Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan)

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1 Santa Clara County, CA 2016 Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on 10/01/2016. Have Questions? Call us toll-free at (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. Pacific time or visit mss.anthem.com/cammp. mss.anthem.com/cammp H6229_16_24684_T_010 CMS Approved 09/01/2015 Formulary ID: Version: 15 Issued 11/01/2016

2 H6229_16_24684_T_010 CMS Approved 09/01/2015 Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) 2016 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan). Anthem Blue Cross Cal MediConnect Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or co-payments may change on January 1 of each year. You can always check Anthem Blue Cross Cal MediConnect Plan s up-to-date List of Covered Drugs online at mss.anthem.com/cammp or by calling (TTY 711). You can get this information for free in other formats, such as large print, braille, or audio. Call (TTY 711). The call is free. Limitations, copays and restrictions may apply. For more information, call Anthem Blue Cross Cal MediConnect Plan Member Services or read the Anthem Blue Cross Cal MediConnect Plan Member Handbook. Co-pays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can get this information for free in other languages. Call (TTY 711). The call is free. Puede recibir esta información sin cargo en otros idiomas. Llame al (TTY 711). La llamada es gratuita. 您可免費獲得本資訊的其他語言版本 請致電免費電話 (TTY 711) Quý vị có thể nhận thông tin này miễn phí bằng các ngôn ngữ khác. Hãy gọi (TTY 711). Cuộc gọi này được miễn phí. Maaari ninyong makuha nang libre ang impormasyon na ito sa ibang mga wika. Tawagan ang (TTY 711). Libre ang tawag. Anthem Blue Cross is the trade name of Blue Cross of California and Anthem Blue Cross Partnership Plan is the trade name of Blue Cross of California Partnership Plan, Inc., independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.? If you have questions, please call Anthem Blue Cross Cal MediConnect Plan at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time. The call is free. For more information, visit mss.anthem.com/cammp. 1

3 Frequently Asked Questions (FAQ) H6229_16_24684_T_010 CMS Approved 09/01/2015 Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the Drug List are the drugs covered by Anthem Blue Cross Cal MediConnect Plan. The drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. Anthem Blue Cross Cal MediConnect Plan will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at an Anthem Blue Cross Cal MediConnect Plan network pharmacy. In some cases, you have to do something before you can get a drug (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at mss.anthem.com/cammp or call Member Services at (TTY 711). 2. Does the Drug List ever change? Yes. Anthem Blue Cross Cal MediConnect Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Anthem Blue Cross Cal MediConnect Plan before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page 3.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes.? If you have questions, please call Anthem Blue Cross Cal MediConnect Plan at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time. The call is free. For more information, visit mss.anthem.com/cammp. 2

4 You can always check Anthem Blue Cross Cal MediConnect Plan s up to date Drug List online at mss.anthem.com/cammp. You can also call Member Services to check the current Drug List at (TTY 711). 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the drug is removed from the drug list.we will send you a letter about any non-maintenance changes made to the drug list throughout the year. We ll also post a copy of the letter on our website. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you get a notice about an unsafe medicine, call your doctor right away. Your doctor can help you find another medicine that will work best for you. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Anthem Blue Cross Cal MediConnect Plan before you fill your prescription. If you don t get approval, Anthem Blue Cross Cal MediConnect Plan may not cover the drug. Quantity limits: Sometimes Anthem Blue Cross Cal MediConnect Plan limits the amount of a drug you can get. Step therapy: Sometimes Anthem Blue Cross Cal MediConnect Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our web site at mss.anthem.com/cammp. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see Question 11 for more information on exceptions.? If you have questions, please call Anthem Blue Cross Cal MediConnect Plan at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time. The call is free. For more information, visit mss.anthem.com/cammp. 3

5 If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Anthem Blue Cross Cal MediConnect Plan member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see Question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 7 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some of the drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask your pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the coverage rules is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it using the first letter of the name of the drug. To search by medical condition, find the section labeled List of drugs by medical condition on page 7. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular, Hypertension / Lipids. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at (TTY 711) and ask about it. If you learn that Anthem Blue Cross Cal MediConnect Plan will not cover the drug, you can do one of these things:? If you have questions, please call Anthem Blue Cross Cal MediConnect Plan at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time. The call is free. For more information, visit mss.anthem.com/cammp. 4

