FORMULARY (LIST OF COVERED DRUGS)

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1 2017 FORMULARY (LIST OF COVERED DRUGS) Michigan Complete Health Medicare-Medicaid Plan (MMP) Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Formulary ID , Version 17 No changes made since 11/01/2017. For more recent information or other questions, please contact Michigan Complete Health Member Services at , TTY:711. Member Services hours are from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. Or visit H9487_LOD17_Approved_ Centene AEP17 FORM Cover MMP_MCH_2.indd 2 3/7/17 3:18 PM

2 H9487_LOD17_Approved_ Michigan Complete Health Medicare-Medicaid Plan (MMP) 2017 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Michigan Complete Health (MMP). Michigan Complete Health Medicare-Medicaid Plan (MMP) is a health plan that contracts with both Medicare and Michigan Medicaid 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 may change on January 1 of each year. You can always check Michigan Complete Health (MMP) s up-to-date List of Covered Drugs online at mmp.michigancompletehealth.com. Limitations, restrictions, and patient pay amounts may apply. This means that you may have to pay for some services and that you need to follow certain rules to have Michigan Complete Health (MMP) pay for your services. For more information, call Michigan Complete Health (MMP) Member Services or read the Michigan Complete Health (MMP) Member Handbook. You can get this information for free in other languages. Call from 8 a.m. to 8 p.m., seven days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. Puede obtener esta información en otros idiomas, en forma gratuita. Llame al de 8:00 a. m. a 8:00 p. m., los siete días de la semana. Los usuarios de TTY deben llamar al 711. Los fines de semana y los días feriados estatales o nacionales, es posible que se le pida que deje un mensaje. Le devolveremos la llamada durante el próximo día hábil. La llamada es gratuita. You can also get this information for free in other formats, such as large print, braille, or audio. Call from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711. The call is free.? If you have questions, please call Michigan Complete Health (MMP) at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. 1

3 In addition to asking for materials in other languages and formats, you can also ask that we send you future materials in the same language or format. To get these materials, please call Member Services. Frequently Asked Questions (FAQ) 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 List of Covered Drugs that starts on page 10 are the drugs covered by Michigan Complete Health (MMP). These 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. Michigan Complete Health (MMP) 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 a Michigan Complete Health (MMP) network pharmacy. Michigan Complete Health (MMP) may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at mmp.michigancompletehealth.com or call Member Services toll-free at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. 2. Does the Drug List ever change? Yes. Michigan Complete Health (MMP) 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:? If you have questions, please call Michigan Complete Health (MMP) at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. 2

4 Decide to require or not require prior approval for a drug. (Prior approval is permission from Michigan Complete Health (MMP) 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 4). 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. You can always check Michigan Complete Health (MMP) s up to date Drug List online at mmp.michigancompletehealth.com. You can also call Member Services to check the current Drug List at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. 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 change to the Drug List is made. We will mail you a notice if you are taking a drug that is removed from the drug list because a cheaper drug that works just as well comes along. You will receive the notice by mail at least 60 days before we remove the drug from our List of Covered Drugs. Or we have to tell you when you request a refill of the drug. If we tell you when you refill your drug, you will receive a 60-day supply of the drug. For more information on the drug rules, see page 5. If you have questions about the notice you receive from Michigan Complete Health (MMP), call Member Services at from 8 a.m. to 8 p.m., seven days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.? If you have questions, please call Michigan Complete Health (MMP) at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. 3

5 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 have any questions after being notified of the change, you should contact the doctor who prescribed the drug 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 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 Michigan Complete Health (MMP) before you fill your prescription. If you don t get approval, Michigan Complete Health (MMP) may not cover the drug. Quantity limits: Sometimes Michigan Complete Health (MMP) limits the amount of a drug you can get. Step therapy: Sometimes Michigan Complete Health (MMP) 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 prescriber 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 9. You can also get more information by visiting our web site at mmp.michigancompletehealth.com. 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 also ask for an exception from these limits. Please see question 11 for more information on exceptions. 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 Michigan Complete Health (MMP) 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 ask for an exception. Please see question 11 for more information about exceptions.? If you have questions, please call Michigan Complete Health (MMP) at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. 4

