Prescription Drug Formulary

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1 Prescription Drug Formulary 018 This formulary was updated on 08/16/017. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service, at or, for TTY users, 711, 8:00 a.m. to 8:00 p.m. You may reach a messaging service on weekends and holidays from February 15 through September 30. Please leave a message and your call will be returned the next business day, or visit Y007_16-099_MK CMS Accepted 08/30/016

2 CoxHealth MedicarePlus (HMO) 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 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 Essence Healthcare, Inc.. When it refers to plan or our plan, it means CoxHealth MedicarePlus (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of August 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, 019, and from time to time during the year. Essence Healthcare is an HMO plan with a Medicare contract. Enrollment in Essence Healthcare depends on contract renewal. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. HPMS Approved Formulary File Submission ID: 1806, Version 8 Effective 01/01/018 Y007_16-099_MK CMS Accepted 08/30/016 i

3 What is the CoxHealth MedicarePlus (HMO) Formulary? A formulary is a list of covered drugs selected by CoxHealth MedicarePlus 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. CoxHealth MedicarePlus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an CoxHealth MedicarePlus 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 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 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 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 August 017. To get updated information about the drugs covered by CoxHealth MedicarePlus, please contact us. Our contact information appears on the front and back cover pages. All mid-year changes in drug coverage are updated monthly with a Formulary Change Notice posted on our web site and available upon request from Customer Service. If we make midyear non-maintenance formulary changes, CoxHealth MedicarePlus will mail written notification to affected members in the form of Formulary Errata Sheets. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. 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. ii

4 What are generic drugs? CoxHealth MedicarePlus 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: CoxHealth MedicarePlus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from CoxHealth MedicarePlus before you fill your prescriptions. If you don t get approval, CoxHealth MedicarePlus may not cover the drug. Quantity Limits: For certain drugs, CoxHealth MedicarePlus limits the amount of the drug that CoxHealth MedicarePlus will cover. For example, CoxHealth MedicarePlus provides eighteen per prescription for sumatriptan. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, CoxHealth MedicarePlus requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, CoxHealth MedicarePlus may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CoxHealth MedicarePlus will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask CoxHealth MedicarePlus 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 CoxHealth MedicarePlus formulary? on page iv 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 CoxHealth MedicarePlus does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by CoxHealth MedicarePlus. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by CoxHealth MedicarePlus. You can ask CoxHealth MedicarePlus to make an exception and cover your drug. See below for information about how to request an exception. iii

5 How do I request an exception to the CoxHealth MedicarePlus (HMO) Formulary? You can ask CoxHealth MedicarePlus 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, CoxHealth MedicarePlus 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, CoxHealth MedicarePlus 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 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (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 maximum of a 98-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 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. iv

6 Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug. For example, members who: Enter long-term care (LTC) facilities from hospitals are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short term planning taken into account (often under 8 hours). Are discharged from a hospital to a home. End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary. End a long-term care facility stay and return to the community. If a member has more than one change in level of care in a month, the pharmacy will have to call CoxHealth MedicarePlus to request an extension of the transition policy. For more information For more detailed information about your CoxHealth MedicarePlus prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about CoxHealth MedicarePlus, 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 ( ) 4 hours a day/7 days a week. TTY users should call Or, visit CoxHealth MedicarePlus Formulary The formulary that below provides coverage information about the drugs covered by CoxHealth MedicarePlus. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin). The information in the Requirements/Limits column tells you if CoxHealth MedicarePlus has any special requirements for coverage of your drug. o o o LA: Limited Access. This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or call Customer Service at or toll free , 7 days a week from 8:00 a.m. to 8:00 p.m. You may receive a messaging service on weekends and holidays from February 15 through September 30. Please leave a message and your call will be returned the next business day. TTY users should call 711. NDS: Non-Extended Days Supply. This drug can only be obtained for a one-month supply or less. You cannot fill a prescription for more than a one-month supply NM: Non Mail Order. The prescription cannot be filled by an CoxHealth MedicarePlus network mail order pharmacy. v