6 Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new Anthem Blue Cross Cal MediConnect Plan member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 31-day supply of your drug during the first 90 days you are a member of Anthem Blue Cross Cal MediConnect Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 31-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by Anthem Blue Cross Cal MediConnect Plan, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 to 98 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception. If you experience a change in the level of care you re getting that requires you to transition from one facility or treatment center to another, you may be eligible for a one-time temporary fill of the prescription you have now. For example, if you were discharged from the hospital and given a discharge list of medications based upon the hospital formulary, you may be able to get a one-time fill of the drug. You can get the temporary one-time fill exception, regardless of whether or not you re in your first 90 days of program enrollment. Have your prescriber call us for details. 11. Can you ask for an exception to cover your drug? Yes. You can ask Anthem Blue Cross Cal MediConnect Plan to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, Anthem Blue Cross Cal MediConnect Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.? If you have questions, please call Anthem Blue Cross Cal MediConnect Plan at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time. The call is free. For more information, visit mss.anthem.com/cammp. 5

7 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Member Services. Member Services will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and their names are less commonly known. Generic drugs are approved by the Food and Drug Administration (FDA). Anthem Blue Cross Cal MediConnect Plan covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. Anthem Blue Cross Cal MediConnect Plan covers some OTC drugs when they are written as prescriptions by your provider. You can read the Anthem Blue Cross Cal MediConnect Plan Drug List to see what OTC drugs are covered. 16. Does Anthem Blue Cross Cal MediConnect Plan cover OTC non-drug products? Anthem Blue Cross Cal MediConnect Plan covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the Anthem Blue Cross Cal MediConnect Plan Drug List to see what OTC non-drug products are covered. 17. What is your co-pay? You can read the Anthem Blue Cross Cal MediConnect Plan Drug List to learn about the co-pay for each drug.? If you have questions, please call Anthem Blue Cross Cal MediConnect Plan at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time. The call is free. For more information, visit mss.anthem.com/cammp. 6

8 Anthem Blue Cross Cal MediConnect Plan members living in nursing homes or other long-term care facilities will have no co-pays. Some members getting long-term care in the community will also have no co-pays. Co-pays are listed by tiers. Tiers are groups of drugs with the same co-pay. Tier 1 drugs are preferred Medicare Part D generic and brand-name drugs. The co-pay will be $0. Tier 2 drugs are preferred and non-preferred Medicare Part D generic and brand-name drugs. The co-pay will be from $0 to $7.40, depending on your level of Medi-Cal eligibility. Tier 3 drugs are non-part D generic and brand-name drugs that are covered by Medi-Cal. They have a co-pay of $0. Tier 4 drugs are over-the-counter (OTC) drugs that are covered by Medi-Cal. They have a co-pay of $0 with a prescription from your provider. List of Covered Drugs The list of covered drugs below gives you information about the drugs covered by Anthem Blue Cross Cal MediConnect Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 130. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., AZOPT) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Necessary actions, restrictions, or limits on use column tells you if Anthem Blue Cross Cal MediConnect Plan has any rules for covering your drug. Here is a list of the abbreviations we use: ABBREVIATION B/D HI LA PAR DESCRIPTION Part B vs. Part D determination Home Infusion Limited Availability Mail-Order Drug Prior Authorization Required EXPLANATION This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. This prescription drug may be covered under our medical benefit. For more information, call Member Services (TTY 711). This prescription may be available only at certain pharmacies. For more information, please call Member Services (TTY 711). This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will? If you have questions, please call Anthem Blue Cross Cal MediConnect Plan at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time. The call is free. For more information, visit mss.anthem.com/cammp. 7

9 QLL ST Quantity Limit Step Therapy need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. For certain drugs, the Plan limits the amount of the drug that we will cover. In some cases, the plan 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Note: The asterisk (*) next to a drug means the drug is not a Part D drug. You will not be required to pay a copay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services at (TTY 711). You can also read the Member Handbook to learn how to appeal a decision.? If you have questions, please call Anthem Blue Cross Cal MediConnect Plan at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time. The call is free. For more information, visit mss.anthem.com/cammp. 8

