Assurance Rx (HMO-POS) Essence Rx (HMO-POS) Esteem Rx (HMO-POS) Promise Rx (HMO-POS) Spirit Rx (HMO-POS) Surety Rx (HMO-POS)

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1 2018 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Assurance Rx (HMO-POS) Essence Rx (HMO-POS) Esteem Rx (HMO-POS) Promise Rx (HMO-POS) Spirit Rx (HMO-POS) Surety Rx (HMO-POS) This formulary was updated on September 8, For more recent information or other questions, please contact Security Health Plan Customer Service at or, for TTY users, 711, from 8 a.m. to 8 p.m., 7 days a week, or visit Y0117_MC C approved Effective date 1/1/2018 Updated 09/2017 Formulary ID , v.9

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 Security Health Plan. When it refers to plan or our plan, it means Assurance Rx (HMO-POS), Essence Rx (HMO-POS), Esteem Rx (HMO-POS), Promise Rx (HMO- POS), Spirit Rx (HMO-POS) or Surety Rx (HMO-POS). This document includes a list of the drugs (formulary) for our plan which is current as of January 1, 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, 2019, and from time to time during the year. Security Health Plan of Wisconsin, Inc., is an HMO, MSA and D-SNP plan with a Medicare contract. Enrollment in Security Health Plan depends on contract renewal. This document is available in alternate formats. Call Customer Service at the number on the covers for more information.

3 A formulary is a list of covered drugs selected by Security Health 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. Security Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Security Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 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, 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 60 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 60-day supply of the drug. 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. The enclosed formulary is current as of January 1, To get updated information about the drugs covered by Security Health Plan, please contact us. Our contact information appears on the front and back cover pages. There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 9. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 10. 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 91. 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 3

4 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. Security Health 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. Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Security Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Security Health Plan before you fill your prescriptions. If you don t get approval, Security Health Plan may not cover the drug. Quantity Limits: For certain drugs, Security Health Plan limits the amount of the drug that your Medicare Advantage plan will cover. For example, Security Health Plan provides 18 tablets per prescription for sumatriptan. This may be in addition to a standard 1-month or 3-month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization restriction. 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 Security Health Plan to make an exception to these restrictions or limits or for a list of other drugs that may treat your health condition. See the section, How do I request an exception to Security Health Plan s formulary? on page 5 for information about how to request an exception. 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 Security Health 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 Security Health 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 Security Health Plan. You can ask Security Health Plan to make an exception and cover your drug. See below for information about how to request an exception. 4

5 You can ask Security Health 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 pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Security Health 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, Security Health 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 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. 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 (unless you have a prescription written for fewer days) when you go to a network pharmacy. 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, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the 5

6 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 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. There are times outside of your first 90 days of new membership when the prescription drug transition process will also apply. One of the more common examples would be if you experience a change in your level of care (for example, when you are discharged from a hospital to either your home or to a long-term care facility, or if you end your long-term care facility stay and return to your home). Security Health Plan will ensure you have an effective transition of care, including your medication therapy, anytime you experience a change in your level of care. For more detailed information about your Security Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Security Health 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 ( ) 24 hours a day/7 days a week. TTY users should call Or, visit 6

7 Discrimination is against the law Security Health Plan of Wisconsin, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Security Health Plan of Wisconsin, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Security Health Plan of Wisconsin, Inc.: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service. If you believe that Security Health Plan of Wisconsin, Inc. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Security Health Plan Attn: Grievances 1515 North Saint Joseph Avenue Marshfield, WI Phone: (TTY: 711) Fax: You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Security Health Plan can help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC Phone: or (TDD) Complaint forms are available at ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711). Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 7

8 Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم والبكم: 117(. (Arabic) ال عرب )رقم هاتف الصم ية Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Deitsch (Pennsylvania Dutch) Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: (TTY: 711). ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລການຊ ວຍເຫອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: 711). Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ह द (Hindi) ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711). Tagalog (Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 8

9 The formulary that begins on the next page provides coverage information about the drugs covered by Security Health Plan. If you have trouble finding your drug in the list, turn to the index that begins on page 91. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZETIA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Requirements/Limits column tells you if Security Health Plan has any special requirements for coverage of your drug. Tier 1 Preferred generic drugs 2 Generic drugs 3 Preferred brand drugs 4 Nonpreferred drugs 5 Specialty drugs 6 Select Part D vaccines Assurance Rx (HMO-POS) $375 deductible (Tiers 3-5 only) Essence Rx (HMO-POS) $300 deductible (Tiers 3-5 only) Esteem Rx (HMO-POS) $300 deductible (Tiers 3-5 only) Promise Rx (HMO-POS) $200 deductible (Tiers 3-5 only) Spirit Rx (HMO-POS) No deductible Surety Rx (HMO-POS) $300 deductible (Tiers 3-5 only) $5 $5 $5 $6 $9 $5 $13 $14 $20 $20 $20 $20 $45 $45 $45 $45 $47 $45 $98 $100 $100 $100 $100 $100 25% of the cost 25% of the cost 25% of the cost 25% of the cost 33% of the cost 25% of the cost $0 $0 $0 $0 $0 $0 PA = Prior authorization required PA NS = Prior authorization required on new starts only PA B vs. D = Prior authorization required for Part B vs. Part D coverage HI = Home infusion coverage This prescription drug may be covered under our medical benefit. For more information call Customer Service at , Monday through Sunday from 8 a.m. to 8 p.m. TTY users should call 711. LA = Limited access This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at , Monday through Sunday from 8 a.m. 8 p.m. TTY users should call 711. QL = Quantity limit 9

