CareMore Classic (HMO) 2018 Formulary (List of Covered Drugs)

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1 CareMore Classic (H) 018 Formulary (List of Covered s) PLEASE READ: This document contains information about the drugs we cover in this plan. Y011_18 U_00 CMS Accepted 10// _P, v1 This formulary was updated on 0/0/018. For more recent information or other questions, please contact CareMore Member Services, at , TTY: 711, 8 a.m. 8 p.m., 7 days a week, October 1 to February 1 (except Thanksgiving and Christmas), and Monday to Friday from February 1 to September 0 (except holi or visit FORMCMAZP18_Classic

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us or our, it means CareMore. When it refers to plan or our plan, it means the plan in which you are enrolled. This document includes a list of the drugs (formulary) for our plan which is current as of 0/0/018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/ coinsurance may change on January 1, 019, and from time to time during the year. Effective Date April 1, FORMCMAZP18_Classic

3 What is the CareMore Classic (H) Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step-therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 0 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 0-day supply of the drug. If the Food and Administration (FDA) deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 0/0/018. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (non-maintenance change) is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated formulary. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular, Hypertension / Lipids. If you know what your drug is used for, look for the category name in the list that begins on page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, our plan may not cover the drug. Effective Date April 1, 018 FORMCMAZP18_Classic

4 Quantity : For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 0 tablets per month per prescription for JANUVIA 100 MG. This may be in addition to a standard one-month or three-month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted on-line documents that explain our prior authorization restriction. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the formulary? on page for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the CareMore Classic (H)'s Formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course Effective Date April 1, 018 FORMCMAZP18_Classic

5 of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term-care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. During the time when you are getting a temporary supply of a drug, you should talk to your prescriber or prescribing physician to decide what to do when your supply runs out. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you while you pursue a formulary exception. Please refer to the Evidence of Coverage for more information about exceptions. For more information For more detailed information about our plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), hours a day/7 days a week. TTY users should call Or, visit Our plan s Formulary The formulary that begins on page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., HUMALOG) and generic drugs are listed in lower-case italics (e.g., enalapril). The information in the column tells you if our plan has any special requirements for coverage of your drug. QLL - Quantity : Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. B/D - Part B vs. Part D: This drug may be covered under either your Part D prescripton drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Member Services at , TTY: a.m. 8 p.m., 7 days a week, October 1 to February 1 (except Thanksgiving and Christmas), and Monday through Friday from February 1 to September 0 (except holi. INJ - Injectable: The drug is available in injectable form. - Mail Orders: Prescription drugs available through mail order. - Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Effective Date April 1, 018 FORMCMAZP18_Classic

6 NEDS Non-Extended Day Supply: This drug is not eligible for an extended days supply. You may have this prescription dispensed by your pharmacy for a maximum of 0 days supply at a time. HI - Home Infusion: The drug may be covered through the medical benefit as a home-infusion medication. For more information, call Member Services at , TTY: a.m. 8 p.m., 7 days a week, October 1 to February 1 (except Thanksgiving and Christmas), and Monday through Friday from February 1 to September 0 (except holi. Effective Date April 1, 018 FORMCMAZP18_Classic