7 o o o o PA: Prior Authorization. CoxHealth MedicarePlus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from CoxHealth MedicarePlus before you fill your prescriptions. If you don't get approval, CoxHealth MedicarePlus may not cover the drug. PA BvD: Prior Authorization for Part B vs Part D Determination. This prescription drug has a Part B versus D administrative prior authorization requirement. You (or your physician) are required to get prior authorization from CoxHealth MedicarePlus to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, CoxHealth MedicarePlus may not cover this drug. PA-HRM: Prior Authorization, High Risk Medications. This prescription drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years of age or older. Members age 65 years or older are required to get prior approval from CoxHealth MedicarePlus before filling prescriptions for this drug. Without prior approval, CoxHealth MedicarePlus may not cover this drug. PA NSO: Prior Authorization, New Starts Only. If you are a new member or if you have not taken this drug before, you or your physician are required to get prior authorization from CoxHealth MedicarePlus before you fill your prescription for this drug. Without prior approval, CoxHealth MedicarePlus may not cover this drug. o QL: Quantity Limit. For certain drugs, CoxHealth MedicarePlus limits the amount of the drug that CoxHealth MedicarePlus will cover. For example, CoxHealth MedicarePlus provides eighteen tablets per prescription for sumatriptan succinate. This may be in addition to a standard one-month or threemonth supply. o ST: Step Therapy. In some cases, CoxHealth MedicarePlus requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, CoxHealth MedicarePlus may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CoxHealth MedicarePlus will then cover Drug B. vi

8 Table of Contents Analgesics... 3 Anesthetics...8 Anti-Addiction/Substance Abuse Treatment Agents...9 Antianxiety Agents...10 Antibacterials...1 Anticancer Agents...0 Anticholinergic Agents...8 Anticonvulsants... 8 Antidementia Agents...31 Antidepressants...3 Antidiabetic Agents...34 Antifungals Antigout Agents...40 Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents... 4 Antiparasite Agents...43 Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents...55 Cardiovascular Agents Central Nervous System Agents...69 Contraceptives... 7 Dental And Oral Agents Dermatological Agents...78 Devices...83 Enzyme Replacement/Modifiers...83 Eye, Ear, Nose, Throat Agents...84 Gastrointestinal Agents...88 Genitourinary Agents...91 Heavy Metal Antagonists...9 Hormonal Agents, Stimulant/Replacement/Modifying

9 Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals

10 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 QL (700 per 30 days) /5 ml acetaminophen-codeine oral tablet QL (360 per 30 days) acetaminophen-codeine oral tablet QL (360 per 30 days) acetaminophen-codeine oral tablet QL (180 per 30 days) ascomp with codeine oral capsule PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) BELBUCA BUCCAL FILM 150 MCG, QL (60 per 30 days) MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml buprenorphine transdermal patch weekly 10 QL (4 per 8 days) mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) butalbital-acetaminop-caf-cod oral capsule , PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) butalbital-acetaminophen oral tablet PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) butalbital-acetaminophen-caff oral capsule PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) butalbital-acetaminophen-caff oral tablet PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) butalbital-aspirin-caffeine oral capsule PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) butorphanol tartrate nasal spray,non-aerosol 10 QL (5 per 8 days) /ml BUTRANS TRANSDERMAL PATCH 3 QL (4 per 8 days) WEEKLY 7.5 MCG/HOUR capacet oral capsule PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) codeine sulfate oral tablet 15, 30, 60 QL (180 per 30 days) EMBEDA ORAL CAPSULE,ORAL 4 QL (60 per 30 days) ONLY,EXT.REL PELL MG, MG, MG, 50- MG, MG, MG endocet oral tablet QL (40 per 30 days) 3

11 endocet oral tablet.5-35, 5-35 QL (360 per 30 days) endocet oral tablet QL (300 per 30 days) fentanyl citrate buccal lozenge on a handle 1,00 5 PA; NDS; QL (10 per 30 days) mcg, 1,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, QL (10 per 30 days) 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution.5- QL (700 per 30 days) 167 /5 ml, /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution 7.5- QL (700 per 30 days) 35 /15 ml hydrocodone-acetaminophen oral tablet QL (390 per 30 days) hydrocodone-acetaminophen oral tablet QL (360 per 30 days), 5-35 hydrocodone-acetaminophen oral tablet.5-35 QL (360 per 30 days) hydrocodone-acetaminophen oral tablet QL (390 per 30 days) hydrocodone-acetaminophen oral tablet QL (390 per 30 days) hydrocodone-acetaminophen oral tablet QL (360 per 30 days) hydrocodone-ibuprofen oral tablet 10-00, 5- QL (150 per 30 days) 00 hydrocodone-ibuprofen oral tablet QL (150 per 30 days) hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone injection solution /ml, 4 /ml hydromorphone injection syringe /ml, 4 /ml hydromorphone oral liquid 1 /ml QL (100 per 30 days) hydromorphone oral tablet, 4, 8 QL (180 per 30 days) HYSINGLA ER ORAL TABLET,ORAL 3 QL (30 per 30 days) ONLY,EXT.REL.4 HR 100 MG, 10 MG, 0 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- 5 PA; NDS; QL (30 per 30 days) AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-35 QL (360 per 30 days) 4