10 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular, Hypertension / Lipids. That is where you will find drugs that treat heart conditions. Name of Drug ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET AMBISOME amphotericin b CANCIDAS clotrimazole mucous membrane ERAXIS(WATER DILUENT) fluconazole fluconazole in dextrose(iso-o) FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml flucytosine griseofulvin microsize oral suspension griseofulvin ultramicrosize itraconazole ketoconazole oral NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet terbinafine hcl oral voriconazole intravenous B/D PAR; B/D PAR; B/D PAR; B/D PAR; PAR; PAR; PAR; ; QLL (630 per 30 days) ; QLL (30 per 30 days) page 7. 9

11 voriconazole oral suspension for reconstitution voriconazole oral tablet 200 mg voriconazole oral tablet 50 mg ANTIVIRALS abacavir abacavir-lamivudine-zidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir amantadine hcl oral capsule amantadine hcl oral tablet APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION cidofovir COMPLERA CRIXIVAN ORAL CAPSULE 200 MG CRIXIVAN ORAL CAPSULE 400 MG DAKLINZA ORAL TABLET 30 MG, 60 MG DAKLINZA ORAL TABLET 90 MG DESCOVY didanosine oral capsule,delayed release(dr/ec) 125 mg didanosine oral capsule,delayed release(dr/ec) 200 mg didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg EDURANT PAR; ; QLL (300 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (60 per 30 days) B/D PAR; ; QLL (120 per 30 days) QLL (380 per 30 days) ; QLL (30 per 30 days) PAR; B/D PAR; ; QLL (30 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) PAR; ; QLL (30 per 30 days) PAR; QLL (30 per 30 days) QLL (30 per 30 days) ; QLL (90 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) page 7. 10

12 EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPCLUSA EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM EVOTAZ famciclovir oral tablet 125 mg, 250 mg famciclovir oral tablet 500 mg foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium GENVOYA HARVONI INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE 25 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine oral solution ; QLL (30 per 30 days) ; QLL (850 per 30 days) PAR; PAR; QLL (30 per 30 days) ; QLL (900 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (21 per 7 days) B/D PAR ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (28 per 28 days) ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (120 per 30 days) ; QLL (120 per 30 days) ; QLL (180 per 30 days) ; QLL (720 per 30 days) ; QLL (480 per 30 days) ; QLL (300 per 30 days) ; QLL (120 per 30 days) ; QLL (900 per 30 days) page 7. 11

13 lamivudine oral tablet 100 mg lamivudine oral tablet 150 mg lamivudine oral tablet 300 mg lamivudine-zidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY OLYSIO PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG REYATAZ ORAL CAPSULE 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (1800 per 30 days) ; QLL (120 per 30 days) ; QLL (1200 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (360 per 30 days) ; QLL (480 per 30 days) ; QLL (360 per 30 days) QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (400 per 30 days) ; QLL (180 per 30 days) ; QLL (60 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 180 days) ; QLL (180 per 30 days) ; QLL (360 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (240 per 30 days) PAR; page 7. 12

14 ribasphere oral tablet 200 mg ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SELZENTRY SOVALDI stavudine oral capsule 15 mg, 20 mg stavudine oral capsule 30 mg, 40 mg stavudine oral recon soln STRIBILD SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SYNAGIS TAMIFLU TECHNIVIE TIVICAY ORAL TABLET 10 MG, 25 MG TIVICAY ORAL TABLET 50 MG TRIUMEQ TRUVADA ORAL TABLET MG, MG, MG TRUVADA ORAL TABLET MG TYBOST TYZEKA valacyclovir valganciclovir oral tablet VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR PAR; PAR; PAR; ; QLL (120 per 30 days) PAR; ; QLL (120 per 30 days) ; QLL (60 per 30 days) ; QLL (2400 per 30 days) ; QLL (30 per 30 days) ; QLL (120 per 30 days) ; QLL (360 per 30 days) ; QLL (30 per 30 days) PAR; ; LA PAR; ; QLL (56 per 28 days) QLL (60 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 2 days) ; QLL (1200 per 30 days) ; QLL (1200 per 30 days) PAR; PAR page 7. 13