7 Covered Medications by Therapeutic Category Name Anti - Infectives abacavir oral solution abacavir oral tablet abacavir-lamivudine abacavir-lamivudinezidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 00 mg/ ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir ALBENZA ALINIA ORAL SUSPEN- SION FOR RECONSTITU- TION ALINIA ORAL TABLET amantadine hcl oral capsule amantadine hcl oral tablet AMBISOME amikacin injection solution 1, 000 mg/ ml amikacin injection solution 00 mg/ ml amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 1 mg, 0 mg amoxicillin-pot clavulanate amphotericin b ampicillin oral capsule 00 mg ; QLL (90 per 0 ; QLL (0 ; QLL (0 ; QLL (0 B/D PAR; ; HI B/D PAR; ; HI; PAR; ; QLL (180 per 0 ; QLL ( per 0 B/D PAR; ; HI; B/D PAR; Name ampicillin sodium injection recon soln 1 gram, 10 gram, 1 mg ampicillin sodium injection recon soln gram, 0 mg, 00 mg ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1. gram, gram ampicillin-sulbactam injection recon soln 1 gram ampicillin-sulbactam intravenous recon soln 1. gram ampicillin-sulbactam intravenous recon soln gram APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 10 mg, 00 mg atazanavir oral capsule 00 mg atovaquone atovaquone-proguanil oral tablet mg ATRIPLA AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) azithromycin intravenous azithromycin oral aztreonam injection recon soln 1 gram baciim bacitracin intramuscular BARACLUDE ORAL SOLUTION ; HI; ; HI; HI; ; QLL (10 per 0 QLL (90 per 0 ; QLL (0 per 0 ; QLL (0 per 0 PAR; ; QLL (0 per 0 ; HI ; HI; PAR; Effective Date April 1, 018 FORMCMAZP18_Classic

8 Name BICILLIN C-R INTRAMUS- CULAR SYRINGE 1,00, 000 UNIT/ ML(00K/ 00K) BILTRICIDE CANCIDAS CAPASTAT CASPOFUNGIN INTRA- VENOUS RECON SOLN 0 MG CASPOFUNGIN INTRA- VENOUS RECON SOLN 70 MG CAYSTON cefaclor oral capsule cefaclor oral suspension for reconstitution 1 mg/ ml, 0 mg/ ml cefaclor oral suspension for reconstitution 7 mg/ ml cefaclor oral tablet extended release 1 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 0 mg/ ml, 00 mg/ ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/ 0 ml cefazolin injection recon soln 1 gram, 00 mg cefazolin injection recon soln 10 gram cefazolin injection recon soln 100 gram, 0 gram, 00 g cefazolin intravenous cefdinir cefepime cefepime in dextrose,iso-osm intravenous piggyback 1 gram/ 0 ml B/D PAR; B/D PAR B/D PAR PAR; ; LA ; HI; HI; ; HI; Name cefepime in dextrose,iso-osm intravenous piggyback gram/ 100 ml cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram, gram cefoxitin intravenous recon soln 10 gram cefpodoxime cefprozil ceftazidime in dw ceftazidime injection recon soln 1 gram, gram ceftazidime injection recon soln gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, gram, 0 mg, 00 mg ceftriaxone injection recon soln 10 gram CEFTRIAXONE INJEC- TION RECON SOLN 100 GRAM ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 70 mg cefuroxime sodium intravenous recon soln 1. gram cefuroxime sodium intravenous recon soln 7. gram cephalexin oral capsule 0 mg, 00 mg cephalexin oral suspension for reconstitution chloramphenicol sod succinate chloroquine phosphate ciprofloxacin (mixture) ciprofloxacin hcl oral tablet 0 mg, 00 mg, 70 mg ciprofloxacin lactate intravenous solution 00 mg/0 ml ; HI; HI; ; HI; HI; ; HI; HI; ; HI; ; HI; HI; Effective Date April 1, FORMCMAZP18_Classic

