Formulario 2017 (Lista de medicamentos cubiertos)

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1 ATRIO Special Needs Plan (HMO SNP) ATRIO Special Needs Plan (Rogue) (HMO SNP) ATRIO Special Needs Plan (Willamette) (HMO SNP) Formulario 207 (Lista de medicamentos cubiertos) POR FAVOR LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN Archivo 7043 del Formulario aprobado del HPMS, versión número 9 Este formulario fue actualizado el 2/0/207. Para obtener información actualizada o si tiene preguntas, contacte a ATRIO Health Plans llamando al o para usuarios de TTY, al , todos los días de 8:00 a.m. a 8:00 p.m., o visite el sitio web atriohp.com/medicare. El formulario puede cambiar en cualquier momento. Recibirá un aviso cuando corresponda. Código de identificación del Formulario: 7043, Versión: 9 Y0084_PHARM_SNPCF_207s Accepted Fecha de entrada en vigencia: 2/0/207 Fecha de entrada en vigencia: 2/0/207

2 Aviso para los miembros existentes: Este formulario ha cambiado desde el año pasado. Por favor revise este documento para asegurarse de que todavía contiene los medicamentos que usted toma. Cuando en esta lista de medicamentos (Formulario) se mencione "nosotros" o "nuestro", estos términos hacen referencia a los planes de salud de ATRIO Health Plans. Cuando se mencione "nosotros" o "nuestro", estos términos hacen referencia a ATRIO Special Needs Plan (HMO SNP), ATRIO Special Needs Plan (Rogue) (HMO SNP), o ATRIO Special Needs Plan (Willamette) (HMO SNP). Este documento incluye una lista de los medicamentos (formulario) de nuestro plan que está en vigencia desde el 2/0/207. Contáctenos si desea solicitar un formulario actualizado. Nuestra información de contacto, así como la fecha en que se actualizó el formulario por última vez, figura en la portada y en la contratapa. Para tener acceso al beneficio de medicamentos recetados, en general, debe utilizar las farmacias de la red. Los beneficios, formulario, red de farmacias y/o copagos/coseguros pueden cambiar el º de enero de 208, y de vez en cuando durante el año. Qué es el Formulario de ATRIO Health Plans? Un formulario es una lista de medicamentos cubiertos seleccionados por ATRIO Health Plans en consulta con un equipo de proveedores de atención médica, el cual representa las terapias prescriptas que se creen son una parte necesaria de un programa de tratamiento de calidad. ATRIO Health Plans generalmente cubrirá los medicamentos que se listan en nuestro formulario siempre que el medicamento sea necesario a nivel médico, la receta sea surtida en una farmacia de la red ATRIO Health Plans y se sigan otras reglas del plan. Para más información sobre cómo surtir sus recetas, por favor revise la Evidencia de cobertura. Puede modificarse este Formulario (Lista de medicamentos)? Generalmente, si usted está tomando un medicamento de nuestro formulario 207 que fue cubierto al comienzo del año, no discontinuaremos ni reduciremos la cobertura de este medicamento durante el año de cobertura 207, excepto si un medicamento genérico nuevo y más económico se encuentra disponible o si existe información nueva adversa sobre la seguridad o eficacia de un medicamento. Otro tipo de cambios en el formulario, tales como la eliminación de un medicamento del formulario, no afectarán a los miembros que actualmente se encuentran tomando el medicamento. Permanecerá disponible al mismo costo compartido para aquellos miembros que estén tomando el medicamento durante el resto del año de cobertura. Creemos que es importante que tenga acceso continuo durante el resto del año de cobertura a los medicamentos del formulario que se encontraban disponibles cuando eligió nuestro plan, excepto en casos en los cuales usted puede ahorrar dinero adicional o podemos garantizarle su seguridad. Si quitamos medicamentos de nuestro formulario, o si agregamos requisitos de autorización previa, límites de cantidad o restricciones de terapia escalonada para un medicamento, debemos notificar el cambio a los miembros afectados por lo menos 60 días antes de la fecha en que el cambio entre en vigencia, o en el momento en que el miembro haga una solicitud para volver a surtir la receta del medicamento (en este último caso, recibirá un suministro del medicamento para 60 días). Si la Administración de Alimentos y Medicamentos (FDA) de los EE.UU. determina que un medicamento de nuestro formulario no es seguro o si el fabricante del medicamento lo retira del mercado, eliminaremos inmediatamente el medicamento de nuestro formulario y se lo notificaremos a los miembros que toman el medicamento. El formulario adjunto está en vigencia desde el 2/0/207. Contáctenos para obtener información actualizada sobre los medicamentos cubiertos por ATRIO Health Plans. Nuestra información de contacto figura en la portada y en la contratapa. ATRIO Health Plans notificará a sus miembros si se quitan medicamentos del formulario o si se agregan requisitos de autorización previa, límites de cantidad o restricciones de terapia escalonada para un medicamento. La notificación de estos cambios se realizará de diversas formas. Su Explicación de beneficios (EOB) mensual, que le brinda un informe de todos los medicamentos comprados durante el mes anterior, ii