12 lorcet hd oral tablet QL (360 per 30 days) lorcet plus oral tablet QL (360 per 30 days) methadone injection solution 10 /ml methadone oral solution 10 /5 ml, 5 /5 ml QL (1800 per 30 days) methadone oral tablet 10 QL (360 per 30 days) methadone oral tablet 5 QL (180 per 30 days) methadose oral tablet,soluble 40 QL (90 per 30 days) morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine 4 /ml carpuject outer,l/f,p/f, sdv 4 /ml morphine 8 /ml syringe 8 /ml morphine concentrate oral solution 100 /5 ml QL (180 per 30 days) (0 /ml) morphine intravenous syringe 10 /ml, /ml, 4 /ml, 8 /ml morphine oral solution 10 /5 ml QL (700 per 30 days) morphine oral solution 0 /5 ml (4 /ml) QL (300 per 30 days) MORPHINE ORAL TABLET 15 MG 4 QL (180 per 30 days) MORPHINE ORAL TABLET 30 MG 4 QL (10 per 30 days) morphine oral tablet extended release 100, QL (60 per 30 days) 00, 60 morphine oral tablet extended release 15, 30 QL (90 per 30 days) morphine sulfate 10 /ml vial 10 /ml NUCYNTA ER ORAL TABLET 3 QL (60 per 30 days) EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 3 QL (181 per 30 days) MG, 75 MG oxycodone oral capsule 5 QL (180 per 30 days) oxycodone oral concentrate 0 /ml QL (10 per 30 days) oxycodone oral solution 5 /5 ml QL (1300 per 30 days) oxycodone oral tablet 10 QL (180 per 30 days) oxycodone oral tablet 15, 30 QL (10 per 30 days) oxycodone oral tablet 0 QL (10 per 30 days) oxycodone oral tablet 5 QL (180 per 30 days) oxycodone oral tablet,oral only,ext.rel.1 hr 10 QL (60 per 30 days), 15, 0, 30, 40, 60 oxycodone oral tablet,oral only,ext.rel.1 hr 80 5 NDS; QL (10 per 30 days) 5

13 oxycodone-acetaminophen oral solution 5-35 QL (1800 per 30 days) /5 ml oxycodone-acetaminophen oral tablet QL (40 per 30 days) oxycodone-acetaminophen oral tablet.5-35 QL (360 per 30 days) oxycodone-acetaminophen oral tablet 5-35 QL (360 per 30 days) oxycodone-acetaminophen oral tablet QL (300 per 30 days) oxycodone-aspirin oral tablet QL (360 per 30 days) OXYCONTIN ORAL TABLET,ORAL 3 QL (60 per 30 days) ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL 3 QL (10 per 30 days) ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10 QL (10 per 30 days) oxymorphone oral tablet 5 QL (180 per 30 days) oxymorphone oral tablet extended release 1 hr QL (60 per 30 days) 10, 15, 0, 30, 40, 5, 7.5 reprexain oral tablet 10-00,.5-00, 5- QL (150 per 30 days) 00 tencon oral tablet PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) tramadol oral tablet 50 1 QL (40 per 30 days) tramadol-acetaminophen oral tablet QL (40 per 30 days) vicodin es oral tablet QL (390 per 30 days) vicodin hp oral tablet QL (390 per 30 days) vicodin oral tablet QL (390 per 30 days) XARTEMIS XR ORAL TAB,ORAL 3 QL (300 per 30 days) ONLY,IR - ER, BIPHASE MG XTAMPZA ER ORAL 3 QL (60 per 30 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 13.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL 3 QL (10 per 30 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 7 MG XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 1HR TMPRR 36 MG 3 QL (40 per 30 days) 6

14 xylon 10 oral tablet QL (150 per 30 days) zebutal oral capsule PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) ZOHYDRO ER ORAL CAPSULE, ORAL 4 QL (60 per 30 days) ONLY, ER 1HR 10 MG, 15 MG, 0 MG, 30 MG, 40 MG, 50 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON 4 SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100, 00, 400, QL (60 per 30 days) 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended release 4 hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 DUEXIS ORAL TABLET MG 5 PA; NDS; QL (90 per 30 days) etodolac oral capsule 00, 300 etodolac oral tablet 400 etodolac oral tablet 500 etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5 ml ibuprofen oral tablet 400, 600, indomethacin oral capsule 5 1 PA-HRM; QL (40 per 30 days); AGE (Max 64 Years) indomethacin oral capsule 50 1 PA-HRM; QL (10 per 30 days); AGE (Max 64 Years) indomethacin oral capsule, extended release 75 PA-HRM; QL (60 per 30 days); AGE (Max 64 Years) indomethacin sodium intravenous recon soln 1 ketoprofen oral capsule 50, 75 7