15 VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA ZEPATIER ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/ 5 ml cefaclor oral suspension for reconstitution 250 mg/ 5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 2 GRAM/50 ML cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram, 20 gram CEFAZOLIN INJECTION RECON SOLN 100 GRAM, 300 G ; QLL (300 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (240 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (960 per 30 days) ; QLL (180 per 30 days) ; QLL (1920 per 30 days) ; QLL (60 per 30 days) page 7. 14

16 cefazolin intravenous cefdinir cefepime cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram, 2 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram CEFTRIAXONE INJECTION RECON SOLN 100 GRAM ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium intravenous vial injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous vial intravenous recon soln 7.5 gram cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution cephalexin oral tablet TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln 500 mg azithromycin intravenous recon soln 500 mg (2 mg/ ml) azithromycin oral page 7. 15

17 clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr e.e.s. 400 oral tablet ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET AMIKACIN INJECTION SOLUTION 1,000 MG/ 4 ML amikacin injection solution 500 mg/2 ml atovaquone atovaquone-proguanil AZACTAM IN DEXTROSE (ISO-OSM) aztreonam baciim BILTRICIDE CAPASTAT CAYSTON chloramphenicol sod succinate chloroquine phosphate oral ; QLL (28 per 2 days) ; QLL (180 per 3 days) PAR; PAR; ; LA page 7. 16

18 clindamycin hcl clindamycin phosphate injection CLINDAMYCIN PHOSPHATE INTRAVENOUS SOLUTION 300 MG/2 ML clindamycin phosphate intravenous solution 600 mg/4 ml clindamycin phosphate intravenous solution 900 mg/6 ml colistin (colistimethate na) DAPSONE DARAPRIM ethambutol gentamicin injection GENTAMICIN SULFATE (PED) (PF) GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 100 MG/10 ML GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/ 8 ml hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION isoniazid oral ivermectin oral linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet LINEZOLID-0.9% SODIUM CHLORIDE mefloquine meropenem METRO I.V. PAR; ; QLL (1800 per 2 days) PAR; ; QLL (28 per 2 days) page 7. 17

19 metronidazole in nacl (iso-os) metronidazole oral NEBUPENT neomycin paromomycin PASER PENTAM PRIFTIN PRIMAQUINE pyrazinamide rifabutin rifampin RIFATER SIRTURO STREPTOMYCIN INTRAMUSCULAR SYNERCID tobramycin in % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR TYGACIL ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet B/D PAR; PAR; ; LA B/D PAR; ; QLL (280 per 28 days) PAR; ; QLL (1800 per 2 days) page 7. 18

20 amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate ampicillin ampicillin sodium injection ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 3 gram BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin injection nafcillin intravenous recon soln 2 gram oxacillin injection oxacillin intravenous PENICILLIN G POT IN DEXTROSE penicillin g potassium penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium piperacillin-tazobactam QUINOLONES ciprofloxacin ciprofloxacin er oral tablet, er multiphase 24 hr 1, 000 mg ciprofloxacin er oral tablet, er multiphase 24 hr 500 mg ; QLL (14 per 2 days) ; QLL (3 per 2 days) page 7. 19

21 ciprofloxacin hcl oral ciprofloxacin lactate intravenous solution 200 mg/ 20 ml ciprofloxacin lactate intravenous solution 400 mg/ 40 ml levofloxacin intravenous levofloxacin oral tablet moxifloxacin ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine oral sulfamethoxazole-trimethoprim TETRACYCLINES demeclocycline DOXY-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet doxycycline hyclate oral tablet,delayed release (dr/ ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet morgidox oral capsule 50 mg tetracycline URINARY TRACT AGENTS methenamine hippurate nitrofurantoin macrocrystal oral capsule 50 mg trimethoprim ; QLL (14 per 2 days) ; QLL (21 per 2 days) PAR; page 7. 20

