2017 Formulary (List of Covered Drugs)

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1 017 Formulary (List of Covered s) PLEASE READ: This document contains information about the drugs we cover in this plan. Y011_17_0810A_CHP_MT_FINAL_ Populated Template (08901) _, v0 This formulary was updated on 10//017. For more recent information or other questions, please contact Member Services, at , TTY: 711, 8 a.m. 8 p.m., 7 days a week, October 1 to February 1 (except Thanksgiving and Christmas), and Monday to Friday from February 1 to September 0 (except holi or visit FORMCMW17_WEB

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 CareMore Health Plan. When it refers to plan or our plan, it means the plan in which you are enrolled. This document includes a list of the drugs (formulary) for our plan which is current as of 10//017. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/ coinsurance may change on January 1, 018, and from time to time during the year. Effective Date November 1, FORMCMW17_WEB

3 What is the formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary (drug list) change? Generally, if you are taking a drug on our 017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 017 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step-therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 0 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 0-day supply of the drug. If the Food and Administration (FDA) deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 10//017. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (non-maintenance change) is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated formulary. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. 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, Hypertension / Lipids. If you know what your drug is used for, look for the category name in the list that begins on page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are prescription drug tiers? Prescription drugs are grouped into one of six tiers. These include: 1 - Preferred Generic: Preferred Generic drugs that are available at the lowest cost share for the plan. - Generic: Generic drugs that the plan offers at a higher cost to you than 1 Preferred Generic s. - Preferred Brand: Preferred Brand drugs that the plan offers at a lower cost to you than Non-Preferred drugs. - Non-Preferred: Non-Preferred Generic or Non-Preferred brand drugs that the plan offers at a higher cost to you than Preferred Brand drugs. - Specialty : Some injectables and other high-cost drugs. : Select Care s Effective Date November 1, 017 FORMCMW17_WEB

4 * You pay a % coinsurance for drugs in s, and in the CareMore Connect (H SNP) plan. What are generic drugs? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 0 tablets per month per prescription for JANUVIA 100 MG. This may be in addition to a standard one-month or three-month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted on-line documents that explain 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 our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the formulary? on page for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within Effective Date November 1, 017 FORMCMW17_WEB

5 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term-care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. During the time when you are getting a temporary supply of a drug, you should talk to your prescriber or prescribing physician to decide what to do when your supply runs out. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you while you pursue a formulary exception. Please refer to the Evidence of Coverage for more information about exceptions. For more information For more detailed information about our plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), hours a day/7 days a week. TTY users should call Or, visit Our plan s formulary The formulary that begins on page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., NOVOLOG) and generic drugs are listed in lower-case italics (e.g., enalapril). The information in the column tells you if our plan has any special requirements for coverage of your drug. QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. B/D - Part B vs. Part D: This drug may be covered under either your Part D prescripton drug benefits or as a Part B Effective Date November 1, 017 FORMCMW17_WEB

6 drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Member Services at , TTY: a.m. 8 p.m., 7 days a week, October 1 to February 1 (except Thanksgiving and Christmas), and Monday through Friday from February 1 to September 0 (except holi. INJ - Injectable: The drug is available in injectable form. - Mail Orders: Prescription drugs available through mail order. - Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Non-Extended Day Supply: This drug is not eligible for an extended days supply. You may have this prescription dispensed by your pharmacy for a maximum of 0 days supply at a time. HI - Home Infusion: The drug may be covered through the medical benefit as a home-infusion medication. For more information, call Member Services at , TTY: a.m. 8 p.m., 7 days a week, October 1 to February 1 (except Thanksgiving and Christmas), and Monday through Friday from February 1 to September 0 (except holi. Effective Date November 1, 017 FORMCMW17_WEB

7 Covered Medications by Therapeutic Category Name Anti - Infectives abacavir abacavir sulfate-lamivudine abacavir-lamivudinezidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 00 / ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amantadine hcl oral capsule amantadine hcl oral tablet AMBISOME amikacin injection solution 1,000 / ml amikacin injection solution 00 / ml amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet, chewable 1, 0 amoxicillin-pot clavulanate amphotericin b ampicillin ampicillin sodium injection recon soln 1 gram, 10 gram, 1 ; QLL (0 per ; QLL (0 per 0 ; ; QLL (0 per B/D; PAR; HI; B/D; PAR; ; HI; PAR; ; QLL (180 per 0 ; QLL ( per B/D; PAR; ; HI; B/D; PAR; ; HI; Name ampicillin sodium injection recon soln gram, 0, 00 ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1. gram ampicillin-sulbactam injection recon soln 1 gram ampicillin-sulbactam injection recon soln gram ampicillin-sulbactam intravenous recon soln 1. gram APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atovaquone atovaquone-proguanil oral tablet ATRIPLA AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) azithromycin intravenous azithromycin oral suspension for reconstitution azithromycin oral tablet 0 ( pack) azithromycin oral tablet 0, 00, 00 aztreonam for inj 1 GM baciim bacitracin intramuscular BARACLUDE ORAL SOLUTION HI; ; HI; HI; ; QLL (10 per 0 QLL (90 per PAR; ; QLL (0 per 0 HI ; HI; HI PAR; QLL (00 per 0 ; Effective Date November 1, 017 FORMCMW17_WEB