3 incluirá un anexo enumerando todos los cambios en el formulario que tendrán efecto a los 60 días de la fecha de la notificación. Además, encontrará este adjunto publicado en atriohp.com/medicare o puede solicitarlo al , todos los días, de 8:00 a.m. a 8:00 p.m. Los usuarios de TTY/TDD deben llamar al Por último, la versión más actual del formulario incluyendo todos los cambios, estará disponible en atriohp.com/medicare o puede solicitarlo al , todos los días de 8:00 a.m. a 8:00 p.m. Los usuarios de TTY/TDD deben llamar al Cómo utilizo el formulario? Existen dos formas de encontrar su medicamento en el formulario: Enfermedad El formulario comienza en la página. En este formulario, los medicamentos están agrupados en categorías según el tipo de enfermedades para las que se utilizan. Por ejemplo, los medicamentos utilizados para tratar una enfermedad cardíaca se enumeran bajo la categoría "Agentes cardiovasculares". Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página. Luego, busque el medicamento dentro de esa categoría. Lista en orden alfabético Si no sabe en qué categoría buscar, busque el medicamento en el Índice que comienza en la página I-. El Índice proporciona una lista en orden alfabético de todos los medicamentos incluidos en este documento. En el Índice se enumeran tanto los medicamentos de marca como los genéricos. Busque en el Índice para encontrar su medicamento. Junto al nombre del medicamento, verá el número de página en la que podrá encontrar información sobre la cobertura. Diríjase a la página que se indica en el Índice y busque el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? ATRIO Health Plans cubre tanto medicamentos de marca como genéricos. Un medicamento genérico está aprobado por el FDA por tener los mismos ingredientes activos que un medicamento de marca. En general, los medicamentos genéricos cuestan menos que los medicamentos de marca. Existen restricciones en mi cobertura? Es posible que algunos medicamentos cubiertos posean requisitos adicionales o límites en la cobertura. Estos requisitos y límites pueden incluir: Autorización previa (PA): ATRIO Health Plans requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que deberá obtener aprobación de ATRIO Health Plans antes de poder surtir sus recetas. Si no obtiene aprobación, ATRIO Health Plans podría no cubrir el medicamento. Límites de cantidad (QL): Para ciertos medicamentos ATRIO Health Plans limita la cantidad de ese medicamento que el plan cubrirá. Por ejemplo, ATRIO Health Plans provee 30 comprimidos por receta para simvastatina. Esto además del suministro estándar de uno o tres meses. Terapia escalonada (ST): En algunos casos, ATRIO Health Plans requiere que pruebe utilizar primero ciertos medicamentos para tratar su enfermedad antes de cubrir otro medicamento para dicha enfermedad. Por ejemplo, si tanto el Medicamento A como el Medicamento B se utilizan para tratar su enfermedad, ATRIO Health Plans podría no cubrir el Medicamento B a menos que pruebe primero con iii

4 el Medicamento A. Si el Medicamento A no funciona para usted, entonces ATRIO Health Plans cubrirá el Medicamento B. Para saber si su medicamento tiene algún requisito o límite adicional, consulte el Formulario que comienza en la página. También puede obtener más información sobre las restricciones aplicadas a determinados medicamentos cubiertos visitando nuestro sitio web. Hemos publicado documentos en línea que explican nuestra autorización previa y las restricciones de la terapia escalonada. También puede solicitar que le enviemos una copia. Nuestra información de contacto, así como la fecha en que se actualizó el formulario por última vez, figura en la portada y en la contratapa. Puede solicitarle a ATRIO Health Plans que haga una excepción a estas restricciones o a los límites o solicitar un lista de otros medicamentos similares que pueden utilizarse en el tratamiento de su afección. Consulte la sección, Cómo solicito una excepción al formulario de ATRIO Health Plans? en la página iv para obtener información sobre cómo solicitar una excepción. Qué son los medicamentos de venta libre (OTC)? Los medicamentos de venta libre (OTC, por sus siglas en inglés) son medicamentos sin receta que normalmente no están cubiertos en un plan de medicamentos recetados de Medicare. Los planes de salud ATRIO pagan por determinados medicamentos de venta libre. ATRIO Health Plans le proporcionarán estos medicamentos de venta libre sin costo. El costo para ATRIO Health Plans de estos medicamentos de venta libre no se tendrá en cuenta para sus costos totales de los medicamentos de la Parte D (esto es, el importe que usted paga no se tiene en cuenta para la brecha de cobertura). MEDICAMENTOS DE VENTA LIBRE CUBIERTOS Nombre del genérico (Marca de referencia) Presentación clorhidrato de cetirizina Clorhidrato de cetirizina/pseudoefedrina hidrocloruro (Zyrtec) (Zyrtec-D) Comprimidos masticables, solución, comprimidos Comprimidos de 2 horas loratadina (Claritin) Solución, comprimidos loratadina/pseudoefedrina sulfato (Claritin-D) Comprimidos de 2 horas Comprimidos de 24 horas ketotifeno fumarato (Zaditor) Gotas Qué sucede si mi medicamento no se encuentra en el formulario? Si su medicamento no se encuentra en este formulario (lista de medicamentos cubiertos), primero debe contactarse con el Servicio de atención al cliente y preguntar si su medicamento está cubierto. En caso de que ATRIO Health Plans no cubra su medicamento, tiene dos opciones: Puede solicitar al Servicio de atención al cliente que le envíen una lista de medicamentos similares que cubre ATRIO Health Plans. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar cubierto por ATRIO Health Plans. También puede solicitarle a ATRIO Health Plans que haga una excepción y cubra su medicamento. Vea a continuación la información sobre cómo solicitar una excepción. iv