15 ketoprofen oral capsule,ext rel. pellets 4 hr 00 ketorolac injection cartridge 15 /ml QL (40 per 30 days) ketorolac injection cartridge 30 /ml QL (0 per 30 days) ketorolac injection solution 15 /ml QL (40 per 30 days) ketorolac injection solution 30 /ml (1 ml) QL (0 per 30 days) ketorolac intramuscular solution 60 / ml QL (0 per 30 days) ketorolac intramuscular syringe 60 / ml QL (0 per 30 days) ketorolac oral tablet 10 PA-HRM; QL (0 per 30 days); AGE (Max 64 Years) mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml naproxen oral tablet 50, naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) 375, 500 piroxicam oral capsule 10, 0 sulindac oral tablet 150, 00 tolmetin oral capsule 400 tolmetin oral tablet 00, 600 VIMOVO ORAL TABLET,IR,DELAYED 5 PA; NDS; QL (60 per 30 days) REL,BIPHASIC MG, MG Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 10 /ml (1 %), 15 /ml (1.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl injection solution 10 /ml (1 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % PA; QL (90 per 30 days) lidocaine topical ointment 5 % PA; QL (90 per 30 days) 8

16 lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 BUNAVAIL BUCCAL FILM MG 3 QL (30 per 30 days) BUNAVAIL BUCCAL FILM MG, 3 QL (60 per 30 days) MG buprenorphine hcl sublingual tablet, 8 PA; QL (90 per 30 days) buprenorphine-naloxone sublingual tablet -0.5 QL (90 per 30 days), 8- bupropion hcl (smoking deter) oral tablet extended release 1 hr 150 CHANTIX CONTINUING MONTH BOX 3 QL (168 per 84 days) ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG 3 QL (168 per 84 days) CHANTIX STARTING MONTH BOX 3 QL (53 per 8 days) ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (4) disulfiram oral tablet 50, 500 naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, 1 /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- 3 QL (4 per 30 days) AEROSOL MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION CARTRIDGE 4 QL (1008 per 90 days) 10 MG SUBOXONE SUBLINGUAL FILM QL (60 per 30 days) MG, 8- MG SUBOXONE SUBLINGUAL FILM QL (30 per 30 days) MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET QL (30 per 30 days) 0.18 MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG 3 QL (60 per 30 days) 9

17 Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 1 QL (10 per 30 days) alprazolam oral tablet 1 QL (150 per 30 days) alprazolam oral tablet extended release 4 hr QL (10 per 30 days) 0.5, 1, alprazolam oral tablet extended release 4 hr 3 QL (90 per 30 days) buspirone oral tablet 10, 15, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 5, 1 QL (10 per 30 days) 5 clonazepam oral tablet 0.5, 1 1 QL (90 per 30 days) clonazepam oral tablet 1 QL (300 per 30 days) clonazepam oral tablet,disintegrating 0.15, QL (90 per 30 days) 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (300 per 30 days) clorazepate dipotassium oral tablet 15, 3.75 QL (180 per 30 days) clorazepate dipotassium oral tablet 7.5 QL (180 per 30 days) DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG 4 diazepam injection solution 5 /ml QL (10 per 8 days) diazepam intensol oral concentrate 5 /ml QL (100 per 30 days) diazepam oral solution 5 /5 ml (1 /ml) QL (100 per 30 days) diazepam oral tablet 10,, 5 1 QL (10 per 30 days) diazepam rectal kit , diazepam rectal kit.5 estazolam oral tablet 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years) 10

18 estazolam oral tablet PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) flurazepam oral capsule 15 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years) flurazepam oral capsule 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) lorazepam /ml oral concent /ml QL (150 per 30 days) lorazepam injection solution /ml, 4 /ml QL ( per 30 days) lorazepam injection syringe /ml QL ( per 30 days) lorazepam intensol oral concentrate /ml QL (150 per 30 days) lorazepam oral tablet 0.5, 1 1 QL (90 per 30 days) lorazepam oral tablet 1 QL (150 per 30 days) midazolam oral syrup /ml QL (10 per 30 days) ONFI ORAL SUSPENSION.5 MG/ML 5 PA NSO; NDS; QL (480 per 30 days) ONFI ORAL TABLET 10 MG, 0 MG 5 PA NSO; NDS; QL (60 per 30 days) oxazepam oral capsule 10, 15, 30 QL (10 per 30 days) temazepam oral capsule 15, 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) triazolam oral tablet 0.15 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (10 per 30 days); AGE (Max 64 Years) 11