6 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 10 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some 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 for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List 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 by reviewing the index of drugs beginning on page 103. To search by medical condition, find the section labeled List of drugs by medical condition on page 10. 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 from 8 a.m. to 8 p.m., 7 days a week, and ask about it. TTY users call 711. If you learn that Michigan Complete Health (MMP) will not cover the drug, you can do one of these things:? If you have questions, please call Michigan Complete Health (MMP) at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. 5

7 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 Michigan Complete Health (MMP) 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 30-day supply of your drug during the first 90 days you are a member of Michigan Complete Health (MMP). 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 ask for an exception. We will cover a 30-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 Michigan Complete Health (MMP), 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 93 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 ones on the Drug List or ask for an exception. Throughout the plan year, you may have a change in your treatment setting (the place where you get and take your medicine) because of the level of care you require. Such transitions may include, but are not limited to: Members who are discharged from a hospital or skilled-nursing facility to a home setting Members who are admitted to a hospital or skilled-nursing facility from a home setting Members who transfer from one skilled-nursing facility to another and are served by a different pharmacy Members who end their skilled-nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who now need to use their Part D plan benefit Members discharged from chronic psychiatric hospitals with highly individualized drug regimens? If you have questions, please call Michigan Complete Health (MMP) at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. 6

8 For these changes in treatment settings, Michigan Complete Health (MMP) will cover as much as a 31-day temporary supply of a Part D-covered drug when you fill your prescription at a network pharmacy. If you change treatment settings multiple times within the same month, you may have to request an exception or prior authorization and get approval for continued coverage of your drug. We will review these requests for continuation of therapy on a case-by-case basis when you are on a stabilized drug regimen that, if changed, is known to have risks. To ask for a temporary supply of a drug, call Member Services. 11. Can you ask for an exception to cover your drug? Yes. You can ask Michigan Complete Health (MMP) 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, Michigan Complete Health (MMP) 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. 12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get 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 getting your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with your provider to help you ask for an exception.? If you have questions, please call Michigan Complete Health (MMP) at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. 7

9 14. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). Michigan Complete Health (MMP) covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. Michigan Complete Health (MMP) covers some OTC drugs when they are written as prescriptions by your provider. You can read the Michigan Complete Health (MMP) Drug List to see what OTC drugs are covered. 16. What is your copay? As a Michigan Complete Health (MMP) member, you have no copays for prescription and OTC drugs as long as you follow Michigan Complete Health (MMP) s rules. 17. What are drug tiers? Tiers are groups of drugs. Every drug on the plan s Drug List is in one of 3 tiers. To find out which tier your drug is in, look for the drug in the Drug List. Tier 1 drugs are Medicare covered generic drugs. Tier 2 drugs are Medicare covered brand drugs. Tier 3 drugs are non-medicare prescription (Rx) drugs / over-the-counter (OTC) drugs. All tiers have a $0 copay.? If you have questions, please call Michigan Complete Health (MMP) at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. 8

10 List of Covered Drugs The list of covered drugs that begins on the next page gives you information about the drugs covered by Michigan Complete Health (MMP). If you have trouble finding your drug in the list, turn to the Index that begins on page 103. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., HUMALOG) 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 Michigan Complete Health (MMP) has any rules for covering your drug. Abbreviations Descriptions The * next to a drug means the drug is not a Part D drug. These drugs have different * rules for appeals. Please see the Note following this table for more information. This prescription drug may be covered under Medicare Part B or D depending upon the B/D PA circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. HI Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Member Services. LA Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Member Services. Mail-Order Drug. 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). Prior Authorization. The plan requires you or your physician to get prior authorization for PA certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. Step Therapy. 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 ST 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 * next to a drug means the drug is not a Part D drug. These drugs have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision 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 Michigan Medicaid. If you or your prescriber disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. You can also read Chapter 9 in the Member Handbook to learn how to appeal a decision.? If you have questions, please call Michigan Complete Health (MMP) at from 8 a.m. to 8 p.m., 7 days a week. TTY users call 711. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. For more information, visit mmp.michigancompletehealth.com. 9

11 ANTI - INFECTIVES ANTIFUNGAL AGENTS What the drug will cost you (tier level) ABELCET B/D PA; AMBISOME B/D PA; amphotericin b B/D PA; CANCIDAS B/D PA; clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL fluconazole fluconazole in dextrose(iso-o) 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 griseofulvin ultramicrosize itraconazole ketoconazole oral MYCAMINE NOXAFIL ORAL nystatin oral suspension nystatin oral tablet SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole ANTIVIRALS abacavir abacavir-lamivudine abacavir-lamivudine-zidovudine acyclovir oral capsule Necessary actions, restrictions, or limits on use 10