22 VANCOMYCIN VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml vancomycin in dextrose 5 % intravenous piggyback 500 mg/100 ml VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 750 MG/150 ML vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg VANCOMYCIN INTRAVENOUS RECON SOLN 5 GRAM, 750 MG vancomycin oral capsule 125 mg vancomycin oral capsule 250 mg ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 250 mg dexrazoxane hcl intravenous recon soln 500 mg ELITEK FUSILEV KEPIVANCE leucovorin calcium injection recon soln 100 mg, 350 mg, 50 mg LEUCOVORIN CALCIUM INJECTION RECON SOLN 200 MG LEUCOVORIN CALCIUM INJECTION RECON SOLN 500 MG leucovorin calcium oral levoleucovorin calcium intravenous recon soln mesna PAR; ; QLL (40 per 2 days) PAR; ; QLL (80 per 2 days) PAR; PAR; page 7. 21

23 MESNEX ORAL XGEVA ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 5 MG AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG AFINITOR ORAL TABLET 5 MG AFINITOR ORAL TABLET 7.5 MG ALECENSA ALIMTA anastrozole ARRANON ARZERRA AVASTIN azacitidine azathioprine azathioprine sodium BELEODAQ BENDEKA bexarotene bicalutamide BICNU bleo 15k bleomycin BLINCYTO BOSULIF ORAL TABLET 100 MG PAR; ; QLL (1.7 per 28 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (40 per 30 days) PAR; ; QLL (30 per 30 days) PAR; PAR; PAR; B/D PAR; B/D PAR PAR; PAR; PAR; PAR; ; QLL (120 per 30 days) page 7. 22

24 BOSULIF ORAL TABLET 500 MG BUSULFEX CABOMETYX ORAL TABLET 20 MG CABOMETYX ORAL TABLET 40 MG, 60 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COTELLIC cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine CYTARABINE (PF) INJECTION SOLUTION 100 MG/5 ML (20 MG/ML) cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) CYTARABINE (PF) INJECTION SOLUTION 20 MG/ML dacarbazine DARZALEX PAR; ; QLL (30 per 30 days) PAR; LA; QLL (90 per 30 days) PAR; LA; QLL (30 per 30 days) PAR; ; LA; QLL (90 per 30 days) PAR; ; LA; QLL (30 per 30 days) B/D PAR; PAR; ; QLL (56 per 28 days) PAR; ; QLL (112 per 28 days) PAR; ; QLL (84 per 28 days) PAR; ; LA; QLL (90 per 30 days) B/D PAR; B/D PAR B/D PAR; B/D PAR; PAR; ; LA page 7. 23

25 daunorubicin intravenous solution decitabine DOCEFREZ INTRAVENOUS RECON SOLN 20 MG DOCETAXEL INTRAVENOUS SOLUTION 10 MG/ML, 160 MG/16 ML (10 MG/ML), 160 MG/ 8 ML (20 MG/ML), 20 MG/2 ML (10 MG/ML) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous solution doxorubicin, peg-liposomal DROXIA EMCYT EMPLICITI ENVARSUS XR epirubicin intravenous solution 200 mg/100 ml epirubicin intravenous solution 50 mg/25 ml ERBITUX ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln B/D PAR; B/D PAR; PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; PAR; page 7. 24

26 FLUDARABINE INTRAVENOUS SOLUTION FLUOROURACIL INTRAVENOUS SOLUTION 1 GRAM/20 ML fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide FOLOTYN GAZYVA gemcitabine intravenous recon soln 1 gram, 200 mg GEMCITABINE INTRAVENOUS RECON SOLN 2 GRAM GEMCITABINE INTRAVENOUS SOLUTION 1 GRAM/26.3 ML (38 MG/ML), 200 MG/5.26 ML (38 MG/ML) GEMCITABINE INTRAVENOUS SOLUTION 2 GRAM/52.6 ML (38 MG/ML) gengraf oral capsule 100 mg, 25 mg gengraf oral capsule 50 mg gengraf oral solution GILOTRIF GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin PAR; B/D PAR; B/D PAR B/D PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) PAR; PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) page 7. 25

27 ifosfamide intravenous recon soln IFOSFAMIDE INTRAVENOUS SOLUTION imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml IRINOTECAN INTRAVENOUS SOLUTION 500 MG/25 ML ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 15 MG JAKAFI ORAL TABLET 20 MG JAKAFI ORAL TABLET 25 MG JAKAFI ORAL TABLET 5 MG JEVTANA KADCYLA KEYTRUDA INTRAVENOUS RECON SOLN KEYTRUDA INTRAVENOUS SOLUTION LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2) LENVIMA ORAL CAPSULE 24 MG/DAY(10 MG X 2-4 MG X 1) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; PAR; ; QLL (150 per 30 days) PAR; ; QLL (100 per 30 days) PAR; ; QLL (75 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (300 per 30 days) PAR; PAR; PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) PAR; QLL (90 per 30 days) PAR; ; QLL (90 per 30 days) page 7. 26