5 Cómo solicito una excepción al formulario de ATRIO Health Plans? Puede solicitarle a ATRIO Health Plans que haga una excepción con respecto a nuestras reglas de cobertura. Hay varios tipos de excepciones que puede pedirnos que hagamos. Puede solicitarnos que cubramos un medicamento, aunque no esté incluido en nuestro formulario. Si se aprueba, este medicamento estará cubierto en un nivel de costo compartido predeterminado y usted no podrá pedirnos que le suministremos el medicamento en un nivel de costo compartido menor. Puede solicitarnos que no apliquemos las restricciones o los límites de cobertura a su medicamento. Por ejemplo, para ciertos medicamentos ATRIO Health Plans limita la cantidad de ese medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede solicitarnos que no apliquemos ese límite y cubramos una cantidad mayor. Generalmente, ATRIO Health Plans aprobará su solicitud de una excepción únicamente si los medicamentos alternativos figuran en el Formulario del plan, el medicamento de nivel de costo compartido inferior o las restricciones adicionales de uso no son tan efectivas para tratar su enfermedad y/o si le provocan efectos médicos adversos. Debe contactarnos para solicitarnos una decisión de cobertura inicial de formulario o de excepción de restricción de uso. Cuando solicita una excepción de formulario o de restricción de uso, deberá enviar una declaración de su médico o persona que le prescribe que justifique su solicitud. Generalmente, tomamos una decisión dentro de las 72 horas de haber recibido la justificación médica. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que su salud podría verse seriamente afectada si debe esperar por la decisión hasta 72 horas. Si se decide tomar una decisión acelerada, debemos informarle la decisión dentro de las 24 horas de haber recibido la justificación médica. Qué hago antes de hablar con mi médico sobre el cambio de medicamento o la solicitud de excepción? Como miembro nuevo o ya existente de nuestro plan, es posible que esté tomando medicamentos que no estén en nuestro formulario, o puede estar tomando un medicamento que esté en nuestro formulario pero su posibilidad de adquirirlo esté limitada. Por ejemplo, es posible que necesite nuestra autorización previa antes de surtir su receta. Debe hablar con su médico para decidir si debe cambiar a un medicamento que sí cubramos o solicitar una excepción al formulario para poder obtener cobertura para el medicamento. Mientras habla con su médico para determinar qué acción tomar, es posible que cubramos el medicamento en ciertos casos durante sus primeros 90 días como miembro de nuestro plan. Para cada uno de sus medicamentos que no se encuentre en el formulario o si posee un límite para obtenerlos, cubriremos un suministro provisorio de 30 días (a menos que tenga una receta para un período de tiempo menor) cuando vaya a una farmacia de la red. Luego del primer suministro de 30 días, no cubriremos más estos medicamentos, aún si ha sido miembro del plan por menos de 30 días. Si usted es residente de un centro de atención prolongada, le permitiremos surtir la receta hasta que le hayamos proporcionado un suministro de transición de 93 días, de acuerdo con el incremento de dispensado (a menos que tenga una receta escrita para menos días). Cubriremos más de una receta para estos medicamentos durante los primeros 90 días como miembro nuevo de nuestro plan. Si usted necesita un medicamento que no se encuentra en nuestro formulario o si posee un límite para obtenerlos y ya han pasado los primeros 90 días desde que se hizo miembro de nuestro plan, cubriremos un suministro de emergencia de 3 días (a menos que posea una receta para un período de tiempo menor) mientras solicita una excepción del formulario. Si lo admiten o le dan de alta de un centro, cubriremos los primeros reabastecimientos de los medicamentos v

6 cubiertos anteriormente según sea necesario al momento de la admisión o el alta del centro. Para más información Para obtener información detallada sobre la cobertura de medicamentos recetados de ATRIO Health Plans, por favor revise la Evidencia de cobertura y otros documentos del plan. Contáctenos si tiene preguntas sobre ATRIO Health Plans. Nuestra información de contacto, así como la fecha en que se actualizó el formulario por última vez, figura en la portada y en la contratapa. Si tiene consultas generales sobre la cobertura de medicamentos de Medicare, por favor comuníquese con Medicare en el -800-MEDICARE ( ) durante las 24 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al O, visitar Formulario de ATRIO Health Plans El formulario de abajo brinda información de cobertura sobre los medicamentos cubiertos por ATRIO Health Plans. Si tiene inconvenientes para encontrar su medicamento, consulte el Índice que comienza en la página I-. La primera columna muestra el nombre del medicamento. Los medicamentos de marca aparecen en mayúscula (por ejemplo: CRESTOR) y los medicamentos genéricos se enumeran en minúscula (por ejemplo: rosuvastatina). Los datos en la columna Requisitos/Límites le informan si ATRIO Health Plans posee algún requerimiento especial para la cobertura del medicamento. NIVELES DE COSTO COMPARTIDO Plan ATRIO Special Needs Plan (HMO SNP) ATRIO Special Needs Plan (Rogue) (HMO SNP) ATRIO Special Needs Plan (Willamette) (HMO SNP) Nombre del nivel del medicam Medicame ntos cubiertos Venta minorista Copago/ (suministro por mes) $ 0 / $.20 / $ 3.30 o $ 0 / 3.70 / $ 8.25 o 25% Según el tipo de medicamento y el nivel de subsidio por bajos ingresos Pedido por correo Copago/ (suministro por 3 mes) $ 0 / $.20 / $ 3.30 o $ 0 / 3.60 / $ 8.25 o 25% Según el tipo de medicamento y el nivel de subsidio por bajos ingresos Vacunas $ 0 $ 0 vi

7 Las siguientes abreviaturas de las Restricciones en la Administración de Uso pueden encontrarse en el cuerpo de este documento. ABREVIATURAS DE COMENTARIOS DE COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN PA PA BvD PA-HRM PA NSO QL ST Restricción de autorización previa Restricción de autorización previa para la Determinación de la Parte D vs Parte B Restricción de autorización previa para Medicamentos de alto riesgo Restricción de autorización previa para Nuevas tomas solamente Restricción de Límite de Cantidad Restricción de terapia escalonada Usted (o su médico) debe solicitar autorización previa de ATRIO Health Plans antes de surtir su receta para este medicamento. Sin la aprobación, es posible que ATRIO Health Plans no cubra este medicamento. Este medicamento puede ser elegible para pago dentro de Medicare Parte B o Parte D. Usted (o su médico) debe solicitar autorización previa de ATRIO Health Plans para determinar si este medicamento está cubierto por Medicare Parte D antes de surtir su receta para este medicamento. Sin la aprobación, es posible que ATRIO Health Plans no cubra este medicamento. Este medicamento es considerado potencialmente riesgoso por los CMS y por lo tanto, un Medicamento de alto riesgo para los beneficiarios de 65 años de edad en adelante. Los beneficiarios de 65 años o más deben solicitar autorización previa de ATRIO Health Plans antes de surtir su receta para este medicamento. Sin la aprobación, es posible que ATRIO Health Plans no cubra este medicamento. Si es un miembro nuevo o si no ha tomado este medicamento previamente, usted (o su médico) debe obtener autorización previa de ATRIO Health Plans antes de surtir su receta por este medicamento. Sin la aprobación, es posible que ATRIO Health Plans no cubra este medicamento. ATRIO Health Plans limita la cantidad de este medicamento que está cubierto por receta, o dentro de un plazo de tiempo específico. Antes que ATRIO Health Plans le brinde cobertura por este medicamento, debe primero probar otro(s) medicamento(s) para tratar su afección médica. Este medicamento puede estar únicamente cubierto si otro(s) medicamento(s) no funcionan en su caso. vii