12 acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous recon soln 500 mg acyclovir sodium intravenous solution adefovir amantadine hcl APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION cidofovir COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DAKLINZA DESCOVY didanosine oral capsule,delayed release(dr/ec) 125 mg didanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg EDURANT EMTRIVA entecavir EPCLUSA EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ famciclovir fosamprenavir foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium GENVOYA HARVONI B/D PA B/D PA; B/D PA; PA; ; QL (84 per 84 days) PA; ; QL (84 per 84 days) B/D PA B/D PA; PA; ; QL (168 per 168 days) 11

13 INTELENCE INVIRASE ISENTRESS ISENTRESS HD KALETRA lamivudine lamivudine-zidovudine LEXIVA lopinavir-ritonavir moderiba moderiba dose pack nevirapine NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY OLYSIO oseltamivir PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere ribasphere ribapak oral tablets,dose pack 200 mg (28)- 400 mg (28), mg (28)-mg (28), mg (28)-mg (28), mg (28)-mg (28) PA; ; QL (168 per 168 days) 12

14 ribasphere ribapak oral tablets,dose pack 200 mg (7)- 400 mg (7), 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) ribavirin inhalation ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SELZENTRY SOVALDI stavudine oral capsule STRIBILD SUSTIVA SYNAGIS TAMIFLU TECHNIVIE TIVICAY TRIUMEQ TRUVADA valacyclovir VALCYTE ORAL RECON SOLN valganciclovir VEMLIDY VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR VIRACEPT ORAL TABLET VIRAZOLE VIREAD ZEPATIER ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION zidovudine PA; ; QL (168 per 168 days) ; LA PA; ; QL (168 per 84 days) ; QL (30 per 30 days) PA; ; QL (672 per 168 days) PA; ; QL (504 per 168 days) PA; ; QL (112 per 112 days) 13

15 CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefaclor oral suspension for reconstitution 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, 2 gram/50 ml cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g cefazolin intravenous cefdinir cefepime cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml cefepime in dextrose,iso-osm intravenous piggyback 2 gram/100 ml cefixime cefotaxime injection recon soln 1 gram, 2 gram, 500 mg What the drug will cost you (tier level) cefotaxime injection recon soln 10 gram cefotetan cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram, 2 gram cefoxitin intravenous recon soln 10 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 2 gram Necessary actions, restrictions, or limits on use 14

16 ceftazidime injection recon soln 6 gram ceftibuten ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 10 gram ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln 1.5 gram cefuroxime sodium intravenous recon soln 7.5 gram cephalexin SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin e.e.s. 400 oral tablet E.E.S. GRANULES 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 suspension for reconstitution erythromycin ethylsuccinate oral tablet 15

17 erythromycin oral capsule,delayed release(dr/ec) What the drug will cost you (tier level) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml atovaquone atovaquone-proguanil aztreonam baciim bacitracin intramuscular Necessary actions, restrictions, or limits on use BETHKIS B/D PA; ; QL (224 per 28 days) BILTRICIDE CAPASTAT CAYSTON ; LA; QL (84 per 28 days) chloramphenicol sod succinate chloroquine phosphate clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection clindamycin phosphate intravenous COARTEM colistin (colistimethate na) CUBICIN CUBICIN RF dapsone daptomycin DARAPRIM PA; EMVERM 16

18 ethambutol gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 90 mg/100 ml gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml gentamicin sulfate (pf) intravenous solution 60 mg/6 ml hydroxychloroquine imipenem-cilastatin INVANZ INJECTION INVANZ INTRAVENOUS isoniazid injection isoniazid oral ivermectin lincomycin linezolid intravenous linezolid oral linezolid-0.9% sodium chloride mefloquine meropenem metro i.v. metronidazole in nacl (iso-os) metronidazole oral NEBUPENT neomycin paromomycin PASER PENTAM B/D PA; ; QL (1 per 28 days) 17

19 polymyxin b sulfate PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin rifampin SIRTURO SIVEXTRO INTRAVENOUS STREPTOMYCIN SYNERCID tinidazole tobramycin in % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR TYGACIL XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate ampicillin oral capsule ampicillin sodium injection ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ; LA B/D PA; ; QL (280 per 28 days) ; QL (9 per 30 days) ; QL (60 per 30 days) 18