28 LENVIMA ORAL CAPSULE 8 MG/DAY (4 MG X 2), 8 MG/DAY (4 MG X 2) (60 PACK) letrozole LEUKERAN leuprolide subcutaneous kit LONSURF LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) LYNPARZA LYSODREN MARQIBO MATULANE MEGESTROL ORAL SUSPENSION 400 MG/10 ML (10 ML), 800 MG/20 ML (20 ML) megestrol oral suspension 400 mg/10 ml (40 mg/ ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan hcl mercaptopurine methotrexate sodium methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil PAR; QLL (60 per 30 days) ; QLL (30 per 30 days) PAR; PAR; PAR; ; QLL (1 per 28 days) PAR; PAR; ; QLL (1 per 28 days) PAR; ; QLL (480 per 30 days) PAR PAR; PAR; PAR; QLL (90 per 30 days) PAR; QLL (30 per 30 days) B/D PAR; page 7. 27

29 mycophenolate sodium NEXAVAR NILANDRON nilutamide NINLARO NIPENT NULOJIX octreotide acetate injection solution OCTREOTIDE ACETATE INJECTION SYRINGE ODOMZO ONCASPAR OPDIVO oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE 2 MG POMALYST ORAL CAPSULE 3 MG, 4 MG PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 5 MG RITUXAN SIGNIFOR B/D PAR; PAR; ; LA; QLL (120 per 30 days) ; QLL (30 per 30 days) QLL (30 per 30 days) PAR; ; QLL (3 per 28 days) PAR; PAR; PAR; PAR; ; LA; QLL (30 per 30 days) PAR; PAR; PAR; PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) B/D PAR; PAR; B/D PAR; PAR; ; LA; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) PAR; ; LA; QLL (150 per 30 days) PAR; page 7. 28

30 SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG SYNRIBO TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 25 MG TARGRETIN ORAL TARGRETIN TOPICAL TASIGNA TECENTRIQ THALOMID ORAL CAPSULE 100 MG, 50 MG THALOMID ORAL CAPSULE 150 MG, 200 MG thiotepa toposar topotecan intravenous recon soln TOPOTECAN INTRAVENOUS SOLUTION B/D PAR B/D PAR; B/D PAR; PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (30 per 30 days) PAR; B/D PAR; PAR; QLL (120 per 30 days) PAR; ; LA; QLL (60 per 30 days) PAR; ; LA; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (300 per 30 days) PAR; PAR; ; QLL (120 per 30 days) LA; QLL (20 per 21 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (60 per 30 days) page 7. 29

31 TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR DEPOT TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML, 3.75 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML TRELSTAR LA tretinoin (chemotherapy) TREXALL TRISENOX TYKERB UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK vinblastine intravenous solution VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML VINCASAR PFS INTRAVENOUS SOLUTION 2 MG/2 ML vincristine vinorelbine VOTRIENT XALKORI XTANDI ; QLL (1 per 168 days) ; QLL (1 per 168 days) PAR; ; LA; QLL (180 per 30 days) PAR; PAR; PAR; LA; QLL (60 per 30 days) PAR; LA; QLL (120 per 30 days) PAR; LA; QLL (30 per 30 days) PAR; LA; QLL (42 per 365 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (120 per 30 days) page 7. 30

32 YERVOY YONDELIS ZALTRAP ZANOSAR ZELBORAF ZOLINZA ZORTRESS ZYDELIG ZYKADIA ZYTIGA AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 75 MG BRIVIACT ORAL TABLET 25 MG BRIVIACT ORAL TABLET 50 MG carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral suspension 200 mg/10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 100 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg PAR; PAR; PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) B/D PAR; PAR; ; QLL (60 per 30 days) PAR; ; QLL (150 per 30 days) PAR; ; QLL (120 per 30 days) ST; PAR; ; QLL (2400 per 30 days) PAR; ; QLL (480 per 30 days) PAR; ; QLL (240 per 30 days) PAR PAR; QLL (600 per 30 days) PAR; QLL (600 per 30 days) PAR; QLL (60 per 30 days) PAR; QLL (240 per 30 days) PAR; QLL (120 per 30 days) page 7. 31