8 OTROS REQUISITOS ESPECIALES PARA LA COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN LA NDS Medicamento de Acceso Limitado Días de suministro no extendido Esta receta puede estar disponible solo en algunas farmacias. Para más información, consulte el Directorio de farmacias o llame al Servicio de atención al cliente al , todos los días, de 8:00 a.m. a 8:00 p.m. Los usuarios de TTY/TDD deben llamar al Este medicamento no está disponible para un suministro de 90 días. viii

9 Table of Contents Analgesics...3 Anesthetics... 9 Anti-Addiction/Substance Abuse Treatment Agents... 0 Antianxiety Agents... Antibacterials... 2 Anticancer Agents... 2 Anticholinergic Agents Anticonvulsants...30 Antidementia Agents...34 Antidepressants Antidiabetic Agents Antifungals...4 Antigout Agents Antihistamines...43 Anti-Infectives (Skin And Mucous Membrane)...43 Antimigraine Agents...43 Antimycobacterials...44 Antinausea Agents...45 Antiparasite Agents...46 Antiparkinsonian Agents...47 Antipsychotic Agents...48 Antivirals (Systemic)...52 Blood Products/Modifiers/Volume Expanders Caloric Agents...6 Cardiovascular Agents Central Nervous System Agents Contraceptives...80 Dental And Oral Agents...87 Dermatological Agents...87 Devices Enzyme Replacement/Modifiers...93 Eye, Ear, Nose, Throat Agents...94 Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying...04

10 Immunological Agents...0 Inflammatory Bowel Disease Agents... 9 Irrigating Solutions...9 Metabolic Bone Disease Agents...20 Miscellaneous Therapeutic Agents...2 Ophthalmic Agents...23 Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents...34 Vitamins And Minerals

11 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 20-2 /5 ml, /5 ml (5 ml) acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule BELBUCA BUCCAL FILM 50 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml buprenorphine transdermal patch weekly 0 mcg/hour, 5 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule , butalbital-acetaminophen oral tablet butalbital-acetaminophen-caff oral capsule QL (2700 per 30 days) QL (360 per 30 days) (Tylenol-Codeine #3) QL (360 per 30 days) (Tylenol-Codeine #4) QL (80 per 30 days) (Buprenex) PA-HRM; QL (360 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) QL (60 per 30 days) (Butrans) QL (4 per 28 days) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) (Marten-Tab) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) (Zebutal) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) 3

12 butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet (Esgic) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) (Fiorinal) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) QL (4 per 28 days) BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HOUR capacet oral capsule PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) codeine sulfate oral tablet 5, 30, QL (80 per 30 days) 60 endocet oral tablet QL (240 per 30 days) endocet oral tablet , QL (360 per 30 days) endocet oral tablet QL (300 per 30 days) endodan oral tablet QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle,200 mcg,,600 mcg, 200 mcg, (Actiq) PA; NDS; QL (20 per 30 days) 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 (Duragesic) QL (0 per 30 days) mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hour 37.5 QL (0 per 30 days) mcg/hour fentanyl transdermal patch 72 hour 62.5 mcg/hour, 87.5 mcg/hour NDS; QL (0 per 30 days) hydrocodone-acetaminophen oral solution QL (2700 per 30 days) /5 ml, 5-63 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) QL (2700 per 30 days) /5 ml hydrocodone-acetaminophen oral tablet (Xodol 0/300) QL (390 per 30 days) hydrocodone-acetaminophen oral tablet (Norco) QL (360 per 30 days) 0-325, hydrocodone-acetaminophen oral tablet (Verdrocet) QL (360 per 30 days) 4

13 hydrocodone-acetaminophen oral tablet (Xodol 5/300) QL (390 per 30 days) hydrocodone-acetaminophen oral tablet (Xodol 7.5/300) QL (390 per 30 days) hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (360 per 30 days) hydrocodone-ibuprofen oral tablet (Xylon 0) QL (50 per 30 days) hydrocodone-ibuprofen oral tablet (Ibudone) QL (50 per 30 days) hydrocodone-ibuprofen oral tablet 7.5- QL (50 per 30 days) 200 hydromorphone (pf) injection solution 0 (/ml) (5 ml) hydromorphone (pf) injection solution 0 /ml hydromorphone 0 /ml vial p/f,sdv,latex-f 0 /ml hydromorphone injection solution 2 /ml, 4 /ml hydromorphone injection syringe 2 (Dilaudid) /ml, 4 /ml hydromorphone oral liquid /ml (Dilaudid) QL (200 per 30 days) hydromorphone oral tablet 2, 4, 8 (Dilaudid) QL (80 per 30 days) HYSINGLA ER ORAL QL (30 per 30 days) TABLET,ORAL ONLY,EXT.REL.24 HR 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 300 PA; NDS; QL (30 per 30 days) MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet QL (360 per 30 days) lorcet hd oral tablet QL (360 per 30 days) lorcet plus oral tablet QL (360 per 30 days) margesic oral capsule PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) methadone injection solution 0 /ml 5