8 Name BICILLIN C-R SYRINGE 1,00,000 UNIT/ ML(00K/ 00K) BILTRICIDE CANCIDAS CAPASTAT CAYSTON cefaclor oral capsule cefaclor oral suspension for reconstitution 1 / ml cefaclor oral suspension for reconstitution 0 / ml, 7 / ml cefaclor oral tablet extended release 1 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 0 / ml, 00 / ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/0 ml cefazolin injection recon soln 1 gram, 00 cefazolin injection recon soln 10 gram cefazolin injection recon soln 100 gram, 0 gram, 00 g cefazolin intravenous cefdinir cefepime cefoxitin in dextrose, isoosm cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram, gram cefpodoxime cefprozil B/D; PAR; PAR; LA; ; HI; HI; ; HI; ; HI; HI; Name ceftazidime ceftazidime injection recon soln 1 gram, gram ceftazidime injection recon soln gram ceftriaxone in dextrose,isoos ceftriaxone injection recon soln 1 gram, gram ceftriaxone injection recon soln 10 gram ceftriaxone injection recon soln 0, 00 ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium intravenous vial injection recon soln 1. gram, 70 cefuroxime sodium intravenous vial intravenous recon soln 7. gram cephalexin oral capsule 0, 00 cephalexin oral suspension for reconstitution chloramphenicol sod succinate chloroquine phosphate oral ciprofloxacin (mixture) oral tablet, er multiphase hr 1,000 ciprofloxacin (mixture) oral tablet, er multiphase hr 00 ciprofloxacin hcl oral tablet 0, 00, 70 ciprofloxacin lactate intravenous solution 00 /0 ml ; ; HI; HI; HI; ; HI; ; HI; ; HI; HI; Effective Date November 1, FORMCMW17_WEB

9 Name ciprofloxacin lactate intravenous solution 00 /0 ml clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release hr clindamycin hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 00 / ml, 900 / ml clindamycin phosphate intravenous solution 00 / ml clotrimazole mucous membrane COARTEM colistin (colistimethate na) COMPLERA CRIXIVAN ORAL CAPSULE 00 MG CRIXIVAN ORAL CAPSULE 00 MG CUBICIN dapsone DARAPRIM demeclocycline DESCOVY dicloxacillin didanosine oral capsule, delayed release(dr/ec) 1 didanosine oral capsule, delayed release(dr/ec) 00 didanosine oral capsule, delayed release(dr/ec) 0, 00 ; QLL (8 per 1 ; HI; ; HI; QLL (0 per ; ; QLL (0 per 0 ; QLL (180 per 0 QLL (0 per ; ; QLL (90 per ; QLL (0 per ; QLL (0 per Name doxy-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100, 0 doxycycline monohydrate oral capsule 100, 0, 7 EDURANT EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPCLUSA EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 0 MG ery-tab oral tablet,delayed release (dr/ec) 0, 00 ERYTHROCIN INTRAVENOUS RECON SOLN 00 MG ethambutol EVOTAZ HI; QLL (0 per ; ; QLL (0 per 0 ; QLL (870 per 0 PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; ; QLL (90 per 0 ; QLL (0 per 0 PAR; ; HI PAR; QLL (0 per ; Effective Date November 1, FORMCMW17_WEB

10 Name famciclovir oral tablet 1, 0 famciclovir oral tablet 00 fluconazole fluconazole in dextrose(isoo) fluconazole in nacl (isoosm) intravenous piggyback 100 /0 ml fluconazole in nacl (isoosm) intravenous piggyback 00 /100 ml fluconazole in nacl (isoosm) intravenous piggyback 00 /00 ml flucytosine foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium gentamicin injection solution 0 / ml gentamicin injection solution 0 /ml gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 /10 ml gentamicin sulfate (pf) intravenous solution 0 / ml gentamicin sulfate (pf) intravenous solution 80 / 8 ml GENVOYA griseofulvin microsize oral suspension griseofulvin ultramicrosize ; QLL (0 per ; QLL (1 per 7 HI; HI; B/D; PAR; QLL (0 per ; B/D; PAR; ; HI; HI; QLL (0 per ; Name HARVONI hydroxychloroquine oral imipenem-cilastatin INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 00 MG INTELENCE ORAL TABLET MG INVANZ INJECTION INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS HD 00MG ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE MG isoniazid oral itraconazole ivermectin tab KALETRA ORAL SOLUTION KALETRA ORAL TABLET 100- MG KALETRA ORAL TABLET 00-0 MG ketoconazole oral lamivudine oral solution lamivudine oral tablet 100 lamivudine oral tablet 10 PAR; QLL (8 per 8 ; ; HI; ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; HI ; QLL (00 per 0 ; QLL (10 per 0 QLL (0 per ; QLL (10 per ; QLL (180 per ; ; QLL (70 per 0 ; QLL (80 per 0 ; QLL (00 per 0 ; QLL (10 per 0 ; QLL (900 per ; QLL (0 per Effective Date November 1, FORMCMW17_WEB

11 Name lamivudine oral tablet 00 lamivudine-zidovudine levofloxacin intravenous levofloxacin oral solution levofloxacin oral tablet LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet lopinavir-ritonavir soln MACRODANTIN ORAL CAPSULE MG, 0 MG mefloquine meropenem intravenous recon soln 1 gram meropenem intravenous recon soln 00 methenamine hippurate methenamine mandelate oral tablet 1 gram metro i.v. metronidazole in nacl (isoos) metronidazole oral minocycline oral capsule minocycline oral tablet moderiba morgidox oral capsule 100 MYCOBUTIN nafcillin injection recon soln 1 gram, 10 gram nafcillin injection recon soln gram ; QLL (0 per ; QLL (0 per ; QLL (1800 per 0 ; QLL (10 per 0 PAR; HI; PAR; ; QLL (180 per PAR; ; QLL ( per ; QLL (80 per 0 ; ; HI; ; HI; ; HI; Name nafcillin intravenous recon soln gram NEBUPENT neomycin nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release hr 100 nevirapine oral tablet extended release hr 00 nitrofurantoin NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet ODEFSEY ofloxacin oral tablet ofloxacin oral tablet 00 OLYSIO oxacillin injection recon soln 1 gram, gram oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 1 gram oxacillin intravenous recon soln gram paromomycin paser B/D; PAR; ; QLL (100 per ; QLL (0 per ; QLL (0 per ; ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (0 per 0 QLL (00 per ; QLL (0 per ; PAR; QLL (0 per 0 ; ; HI; HI; Effective Date November 1, FORMCMW17_WEB