20 ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 1.5 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml nafcillin in dextrose iso-osm intravenous piggyback 2 gram/100 ml oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml oxacillin injection recon soln 1 gram, 10 gram oxacillin injection recon soln 2 gram oxacillin intravenous 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 pfizerpen-g piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram QUINOLONES ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose 19

21 ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback 250 mg/50 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous levofloxacin oral moxifloxacin oral ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine sulfamethoxazole-trimethoprim sulfatrim TETRACYCLINES demeclocycline doxy-100 doxycycline hyclate oral capsule doxycycline hyclate oral tablet doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline mondoxyne nl morgidox oral capsule 100 mg morgidox oral capsule 50 mg tetracycline URINARY TRACT AGENTS 20

22 methenamine hippurate methenamine mandelate nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst PRIMSOL trimethoprim VANCOMYCIN VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK vancomycin intravenous vancomycin oral capsule 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, 200 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral LEVOLEUCOVORIN INTRAVENOUS RECON SOLN 175 MG levoleucovorin intravenous recon soln 50 mg levoleucovorin intravenous solution mesna MESNEX ORAL XGEVA ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 21

23 adriamycin intravenous solution adrucil intravenous solution 2.5 gram/50 ml adrucil intravenous solution 5 gram/100 ml, 500 mg/10 ml AFINITOR DISPERZ AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ALIMTA ALKERAN ORAL ALUNBRIG anastrozole ARRANON ARZERRA AVASTIN azacitidine azathioprine azathioprine sodium BAVENCIO BELEODAQ BENDEKA BESPONSA bexarotene bicalutamide BICNU bleo 15k bleomycin BLINCYTO INTRAVENOUS KIT BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG busulfan BUSULFEX B/D PA B/D PA; PA; PA; ; QL (60 per 30 days) PA; PA; ; QL (240 per 30 days) B/D PA; PA; ; LA; QL (180 per 30 days) B/D PA; B/D PA; B/D PA ; LA B/D PA B/D PA; B/D PA; PA; PA; ; QL (30 per 30 days) 22

24 CABOMETYX CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine clofarabine CLOLAR COMETRIQ COSMEGEN COTELLIC cyclophosphamide intravenous CYCLOPHOSPHAMIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) cytarabine (pf) injection solution 20 mg/ml dacarbazine DARZALEX daunorubicin intravenous solution decitabine docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 160 mg/8 ml (20 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) DOCETAXEL INTRAVENOUS SOLUTION 20 MG/ML PA; ; LA PA; ; LA; QL (90 per 30 days) PA; ; LA; QL (30 per 30 days) B/D PA; B/D PA; PA; PA; ; LA; QL (63 per 28 days) B/D PA; B/D PA B/D PA; B/D PA; B/D PA; B/D PA; B/D PA; B/D PA ; LA 23

25 What the drug will cost you (tier level) doxorubicin intravenous recon soln 10 mg doxorubicin intravenous recon soln 50 mg doxorubicin intravenous solution doxorubicin, peg-liposomal DROXIA EMCYT EMPLICITI epirubicin intravenous solution ERBITUX ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 20 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE floxuridine fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous 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) Necessary actions, restrictions, or limits on use B/D PA; PA; ; QL (30 per 30 days) PA; ; QL (12 per 21 days) PA; ; QL (6 per 21 days) B/D PA; 24

26 gengraf B/D PA; GILOTRIF ORAL TABLET 20 MG GILOTRIF ORAL TABLET 30 MG GILOTRIF ORAL TABLET 40 MG GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG idarubicin IDHIFA ORAL TABLET 100 MG IDHIFA ORAL TABLET 50 MG ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA IMFINZI 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, 15 MG, 20 MG, 5 MG JAKAFI ORAL TABLET 25 MG JEVTANA PA; ; QL (60 per 30 days) PA; ; QL (40 per 30 days) PA; ; QL (30 per 30 days) PA; ; QL (21 per 28 days) PA; QL (90 per 30 days) PA; ; QL (30 per 30 days) PA; ; LA; QL (30 per 30 days) PA; ; LA; QL (60 per 30 days) PA; PA; ; QL (60 per 30 days) PA; ; QL (120 per 30 days) ; LA PA; PA; ; QL (120 per 30 days) PA; ; QL (30 per 30 days) PA; PA; ; QL (60 per 30 days) 25