19 triazolam oral tablet 0.5 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 days); AGE (Max 64 Years) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR 5 PA BvD; NDS NEBULIZATION 300 MG/4 ML gentamicin 10 /ml vial sdv 60 /6 ml gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 10 /100 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 40 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml neomycin oral tablet streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION 5 NDS; QL (4 per 8 days) CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution 5 PA BvD; NDS for nebulization 300 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 40 /ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin 75 /5 ml soln 75 /5 ml clindamycin hcl oral capsule 150, 300, 75 1

20 clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution 150 /ml clindamycin phosphate intravenous solution 600 /4 ml colistin (colistimethate na) injection recon soln 150 daptomycin intravenous recon soln NDS linezolid intravenous parenteral solution NDS /300 ml linezolid oral suspension for reconstitution NDS /5 ml linezolid oral tablet NDS methenamine hippurate oral tablet 1 gram metronidazole in nacl (iso-os) intravenous piggyback 500 /100 ml metronidazole oral tablet 50, 500 nitrofurantoin macrocrystal oral capsule 100, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 100 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 30 days); AGE (Max 64 Years) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 days); AGE (Max 64 Years) nitrofurantoin oral suspension 5 /5 ml PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (400 per 30 days); AGE (Max 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON 5 NDS SOLN 500 MG trimethoprim oral tablet

21 vancomycin in dextrose 5 % intravenous piggyback 1 gram/00 ml, 500 /100 ml, 750 /150 ml vancomycin intravenous recon soln 1,000, 10 gram, 5 gram, 500, 750 vancomycin oral capsule 15, 50 5 NDS XIFAXAN ORAL TABLET 00 MG 5 PA; NDS; QL (9 per 30 days) XIFAXAN ORAL TABLET 550 MG 5 PA; NDS Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 375 /5 ml cefaclor oral tablet extended release 1 hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback gram/100 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefazolin intravenous recon soln 1 gram cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 400 CEFEPIME 1 GM INJECTION 1 GRAM/50 4 ML CEFEPIME INJECTION RECON SOLN 1 4 GRAM, GRAM CEFEPIME-DEXTROSE GM/50 ML 4 GRAM/50 ML cefixime oral suspension for reconstitution 100 /5 ml, 00 /5 ml cefotaxime injection recon soln 1 gram, 10 gram, gram cefotaxime injection recon soln 500 cefoxitin gm piggyback bag gram/50 ml 14

22 cefoxitin intravenous recon soln 1 gram, 10 gram, gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram ceftazidime injection recon soln 6 gram ceftibuten oral capsule 400 ceftibuten oral suspension for reconstitution 180 /5 ml ceftriaxone 1 gm piggyback l/g, single use 1 gram/50 ml ceftriaxone gm piggyback l/f, single use gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 50, 500 ceftriaxone intravenous recon soln 1 gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cephalexin oral capsule 50, cephalexin oral capsule 750 cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 MEFOXIN IN DEXTROSE (ISO-OSM) 4 INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG 4 SUPRAX ORAL SUSPENSION FOR 4 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE MG, 00 MG tazicef injection recon soln 1 gram, gram, 6 gram 15

23 TEFLARO INTRAVENOUS RECON SOLN MG, 600 MG Macrolides azithromycin intravenous recon soln 500 azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 (3 pack) azithromycin oral tablet 50, 500, 600 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 DIFICID ORAL TABLET 00 MG 5 ST; NDS; QL (0 per 10 days) e.e.s. 400 oral tablet e.e.s. granules oral suspension for reconstitution 4 00 /5 ml ERYPED 00 ORAL SUSPENSION FOR 4 RECONSTITUTION 00 MG/5 ML ERYPED 400 ORAL SUSPENSION FOR 4 RECONSTITUTION 400 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL TABLET,DELAYED 4 RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON 4 SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet 400 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 LA; NDS 16