9 Name ciprofloxacin lactate intravenous solution 00 mg/0 ml clarithromycin clindamycin hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 00 mg/ ml, 900 mg/ ml clindamycin phosphate intravenous solution 00 mg/ ml clotrimazole mucous membrane COARTEM colistin (colistimethate na) COMPLERA CRIXIVAN ORAL CAPSULE 00 MG CRIXIVAN ORAL CAPSULE 00 MG dapsone oral DAPTOMYCIN DARAPRIM demeclocycline DESCOVY dicloxacillin didanosine oral capsule,delayed release(dr/ec) 1 mg didanosine oral capsule,delayed release(dr/ec) 00 mg didanosine oral capsule,delayed release(dr/ec) 0 mg, 00 mg doxy-100 doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline monohydrate oral capsule 100 mg, 0 mg, 7 mg EDURANT efavirenz oral capsule 00 mg HI; ; HI; ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (0 per 0 ; QLL (90 per 0 ; QLL (0 ; QLL (0 ; QLL (0 per 0 ; QLL (10 per 0 Name efavirenz oral capsule 0 mg efavirenz oral tablet EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPCLUSA EPIVIR HBV ORAL SOLUTION ERAXIS(WATER DILUENT) INTRA- VENOUS RECON SOLN 100 MG ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/ EC) 0 MG, 00 MG ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/ EC) MG ERYTHROCIN (AS STEARATE) ORAL TABLET 0 MG ERYTHROCIN INTRA- VENOUS RECON SOLN 00 MG erythromycin ethylsuccinate oral tablet erythromycin oral tablet 0 mg ERYTHROMYCIN ORAL TABLET 00 MG ethambutol EVOTAZ famciclovir oral tablet 1 mg, 0 mg famciclovir oral tablet 00 mg fluconazole ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (870 per 0 PAR; PAR; ; QLL (0 PAR; ; HI ; QLL (0 per 0 ; QLL (0 ; QLL (1 per 7 Effective Date April 1, FORMCMAZP18_Classic

10 Name fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/ 0 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/ 100 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/ 00 ml flucytosine fosamprenavir foscarnet FUZEON SUBCUTA- NEOUS RECON SOLN ganciclovir sodium gentamicin injection solution 0 mg/ ml gentamicin injection solution 0 mg/ml gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml gentamicin sulfate (pf) intravenous solution 0 mg/ ml GENVOYA griseofulvin microsize oral suspension griseofulvin ultramicrosize HARVONI hydroxychloroquine imipenem-cilastatin INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 00 MG INTELENCE ORAL TABLET MG ; HI; HI; ; QLL (10 per 0 B/D PAR; ; QLL (0 per 0 B/D PAR; ; HI; ; HI; ; QLL (0 per 0 PAR; ; QLL (8 per 8 ; HI; ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (80 per 0 Name INVANZ INJECTION INVANZ INTRAVENOUS INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE MG isoniazid oral itraconazole ivermectin JULUCA KALETRA ORAL TABLET 100- MG KALETRA ORAL TABLET 00-0 MG ketoconazole oral lamivudine oral solution lamivudine oral tablet 100 mg lamivudine oral tablet 10 mg lamivudine oral tablet 00 mg lamivudine-zidovudine levofloxacin intravenous levofloxacin oral LEXIVA ORAL SUSPEN- SION LEXIVA ORAL TABLET ; HI ; QLL (00 per 0 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (180 per 0 ; QLL (70 per 0 ; QLL (0 per 0 ; QLL (00 per 0 ; QLL (10 per 0 ; QLL (900 ; QLL (0 ; QLL (0 ; QLL (0 ; QLL (1800 per 0 ; QLL (10 per 0 Effective Date April 1, FORMCMAZP18_Classic