27 KADCYLA PA; KEYTRUDA KISQALI KISQALI FEMARA CO-PACK KYPROLIS LARTRUVO LENVIMA letrozole LEUKERAN leuprolide subcutaneous kit LONSURF LUPRON DEPOT LUPRON DEPOT (3 NTH) LUPRON DEPOT (4 NTH) LUPRON DEPOT (6 NTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 NTH) LYNPARZA LYSODREN MARQIBO MATULANE megestrol oral suspension 400 mg/10 ml (10 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan oral melphalan hcl mercaptopurine methotrexate sodium methotrexate sodium (pf) injection recon soln PA; PA; ; LA PA; PA; PA; PA; PA; PA; PA; PA; PA; B/D PA; PA PA; PA; PA; ; QL (120 per 30 days) PA; ; QL (30 per 30 days) B/D PA; B/D PA; B/D PA 26

28 methotrexate sodium (pf) injection solution B/D PA; mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium NERLYNX NEXAVAR NILANDRON nilutamide NINLARO ORAL CAPSULE 2.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG NULOJIX octreotide acetate ODOMZO ONCASPAR ONIVYDE OPDIVO oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID RITUXAN B/D PA; B/D PA B/D PA; ; LA PA; ; LA; QL (120 per 30 days) PA; ; QL (6 per 28 days) PA; ; QL (4 per 28 days) PA; ; QL (3 per 28 days) B/D PA; PA; ; LA; QL (30 per 30 days) B/D PA; B/D PA; B/D PA; PA; ; LA PA; 27

29 RITUXAN HYCELA RUBRACA ORAL TABLET 200 MG RUBRACA ORAL TABLET 250 MG RUBRACA ORAL TABLET 300 MG RYDAPT SANDIMMUNE ORAL SOLUTION SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100 MG, 20 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 140 MG SPRYCEL ORAL TABLET 70 MG STIVARGA SUTENT ORAL CAPSULE 12.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG SUTENT ORAL CAPSULE 50 MG SYLVANT SYNRIBO TABLOID tacrolimus oral TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG PA; PA; ; LA; QL (180 per 30 days) PA; ; LA; QL (150 per 30 days) PA; ; LA; QL (120 per 30 days) PA; B/D PA; B/D PA B/D PA; B/D PA; PA; PA; ; QL (30 per 30 days) PA; ; QL (60 per 30 days) PA; ; QL (84 per 28 days) PA; PA; ; QL (60 per 30 days) PA; ; QL (30 per 30 days) B/D PA; PA; ; QL (180 per 30 days) PA; ; QL (120 per 30 days) PA; ; LA; QL (60 per 30 days) PA; ; LA; QL (30 per 30 days) 28

30 tamoxifen TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 150 MG TASIGNA ORAL CAPSULE 200 MG TECENTRIQ TEDAR INTRAVENOUS THALOMID thiotepa toposar topotecan intravenous recon soln topotecan intravenous solution TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR tretinoin (chemotherapy) TRISENOX TYKERB UNITUXIN VALSTAR VANTAS VECTIBIX VELCADE VENCLEXTA VENCLEXTA STARTING PACK vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ml vincasar pfs intravenous solution 2 mg/2 ml vincristine vinorelbine VOTRIENT PA; PA; ; QL (30 per 30 days) PA; PA; ; QL (112 per 28 days) ; LA PA; PA; ; LA; QL (180 per 30 days) B/D PA; PA; ; LA PA; ; LA; QL (42 per 180 days) B/D PA; B/D PA B/D PA; B/D PA; PA; ; QL (120 per 30 days) 29

31 VYXEOS B/D PA; XALKORI ORAL CAPSULE 200 MG PA; XALKORI ORAL CAPSULE 250 MG PA; ; QL (60 per 30 days) XATMEP B/D PA; XERMELO ; LA XTANDI PA; ; QL (120 per 30 days) YERVOY YONDELIS ZALTRAP ZANOSAR ZEJULA PA; ; LA; QL (90 per 30 days) ZELBORAF PA; ; QL (240 per 30 days) ZOLADEX ZOLINZA ZORTRESS B/D PA; ZYDELIG PA; ; QL (90 per 30 days) ZYKADIA PA; ; QL (150 per 30 days) ZYTIGA ORAL TABLET 250 MG PA; ; QL (120 per 30 days) ZYTIGA ORAL TABLET 500 MG PA; ; QL (60 per 30 days) AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM BANZEL BRIVIACT INTRAVENOUS BRIVIACT ORAL carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam PA; 30