24 imipenem-cilastatin intravenous recon soln 50, 500 INVANZ INJECTION RECON SOLN 1 4 GRAM meropenem intravenous recon soln 1 gram, 500 Penicillins amoxicillin oral capsule 50, amoxicillin oral suspension for reconstitution 1 15 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, amoxicillin oral tablet,chewable 15, 50 1 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet , amoxicillin-pot clavulanate oral tablet extended release 1 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, ampicillin oral suspension for reconstitution 15 1 /5 ml, 50 /5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram BICILLIN C-R INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/300K) BICILLIN L-A INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML 17

25 dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram 5 NDS nafcillin intravenous recon soln gram 5 NDS oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, gram/50 ml oxacillin injection recon soln 10 gram, gram oxacillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin gk 0 million unit 0 million unit penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous recon soln.5 gram, gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin (mixture) oral tablet, er multiphase 4 hr 1,000, 500 ciprofloxacin hcl oral tablet 100, ciprofloxacin hcl oral tablet 50, ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous piggyback 400 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml ciprofloxacin oral suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml 18

26 levofloxacin oral tablet 50, 500, 750 moxifloxacin oral tablet 400 ofloxacin oral tablet 300, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral suspension /5 ml sulfamethoxazole-trimethoprim oral tablet sulfamethoxazole-trimethoprim oral tablet sulfatrim oral suspension /5 ml Tetracyclines demeclocycline oral tablet 150, 300 doxy-100 intravenous recon soln 100 doxycycline hyclate oral capsule 100 doxycycline hyclate oral capsule 50 doxycycline hyclate oral tablet 100, 0 doxycycline hyclate oral tablet,delayed release (dr/ec) 100, 150, 75 doxycycline hyclate oral tablet,delayed release (dr/ec) 00, 50 doxycycline monohydrate oral capsule 100, 75 doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral capsule 50 doxycycline monohydrate oral suspension for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 doxycycline monohydrate oral tablet 150, 50, 75 MINOCIN INTRAVENOUS RECON SOLN 5 NDS 100 MG minocycline oral capsule 100, 50, 75 minocycline oral tablet 100, 50, 75 minocycline oral tablet extended release 4 hr 135, 45, 90 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 5 NDS 19

27 Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS 5 NDS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 /5 ml, 0 PA BvD /10 ml adrucil intravenous solution.5 gram/50 ml, 500 PA BvD /10 ml AFINITOR DISPERZ ORAL TABLET FOR 5 PA NSO; NDS; QL (11 per 8 days) SUSPENSION MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG 5 PA NSO; NDS; QL (56 per 8 days) AFINITOR ORAL TABLET.5 MG, 5 MG, 5 PA NSO; NDS; QL (8 per 8 days) 7.5 MG ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (40 per 30 days) ALIMTA INTRAVENOUS RECON SOLN 5 NDS 100 MG, 500 MG ALUNBRIG ORAL TABLET 30 MG 5 PA NSO; NDS; QL (180 per 30 days) anastrozole oral tablet 1 1 AVASTIN INTRAVENOUS SOLUTION 5 5 PA NSO; NDS MG/ML, 5 MG/ML (16 ML) azacitidine injection recon soln NDS BAVENCIO INTRAVENOUS SOLUTION 5 PA NSO; NDS 0 MG/ML BELEODAQ INTRAVENOUS RECON 5 PA NSO; NDS SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 5 PA NSO; NDS 5 MG/ML bexarotene oral capsule 75 5 PA NSO; NDS; QL (40 per 30 days) bicalutamide oral tablet 50 bleomycin injection recon soln 15 unit PA BvD bleomycin injection recon soln 30 unit PA BvD BLINCYTO INTRAVENOUS KIT 35 MCG 5 PA NSO; NDS; QL (140 per 365 days) BOSULIF ORAL TABLET 100 MG 5 PA NSO; NDS; QL (10 per 30 days) BOSULIF ORAL TABLET 500 MG 5 PA NSO; NDS; QL (30 per 30 days) CABOMETYX ORAL TABLET 0 MG, 60 5 PA NSO; NDS; QL (30 per 30 days) MG CABOMETYX ORAL TABLET 40 MG 5 PA NSO; NDS; QL (60 per 30 days) CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (60 per 30 days) CAPRELSA ORAL TABLET 300 MG 5 PA NSO; NDS; QL (30 per 30 days) carboplatin intravenous solution 10 /ml 0