14 methadone oral solution 0 /5 ml, 5 QL (800 per 30 days) /5 ml methadone oral tablet 0 (Dolophine) QL (360 per 30 days) methadone oral tablet 5 (Dolophine) QL (80 per 30 days) methadose oral tablet,soluble 40 QL (90 per 30 days) morphine 0 /ml carpuject outer, p/f, l/f, suv 0 /ml morphine 2 /ml carpuject outer, l/f, p/f, sdv 2 /ml morphine 4 /ml syringe p/f, latexfree,suv 4 /ml morphine 8 /ml syringe 8 /ml morphine concentrate oral solution 00 QL (80 per 30 days) /5 ml (20 /ml) morphine intramuscular pen injector 0 /0.7 ml morphine intravenous cartridge 5 /ml morphine intravenous syringe 0 /ml, 2 /ml, 4 /ml, 8 /ml morphine oral solution 0 /5 ml QL (700 per 30 days) morphine oral solution 20 /5 ml (4 QL (300 per 30 days) /ml) MORPHINE ORAL TABLET 5 MG QL (80 per 30 days) MORPHINE ORAL TABLET 30 MG QL (20 per 30 days) morphine oral tablet extended release 00 (MS Contin) QL (60 per 30 days), 200, 60 morphine oral tablet extended release 5 (MS Contin) QL (80 per 30 days) morphine oral tablet extended release 30 (MS Contin) QL (20 per 30 days) NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 2 HR 00 MG, 50 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 00 MG, QL (8 per 30 days) 50 MG, 75 MG oxycodone oral concentrate 20 /ml QL (20 per 30 days) oxycodone oral solution 5 /5 ml QL (300 per 30 days) oxycodone oral tablet 0 QL (80 per 30 days) oxycodone oral tablet 5, 30 (Roxicodone) QL (20 per 30 days) 6

15 oxycodone oral tablet 20 QL (20 per 30 days) oxycodone oral tablet 5 (Roxicodone) QL (80 per 30 days) oxycodone oral tablet,oral only,ext.rel.2 (OxyContin) QL (60 per 30 days) hr 0, 5, 20, 30, 40, 60 oxycodone oral tablet,oral only,ext.rel.2 hr 80 (OxyContin) NDS; QL (20 per 30 days) oxycodone-acetaminophen oral solution QL (800 per 30 days) /5 ml oxycodone-acetaminophen oral tablet 0- (Endocet) QL (240 per 30 days) 325 oxycodone-acetaminophen oral tablet (Endocet) QL (360 per 30 days) , oxycodone-acetaminophen oral tablet (Percocet) QL (300 per 30 days) oxycodone-aspirin oral tablet QL (360 per 30 days) OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (20 per 30 days) TABLET,ORAL ONLY,EXT.REL.2 HR 80 MG oxymorphone oral tablet 0 (Opana) QL (20 per 30 days) oxymorphone oral tablet 5 (Opana) QL (80 per 30 days) oxymorphone oral tablet extended release QL (60 per 30 days) 2 hr 0, 5, 20, 30, 40, 5, 7.5 reprexain oral tablet 0-200, QL (50 per 30 days), tencon oral tablet PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) tramadol oral tablet 50 (Ultram) QL (240 per 30 days) tramadol-acetaminophen oral tablet (Ultracet) QL (240 per 30 days) 325 vicodin es oral tablet QL (390 per 30 days) vicodin hp oral tablet QL (390 per 30 days) vicodin oral tablet QL (390 per 30 days) 7

16 XTAMPZA ER ORAL QL (60 per 30 days) CAPSULE,SPRINKLE,ER 2HR TMPRR 3.5 MG, 8 MG, 9 MG XTAMPZA ER ORAL QL (20 per 30 days) CAPSULE,SPRINKLE,ER 2HR TMPRR 27 MG XTAMPZA ER ORAL QL (240 per 30 days) CAPSULE,SPRINKLE,ER 2HR TMPRR 36 MG xylon 0 oral tablet QL (50 per 30 days) zebutal oral capsule PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (00 MG/ML), 800 MG/8 ML (00 MG/ML) celecoxib oral capsule 00, 200, (Celebrex) QL (60 per 30 days) 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 25, 50, 75 diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 etodolac oral capsule 200, 300 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release 24 hr 400, 500, 600 fenoprofen oral tablet 600 FLECTOR TRANSDERMAL PA PATCH 2 HOUR.3 % flurbiprofen oral tablet 00, 50 8

17 ibuprofen oral suspension 00 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 25 QL (240 per 30 days) indomethacin oral capsule 50 QL (20 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) release 75 indomethacin sodium intravenous recon soln ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets 24 hr 200 ketorolac oral tablet 0 QL (20 per 30 days) mefenamic acid oral capsule 250 (Ponstel) meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral suspension 25 /5 ml (Naprosyn) naproxen oral tablet 250, 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375, 500 naproxen sodium oral tablet 275 naproxen sodium oral tablet 550 (Anaprox DS) piroxicam oral capsule 0, 20 (Feldene) sulindac oral tablet 50, 200 tolmetin oral capsule 400 tolmetin oral tablet 200, 600 VOLTAREN TOPICAL GEL % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % lidocaine (pf) injection solution 0 /ml (Xylocaine-MPF) ( %), 5 /ml (.5 %), 20 /ml (2 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine (pf) injection solution 5 /ml (0.5 %) (Xylocaine-MPF) 9