10 Analgesics acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet QL (90 EA per 30 days) BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR butalbital compound w/codeine oral capsule QL (360 EA per 30 days) butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg QL (360 EA per 30 days) butalbital-acetaminophen oral tablet mg QL (180 EA per 30 days) butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule QL (180 EA per 30 days) butorphanol tartrate injection solution 1 mg/ml QL (960 ML per 30 days) butorphanol tartrate injection solution 2 mg/ml QL (480 ML per 30 days) butorphanol tartrate nasal spray,non-aerosol QL (5 ML per 28 days) celecoxib oral capsule QL (60 EA per 30 days) codeine sulfate oral tablet diclofenac sodium topical gel 3 % PA diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic diflunisal oral tablet DURAMORPH (PF) INJECTION SOLUTION ENDOCET ORAL TABLET MG, MG, MG etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release 24 hr fentanyl citrate buccal lozenge on a handle PA; QL (120 EA per 30 days) 10

11 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr QL (20 EA per 30 days) fentanyl transdermal patch 72 hour 25 mcg/hr QL (1 EA per 2 days) flurbiprofen oral tablet hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg hydromorphone (pf) injection solution hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr ibuprofen oral suspension Tier 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1 indomethacin oral capsule indomethacin oral capsule, extended release ketorolac injection solution 15 mg/ml QL (20 ML per 5 days) ketorolac injection solution 30 mg/ml (1 ml) ketorolac oral tablet QL (120 EA per 30 days) levorphanol tartrate oral tablet QL (180 EA per 30 days) LORCET HD ORAL TABLET meloxicam oral tablet 15 mg Tier 1 QL (30 EA per 30 days) meloxicam oral tablet 7.5 mg Tier 1 QL (60 EA per 30 days) meperidine oral solution QL (900 ML per 30 days) meperidine oral tablet 100 mg meperidine oral tablet 50 mg QL (180 EA per 30 days) METHADONE INJECTION SOLUTION QL (300 ML per 30 days) methadone oral solution 10 mg/5 ml QL (450 ML per 30 days) methadone oral solution 5 mg/5 ml QL (900 ML per 30 days) methadone oral tablet QL (180 EA per 30 days) morphine concentrate oral solution morphine intravenous syringe morphine oral solution morphine oral tablet QL (180 EA per 30 days) 11

12 morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg QL (120 EA per 30 days) morphine oral tablet extended release 200 mg QL (180 EA per 30 days) nabumetone oral tablet NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR QL (60 EA per 30 days) NUCYNTA ORAL TABLET QL (180 EA per 30 days) oxycodone oral concentrate QL (360 ML per 30 days) oxycodone oral solution QL (7200 ML per 30 days) oxycodone oral tablet QL (360 EA per 30 days) oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin oral tablet OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet sulindac oral tablet QL (90 EA per 30 days) QL (120 EA per 30 days) QL (90 EA per 30 days) QL (120 EA per 30 days) tramadol oral tablet QL (240 EA per 30 days) tramadol oral tablet extended release 24 hr 100 mg tramadol oral tablet extended release 24 hr 200 mg QL (90 EA per 30 days) QL (60 EA per 30 days) tramadol oral tablet, er multiphase 24 hr 300 mg QL (30 EA per 30 days) tramadol-acetaminophen oral tablet QL (240 EA per 30 days) Anesthetics lidocaine (pf) injection solution 5 mg/ml (0.5 %) lidocaine hcl injection solution 20 mg/ml (2 %) lidocaine hcl mucous membrane jelly lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated PA NS; QL (90 EA per 30 days) lidocaine topical ointment 12