12 Name PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/0 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK MILLION UNIT/0 ML, MILLION UNIT/0 ML penicillin g potassium injection recon soln 0 million unit penicillin g potassium injection recon soln million unit penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 00, 000 unit/ml penicillin g sodium penicillin v potassium PENTAM piperacillin-tazobactam intravenous recon soln. gram piperacillin-tazobactam intravenous recon soln.7 gram,. gram, 0. gram PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 10 MG PREZISTA ORAL TABLET 00 MG, 800 MG HI ; HI; ; HI; ; HI; QLL (0 per ; QLL (0 per ; ; QLL (180 per 0 ; QLL (0 per 0 Name PREZISTA ORAL TABLET 7 MG PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 10 MG, 00 MG REYATAZ ORAL CAPSULE 00 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 ribavirin oral capsule ribavirin oral tablet 00 rifampin intravenous rifampin oral RIFATER rimantadine SELZENTRY SELZENTRY ORAL SOL SELZENTRY TABLET MG SELZENTRY TABLET 7 MG SIRTURO SOVALDI ; QLL (00 per 0 PAR; ; QLL (0 per 180 ; QLL (180 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; HI; QLL (10 per ; QLL (180 per ; QLL (10 per QLL (0 per PAR; LA; PAR; QLL (0 per 0 ; Effective Date November 1, FORMCMW17_WEB

13 Name stavudine oral capsule 1, 0 stavudine oral capsule 0, 0 stavudine oral recon soln STREPTOMYCIN STRIBILD STROMECTOL sulfadiazine oral sulfamethoxazoletrimethoprim SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 0 MG SUSTIVA ORAL TABLET SYNAGIS SYNERCID TAMIFLU TECHNIVIE TEFLARO INTRAVENOUS RECON SOLN 00 MG TEFLARO INTRAVENOUS RECON SOLN 00 MG terbinafine hcl oral tetracycline TIGECYCLINE TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET MG, 0 MG TOBI tobramycin sulfate injection recon soln ; QLL (10 per ; QLL (0 per ; QLL (00 per ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (0 per 0 PAR; LA; PAR; QLL ( per 8 ; ; QLL (0 per QLL (0 per QLL (0 per ; PAR; QLL (80 per 8 ; Name tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ TRIZIVIR TRUVADA ORAL TABLET MG, 1-00 MG, 17-0 MG TRUVADA ORAL TABLET MG TYBOST TYGACIL TYZEKA valacyclovir valganciclovir vancomycin in 0.9% sodium cl intravenous piggyback 00 /100 ml, 70 /10 ml vancomycin in dextrose % intravenous piggyback 1 gram/00 ml vancomycin in dextrose % intravenous piggyback 00 /100 ml, 70 / 10 ml vancomycin intravenous recon soln 1,000, 10 gram, 00 vancomycin intravenous recon soln gram, 70 vancomycin oral capsule 1 vancomycin oral capsule 0 VIDEX GRAM PEDIATRIC ; HI; QLL (0 per ; ; QLL (0 per 0 QLL (0 per ; QLL (0 per 0 ; QLL (0 per 0 HI; ; QLL (0 per B/D; PAR; B/D; PAR; B/D; PAR; ; HI; B/D; PAR; PAR; QLL (0 per 10 ; PAR; QLL (80 per 10 ; ; QLL (100 per 0 Effective Date November 1, FORMCMW17_WEB

14 Name VIDEX GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR VIRACEPT ORAL TABLET 0 MG VIRACEPT ORAL TABLET MG VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 00 voriconazole oral tablet 0 VOSEVI XIFAXAN ORAL TABLET 0 MG ZEPATIER ZERIT ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK. ; QLL (100 per 0 PAR; QLL (11 per 8 ; PAR; QLL (8 per 8 ; ; QLL (00 per 0 ; QLL (10 per 0 PAR; ; QLL (0 per 0 ; QLL (0 per 0 QLL (0 per ; PAR; QLL (00 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (10 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (8 per 8 ; PAR; QLL (0 per 0 ; QLL (00 per ; QLL (90 per 0 ; QLL (180 per ; QLL (190 per ; QLL (0 per Name GRAM/0 ML,. GRAM/100 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK.7 GRAM/0 ML Antineoplastic / Immunosuppressant s ABRAXANE AFINITOR PAR; AFINITOR DISPERZ PAR; ALECENSA ALIMTA ALUNBRIG PAR; QLL (180 per 0 ; amifostine crystalline anastrozole ; QLL (0 per ARRANON ARZERRA ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE HR 0. MG, 1 MG B/D; PAR; ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE HR MG B/D; PAR; AVASTIN PAR; azacitidine azasan B/D; PAR; azathioprine B/D; PAR; azathioprine sodium B/D; PAR; BAVENCIO PAR; BELEODAQ PAR; BENDEKA bexarotene PAR; bicalutamide ; QLL (0 per BICNU bleomycin B/D; PAR; BLINCYTO PAR; BOSULIF ORAL TABLET 100 MG PAR; QLL (10 per 0 ; Effective Date November 1, FORMCMW17_WEB