18 lidocaine hcl 2% vial inner,ltx-fr,p/f,sdv (Xylocaine-MPF) 20 /ml (2 %) lidocaine hcl injection solution 0 /ml (Xylocaine) ( %), 20 /ml (2 %), 5 /ml (0.5 %) lidocaine hcl injection syringe 0 /ml ( %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine hcl(pf) in 0.9% nacl injection syringe 00 /0 ml ( %) lidocaine topical adhesive (Lidoderm) PA patch,medicated 5 % lidocaine topical ointment 5 % PA NSO; QL (90 per 30 days) lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 BUNAVAIL BUCCAL FILM QL (30 per 30 days) MG BUNAVAIL BUCCAL FILM QL (60 per 30 days) MG, 6.3- MG buprenorphine hcl sublingual tablet 2, 8 PA; QL (90 per 30 days) buprenorphine-naloxone sublingual tablet QL (90 per 30 days) 2-0.5, 8-2 buproban oral tablet extended release 2 hr 50 bupropion hcl (smoking deter) oral tablet (Zyban) extended release 2 hr 50 CHANTIX CONTINUING MONTH QL (68 per 84 days) BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG QL (68 per 84 days) 0

19 CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) QL (53 per 28 days) disulfiram oral tablet 250, 500 (Antabuse) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 (Revia) NARCAN NASAL SPRAY,NON- QL (4 per 30 days) AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION QL (008 per 90 days) CARTRIDGE 0 MG SUBOXONE SUBLINGUAL FILM QL (60 per 30 days) 2-3 MG, 8-2 MG SUBOXONE SUBLINGUAL FILM 2- QL (30 per 30 days) 0.5 MG, 4- MG ZUBSOLV SUBLINGUAL TABLET QL (30 per 30 days) MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET QL (60 per 30 days) MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25, 0.5, (Xanax) QL (20 per 30 days) alprazolam oral tablet 2 (Xanax) QL (50 per 30 days) chlordiazepoxide hcl oral capsule 0, QL (20 per 30 days) 25, 5 clonazepam oral tablet 0.5, (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating QL (90 per 30 days) 0.25, 0.25, 0.5, clonazepam oral tablet,disintegrating 2 QL (300 per 30 days) clorazepate dipotassium oral tablet 5 QL (80 per 30 days), 3.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (80 per 30 days) DIASTAT ACUDIAL RECTAL KIT MG, MG

20 DIASTAT RECTAL KIT 2.5 MG diazepam injection solution 5 /ml QL (0 per 28 days) diazepam intensol oral concentrate 5 QL (200 per 30 days) /ml diazepam oral solution 5 /5 ml ( QL (200 per 30 days) /ml) diazepam oral tablet 0, 2, 5 (Valium) QL (20 per 30 days) diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit 2.5 (Diastat) lorazepam injection solution 2 /ml (Ativan) QL (2 per 30 days) lorazepam oral tablet 0.5, (Ativan) QL (90 per 30 days) lorazepam oral tablet 2 (Ativan) QL (50 per 30 days) ONFI ORAL SUSPENSION 2.5 MG/ML PA NSO; NDS; QL (480 per 30 days) ONFI ORAL TABLET 0 MG, 20 MG PA NSO; NDS; QL (60 per 30 days) Antibacterials Aminoglycosides BETHKIS INHALATION PA BvD; NDS SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 00 /50 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin injection solution 40 /ml gentamicin ped 20 /2 ml vial latexfree, sdv 20 /2 ml gentamicin sulfate (pf) intravenous solution 00 /0 ml neomycin oral tablet 500 streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION NDS; QL (224 per 28 days) DEVICE 28 MG tobramycin in % nacl inhalation (Tobi) PA BvD; NDS solution for nebulization 300 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml 2

21 tobramycin sulfate injection solution 0 /ml, 40 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln (BACiiM) 50,000 unit chloramphenicol sod succinate intravenous recon soln gram clindamycin 75 /5 ml soln 75 /5 ml (Clindamycin Pediatric) clindamycin hcl oral capsule 50, 300 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous (Cleocin in 5 % piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml dextrose) clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 50 /ml clindamycin phosphate intravenous (Cleocin) solution 600 /4 ml colistin (colistimethate na) injection (Coly-Mycin M recon soln 50 Parenteral) daptomycin intravenous recon soln 500 (Cubicin) NDS linezolid intravenous parenteral solution (Zyvox) NDS 600 /300 ml linezolid oral suspension for (Zyvox) NDS reconstitution 00 /5 ml linezolid oral tablet 600 (Zyvox) NDS methenamine hippurate oral tablet (Hiprex) gram metronidazole in nacl (iso-os) (Metro I.V.) intravenous piggyback 500 /00 ml metronidazole oral capsule 375 (Flagyl) metronidazole oral tablet 250, 500 (Flagyl) 3

22 nitrofurantoin macrocrystal oral capsule 00, 25, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (20 per 30 days); AGE (Max 64 Years) (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 days); AGE (Max 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS NDS RECON SOLN 500 MG trimethoprim oral tablet 00 vancomycin hcl g/200 ml bag gram/200 ml vancomycin intravenous recon soln,000, 0 gram, 750 vancomycin intravenous recon soln 500 vancomycin oral capsule 25, 250 (Vancocin) NDS XIFAXAN ORAL TABLET 200 MG PA; NDS; QL (9 per 30 days) XIFAXAN ORAL TABLET 550 MG PA; NDS Cephalosporins cefaclor oral capsule 250, 500 cefaclor oral suspension for reconstitution 25 /5 ml, 250 /5 ml, 375 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml cefadroxil oral tablet gram 4