13 lidocaine viscous mucous membrane solution lidocaine-prilocaine topical cream Anti-Addiction/ Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet QL (90 EA per 30 days) buprenorphine-naloxone sublingual tablet bupropion hcl (smoking deter) oral tablet extended release 12 hr CHANTIX CONTINUING MONTH BOX ORAL TABLET QL (60 EA per 30 days) QL (60 EA per 30 days) CHANTIX ORAL TABLET QL (60 EA per 30 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK disulfiram oral tablet naloxone injection solution naloxone injection syringe 1 mg/ml naltrexone oral tablet NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION NICOTROL INHALATION CARTRIDGE NICOTROL NS NASAL SPRAY,NON- AEROSOL QL (60 EA per 30 days) SUBOXONE SUBLINGUAL FILM 12-3 MG QL (60 EA per 30 days) SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG Antibacterials acetic acid otic solution alcohol pads topical pads, medicated Tier 1 amikacin injection solution 500 mg/2 ml HI amoxicillin oral capsule Tier 1 amoxicillin oral suspension for reconstitution Tier 1 amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg Tier 1 amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet QL (90 EA per 30 days) 13

14 amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin-sulbactam injection recon soln HI AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK AZASITE OPHTHALMIC DROPS azithromycin intravenous recon soln HI azithromycin oral packet azithromycin oral suspension for reconstitution Tier 1 azithromycin oral tablet Tier 1 aztreonam injection recon soln 1 gram HI BACIIM INTRAMUSCULAR RECON SOLN bacitracin intramuscular recon soln bacitracin ophthalmic ointment BACTROBAN NASAL NASAL OINTMENT BESIVANCE OPHTHALMIC DROPS,SUSPENSION BETHKIS INHALATION SOLUTION FOR NEBULIZATION bicillin c-r intramuscular syringe BICILLIN L-A INTRAMUSCULAR SYRINGE cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefdinir oral capsule cefdinir oral suspension for reconstitution cefepime injection recon soln HI cefixime oral suspension for reconstitution cefotaxime injection recon soln 1 gram, 2 gram HI cefotaxime injection recon soln 500 mg HI HI PA; LA; QL (224 ML per 28 days) HI 14

15 cefotetan injection recon soln cefoxitin intravenous recon soln HI cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet ceftazidime injection recon soln HI ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln HI cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln 1.5 gram cefuroxime sodium intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg Tier 1 cephalexin oral suspension for reconstitution Tier 1 chloramphenicol sod succinate intravenous recon soln CILOXAN OPHTHALMIC OINTMENT ciprofloxacin hcl ophthalmic drops Tier 1 ciprofloxacin hcl oral tablet Tier 1 ciprofloxacin lactate intravenous solution 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr clindamycin hcl oral capsule clindamycin in 5 % dextrose intravenous piggyback clindamycin pediatric oral recon soln clindamycin phosphate injection solution HI clindamycin phosphate intravenous solution 600 mg/4 ml clindamycin phosphate topical foam clindamycin phosphate topical gel HI HI HI HI HI HI 15

16 clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab clindamycin phosphate vaginal cream colistin (colistimethate na) injection recon soln HI daptomycin intravenous recon soln HI demeclocycline oral tablet dicloxacillin oral capsule DIFICID ORAL TABLET PA; QL (20 EA per 10 days) doxy-100 intravenous recon soln HI doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral capsule 150 mg, 75 mg Tier 1 doxycycline monohydrate oral tablet ERY PADS TOPICAL SWAB ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) erythrocin intravenous recon soln 500 mg Tier 1 HI erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin ophthalmic ointment erythromycin oral tablet erythromycin with ethanol topical gel erythromycin with ethanol topical solution QL (60 EA per 30 days) QL (60 EA per 30 days) gatifloxacin ophthalmic drops QL (2.5 ML per 25 days) gentak ophthalmic ointment gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 60 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 80 mg/100 ml gentamicin injection solution 40 mg/ml gentamicin ophthalmic drops HI HI 16

17 gentamicin sulfate (pf) intravenous solution 100 mg/10 ml gentamicin topical cream gentamicin topical ointment imipenem-cilastatin intravenous recon soln 250 mg imipenem-cilastatin intravenous recon soln 500 mg INVANZ INJECTION RECON SOLN HI levofloxacin in d5w intravenous piggyback 500 mg/100 ml levofloxacin in d5w intravenous piggyback 750 mg/150 ml levofloxacin intravenous solution HI levofloxacin ophthalmic drops levofloxacin oral solution levofloxacin oral tablet lincomycin injection solution linezolid intravenous parenteral solution PA; HI linezolid oral suspension for reconstitution PA linezolid oral tablet PA meropenem intravenous recon soln 500 mg HI methenamine hippurate oral tablet metronidazole in nacl (iso-os) intravenous piggyback metronidazole oral capsule metronidazole oral tablet metronidazole topical cream metronidazole topical gel metronidazole topical lotion metronidazole vaginal gel minocycline oral capsule MOXEZA OPHTHALMIC DROPS, VISCOUS moxifloxacin oral tablet mupirocin calcium topical cream mupirocin topical ointment nafcillin injection recon soln 1 gram, 10 gram HI neomycin oral tablet HI HI HI HI 17