11 Name linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet linezolid-0.9% sodium chloride lopinavir-ritonavir MACRODANTIN ORAL CAPSULE MG, 0 MG mefloquine meropenem intravenous recon soln 1 gram meropenem intravenous recon soln 00 mg meropenem-0.9% sodium chloride intravenous piggyback 00 mg/0 ml methenamine hippurate methenamine mandelate oral tablet 1 gram metro i.v. metronidazole in nacl (iso-os) metronidazole oral minocycline oral capsule minocycline oral tablet moderiba morgidox MYCOBUTIN nafcillin in dextrose iso-osm intravenous piggyback 1 gram/ 0 ml nafcillin injection recon soln 1 gram, 10 gram nafcillin injection recon soln gram nafcillin intravenous NEBUPENT neomycin nevirapine oral suspension nevirapine oral tablet PAR; HI; PAR; ; QLL (180 PAR; ; QLL ( PAR; ; QLL (80 ; HI; ; HI; ; HI; B/D PAR; ; QLL (100 ; QLL (0 Name nevirapine oral tablet extended release hr 100 mg nevirapine oral tablet extended release hr 00 mg nitrofurantoin macrocrystal oral capsule 100 mg, 0 mg nitrofurantoin monohyd/m-cryst NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET NOXAFIL ORAL SUSPEN- SION nystatin oral suspension nystatin oral tablet ODEFSEY ofloxacin oral tablet 00 mg ofloxacin oral tablet 00 mg oseltamivir oxacillin injection recon soln 1 gram oxacillin injection recon soln 10 gram paromomycin paser PENICILLIN G POT IN DEXTROSE INTRA- VENOUS PIGGYBACK 1 MILLION UNIT/0 ML PENICILLIN G POT IN DEXTROSE INTRA- VENOUS PIGGYBACK MILLION UNIT/0 ML PENICILLIN G POT IN DEXTROSE INTRA- VENOUS PIGGYBACK MILLION UNIT/0 ML penicillin g potassium injection recon soln 0 million unit ; QLL (0 QLL (0 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (00 per 0 ; QLL (0 per 0 HI; HI ; HI ; HI; Effective Date April 1, FORMCMAZP18_Classic

12 Name penicillin g potassium injection recon soln million unit penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 00,000 unit/ml penicillin g sodium penicillin v potassium PENTAM pfizerpen-g injection recon soln million unit piperacillin-tazobactam intravenous recon soln 1. gram piperacillin-tazobactam intravenous recon soln. gram piperacillin-tazobactam intravenous recon soln.7 gram,. gram, 0. gram PREZCOBIX PREZISTA ORAL SUSPEN- SION PREZISTA ORAL TABLET 10 MG PREZISTA ORAL TABLET 00 MG, 800 MG PREZISTA ORAL TABLET 7 MG PRIFTIN primaquine pyrazinamide quinine sulfate RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE ; HI; ; HI; ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (0 per 0 ; QLL (00 per 0 PAR; ; QLL (0 per 180 ; QLL (180 per 0 ; QLL (0 per 0 Name RETROVIR INTRA- VENOUS REYATAZ ORAL CAPSULE 10 MG, 00 MG REYATAZ ORAL CAPSULE 00 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg ribavirin oral capsule ribavirin oral tablet 00 mg rifampin intravenous rifampin oral RIFATER rimantadine SELZENTRY ORAL SOLUTION SELZENTRY ORAL TABLET 10 MG, 00 MG SELZENTRY ORAL TABLET MG SELZENTRY ORAL TABLET 7 MG SIRTURO stavudine oral capsule 1 mg, 0 mg stavudine oral capsule 0 mg, 0 mg STREPTOMYCIN STRIBILD STROMECTOL sulfadiazine sulfamethoxazole-trimethoprim SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 0 MG SUSTIVA ORAL TABLET SYNAGIS SYNERCID ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; HI; ; QLL (180 per 0 ; QLL (10 per 0 ; QLL (10 per 0 ; QLL (0 per 0 PAR; ; LA ; QLL (10 ; QLL (0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (0 per 0 PAR; ; LA Effective Date April 1, FORMCMAZP18_Classic