15 Name BOSULIF ORAL TABLET 00 MG busulfan BUSULFEX CABOMETYX ORAL TABLET 0 MG CABOMETYX ORAL TABLET 0 MG, 0 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 00 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine clofarabine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/ DAY(80 MG X1-0 MG X1) COMETRIQ ORAL CAPSULE 10 MG/ DAY(80 MG X1-0 MG X) COMETRIQ ORAL CAPSULE 0 MG/DAY (0 MG X /DAY) COSMEGEN COTELLIC cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine cytarabine (pf) injection solution 100 / ml (0 PAR; QLL (0 per 0 ; B/D; PAR PAR; LA; QLL (90 per 0 ; PAR; LA; QLL (0 per 0 ; PAR; LA; QLL (90 per 0 ; PAR; LA; QLL (0 per 0 ; B/D; PAR; B/D; PAR; PAR; QLL ( per 8 ; PAR; QLL (11 per 8 ; PAR; QLL (8 per 8 ; PAR; LA; QLL (90 per 0 ; B/D; PAR; B/D; PAR; B/D; PAR; B/D; PAR; PAR; B/D; PAR; B/D; PAR; Name /ml), gram/0 ml (100 /ml) cytarabine (pf) injection solution 0 /ml dacarbazine DACOGEN DARZALEX daunorubicin intravenous solution decitabine dexrazoxane hcl intravenous recon soln 0 dexrazoxane hcl intravenous recon soln 00 DOCEFREZ INTRAVENOUS RECON SOLN 0 MG docetaxel intravenous solution 10 /ml, 10 / 1 ml (10 /ml), 10 / 8 ml (0 /ml), 0 / ml (10 /ml), 0 /ml (1 ml), 80 / ml (0 / ml), 80 /8 ml (10 / ml) DOCETAXEL INTRAVENOUS SOLUTION 00 MG/10 ML doxorubicin intravenous recon soln doxorubicin intravenous solution doxorubicin, peg-liposomal DROXIA ELITEK EMCYT EMPLICITI epirubicin intravenous solution 00 /100 ml epirubicin intravenous solution 0 / ml ERBITUX B/D; PAR; LA; B/D; PAR; PAR; B/D; PAR; PAR; Effective Date November 1, FORMCMW17_WEB

16 Name ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 1 MG, 0 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN FUSILEV GAZYVA gemcitabine intravenous recon soln 1 gram, 00 gemcitabine intravenous recon soln gram gemcitabine intravenous solution 1 gram/. ml (8 /ml), 00 /. ml (8 /ml) PAR; QLL (0 per 0 ; ; QLL (0 per QLL (0 per ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL ( per ; ; QLL (1 per 8 B/D; PAR; PAR; Name gemcitabine intravenous solution gram/. ml (8 /ml) gengraf oral capsule 100, gengraf oral capsule 0 gengraf oral solution GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 00 MG GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyprogesterone caproate hydroxyurea IBRANCE ICLUSIG ORAL TABLET 1 MG ICLUSIG ORAL TABLET MG idarubicin IDHIFA ORAL TABLET 100 MG IDHIFA ORAL TABLET 0 MG ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 imatinib oral tablet 00 IMBRUVICA IMFINZI B/D; PAR; B/D; PAR; B/D; PAR; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (10 per 0 ; PAR; Effective Date November 1, FORMCMW17_WEB

17 Name INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET MG IRESSA irinotecan intravenous solution 100 / ml, 0 / ml irinotecan intravenous solution 00 / ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 1 MG JAKAFI ORAL TABLET 0 MG JAKAFI ORAL TABLET MG JAKAFI ORAL TABLET MG JEVTANA KADCYLA KEPIVANCE KEYTRUDA KISQALI 00 DOSE KISQALI 00 PAK FEMARA KISQALI 00 DOSE KISQALI 00 PAK FEMARA KISQALI 00 DOSE KISQALI 00 PAK FEMARA KYPROLIS LARTRUVO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) PAR; QLL (0 per 0 ; PAR; QLL (10 per 0 ; PAR; QLL (10 per 0 ; PAR; QLL (100 per 0 ; PAR; QLL (7 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (00 per 0 ; PAR; PAR; PAR; QLL (1 per 1 ; PAR; QLL (1 per 8 ; PAR; QLL ( per 1 ; PAR; QLL ( per 8 ; PAR; QLL ( per 1 ; PAR; QLL ( per 8 ; B/D; PAR; PAR; QLL (0 per 0 ; Name LENVIMA ORAL CAPSULE 1 MG/ DAY(10 MG X 1- MG X 1), 0 MG/DAY (10 MG X ), 8 MG/DAY ( MG X ) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1- MG X), MG/DAY(10 MG X - MG X 1) letrozole leucovorin calcium injection recon soln 100, 00, 0, 0 leucovorin calcium injection recon soln 00 leucovorin calcium oral LEUKERAN leuprolide subcutaneous kit levoleucovorin inj 0 LONSURF LUPRON DEPOT SYRINGE KIT.7 MG, 7. MG LUPRON DEPOT ( NTH) SYRINGE KIT 11. MG LUPRON DEPOT ( NTH) SYRINGE KIT. MG LYNPARZA LYNPARZA ORAL TABLET 100 MG, 10 MG LYSODREN MARQIBO PAR; QLL (0 per 0 ; PAR; QLL (90 per 0 ; ; QLL (0 per PAR; PAR; QLL (1 per 8 ; PAR; QLL (1 per 8 ; PAR; QLL (1 per 8 ; PAR; QLL (80 per 0 ; PAR; QLL (10 per 0 ; Effective Date November 1, FORMCMW17_WEB