18 neomycin-polymyxin b gu irrigation solution nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule nitrofurantoin oral suspension ofloxacin ophthalmic drops ofloxacin oral tablet 400 mg ofloxacin otic drops paromomycin oral capsule penicillin g pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin v potassium oral recon soln penicillin v potassium oral tablet piperacillin-tazobactam intravenous recon soln gram, 4.5 gram piperacillin-tazobactam intravenous recon soln 40.5 gram polymyxin b sulfate injection recon soln HI silver sulfadiazine topical cream SIVEXTRO INTRAVENOUS RECON SOLN PA; HI; QL (6 EA per 28 days) SIVEXTRO ORAL TABLET PA; QL (6 EA per 28 days) ssd topical cream streptomycin intramuscular recon soln sulfacetamide sodium (acne) topical suspension sulfacetamide sodium ophthalmic drops sulfadiazine oral tablet sulfamethoxazole-trimethoprim intravenous solution Tier 1 sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet Tier 1 SULFAMYLON TOPICAL CREAM SULFAMYLON TOPICAL PACKET SUPRAX ORAL CAPSULE SYNERCID INTRAVENOUS RECON SOLN HI TEFLARO INTRAVENOUS RECON SOLN HI tetracycline oral capsule HI HI HI HI 18

19 tinidazole oral tablet TOBRADEX OPHTHALMIC OINTMENT tobramycin in % nacl inhalation solution for nebulization tobramycin ophthalmic drops tobramycin sulfate injection solution HI TOBREX OPHTHALMIC OINTMENT trimethoprim oral tablet TYGACIL INTRAVENOUS RECON SOLN HI vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg vancomycin oral capsule PA PA B vs. D; HI XIFAXAN ORAL TABLET 200 MG QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG QL (84 EA per 28 days) ZERBAXA INTRAVENOUS RECON SOLN Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG QL (30 EA per 30 days) APTIOM ORAL TABLET 600 MG QL (60 EA per 30 days) BANZEL ORAL SUSPENSION QL (2760 ML per 30 days) BANZEL ORAL TABLET 200 MG QL (480 EA per 30 days) BANZEL ORAL TABLET 400 MG QL (240 EA per 30 days) BRIVIACT INTRAVENOUS SOLUTION BRIVIACT ORAL SOLUTION QL (600 ML per 30 days) BRIVIACT ORAL TABLET QL (60 EA per 30 days) carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG DIASTAT ACUDIAL RECTAL KIT DIASTAT RECTAL KIT DILANTIN EXTENDED ORAL CAPSULE DILANTIN INFATABS ORAL TABLET,CHEWABLE DILANTIN ORAL CAPSULE DILANTIN-125 ORAL SUSPENSION 19

20 divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) EPITOL ORAL TABLET EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR ethosuximide oral capsule ethosuximide oral solution felbamate oral suspension felbamate oral tablet fosphenytoin injection solution 100 mg pe/2 ml Tier 1 FYCOMPA ORAL SUSPENSION QL (680 ML per 28 days) FYCOMPA ORAL TABLET QL (30 EA per 30 days) gabapentin oral capsule QL (270 EA per 30 days) gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg QL (180 EA per 30 days) lamotrigine oral tablet lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible levetiracetam in nacl (iso-os) intravenous piggyback levetiracetam intravenous solution levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 300 MG, 50 MG, 75 MG QL (90 EA per 30 days) LYRICA ORAL CAPSULE 225 MG QL (60 EA per 30 days) LYRICA ORAL CAPSULE 25 MG LYRICA ORAL SOLUTION QL (900 ML per 30 days) ONFI ORAL SUSPENSION QL (480 ML per 30 days) ONFI ORAL TABLET 10 MG, 20 MG QL (60 EA per 30 days) oxcarbazepine oral suspension oxcarbazepine oral tablet PEGANONE ORAL TABLET phenobarbital oral elixir QL (1500 ML per 30 days) 20

21 phenobarbital oral tablet 100 mg, 16.2 mg, 32.4 mg, 64.8 mg, 97.2 mg QL (90 EA per 30 days) phenobarbital oral tablet 15 mg, 60 mg QL (120 EA per 30 days) phenobarbital oral tablet 30 mg QL (300 EA per 30 days) PHENYTEK ORAL CAPSULE phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended oral capsule phenytoin sodium intravenous solution primidone oral tablet roweepra oral tablet 1,000 mg, 750 mg SABRIL ORAL POWDER IN PACKET QL (180 EA per 30 days) SABRIL ORAL TABLET QL (180 EA per 30 days) SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG SPRITAM ORAL TABLET FOR SUSPENSION 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET tiagabine oral tablet topiramate oral capsule, sprinkle TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR QL (90 EA per 30 days) QL (360 EA per 30 days) QL (180 EA per 30 days) QL (120 EA per 30 days) topiramate oral tablet 100 mg, 200 mg, 50 mg QL (120 EA per 30 days) topiramate oral tablet 25 mg QL (90 EA per 30 days) valproate sodium intravenous solution valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid oral capsule VIMPAT INTRAVENOUS SOLUTION VIMPAT ORAL SOLUTION QL (1395 ML per 30 days) VIMPAT ORAL TABLET zonisamide oral capsule Antidementia Agents 21