28 cladribine intravenous solution 10 /10 ml PA BvD clofarabine intravenous solution 0 /0 ml 5 NDS COMETRIQ ORAL CAPSULE PA NSO; NDS; QL (11 per 8 days) MG/DAY(80 MG X1-0 MG X1), 140 MG/DAY(80 MG X1-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) COTELLIC ORAL TABLET 0 MG 5 PA NSO; LA; NDS; QL (63 per 8 days) cyclophosphamide intravenous recon soln 1 5 PA BvD; NDS gram, gram, 500 CYCLOPHOSPHAMIDE ORAL CAPSULE 4 PA BvD; ST 5 MG, 50 MG CYRAMZA INTRAVENOUS SOLUTION 5 PA NSO; NDS 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 5 PA NSO; LA; NDS 0 MG/ML decitabine intravenous recon soln 50 5 NDS docetaxel 160 /16 ml vial mdv 160 /16 ml 5 NDS (10 /ml) docetaxel intravenous solution 0 /ml, 80 5 NDS /8 ml (10 /ml) docetaxel intravenous solution 80 /4 ml (0 5 NDS /ml) doxorubicin intravenous solution 10 /5 ml, PA BvD /ml, 0 /10 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous 5 PA BvD; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS 4 SYRINGE.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS 4 SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS 4 SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG 5 NDS EMPLICITI INTRAVENOUS RECON 5 PA NSO; NDS SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (30 per 30 days) 1

29 ETOPOPHOS INTRAVENOUS RECON 4 SOLN 100 MG etoposide intravenous solution 0 /ml exemestane oral tablet 5 FARESTON ORAL TABLET 60 MG 5 NDS FARYDAK ORAL CAPSULE 10 MG, 15 5 PA NSO; NDS MG, 0 MG FASLODEX INTRAMUSCULAR 5 NDS SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil 5,000 /100 ml latex-free 5 PA BvD gram/100 ml fluorouracil intravenous solution 1 gram/0 ml PA BvD fluorouracil intravenous solution.5 gram/50 PA BvD ml, 500 /10 ml flutamide oral capsule 15 GAZYVA INTRAVENOUS SOLUTION 5 PA NSO; NDS 1,000 MG/40 ML gemcitabine intravenous recon soln 1 gram, 00 5 NDS gemcitabine intravenous recon soln gram 5 NDS gemcitabine intravenous solution 1 gram/6.3 ml 5 NDS (38 /ml), gram/5.6 ml (38 /ml), 00 /5.6 ml (38 /ml) GILOTRIF ORAL TABLET 0 MG, 30 MG, 5 PA NSO; NDS; QL (30 per 30 days) 40 MG GLEOSTINE ORAL CAPSULE 10 MG, MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON 5 PA NSO; NDS SOLN 150 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG 5 NDS hydroxyurea oral capsule 500 IBRANCE ORAL CAPSULE 100 MG, 15 5 PA NSO; NDS; QL (1 per 8 days) MG, 75 MG ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NDS; QL (60 per 30 days) ICLUSIG ORAL TABLET 45 MG 5 PA NSO; NDS; QL (30 per 30 days) ifosfamide intravenous recon soln 1 gram, 3 PA BvD gram ifosfamide intravenous solution 1 gram/0 ml, 3 gram/60 ml PA BvD

30 ifosfamide-mesna intravenous kit 1-1 gram, 5 PA BvD; NDS 3,000-1,000 imatinib oral tablet PA NSO; NDS; QL (90 per 30 days) imatinib oral tablet PA NSO; NDS; QL (60 per 30 days) IMBRUVICA ORAL CAPSULE 140 MG 5 PA NSO; NDS IMFINZI INTRAVENOUS SOLUTION 50 5 PA NSO; NDS MG/ML, 50 MG/ML (10 ML) IMLYGIC INJECTION SUSPENSION 5 PA NSO; NDS; QL (4 per 365 days) 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 5 PA NSO; NDS; QL (8 per 8 days) 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG 5 PA NSO; NDS; QL (180 per 30 days) INLYTA ORAL TABLET 5 MG 5 PA NSO; NDS; QL (60 per 30 days) IRESSA ORAL TABLET 50 MG 5 PA NSO; NDS; QL (60 per 30 days) irinotecan intravenous solution 100 /5 ml, 40 / ml irinotecan intravenous solution 500 /5 ml IXEMPRA INTRAVENOUS RECON SOLN 5 NDS 15 MG, 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 5 PA NSO; NDS; QL (60 per 30 days) MG, 5 MG, 5 MG KEYTRUDA INTRAVENOUS RECON 5 PA NSO; NDS; QL (4 per 1 days) SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 5 PA NSO; NDS; QL (8 per 1 days) 100 MG/4 ML (5 MG/ML) KISQALI FEMARA CO-PACK ORAL 5 PA NSO; NDS; QL (49 per 8 days) TABLET 00 MG/DAY(00 MG X 1)-.5 MG KISQALI FEMARA CO-PACK ORAL 5 PA NSO; NDS; QL (70 per 8 days) TABLET 400 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL 5 PA NSO; NDS; QL (91 per 8 days) TABLET 600 MG/DAY(00 MG X 3)-.5 MG KISQALI ORAL TABLET 00 MG/DAY 5 PA NSO; NDS; QL (63 per 8 days) (00 MG X 1), 400 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X 3) KYPROLIS INTRAVENOUS RECON 5 PA NSO; NDS SOLN 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML 5 PA NSO; LA; NDS 3