18 Name MATULANE megestrol oral suspension 00 /10 ml (10 ml), 800 /0 ml (0 ml) megestrol oral suspension 00 /10 ml (0 /ml) megestrol oral tablet MEKINIST ORAL TABLET 0. MG MEKINIST ORAL TABLET MG melphalan hcl mercaptopurine mesna MESNEX ORAL methotrexate sodium methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium NERLYNX NEXAVAR NILANDRON NINLARO NIPENT NULOJIX octreotide acetate injection solution 1,000 mcg/ml, 00 mcg/ml PAR; QLL (90 per 0 ; PAR; QLL (0 per 0 ; B/D; PAR; B/D; PAR; B/D; PAR; B/D; PAR; PAR; QLL (180 per 0 ; PAR; LA; QLL (10 per ; QLL (0 per ; PAR; QLL ( per 8 ; B/D; PAR; PAR; Name octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 0 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 0 mcg/ml (1 ml) octreotide acetate injection syringe 00 mcg/ml (1 ml) ODOMZO OPDIVO oxaliplatin intravenous recon soln 100 oxaliplatin intravenous recon soln 0 oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE MG POMALYST ORAL CAPSULE MG, MG PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 1 MG,. MG, 0 MG, MG REVLIMID ORAL CAPSULE MG RITUXAN RITUXAN HYCELA RUBRACA ORAL TABLET 00MG PAR; PAR; PAR; PAR; LA; QLL (0 per 0 ; PAR; PAR; QLL (10 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; B/D; PAR; PAR; B/D; PAR; LA; QLL (0 per 0 ; LA; QLL (0 per 0 ; LA; QLL (10 per 0 ; B/D; PAR; PAR; QLL (180 per 0 ; Effective Date November 1, FORMCMW17_WEB

19 Name RUBRACA ORAL TABLET 0MG RUBRACA ORAL TABLET 00MG RYDAPT SANDIMMUNE ORAL SOLUTION SIGNIFOR SIMULECT sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 1. MG SUTENT ORAL CAPSULE MG, 7. MG, 0 MG SYNRIBO TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 0 MG TAGRISSO ORAL TABLET 80 MG tamoxifen TARCEVA ORAL TABLET 100 MG, 10 MG TARCEVA ORAL TABLET MG TARGRETIN ORAL TARGRETIN TOPICAL TASIGNA PAR; QLL (10 per 0 ; PAR; QLL (10 per 0 ; PAR; QLL (0 per 0 ; B/D; PAR; B/D; PAR; B/D; PAR; QLL (0 per ; PAR; QLL (10 per 0 ; QLL (90 per ; QLL (0 per ; B/D; PAR; PAR; QLL (10 per 0 ; PAR; LA; QLL (0 per 0 ; PAR; LA; QLL (0 per 0 ; QLL (0 per ; QLL (90 per ; PAR; PAR; QLL (0 per 0 ; QLL (11 per 8 ; Name TECENTRIQ TEPADINA THALOMID ORAL CAPSULE 100 MG, 0 MG THALOMID ORAL CAPSULE 10 MG, 00 MG thiotepa toposar topotecan TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR SUSPENSION FOR RECONSTITUTION TRELSTAR SYRINGE 11. MG/ ML TRELSTAR SYRINGE. MG/ ML TRELSTAR SYRINGE.7 MG/ ML tretinoin (chemotherapy) trexall TRISENOX TYKERB UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 10 MG LA; QLL (0 per 1 ; QLL (0 per ; QLL (0 per ; QLL (1 per 18 ; QLL (1 per 8 ; QLL (1 per 18 ; QLL (1 per 8 ; LA; QLL (180 per 0 ; PAR; PAR; LA; QLL (0 per 0 Effective Date November 1, FORMCMW17_WEB

20 Name VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 0 MG VENCLEXTA STARTING PACK vinblastine intravenous solution vincasar pfs intravenous solution 1 /ml vincasar pfs intravenous solution / ml vincristine vinorelbine VOTRIENT VYXEOS XALKORI XATMEP XGEVA XTANDI YERVOY YONDELIS ZALTRAP ZANOSAR ZEJULA ZELBORAF ZOLINZA ZORTRESS ORAL TABLET 0. MG ZORTRESS ORAL TABLET 0. MG, 0.7 MG ZYDELIG ZYKADIA PAR; LA; QLL (10 per ; PAR; LA; QLL (0 per 0 PAR; LA; QLL (8 per ; B/D; PAR; B/D; PAR; B/D; PAR; QLL (10 per ; B/D; PAR; PAR; QLL (0 per 0 ; PAR; QLL (1.7 per 8 ; PAR; QLL (10 per 0 ; B/D; PAR; PAR; PAR; QLL (90 per 0 ; PAR; QLL (0 per 0 ; QLL (10 per ; B/D; PAR; B/D; PAR; PAR; QLL (0 per 0 ; PAR; QLL (10 per 0 ; Name ZYTIGA PAR; QLL (10 per 0 ; ZYTIGA 00 MG PAR; QLL (0 per 0 ; Autonomic / Cns s, Neurology / Psych ABILIFY MAINTENA QLL (1 per 8 ; ABSTRAL SUBLINGUAL TABLET PAR; ; QLL (10 per 100 M ABSTRAL SUBLINGUAL TABLET 00 M, 00 M, 00 M, 00 M, 800 M acetaminophen-codeine oral solution 10-1 / ml ( ml), 0 - /10 ml (10 ml), 00-0 /1. ml acetaminophen-codeine oral solution 10-1 / ml acetaminophen-codeine oral tablet 00-1 acetaminophen-codeine oral tablet 00-0 acetaminophen-codeine oral tablet 00-0 ADASUVE alprazolam oral tablet amitriptyline amoxapine AMPYRA AMRIX APOKYN APTIOM aripiprazole oral solution aripiprazole oral tablet 10 PAR; QLL (10 per 0 ; ; QLL (00 per 0 ; QLL (00 per ; QLL (90 per ; QLL (0 per ; QLL (180 per ; QLL (10 per PAR; LA; QLL (0 per 0 ; PAR; PAR; LA; QLL (900 per ; ; QLL (90 per Effective Date November 1, FORMCMW17_WEB