22 donepezil oral tablet 10 mg Tier 1 QL (60 EA per 30 days) donepezil oral tablet 23 mg QL (30 EA per 30 days) donepezil oral tablet 5 mg Tier 1 QL (30 EA per 30 days) donepezil oral tablet,disintegrating Tier 1 QL (30 EA per 30 days) ergoloid oral tablet galantamine oral capsule,ext rel. pellets 24 hr QL (30 EA per 30 days) galantamine oral solution QL (200 ML per 30 days) galantamine oral tablet QL (60 EA per 30 days) memantine oral solution QL (360 ML per 30 days) memantine oral tablet Tier 1 QL (60 EA per 30 days) memantine oral tablets,dose pack Tier 1 QL (98 EA per 30 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 7 MG NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR QL (28 EA per 30 days) QL (30 EA per 30 days) QL (28 EA per 30 days) QL (28 EA per 28 days) QL (30 EA per 30 days) rivastigmine tartrate oral capsule 1.5 mg, 3 mg QL (90 EA per 30 days) rivastigmine tartrate oral capsule 4.5 mg, 6 mg QL (60 EA per 30 days) rivastigmine transdermal patch 24 hour QL (30 EA per 30 days) Antidepressants amitriptyline oral tablet amitriptyline-chlordiazepoxide oral tablet amoxapine oral tablet bupropion hcl oral tablet 100 mg QL (180 EA per 30 days) bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release 12 hr 100 mg bupropion hcl oral tablet extended release 12 hr 150 mg bupropion hcl oral tablet extended release 12 hr 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg QL (120 EA per 30 days) QL (90 EA per 30 days) QL (60 EA per 30 days) QL (90 EA per 30 days) 22

23 bupropion hcl oral tablet extended release 24 hr 300 mg citalopram oral solution QL (60 EA per 30 days) citalopram oral tablet 10 mg, 40 mg Tier 1 QL (30 EA per 30 days) citalopram oral tablet 20 mg Tier 1 QL (60 EA per 30 days) clomipramine oral capsule desipramine oral tablet desvenlafaxine succinate oral tablet extended release 24 hr doxepin oral capsule doxepin oral concentrate duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg QL (60 EA per 30 days) QL (60 EA per 30 days) EMSAM TRANSDERMAL PATCH 24 HOUR QL (30 EA per 30 days) escitalopram oxalate oral solution QL (600 ML per 30 days) escitalopram oxalate oral tablet 10 mg Tier 1 QL (45 EA per 30 days) escitalopram oxalate oral tablet 20 mg, 5 mg Tier 1 QL (30 EA per 30 days) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR QL (28 EA per 28 days) QL (30 EA per 30 days) fluoxetine oral capsule 10 mg, 40 mg Tier 1 QL (60 EA per 30 days) fluoxetine oral capsule 20 mg Tier 1 QL (120 EA per 30 days) fluoxetine oral solution fluvoxamine oral capsule,extended release 24hr fluvoxamine oral tablet QL (90 EA per 30 days) imipramine hcl oral tablet imipramine pamoate oral capsule maprotiline oral tablet MARPLAN ORAL TABLET mirtazapine oral tablet QL (30 EA per 30 days) mirtazapine oral tablet,disintegrating QL (30 EA per 30 days) nefazodone oral tablet nortriptyline oral capsule Tier 1 nortriptyline oral solution paroxetine hcl oral tablet 10 mg, 20 mg Tier 1 QL (30 EA per 30 days) 23

24 paroxetine hcl oral tablet 30 mg, 40 mg Tier 1 QL (60 EA per 30 days) PAXIL ORAL SUSPENSION perphenazine-amitriptyline oral tablet phenelzine oral tablet protriptyline oral tablet sertraline oral concentrate sertraline oral tablet 100 mg Tier 1 QL (60 EA per 30 days) sertraline oral tablet 25 mg, 50 mg Tier 1 QL (300 EA per 30 days) SILENOR ORAL TABLET tranylcypromine oral tablet trazodone oral tablet 100 mg, 150 mg, 50 mg Tier 1 trazodone oral tablet 300 mg trimipramine oral capsule TRINTELLIX ORAL TABLET QL (30 EA per 30 days) venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet QL (60 EA per 30 days) QL (30 EA per 30 days) QL (90 EA per 30 days) VIIBRYD ORAL TABLET QL (30 EA per 30 days) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) Antiemetics ANZEMET ORAL TABLET 100 MG PA B vs. D ANZEMET ORAL TABLET 50 MG PA B vs. D aprepitant oral capsule PA B vs. D aprepitant oral capsule,dose pack PA B vs. D CESAMET ORAL CAPSULE PA B vs. D compro rectal suppository diphenhydramine hcl injection solution 50 mg/ml dronabinol oral capsule granisetron (pf) intravenous solution 100 mcg/ml granisetron hcl intravenous solution granisetron hcl oral tablet QL (30 EA per 30 days) PA B vs. D; QL (120 EA per 30 days) PA B vs. D; QL (28 EA per 28 days) 24