23 cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, 2 gram/50 ml cefazolin injection recon soln gram, 0 gram, 500 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefditoren pivoxil oral tablet 200 cefditoren pivoxil oral tablet 400 (Spectracef) CEFEPIME GM INJECTION GRAM/50 ML cefepime hcl gm vial 0's, sdv gram (Maxipime) cefepime hcl 2 gram vial latex/f, sdv, (Maxipime) outer 2 gram CEFEPIME INJECTION RECON (Maxipime) SOLN GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 ML 2 GRAM/50 ML cefotaxime injection recon soln gram, (Claforan) 0 gram, 2 gram cefotaxime injection recon soln 500 cefoxitin 2 gm piggyback bag 2 gram/50 ml cefoxitin 2 gm vial l/f, outer, sdv 2 gram cefoxitin intravenous recon soln gram, 0 gram cefoxitin intravenous recon soln 2 gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 200 cefprozil oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 ceftazidime injection recon soln 2 gram (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) ceftibuten oral capsule 400 (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 80 /5 ml ceftriaxone gm piggyback l/g, single use gram/50 ml 5

24 ceftriaxone 2 gm piggyback l/f, single use 2 gram/50 ml ceftriaxone injection recon soln 0 gram, 250, 500 ceftriaxone intravenous recon soln gram, 2 gram cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection recon soln (Zinacef) 750 cefuroxime sodium intravenous recon soln (Zinacef).5 gram, 7.5 gram cefuroxime-dextrose (iso-osm) intravenous piggyback 750 /50 ml cephalexin oral capsule 250, 500, (Keflex) 750 cephalexin oral suspension for reconstitution 25 /5 ml, 250 /5 ml cephalexin oral tablet 250, 500 MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET,CHEWABLE 00 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 200 /5 ml azithromycin oral tablet 250 (Zithromax Z-Pak) azithromycin oral tablet 250 (6 pack), 500 (3 pack) azithromycin oral tablet 500, 600 (Zithromax) 6

25 clarithromycin oral suspension for reconstitution 25 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 clarithromycin oral tablet extended release 24 hr 500 DIFICID ORAL TABLET 200 MG NDS; QL (20 per 0 days) e.e.s. 400 oral tablet 400 e.e.s. granules oral suspension for reconstitution 200 /5 ml ery-tab oral tablet,delayed release (dr/ec) 250, 500 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG, 500 MG erythromycin ethylsuccinate oral (EryPed 200) suspension for reconstitution 200 /5 ml erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 erythromycin oral capsule,delayed release(dr/ec) 250 erythromycin oral tablet 250, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram, 2 gram (Azactam) CAYSTON INHALATION LA; NDS SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln gram, 500 (Merrem) 7

26 Penicillins amoxicillin oral capsule 250, 500 amoxicillin oral suspension for reconstitution 25 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 25, 250 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 2 hr, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 250, 500 ampicillin oral suspension for reconstitution 25 /5 ml, 250 /5 ml ampicillin sodium injection recon soln gram, 0 gram, 25, 2 gram, 250, 500 ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln (Unasyn).5 gram, 5 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE,200,000 UNIT/ 2 ML(600K/600K),,200,000 UNIT/ 2 ML(900K/300K) 8

27 BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250, 500 nafcillin 2 gm vial 0's, latex-free 2 gram nafcillin injection recon soln gram, 0 gram nafcillin intravenous recon soln 2 gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 0 gram, 2 gram oxacillin intravenous recon soln gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 5 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million (Pfizerpen-G) unit penicillin v potassium oral recon soln 25 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous (Zosyn) recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 00, 750 ciprofloxacin hcl oral tablet 250, 500 (Cipro) ciprofloxacin in 5 % dextrose intravenous piggyback 200 /00 ml 9

28 ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /200 ml ciprofloxacin lactate intravenous solution 200 /20 ml, 400 /40 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 250 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 25 /ml levofloxacin oral solution 250 /0 ml levofloxacin oral tablet 250, 500, (Levaquin) 750 moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 300, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) tablet sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) (dr/ec) 500 sulfatrim oral suspension /5 ml Tetracyclines doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon (Doxy-00) soln 00 doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 20 doxycycline monohydrate oral capsule 00, 50, 75 (Mondoxyne NL) 20

29 doxycycline monohydrate oral capsule 50 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 25 /5 ml doxycycline monohydrate oral tablet 00 (Avidoxy) doxycycline monohydrate oral tablet 50, 50, 75 minocycline oral capsule 00, 50, (Minocin) 75 minocycline oral tablet 00, 50, 75 tetracycline oral capsule 250, 500 tigecycline intravenous recon soln 50 (Tygacil) NDS Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS NDS SUSPENSION FOR RECONSTITUTION 00 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG PA NSO; NDS; QL (4 per 2 days) adriamycin intravenous solution 2 /ml, PA BvD 20 /0 ml adrucil 2,500 /50 ml vial outer, latexfree PA BvD 2.5 gram/50 ml adrucil intravenous solution 500 /0 ml PA BvD AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 PA NSO; NDS; QL (2 per 28 days) MG, 5 MG AFINITOR ORAL TABLET 0 MG PA NSO; NDS; QL (56 per 28 days) AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG PA NSO; NDS; QL (28 per 28 days) ALECENSA ORAL CAPSULE 50 MG PA NSO; NDS; QL (240 per 30 days) ALIMTA INTRAVENOUS RECON NDS SOLN 00 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG PA NSO; NDS; QL (3 per 28 days) ALUNBRIG ORAL TABLET 30 MG PA NSO; NDS; QL (80 per 30 days) 2