21 Name aripiprazole oral tablet 1 aripiprazole oral tablet aripiprazole oral tablet 0, 0 aripiprazole oral tablet aripiprazole oral tablet, disintegrating 10 aripiprazole oral tablet, disintegrating 1 ARISTADA SUSPENSION, EXTENDED REL SYRING 10 MG/.9 ML ARISTADA SUSPENSION, EXTENDED REL SYRING 1 MG/1. ML ARISTADA SUSPENSION, EXTENDED REL SYRING MG/. ML ARISTADA SUSPENSION, EXTENDED REL SYRING 88 MG/. ML AZILECT baclofen BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 00 MG ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (180 per ; QLL (90 per ; QLL (0 per PAR; PAR; QLL (1. per 0 ; PAR; QLL (. per 0 ; PAR; QLL (. per 0 ; PAR; QLL (00 per 0 ; PAR; ; QLL (80 per Name BANZEL ORAL TABLET 00 MG benztropine oral BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 7 MG BRIVIACT ORAL TABLET MG BRIVIACT ORAL TABLET 0 MG bromocriptine buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet buprenorphine hcl sublingual tablet 8 buprenorphine-naloxone sublingual tablet -0. buprenorphine-naloxone sublingual tablet 8- bupropion hcl oral tablet 100 bupropion hcl oral tablet 7 bupropion hcl oral tablet extended release 100 bupropion hcl oral tablet extended release 10, 00 bupropion hcl oral tablet extended release hr 10 PAR; QLL (0 per 0 ; PAR PAR; QLL (00 per 0 PAR; QLL (00 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (0 per 0 ; PAR; QLL (10 per 0 ; ; QLL (90 per ; QLL (10 per 0 ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (90 per ; QLL (1 per ; QLL (180 per ; QLL (10 per ; QLL (0 per ; QLL (90 per Effective Date November 1, FORMCMW17_WEB

22 Name bupropion hcl oral tablet extended release hr 00 buspirone butalbital-acetaminop-cafcod oral capsule butorphanol tartrate injection butorphanol tartrate nasal carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 / ml carbamazepine oral suspension 00 /10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr 100 carbamazepine oral tablet extended release 1 hr 00, 00 carbamazepine oral tablet, chewable carbidopa-levodopa celecoxib oral capsule 100, 00, 0 celecoxib oral capsule 00 CELONTIN ORAL CAPSULE 00 MG chlorpromazine citalopram oral solution citalopram oral tablet 10 citalopram oral tablet 0 citalopram oral tablet 0 clomipramine ; QLL (0 per ; QLL (180 per ; QLL ( per 8 PAR; ; QLL (0 per PAR; ; QLL (0 per ; QLL (00 per ; QLL (10 per ; QLL (0 per ; QLL (0 per Name clonazepam oral tablet 0. clonazepam oral tablet 1 clonazepam oral tablet clonazepam oral tablet, disintegrating 0.1 clonazepam oral tablet, disintegrating 0. clonazepam oral tablet, disintegrating 0. clonazepam oral tablet, disintegrating 1 clonazepam oral tablet, disintegrating clorazepate dipotassium clozapine oral tablet 100 clozapine oral tablet 00 clozapine oral tablet clozapine oral tablet 0 clozapine oral tablet, disintegrating 100 clozapine oral tablet, disintegrating 1. CLOZAPINE ORAL TABLET, DISINTEGRATING 10 MG CLOZAPINE ORAL TABLET, DISINTEGRATING 00 MG clozapine oral tablet, disintegrating COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML ; QLL (100 per ; QLL (00 per ; QLL (00 per ; QLL (800 per ; QLL (00 per ; QLL (100 per ; QLL (00 per ; QLL (00 per ; QLL (70 per ; QLL (10 per ; QLL (1080 per ; QLL (0 per ; QLL (70 per 0 ; QLL (10 per 0 QLL (180 per QLL (10 per ; QLL (1080 per 0 PAR; QLL (0 per 0 ; Effective Date November 1, FORMCMW17_WEB