25 hydroxyzine hcl intramuscular solution 25 mg/ml hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet meclizine oral tablet 12.5 mg, 25 mg ondansetron hcl (pf) injection solution PA B vs. D; HI ondansetron hcl (pf) injection syringe PA B vs. D; HI ondansetron hcl oral solution PA B vs. D ondansetron hcl oral tablet ondansetron oral tablet,disintegrating perphenazine oral tablet PHENADOZ RECTAL SUPPOSITORY 12.5 MG prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet Tier 1 prochlorperazine rectal suppository promethazine injection solution promethazine oral syrup promethazine oral tablet promethazine rectal suppository promethegan rectal suppository 25 mg, 50 mg TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY Antifungals ABELCET INTRAVENOUS SUSPENSION PA B vs. D AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION PA B vs. D; QL (450 EA per 30 days) PA B vs. D; QL (450 EA per 30 days) QL (10 EA per 30 days) PA B vs. D amphotericin b injection recon soln PA B vs. D CANCIDAS INTRAVENOUS RECON SOLN HI ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical suspension clotrimazole mucous membrane troche clotrimazole topical cream clotrimazole topical solution 25

26 econazole topical cream fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution fluconazole oral tablet flucytosine oral capsule griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet itraconazole oral capsule PA; QL (120 EA per 30 days) ketoconazole oral tablet ketoconazole topical cream ketoconazole topical shampoo miconazole-3 vaginal suppository naftifine topical cream NAFTIN TOPICAL GEL NATACYN OPHTHALMIC DROPS,SUSPENSION NOXAFIL ORAL SUSPENSION PA; QL (840 ML per 28 days) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) nyamyc topical powder nystatin oral suspension nystatin oral tablet nystatin topical cream nystatin topical ointment nystatin topical powder nystop topical powder SPORANOX ORAL SOLUTION PA HI PA; QL (93 EA per 30 days) terbinafine hcl oral tablet QL (90 EA per 365 days) terconazole vaginal cream terconazole vaginal suppository voriconazole intravenous solution voriconazole oral suspension for reconstitution PA; QL (400 ML per 30 days) voriconazole oral tablet PA; QL (120 EA per 30 days) Antigout Agents allopurinol oral tablet Tier 1 26

27 COLCHICINE ORAL CAPSULE COLCHICINE ORAL TABLET COLCRYS ORAL TABLET QL (120 EA per 30 Days) probenecid oral tablet probenecid-colchicine oral tablet ULORIC ORAL TABLET QL (30 EA per 30 days) Anti-Inflammatory Agents betamethasone dipropionate topical cream betamethasone dipropionate topical lotion betamethasone dipropionate topical ointment betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical gel betamethasone, augmented topical lotion betamethasone, augmented topical ointment BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSION BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT celecoxib oral capsule QL (60 EA per 30 days) cortisone oral tablet DEPO-MEDROL INJECTION SUSPENSION 40 MG/ML, 80 MG/ML dexamethasone oral elixir dexamethasone oral tablet dexamethasone sodium phosphate injection solution diclofenac potassium oral tablet diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) FLECTOR TRANSDERMAL PATCH 12 HOUR PA NS; QL (60 EA per 30 days) flurbiprofen oral tablet hydrocortisone oral tablet 20 mg, 5 mg ibuprofen oral suspension Tier 1 27

28 ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1 indomethacin oral capsule indomethacin oral capsule, extended release ketoprofen oral capsule ketorolac injection solution 15 mg/ml QL (20 ML per 5 days) ketorolac injection solution 30 mg/ml (1 ml) ketorolac oral tablet QL (120 EA per 30 days) meloxicam oral tablet 15 mg Tier 1 QL (30 EA per 30 days) meloxicam oral tablet 7.5 mg Tier 1 QL (60 EA per 30 days) methylprednisolone oral tablet methylprednisolone sodium succ injection recon soln 40 mg methylprednisolone sodium succ intravenous recon soln nabumetone oral tablet naproxen oral suspension naproxen oral tablet Tier 1 naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr oxaprozin oral tablet piroxicam oral capsule PRED MILD OPHTHALMIC DROPS,SUSPENSION prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml) prednisone oral tablet Tier 1 SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML, 250 MG/2 ML SOLU-MEDROL (PF) INJECTION RECON SOLN SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 500 MG/4 ML SOLU-MEDROL INTRAVENOUS RECON SOLN 2 GRAM sulfacetamide-prednisolone ophthalmic drops sulindac oral tablet Antimigraine Agents HI HI 28