32 DIASTAT DIASTAT ACUDIAL diazepam rectal DILANTIN 30 MG divalproex epitol ethosuximide felbamate fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule 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, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine 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 LYRICA ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG oxcarbazepine PEGANONE phenobarbital PA; PA; PA; 31

33 phenobarbital sodium injection solution 130 mg/ml phenobarbital sodium injection solution 65 mg/ml 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 primidone roweepra oral tablet 1,000 mg, 750 mg roweepra oral tablet 500 mg SABRIL SPRITAM tiagabine topiramate oral capsule, sprinkle topiramate oral tablet 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) vigabatrin VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET zonisamide ANTIPARKINSONISM AGENTS ; LA PA; PA; ; LA PA; APOKYN ; LA AZILECT benztropine bromocriptine 32

34 carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone entacapone NEUPRO pramipexole rasagiline ropinirole selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY almotriptan malate oral tablet 12.5 mg ; QL (24 per 28 days) almotriptan malate oral tablet 6.25 mg ; QL (18 per 28 days) dihydroergotamine injection dihydroergotamine nasal ; QL (8 per 28 days) eletriptan hbr ergotamine-caffeine frovatriptan ; QL (27 per 28 days) migergot naratriptan ; QL (18 per 28 days) rizatriptan ; QL (36 per 28 days) sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation ; QL (18 per 28 days) ; QL (36 per 28 days) sumatriptan succinate oral ; QL (18 per 28 days) sumatriptan succinate subcutaneous cartridge ; QL (8 per 28 days) sumatriptan succinate subcutaneous pen injector ; QL (8 per 28 days) sumatriptan succinate subcutaneous solution ; QL (8 per 28 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml ; QL (8 per 28 days) zolmitriptan ; QL (18 per 28 days) MISCELLANEOUS NEUROLOGICAL THERAPY 33

35 AMPYRA donepezil galantamine GILENYA glatopa LEMTRADA memantine oral solution memantine oral tablet NAMENDA XR NAMZARIC NUEDEXTA OCREVUS RADICAVA rivastigmine rivastigmine tartrate TECFIDERA tetrabenazine TYSABRI PA; ; LA MUSCLE RELAXANTS / ANTISPASDIC THERAPY anectine PA; PA; ; QL (30 per 30 days) PA; PA; PA; PA; PA; PA; baclofen PA; PA; PA; ; LA cyclobenzaprine oral tablet PA; dantrolene enlon LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML B/D PA; B/D PA MESTINON ORAL SYRUP neostigmine methylsulfate intravenous solution 0.5 mg/ml neostigmine methylsulfate intravenous solution 1 mg/ml 34

36 pyridostigmine bromide regonol revonto tizanidine NARCOTIC ANALGESICS acetaminophen-caff-dihydrocod oral capsule 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 tablet mg, mg 35 acetaminophen-codeine oral tablet mg aspirin-caffeine-dihydrocodein buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual codeine sulfate oral tablet diskets duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet mg, mg, mg, mg fentanyl citrate fentanyl citrate (pf) injection fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50 mcg/ml) fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg ; QL (300 per 30 days) QL (4500 per 30 days) ; QL (4500 per 30 days) ; QL (360 per 30 days) ; QL (180 per 30 days) QL (300 per 30 days) ; QL (267 per 30 days) QL (267 per 30 days) ; QL (180 per 30 days) QL (30 per 30 days) ; QL (4000 per 30 days) QL (2000 per 30 days) ; QL (360 per 30 days) PA; ; QL (120 per 30 days) ; QL (400 per 30 days) QL (400 per 30 days) ; QL (9 per 30 days) ; QL (10 per 30 days) ; QL (5550 per 30 days) ; QL (360 per 30 days)