33 carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg clonazepam oral tablet 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating mg clonazepam oral tablet,disintegrating 0.25 mg clonazepam oral tablet,disintegrating 0.5 mg clonazepam oral tablet,disintegrating 1 mg clonazepam oral tablet,disintegrating 2 mg diazepam rectal kit mg diazepam rectal kit 2.5 mg, mg DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 MG DILANTIN INFATABS divalproex epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ethosuximide felbamate fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 12 MG FYCOMPA ORAL TABLET 2 MG FYCOMPA ORAL TABLET 4 MG PAR; ; QLL (1200 per 30 days) PAR; ; QLL (600 per 30 days) PAR; ; QLL (300 per 30 days) PAR; ; QLL (4800 per 30 days) PAR; ; QLL (2400 per 30 days) PAR; ; QLL (1200 per 30 days) PAR; ; QLL (600 per 30 days) PAR; ; QLL (300 per 30 days) ; QLL (2 per 2 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (180 per 30 days) QLL (720 per 30 days) ; QLL (30 per 30 days) ; QLL (180 per 30 days) ; QLL (90 per 30 days) page 7. 32

34 FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml GABAPENTIN ORAL SOLUTION 250 MG/5 ML (5 ML), 300 MG/6 ML (6 ML) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml levetiracetam intravenous levetiracetam oral solution 100 mg/ml LEVETIRACETAM ORAL SOLUTION 500 MG/ 5 ML (5 ML) levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 150 MG LYRICA ORAL CAPSULE 200 MG LYRICA ORAL CAPSULE 225 MG, 300 MG LYRICA ORAL CAPSULE 25 MG LYRICA ORAL CAPSULE 50 MG ; QLL (60 per 30 days) ; QLL (45 per 30 days) ; QLL (1080 per 30 days) ; QLL (360 per 30 days) ; QLL (270 per 30 days) ; QLL (2160 per 30 days) QLL (2160 per 30 days) ; QLL (180 per 30 days) ; QLL (135 per 30 days) ; QLL (180 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (180 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (90 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (720 per 30 days) PAR; ; QLL (360 per 30 days) page 7. 33

35 LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG oxcarbazepine OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG PEGANONE phenobarbital oral elixir phenobarbital oral tablet 100 mg phenobarbital oral tablet 15 mg phenobarbital oral tablet 16.2 mg phenobarbital oral tablet 30 mg phenobarbital oral tablet 32.4 mg phenobarbital oral tablet 60 mg phenobarbital oral tablet 64.8 mg phenobarbital oral tablet 97.2 mg PHENYTEK PHENYTOIN ORAL SUSPENSION 100 MG/4 ML phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution phenytoin sodium intravenous syringe PAR; ; QLL (240 per 30 days) PAR; ; QLL (900 per 30 days) PAR; ; QLL (480 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (60 per 30 days) ; QLL (480 per 30 days) ; QLL (240 per 30 days) ; QLL (120 per 30 days) PAR; ; QLL (3000 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; QLL (800 per 30 days) PAR; ; QLL (741 per 30 days) PAR; ; QLL (400 per 30 days) PAR; ; QLL (370 per 30 days) PAR; ; QLL (200 per 30 days) PAR; ; QLL (185 per 30 days) PAR; ; QLL (123 per 30 days) page 7. 34