23 Name COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML dantrolene desipramine oral desvenlafaxine fumarate oral tablet extended release hr 100 desvenlafaxine fumarate oral tablet extended release hr 0 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG desvenlafaxine succinate oral tablet extended release hr 100 desvenlafaxine succinate oral tablet extended release hr desvenlafaxine succinate oral tablet extended release hr 0 dextroamphetamine oral tablet 10 dextroamphetamine oral tablet dextroamphetamineamphetamine oral tablet 10, 1., 1, 0,, 7. dextroamphetamineamphetamine oral tablet 0 DIASTAT RECTAL GEL. MG, 10 MG diazepam injection solution diazepam injection syringe PAR; QLL (1 per 8 ; ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (80 per 0 ; QLL (0 per 0 PAR; ; QLL (180 per PAR; ; QLL (90 per ; QLL (90 per ; QLL (0 per Name diazepam intensol diazepam oral concentrate diazepam oral solution / ml (1 /ml) diazepam oral solution / ml (1 /ml, ml) diazepam oral tablet 10 diazepam oral tablet diazepam oral tablet DIAZEPAM RECTAL diazepam rectal diclofenac potassium diclofenac sodium oral diflunisal DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 MG DILANTIN INFATABS divalproex donepezil oral tablet 10 donepezil oral tablet doxepin oral duloxetine oral capsule, delayed release(dr/ec) 0 duloxetine oral capsule, delayed release(dr/ec) 0 duloxetine oral capsule, delayed release(dr/ec) 0 duloxetine oral capsule, delayed release(dr/ec) 0 duramorph (pf) injection solution 0. /ml duramorph (pf) injection solution 1 /ml EMSAM ; QLL (0 per ; QLL (0 per ; QLL (100 per ; QLL (100 per 0 ; QLL (10 per ; QLL (00 per ; QLL (0 per ; QLL (0 per ; QLL (180 per ; QLL (10 per ; QLL (90 per ; QLL (0 per ; QLL (180 per ; QLL (180 per 0 QLL (0 per ; Effective Date November 1, 017 FORMCMW17_WEB

24 Name endocet oral tablet 10-, -, 7.- entacapone epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 00 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 00 MG ergoloid ergomar escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 escitalopram oxalate oral tablet 0 escitalopram oxalate oral tablet ethosuximide FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS,DOSE PACK ; QLL (0 per ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (00 per ; QLL (0 per ; QLL (0 per ; QLL (10 per ; QLL (70 per 0 QLL (0 per ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (10 per 0 ; QLL (90 per 0 ; QLL (1 per Name FAZACLO ORAL TABLET, DISINTEGRATING 100 MG FAZACLO ORAL TABLET, DISINTEGRATING 1. MG FAZACLO ORAL TABLET, DISINTEGRATING MG felbamate fenoprofen oral tablet fentanyl citrate fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, mcg/hr, 0 mcg/ hr, 7 mcg/hr FENTORA FETZIMA ORAL CAPSULE,EXT REL HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 10 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG fluoxetine oral capsule 10 fluoxetine oral capsule 0 fluoxetine oral capsule 0 fluoxetine oral solution QLL (70 per QLL (10 per QLL (1080 per PAR; QLL (10 per 0 ; ; QLL (1 per PAR; QLL (10 per 0 ; PAR; ; QLL ( per PAR; ; QLL (0 per PAR; ; QLL (180 per PAR; ; QLL (90 per ; QLL (0 per ; QLL (10 per ; QLL (0 per ; QLL (00 per Effective Date November 1, 017 FORMCMW17_WEB

25 Name fluphenazine decanoate fluphenazine hcl flurbiprofen fluvoxamine oral tablet 100 fluvoxamine oral tablet fluvoxamine oral tablet 0 fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 1 MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 100 gabapentin oral capsule 00 gabapentin oral capsule 00 gabapentin oral solution 0 / ml gabapentin oral solution 0 / ml ( ml), 00 / ml ( ml) gabapentin oral tablet 00 gabapentin oral tablet 800 GABITRIL ORAL TABLET 1 MG, 1 MG GEODON GILENYA ; QLL (90 per ; QLL (0 per ; QLL (180 per QLL (70 per ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (90 per 0 ; QLL (0 per 0 ; QLL ( per 0 ; QLL (1080 per ; QLL (0 per ; QLL (70 per ; QLL (10 per ; QLL (10 per 0 ; QLL (180 per ; QLL (10 per PAR; QLL (0 per 0 ; Name GLATOPA guanfacine oral tablet extended release hr GUANIDINE haloperidol haloperidol decanoate haloperidol lactate HETLIOZ hydrocodone-acetaminophen oral solution 10- /1 ml(1 ml), -1 / 7.ml(7.ml) hydrocodone-acetaminophen oral solution 7.- / 1 ml hydrocodone-acetaminophen oral tablet 10-, -, 7.- hydrocodone-ibuprofen oral tablet hydromorphone oral tablet, hydromorphone oral tablet 8 ibuprofen oral suspension ibuprofen oral tablet 00, 00, 800 imipramine hcl INVEGA SUSTENNA SYRINGE 117 MG/0.7 ML INVEGA SUSTENNA SYRINGE 1 MG/ML INVEGA SUSTENNA SYRINGE MG/1. ML INVEGA SUSTENNA PAR; QLL (0 per 0 ; PAR; ; QLL (0 per PAR; QLL (0 per 0 ; ; QLL (700 per 0 ; QLL (700 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (180 per QLL (0.7 per 8 ; QLL (1 per 8 ; QLL (1. per 8 ; ; QLL (0. per 8 Effective Date November 1, 017 FORMCMW17_WEB