30 anastrozole oral tablet (Arimidex) AVASTIN INTRAVENOUS PA NSO; NDS SOLUTION 25 MG/ML, 25 MG/ML (6 ML) azacitidine injection recon soln 00 (Vidaza) NDS BAVENCIO INTRAVENOUS PA NSO; NDS SOLUTION 20 MG/ML BELEODAQ INTRAVENOUS PA NSO; NDS RECON SOLN 500 MG BENDEKA INTRAVENOUS PA NSO; NDS SOLUTION 25 MG/ML BESPONSA INTRAVENOUS PA NSO; NDS RECON SOLN 0.9 MG (0.25 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) PA NSO; NDS; QL (420 per 30 days) bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 5 unit (Bleo 5K) PA BvD bleomycin injection recon soln 30 unit PA BvD BLINCYTO INTRAVENOUS KIT 35 MCG PA NSO; NDS; QL (40 per 365 days) BOSULIF ORAL TABLET 00 MG PA NSO; NDS; QL (20 per 30 days) BOSULIF ORAL TABLET 500 MG PA NSO; NDS; QL (30 per 30 days) CABOMETYX ORAL TABLET 20 MG, 60 MG PA NSO; NDS; QL (30 per 30 days) CABOMETYX ORAL TABLET 40 MG PA NSO; NDS; QL (60 per 30 days) CAPRELSA ORAL TABLET 00 MG PA NSO; NDS; QL (60 per 30 days) CAPRELSA ORAL TABLET 300 MG PA NSO; NDS; QL (30 per 30 days) clofarabine intravenous solution 20 /20 (Clolar) NDS ml COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-20 MG X), 40 PA NSO; NDS; QL (2 per 28 days) MG/DAY(80 MG X-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG PA NSO; LA; NDS; QL (63 per 28 days) 22

31 cyclophosphamide intravenous recon soln PA BvD; NDS gram, 2 gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 25 MG, 50 MG CYRAMZA INTRAVENOUS PA NSO; NDS SOLUTION 0 MG/ML, 0 MG/ML (50 ML) DARZALEX INTRAVENOUS PA NSO; LA; NDS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 (Dacogen) NDS doxorubicin 200 /00 ml vial latexfree (Adriamycin) PA BvD 2 /ml doxorubicin intravenous solution 50 (Adriamycin) PA BvD /25 ml doxorubicin, peg-liposomal intravenous (Doxil) PA BvD; NDS suspension 2 /ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) QL ( per 84 days) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) QL ( per 2 days) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) QL ( per 68 days) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG NDS EMPLICITI INTRAVENOUS PA NSO; NDS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG PA NSO; NDS; QL (30 per 30 days) ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG etoposide intravenous solution 20 /ml (Toposar) exemestane oral tablet 25 (Aromasin) FARESTON ORAL TABLET 60 MG NDS FARYDAK ORAL CAPSULE 0 PA NSO; NDS MG, 5 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML NDS 23

32 floxuridine injection recon soln 0.5 gram PA BvD fluorouracil 5,000 /00 ml latex-free 5 (Adrucil) PA BvD gram/00 ml fluorouracil intravenous solution PA BvD gram/20 ml fluorouracil intravenous solution 2.5 (Adrucil) PA BvD gram/50 ml, 500 /0 ml flutamide oral capsule 25 GAZYVA INTRAVENOUS PA NSO; NDS SOLUTION,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG PA NSO; NDS; QL (30 per 30 days) GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS PA NSO; NDS RECON SOLN 50 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG NDS hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG PA NSO; NDS; QL (2 per 28 days) ICLUSIG ORAL TABLET 5 MG PA NSO; NDS; QL (60 per 30 days) ICLUSIG ORAL TABLET 45 MG PA NSO; NDS; QL (30 per 30 days) IDHIFA ORAL TABLET 00 MG, 50 MG PA NSO; NDS; QL (30 per 30 days) ifosfamide gm/20 ml vial sdv,p/f,latexfree PA BvD gram/20 ml ifosfamide intravenous recon soln gram (Ifex) PA BvD ifosfamide-mesna intravenous kit - PA BvD; NDS gram, 3,000-,000 imatinib oral tablet 00 (Gleevec) PA NSO; NDS; QL (90 per 30 days) imatinib oral tablet 400 (Gleevec) PA NSO; NDS; QL (60 per 30 days) IMBRUVICA ORAL CAPSULE 40 PA NSO; NDS MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (0 ML) PA NSO; NDS 24

33 IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML PA NSO; NDS; QL (4 per 365 days) PA NSO; NDS; QL (8 per 28 days) INLYTA ORAL TABLET MG PA NSO; NDS; QL (80 per 30 days) INLYTA ORAL TABLET 5 MG PA NSO; NDS; QL (60 per 30 days) IRESSA ORAL TABLET 250 MG PA NSO; NDS; QL (60 per 30 days) IXEMPRA INTRAVENOUS RECON NDS SOLN 5 MG, 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG PA NSO; NDS; QL (60 per 30 days) KEYTRUDA INTRAVENOUS PA NSO; NDS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML PA NSO; NDS KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X )-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X ), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LARTRUVO INTRAVENOUS SOLUTION 0 MG/ML PA NSO; NDS; QL (49 per 28 days) PA NSO; NDS; QL (70 per 28 days) PA NSO; NDS; QL (9 per 28 days) PA NSO; NDS; QL (63 per 28 days) PA NSO; NDS; QL (2 per 28 days) PA NSO; NDS; QL (6 per 28 days) PA NSO; LA; NDS 25

34 LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 8 MG/DAY (4 MG X 2) PA NSO; NDS letrozole oral tablet 2.5 (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit /0.2 ml LONSURF ORAL TABLET MG PA NSO; NDS; QL (00 per 28 days) LONSURF ORAL TABLET MG PA NSO; NDS; QL (80 per 28 days) LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYNPARZA ORAL TABLET 00 MG, 50 MG NDS; QL ( per 84 days) NDS; QL ( per 84 days) NDS; QL ( per 68 days) NDS PA NSO; NDS; QL (480 per 30 days) PA NSO; NDS; QL (20 per 30 days) LYSODREN ORAL TABLET 500 MG NDS MATULANE ORAL CAPSULE 50 NDS MG megestrol oral tablet 20, 40 MEKINIST ORAL TABLET 0.5 MG PA NSO; NDS; QL (90 per 30 days) MEKINIST ORAL TABLET 2 MG PA NSO; NDS; QL (30 per 30 days) mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln gram PA BvD 26

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