36 POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG POTIGA ORAL TABLET 50 MG primidone roweepra SABRIL SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 250 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG tiagabine topiramate oral capsule, sprinkle topiramate oral tablet 100 mg topiramate oral tablet 200 mg topiramate oral tablet 25 mg topiramate oral tablet 50 mg valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/ 5 ml VALPROIC ACID (AS SODIUM SALT) ORAL SOLUTION 250 MG/5 ML (5 ML), 500 MG/10 ML (10 ML) VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 100 MG VIMPAT ORAL TABLET 150 MG VIMPAT ORAL TABLET 200 MG VIMPAT ORAL TABLET 50 MG zonisamide ANTIPARKINSONISM AGENTS APOKYN ; QLL (90 per 30 days) ; QLL (270 per 30 days) PAR; ; LA; QLL (180 per 30 days) PAR; QLL (60 per 30 days) PAR; QLL (120 per 30 days) PAR; PAR; ; QLL (480 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (1920 per 30 days) PAR; ; QLL (960 per 30 days) QLL (1200 per 30 days) ; QLL (1200 per 30 days) ; QLL (120 per 30 days) ; QLL (80 per 30 days) ; QLL (60 per 30 days) ; QLL (240 per 30 days) PAR; ; LA page 7. 35

37 AZILECT benztropine oral bromocriptine carbidopa-levodopa entacapone NEUPRO pramipexole oral tablet ropinirole oral tablet selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine injection ERGOMAR rizatriptan sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution SUMATRIPTAN SUCCINATE SUBCUTANEOUS SYRINGE 6 MG/0.5 ML zolmitriptan ZOMIG NASAL MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML donepezil oral tablet 10 mg, 5 mg donepezil oral tablet,disintegrating galantamine oral capsule,ext rel. pellets 24 hr PAR; PAR; ; QLL (30 per 30 days) PAR; ; QLL (12 per 30 days) ; QLL (9 per 30 days) ; QLL (4 per 30 days) ; QLL (4 per 30 days) ; QLL (4 per 30 days) QLL (4 per 30 days) ; QLL (9 per 30 days) ; QLL (6 per 30 days) PAR; ; LA; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (12 per 28 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) ; QLL (30 per 30 days) page 7. 36

38 galantamine oral solution galantamine oral tablet GILENYA GLATOPA memantine oral solution memantine oral tablet 10 mg memantine oral tablet 5 mg NAMENDA ORAL SOLUTION NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE, ER 24HR NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR MG, MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR MG, 7-10 MG NUEDEXTA rivastigmine rivastigmine tartrate TECFIDERA tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg TYSABRI XENAZINE ORAL TABLET 12.5 MG XENAZINE ORAL TABLET 25 MG MUSCLE RELAXANTS / ANTISPASDIC THERAPY baclofen cyclobenzaprine oral tablet dantrolene MESTINON ORAL SYRUP MESTINON TIMESPAN ; QLL (180 per 30 days) ; QLL (60 per 30 days) PAR; ; QLL (30 per 30 days) PAR; ; QLL (30 per 30 days) ; QLL (300 per 30 days) ; QLL (60 per 30 days) ; QLL (90 per 30 days) ; QLL (300 per 30 days) ; QLL (56 per 365 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) ; QLL (30 per 30 days) ; QLL (60 per 30 days) PAR; PAR; ; QLL (240 per 30 days) PAR; ; QLL (120 per 30 days) PAR; ; LA PAR; ; LA; QLL (240 per 30 days) PAR; ; LA; QLL (120 per 30 days) PAR; page 7. 37

39 pyridostigmine bromide tizanidine oral tablet NARCOTIC ANALGESICS acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral solution mg/5 ml ACETAMINOPHEN-CODEINE ORAL SOLUTION 240 MG-24 MG /10 ML (10 ML) acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg BUTALBITAL COMPOUND W/CODEINE duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet mg, mg, mg fentanyl citrate fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr HYDROCODONE-ACETAMINOPHEN ORAL SOLUTION MG/5 ML hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg QLL (4500 per 30 days) ; QLL (4500 per 30 days) QLL (4500 per 30 days) ; QLL (390 per 30 days) ; QLL (360 per 30 days) ; QLL (180 per 30 days) ; QLL (150 per 30 days) QLL (150 per 30 days) PAR; ; QLL (240 per 30 days) PAR; ; QLL (60 per 30 days) PAR; ; QLL (180 per 30 days) ; QLL (180 per 30 days) QLL (180 per 30 days) ; QLL (360 per 30 days) PAR; ; QLL (120 per 30 days) ST; ; QLL (15 per 30 days) QLL (2700 per 30 days) ; QLL (2700 per 30 days) ; QLL (390 per 30 days) ; QLL (360 per 30 days) page 7. 38

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