37 hydrocodone-ibuprofen oral tablet mg, 5- ; QL (50 per 30 days) 200 mg, mg hydromorphone (pf) hydromorphone injection solution 1 mg/ml hydromorphone injection solution 2 mg/ml hydromorphone injection solution 4 mg/ml hydromorphone injection syringe 1 mg/ml hydromorphone injection syringe 2 mg/ml hydromorphone injection syringe 4 mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 8 mg hydromorphone oral tablet extended release 24 hr 32 mg ibuprofen-oxycodone levorphanol tartrate lorcet (hydrocodone) lorcet hd lorcet plus oral tablet mg methadone injection solution methadone intensol methadone oral concentrate methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg methadone oral tablet,soluble methadose oral concentrate methadose oral tablet,soluble morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ml ; QL (240 per 30 days) QL (300 per 30 days) ; QL (150 per 30 days) ; QL (75 per 30 days) QL (300 per 30 days) QL (1200 per 30 days) ; QL (75 per 30 days) ; QL (1500 per 30 days) ; QL (180 per 30 days) ; QL (60 per 30 days) ; QL (47 per 30 days) ; QL (28 per 30 days) ; QL (120 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (160 per 30 days) ; QL (90 per 30 days) ; QL (90 per 30 days) ; QL (600 per 30 days) ; QL (1200 per 30 days) ; QL (120 per 30 days) ; QL (240 per 30 days) QL (30 per 30 days) ; QL (90 per 30 days) ; QL (30 per 30 days) QL (4000 per 30 days) ; QL (2000 per 30 days) 36

38 morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine injection syringe 10 mg/ml, 2 mg/ml, 4 mg/ml morphine injection syringe 8 mg/ml morphine intravenous cartridge 10 mg/ml morphine intravenous cartridge 2 mg/ml morphine intravenous cartridge 4 mg/ml morphine intravenous solution 10 mg/ml morphine intravenous syringe 2 mg/ml morphine intravenous syringe 4 mg/ml morphine oral capsule, er multiphase 24 hr 120 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.release pellets 10 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.release pellets 100 mg morphine oral capsule,extend.release pellets 80 mg morphine oral solution morphine oral tablet morphine oral tablet extended release 100 mg morphine oral tablet extended release 15 mg, 30 mg morphine oral tablet extended release 200 mg morphine oral tablet extended release 60 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 20 mg B/D PA; ; QL (400 per 30 days) B/D PA; QL (2000 per 30 days) ; QL (300 per 30 days) QL (200 per 30 days) QL (1000 per 30 days) QL (500 per 30 days) ; QL (200 per 30 days) QL (1000 per 30 days) QL (500 per 30 days) ; QL (50 per 30 days) ; QL (60 per 30 days) ; QL (90 per 30 days) ; QL (60 per 30 days) ; QL (75 per 30 days) ; QL (900 per 30 days) ; QL (180 per 30 days) ; QL (60 per 30 days) ; QL (120 per 30 days) ; QL (30 per 30 days) ; QL (100 per 30 days) ; QL (360 per 30 days) ; QL (180 per 30 days) ; QL (1200 per 30 days) ; QL (180 per 30 days) 37

39 oxycodone oral tablet 5 mg oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg, mg, mg, mg 38 oxycodone-aspirin oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 12 hr 30 mg oxymorphone oral tablet extended release 12 hr 40 mg vicodin vicodin es vicodin hp xylon 10 zamicet NON-NARCOTIC ANALGESICS 8 hour pain reliever $0 (Tier 3) acetaminophen rectal suppository 650 mg $0 (Tier 3) all day pain relief $0 (Tier 3) arthritis pain relief (acetam) $0 (Tier 3) aspir-81 $0 (Tier 3) aspirin oral tablet,chewable $0 (Tier 3) aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg $0 (Tier 3) aspir-low $0 (Tier 3) buprenorphine-naloxone sublingual tablet mg buprenorphine-naloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml oxycodone oral tablet 30 mg ; QL (134 per 30 days) ; QL (360 per 30 days) QL (1846 per 30 days) ; QL (360 per 30 days) ; QL (360 per 30 days) ; QL (200 per 30 days) ; QL (180 per 30 days) ; QL (90 per 30 days) ; QL (67 per 30 days) ; QL (50 per 30 days) ; QL (360 per 30 days) ; QL (360 per 30 days) ; QL (360 per 30 days) QL (50 per 30 days) QL (5550 per 30 days) ; * * * * * ; * ; * ; * ; QL (360 per 30 days) ; QL (90 per 30 days) ; QL (720 per 30 days) ; QL (360 per 30 days)

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