29 almotriptan malate oral tablet QL (12 EA per 30 days) dihydroergotamine injection solution dihydroergotamine nasal spray,non-aerosol divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) ergotamine-caffeine oral tablet frovatriptan oral tablet QL (12 EA per 30 days) migergot rectal suppository naratriptan oral tablet QL (18 EA per 30 days) rizatriptan oral tablet QL (18 EA per 30 days) rizatriptan oral tablet,disintegrating QL (18 EA per 30 days) sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation QL (12 EA per 30 days) QL (6 EA per 30 days) sumatriptan succinate oral tablet QL (18 EA per 30 days) sumatriptan succinate subcutaneous cartridge QL (8 ML per 30 days) sumatriptan succinate subcutaneous pen injector QL (8 ML per 30 days) sumatriptan succinate subcutaneous solution QL (8 ML per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid oral capsule QL (8 ML per 30 days) zolmitriptan oral tablet QL (12 EA per 30 days) zolmitriptan oral tablet,disintegrating QL (12 EA per 30 days) Antimyasthenic Agents guanidine oral tablet pyridostigmine bromide oral tablet pyridostigmine bromide oral tablet extended release Antimycobacterials CAPASTAT INJECTION RECON SOLN dapsone oral tablet ethambutol oral tablet isoniazid injection solution Tier 1 isoniazid oral solution 29

30 isoniazid oral tablet Tier 1 PASER ORAL GRANULES DR FOR SUSP IN PACKET PRIFTIN ORAL TABLET pyrazinamide oral tablet rifabutin oral capsule rifampin intravenous recon soln rifampin oral capsule RIFATER ORAL TABLET SIRTURO ORAL TABLET QL (68 EA per 28 days) TRECATOR ORAL TABLET Antineoplastics ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION ADRUCIL INTRAVENOUS SOLUTION 500 MG/10 ML PA B vs. D AFINITOR ORAL TABLET PA NS; QL (30 EA per 30 days) ALECENSA ORAL CAPSULE PA NS ALIMTA INTRAVENOUS RECON SOLN 500 MG ALUNBRIG ORAL TABLET PA NS anastrozole oral tablet Tier 1 QL (30 EA per 30 days) AVASTIN INTRAVENOUS SOLUTION azacitidine injection recon soln BAVENCIO INTRAVENOUS SOLUTION PA B vs. D BELEODAQ INTRAVENOUS RECON SOLN bexarotene oral capsule PA NS; QL (300 EA per 30 days) bicalutamide oral tablet Tier 1 QL (30 EA per 30 days) BICNU INTRAVENOUS RECON SOLN bleomycin injection recon soln 30 unit PA B vs. D BOSULIF ORAL TABLET 100 MG PA NS; QL (120 EA per 30 days) BOSULIF ORAL TABLET 500 MG PA NS; QL (30 EA per 30 days) CABOMETYX ORAL TABLET PA NS; QL (30 EA per 30 days) CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution PA NS; LA; QL (60 EA per 30 days) PA NS; LA; QL (30 EA per 30 days) 30

31 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) 31 COTELLIC ORAL TABLET CYCLOPHOSPHAMIDE ORAL CAPSULE PA B vs. D PA NS; LA; QL (56 EA per 28 days) PA NS; LA; QL (112 EA per 28 days) PA NS; LA; QL (84 EA per 28 days) PA NS; LA; QL (63 EA per 28 days) CYRAMZA INTRAVENOUS SOLUTION PA NS; QL (200 ML per 28 days) DARZALEX INTRAVENOUS SOLUTION dexrazoxane hcl intravenous recon soln 250 mg doxorubicin, peg-liposomal intravenous suspension DROXIA ORAL CAPSULE ELITEK INTRAVENOUS RECON SOLN 1.5 MG EMCYT ORAL CAPSULE EMPLICITI INTRAVENOUS RECON SOLN PA NS epirubicin intravenous solution 200 mg/100 ml PA NS; LA; QL (400 ML per 30 days) ERIVEDGE ORAL CAPSULE PA NS; QL (28 EA per 28 days) ETOPOPHOS INTRAVENOUS RECON SOLN etoposide intravenous solution exemestane oral tablet QL (60 EA per 30 days) FARESTON ORAL TABLET QL (30 EA per 30 days) FARYDAK ORAL CAPSULE PA NS; QL (6 EA per 21 days) FASLODEX INTRAMUSCULAR SYRINGE QL (30 ML per 30 days) flutamide oral capsule GILOTRIF ORAL TABLET PA NS; QL (30 EA per 30 days) GLEOSTINE ORAL CAPSULE PA NS HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN ORAL CAPSULE HYCAMTIN INTRAVENOUS RECON SOLN hydroxyurea oral capsule IBRANCE ORAL CAPSULE PA NS; QL (21 EA per 28 days) ICLUSIG ORAL TABLET PA NS; LA; QL (30 EA per 30 days)

