 mg/ ml ( ml), 00 mg/ ml ( ml) gabapentin oral tablet 00 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 1 MG, 1 MG ; QLL (10 per 0 per 0 0 per 0 ; QLL (90 per 0 per 0 ; QLL (180 per 0 QLL (70 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (90 per 0 ; QLL (0 per 0 ; QLL ( per 0 ; QLL (1080 per 0 per 0 ; QLL (70 per 0 ; QLL (10 per 0 ; QLL (10 per 0 ; QLL (180 per 0 ; QLL (10 per 0 CM_MAPD_1709_1_v0_1711_1 Effective Date November 1, 017

25 GEODON GILENYA GLATOPA guanfacine oral tablet extended release hr GUANIDINE haloperidol haloperidol decanoate haloperidol lactate HETLIOZ hydrocodone-acetaminophen oral solution 10- mg/1 ml(1 ml), -1 mg/ 7.ml(7.ml) hydrocodone-acetaminophen oral solution 7.- mg/1 ml hydrocodone-acetaminophen oral tablet 10- mg, - mg, 7.- mg hydrocodone-ibuprofen oral tablet mg hydromorphone oral tablet mg, mg hydromorphone oral tablet 8 mg ibuprofen oral suspension ibuprofen oral tablet 00 mg, 00 mg, 800 mg imipramine hcl INVEGA SUSTENNA SYRINGE 117 MG/0.7 ML INVEGA SUSTENNA SYRINGE 1 MG/ML INVEGA SUSTENNA SYRINGE MG/1. ML INVEGA SUSTENNA SYRINGE 9 MG/0. ML PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; ; QLL (0 per 0 PAR; QLL (0 per 0 ; ; QLL (700 per 0 ; QLL (700 per 0 per 0 ; QLL (0 per 0 per 0 ; QLL (180 per 0 QLL (0.7 per 8 ; QLL (1 per 8 ; QLL (1. per 8 ; ; QLL (0. per 8 INVEGA SUSTENNA SYRINGE 78 MG/0. ML INVEGA TRINZA SYRINGE 7 MG/0.87 ML INVEGA TRINZA SYRINGE 10 MG/1.1 ML INVEGA TRINZA SYRINGE MG/1.7 ML INVEGA TRINZA SYRINGE 819 MG/. ML KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 0 MG lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible LATUDA ORAL TABLET 10 MG, 0 MG LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 80 MG LAZANDA levetiracetam levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 00 mg/ ml ( ml) levetiracetam oral tablet levetiracetam oral tablet extended release hr 00 mg QLL (0. per 8 ; QLL (0.87 per 90 ; QLL (1.1 per 90 ; QLL (1.7 per 90 ; QLL (. per 90 ; ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (0 per 0 PAR; QLL (0 per 0 ; ; ; QLL (180 per 0 CM_MAPD_1709_1_v0_1711_1 Effective Date November 1, 017