26 Name SYRINGE 9 MG/0. ML INVEGA SUSTENNA SYRINGE 78 MG/0. ML INVEGA TRINZA SYRINGE 7 MG/0.87 ML INVEGA TRINZA SYRINGE 10 MG/1.1 ML INVEGA TRINZA SYRINGE MG/1.7 ML INVEGA TRINZA SYRINGE 819 MG/. ML KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 0 MG lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible LATUDA ORAL TABLET 10 MG, 0 MG LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 80 MG LAZANDA QLL (0. per 8 ; QLL (0.87 per 90 ; QLL (1.1 per 90 ; QLL (1.7 per 90 ; QLL (. per 90 ; ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (0 per 0 PAR; QLL (0 per 0 ; Name levetiracetam levetiracetam intravenous levetiracetam oral solution 100 /ml levetiracetam oral solution 00 / ml ( ml) levetiracetam oral tablet levetiracetam oral tablet extended release hr 00 levetiracetam oral tablet extended release hr 70 levorphanol tartrate lithium carbonate LITHIUM CITRATE ORAL SOLUTION 8 MEQ/ ML LODOSYN lorazepam intensol lorazepam oral tablet lorcet (hydrocodone) lorcet hd lorcet plus oral tablet 7.- lortab 10- lortab - lortab 7.- loxapine succinate LUNESTA LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 10 MG ; ; QLL (180 per ; QLL (10 per ; QLL (180 per ; QLL (90 per ; QLL (90 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (10 per 0 Effective Date November 1, 017 FORMCMW17_WEB

27 Name LYRICA ORAL CAPSULE 00 MG LYRICA ORAL CAPSULE MG, 00 MG LYRICA ORAL CAPSULE MG LYRICA ORAL CAPSULE 0 MG LYRICA ORAL CAPSULE 7 MG LYRICA ORAL SOLUTION maprotiline oral tablet maprotiline oral tablet 0 maprotiline oral tablet 7 MARPLAN meclofenamate oral MELOXICAM ORAL SUSPENSION meloxicam oral tablet memantine oral solution memantine oral tablet 10 memantine oral tablet MESTINON ORAL SYRUP metadate er methadone injection methadone intensol methadone oral concentrate methadone oral solution 10 / ml 1 ; QLL (90 per 0 ; QLL (0 per 0 ; QLL (70 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (900 per 0 ; QLL (70 per ; QLL (1 per ; QLL (00 per 0 ; QLL (0 per ; QLL (00 per ; QLL (0 per ; QLL (90 per ; QLL (90 per QLL (10 per ; QLL (0 per ; QLL (0 per ; QLL (900 per Name methadone oral solution / ml methadone oral tablet 10 methadone oral tablet methadose oral concentrate methylphenidate oral tablet methylphenidate oral tablet extended release MIGRANAL mirtazapine oral tablet 1 mirtazapine oral tablet 0 mirtazapine oral tablet mirtazapine oral tablet 7. mirtazapine oral tablet, disintegrating 1 mirtazapine oral tablet, disintegrating 0 mirtazapine oral tablet, disintegrating modafinil oral tablet 100 modafinil oral tablet 00 molindone morphine (pf) injection solution 0. /ml morphine (pf) injection solution 1 /ml morphine (pf) intravenous patient control.analgesia soln 10 /0 ml morphine (pf) intravenous patient control.analgesia soln 0 /0 ml ; QLL (1800 per ; QLL (180 per ; QLL (0 per ; QLL (0 per ; QLL (90 per ; QLL (90 per ; QLL (8 per 8 ; QLL (90 per ; QLL ( per ; QLL (0 per ; QLL (180 per ; QLL (90 per ; QLL ( per ; QLL (0 per PAR; ; QLL (0 per PAR; ; QLL (0 per ; QLL (180 per 0 ; QLL (180 per ; QLL (0 per B/D; PAR; ; QLL (180 per Effective Date November 1, 017 FORMCMW17_WEB

28 Name morphine concentrate oral solution morphine intravenous cartridge /ml, 8 /ml morphine intravenous solution 10 /ml morphine intravenous solution /ml, 8 /ml morphine intravenous syringe /ml, /ml morphine oral solution 10 / ml morphine oral solution 0 / ml ( /ml) morphine oral tablet 1 morphine oral tablet 0 morphine oral tablet extended release 100, 1, 0, 0 morphine oral tablet extended release 00 nabumetone nalbuphine injection solution 10 /ml nalbuphine injection solution 0 /ml naloxone naltrexone NAMENDA XR ORAL CAP,SPRINKLE,ER HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE, ER HR naproxen oral tablet NARCAN nefazodone oral tablet 100 nefazodone oral tablet 10 ; QLL (70 per ; QLL (180 per 0 ; QLL (10 per ; QLL (180 per ; QLL (180 per 0 ; QLL (700 per 0 ; QLL (10 per 0 ; QLL (0 per ; QLL (180 per ; QLL (90 per ; QLL (0 per ; QLL (180 per ; QLL (90 per ; QLL ( per ; QLL (0 per 0 ; QLL (180 per ; QLL (10 per Name nefazodone oral tablet 00 nefazodone oral tablet 0 nefazodone oral tablet 0 NEUPRO norco nortriptyline NUEDEXTA NUPLAZID olanzapine intramuscular olanzapine oral tablet 10 olanzapine oral tablet 1 olanzapine oral tablet. olanzapine oral tablet 0 olanzapine oral tablet olanzapine oral tablet 7. olanzapine oral tablet, disintegrating 10 olanzapine oral tablet, disintegrating 1 olanzapine oral tablet, disintegrating 0 olanzapine oral tablet, disintegrating ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 0 MG ; QLL (90 per ; QLL (7 per ; QLL (0 per PAR; ; QLL (0 per ; QLL (0 per ; QLL (0 per 0 PAR; QLL (0 per 0 ; ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (10 per ; QLL (80 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (10 per PAR; ; QLL (80 per PAR; ; QLL (10 per PAR; ; QLL (0 per Effective Date November 1, FORMCMW17_WEB

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