32 imatinib oral tablet PA NS IMBRUVICA ORAL CAPSULE PA NS; QL (120 EA per 30 days) IMFINZI INTRAVENOUS SOLUTION PA B vs. D INLYTA ORAL TABLET 1 MG PA NS; QL (180 EA per 30 days) INLYTA ORAL TABLET 5 MG PA NS; QL (60 EA per 30 days) IRESSA ORAL TABLET PA NS; LA; QL (30 EA per 30 days) JAKAFI ORAL TABLET PA NS; QL (60 EA per 30 days) KADCYLA INTRAVENOUS RECON SOLN 100 MG KEYTRUDA INTRAVENOUS RECON SOLN PA NS KEYTRUDA INTRAVENOUS SOLUTION PA NS KISQALI FEMARA CO-PACK ORAL TABLET PA NS KISQALI ORAL TABLET PA NS LARTRUVO INTRAVENOUS SOLUTION PA NS LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1) PA NS; LA; QL (30 EA per 30 days) PA NS; LA; QL (60 EA per 30 days) PA NS; LA; QL (90 EA per 30 days) letrozole oral tablet Tier 1 QL (30 EA per 30 days) leucovorin calcium injection recon soln 100 mg leucovorin calcium oral tablet LEUKERAN ORAL TABLET levoleucovorin intravenous solution LONSURF ORAL TABLET MG PA NS; QL (100 EA per 30 days) LONSURF ORAL TABLET MG PA NS; QL (80 EA per 30 days) LYNPARZA ORAL CAPSULE MATULANE ORAL CAPSULE LA PA NS; LA; QL (448 EA per 28 days) MEKINIST ORAL TABLET 0.5 MG PA NS; QL (120 EA per 30 days) MEKINIST ORAL TABLET 2 MG PA NS; QL (30 EA per 30 days) mesna intravenous solution MESNEX INTRAVENOUS SOLUTION MESNEX ORAL TABLET 32

33 mitoxantrone intravenous concentrate MUSTARGEN INJECTION RECON SOLN NEXAVAR ORAL TABLET QL (120 EA per 30 days) nilutamide oral tablet QL (60 EA per 30 days) NINLARO ORAL CAPSULE PA NS; QL (3 EA per 28 days) ODOMZO ORAL CAPSULE OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML paclitaxel intravenous concentrate PANRETIN TOPICAL GEL PERJETA INTRAVENOUS SOLUTION PA NS POMALYST ORAL CAPSULE PROLEUKIN INTRAVENOUS RECON SOLN PA NS; LA; QL (30 EA per 30 days) QL (80 ML per 28 days) PA NS; LA; QL (21 EA per 28 days) PURIXAN ORAL SUSPENSION QL (300 ML per 30 days) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG REVLIMID ORAL CAPSULE 2.5 MG, 20 MG PA NS; LA RITUXAN INTRAVENOUS CONCENTRATE RUBRACA ORAL TABLET 200 MG, 300 MG PA NS RYDAPT ORAL CAPSULE PA NS SOLTAMOX ORAL SOLUTION SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 MG, 80 MG PA NS; LA; QL (28 EA per 28 days) PA NS; QL (60 EA per 30 days) SPRYCEL ORAL TABLET 140 MG PA NS; QL (30 EA per 30 days) SPRYCEL ORAL TABLET 20 MG PA NS; QL (90 EA per 30 days) STIVARGA ORAL TABLET PA NS; QL (84 EA per 28 days) SUTENT ORAL CAPSULE PA NS; QL (28 EA per 28 days) SYLATRON SUBCUTANEOUS KIT PA NS; QL (4 EA per 28 days) SYNRIBO SUBCUTANEOUS RECON SOLN PA NS; QL (28 EA per 28 days) TABLOID ORAL TABLET TAFINLAR ORAL CAPSULE 50 MG PA NS; QL (180 EA per 30 days) TAFINLAR ORAL CAPSULE 75 MG PA NS; QL (120 EA per 30 days) TAGRISSO ORAL TABLET tamoxifen oral tablet Tier 1 PA NS; LA; QL (30 EA per 30 days) TARCEVA ORAL TABLET 100 MG, 150 MG PA NS; QL (30 EA per 30 days) 33

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