31 LENVIMA ORAL CAPSULE 10 MG/DAY 5 PA NSO; NDS (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X), 0 MG/DAY (10 MG X ), 4 MG/DAY(10 MG X -4 MG X 1), 8 MG/DAY (4 MG X ) letrozole oral tablet.5 LEUKERAN ORAL TABLET MG 4 leuprolide subcutaneous kit 1 /0. ml LONSURF ORAL TABLET MG 5 PA NSO; NDS; QL (100 per 8 days) LONSURF ORAL TABLET MG 5 PA NSO; NDS; QL (80 per 8 days) LUPRON DEPOT (3 MONTH) 5 NDS INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT (4 MONTH) 5 NDS INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) 5 NDS INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR 5 NDS SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (448 per 8 days) LYSODREN ORAL TABLET 500 MG 5 NDS MARQIBO INTRAVENOUS KIT 5 MG/31 5 PA NSO; NDS; QL (4 per 8 days) ML(0.16 MG/ML) FINAL MATULANE ORAL CAPSULE 50 MG 5 NDS megestrol oral tablet 0, 40 PA NSO-HRM; AGE (Max 64 Years) MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NDS; QL (90 per 30 days) MEKINIST ORAL TABLET MG 5 PA NSO; NDS; QL (30 per 30 days) melphalan hcl intravenous recon soln 50 5 NDS mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln 1 PA BvD gram methotrexate sodium (pf) injection solution 5 PA BvD /ml methotrexate sodium injection solution 5 /ml PA BvD methotrexate sodium oral tablet.5 PA BvD; ST mitoxantrone intravenous concentrate /ml NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NDS; QL (10 per 30 days) nilutamide oral tablet NDS NINLARO ORAL CAPSULE.3 MG, 3 MG, 4 MG 5 PA NSO; NDS; QL (3 per 8 days) 4

32 ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; LA; NDS ONCASPAR INJECTION SOLUTION PA NSO; NDS UNIT/ML ONIVYDE INTRAVENOUS DISPERSION 5 PA BvD; NDS 4.3 MG/ML OPDIVO INTRAVENOUS SOLUTION PA NSO; NDS MG/10 ML, 40 MG/4 ML oxaliplatin intravenous recon soln 100, 50 oxaliplatin intravenous solution 100 /0 ml, 50 /10 ml (5 /ml) paclitaxel intravenous concentrate 6 /ml PERJETA INTRAVENOUS SOLUTION 40 5 PA NSO; NDS MG/14 ML (30 MG/ML) POMALYST ORAL CAPSULE 1 MG, 5 PA NSO; NDS; QL (1 per 8 days) MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS 5 PA NSO; NDS; QL (100 per 1 days) SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON 5 NDS SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 5 NDS MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 5 PA NSO; LA; NDS MG,.5 MG, 0 MG, 5 MG, 5 MG RITUXAN HYCELA SUBCUTANEOUS 5 PA NSO; NDS SOLUTION 1400 MG/11.7 ML (10 MG/ML), 1600 MG/13.4 ML (10 MG/ML) RITUXAN INTRAVENOUS 5 PA NSO; NDS CONCENTRATE 10 MG/ML RUBRACA ORAL TABLET 00 MG, 50 5 PA NSO; NDS; QL (10 per 30 days) MG, 300 MG RYDAPT ORAL CAPSULE 5 MG 5 PA NSO; NDS; QL (4 per 8 days) SOLTAMOX ORAL SOLUTION 10 MG/5 4 ML SPRYCEL ORAL TABLET 100 MG, PA NSO; NDS; QL (30 per 30 days) MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 0 MG 5 PA NSO; NDS; QL (60 per 30 days) STIVARGA ORAL TABLET 40 MG 5 PA NSO; NDS; QL (84 per 8 days) SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 37.5 MG, 50 MG 5 PA NSO; NDS; QL (30 per 30 days) 5

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