13 Name TAMIFLU ORAL SUSPEN- SION FOR RECONSTITU- TION tazicef injection recon soln 1 gram tazicef injection recon soln gram, gram TECHNIVIE TEFLARO INTRAVENOUS RECON SOLN 00 MG TEFLARO INTRAVENOUS RECON SOLN 00 MG tenofovir disoproxil fumarate terbinafine hcl oral tetracycline TIGECYCLINE TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET MG, 0 MG tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ TRUVADA TYBOST valacyclovir valganciclovir vancomycin in 0.9 % sodium chl intravenous piggyback 1 gram/00 ml PAR; ; QLL ( per 8 ; QLL (0 per 0 ; QLL (0 ; QLL (0 per 0 ; QLL (0 per 0 ; HI; ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 Name vancomycin in 0.9 % sodium chl intravenous piggyback 00 mg/100 ml, 70 mg/10 ml vancomycin in dextrose % intravenous piggyback 1 gram/ 00 ml vancomycin in dextrose % intravenous piggyback 00 mg/ 100 ml, 70 mg/10 ml vancomycin injection vancomycin intravenous recon soln 1,000 mg, 10 gram, 00 mg vancomycin intravenous recon soln gram, 70 mg vancomycin oral capsule 1 mg vancomycin oral capsule 0 mg VIDEX GRAM PEDIATRIC VIDEX GRAM PEDIATRIC VIRACEPT ORAL TABLET 0 MG VIRACEPT ORAL TABLET MG VIREAD ORAL POWDER VIREAD ORAL TABLET voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 00 mg voriconazole oral tablet 0 mg VOSEVI XIFAXAN ORAL TABLET 0 MG B/D PAR; B/D PAR; ; HI; PAR; ; QLL (0 per 10 PAR; ; QLL (80 per 10 ; QLL (100 per 0 ; QLL (100 per 0 ; QLL (00 per 0 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (0 per 0 PAR; ; QLL (00 PAR; ; QLL (0 PAR; ; QLL (10 PAR; ; QLL (0 PAR; ; QLL (8 per 8 Effective Date April 1, FORMCMAZP18_Classic

14 Name ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZOSYN IN DEXTROSE (ISO-OSM) INTRA- VENOUS PIGGYBACK. GRAM/0 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRA- VENOUS PIGGYBACK.7 GRAM/0 ML,. GRAM/100 ML ; QLL (00 per 0 ; QLL (90 per 0 ; QLL (180 ; QLL (190 ; QLL (0 Antineoplastic / Immunosuppressant s ABRAXANE ADAGEN ; LA adriamycin intravenous solution adrucil intravenous solution. gram/0 ml B/D PAR; adrucil intravenous solution 00 mg/10 ml B/D PAR; AFINITOR PAR; AFINITOR DISPERZ PAR; ALECENSA ; LA ALIMTA ALIQOPA PAR; ; LA ALUNBRIG ORAL TABLET 180 MG, 90 MG ; QLL (0 per 0 ALUNBRIG ORAL TABLET 0 MG PAR; ; QLL (180 ALUNBRIG ORAL TABLETS,DOSE PACK ; QLL (0 per 180 anastrozole ; QLL (0 ARRANON ARZERRA Name ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE HR 0. MG, 1 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE HR MG AVASTIN azacitidine azasan azathioprine azathioprine sodium BAVENCIO BELEODAQ BENDEKA BESPONSA bexarotene bicalutamide BICNU bleomycin BLINCYTO INTRA- VENOUS KIT BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 00 MG, 00 MG BUSULFEX CABOMETYX ORAL TABLET 0 MG CABOMETYX ORAL TABLET 0 MG, 0 MG CALQUENCE CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 00 MG carboplatin intravenous solution CELLCEPT INTRA- VENOUS cisplatin cladribine clofarabine B/D PAR; B/D PAR; PAR; ; LA B/D PAR; B/D PAR; B/D PAR; PAR; ; LA PAR; B/D PAR; PAR; ; QLL (0 B/D PAR; PAR; PAR; ; QLL (10 PAR; ; QLL (0 B/D PAR PAR; ; LA; QLL (90 PAR; ; LA; QLL (0 PAR; ; LA PAR; ; LA; QLL (90 PAR; ; LA; QLL (0 B/D PAR; B/D PAR; Effective Date April 1, FORMCMAZP18_Classic

15 Name CLOLAR COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1) COMETRIQ ORAL CAPSULE 10 MG/DAY(80 MG X1-0 MG X) COMETRIQ ORAL CAPSULE 0 MG/DAY (0 MG X /DAY) COSMEGEN COTELLIC CYCLOPHOSPHAMIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine cytarabine (pf) injection solution 100 mg/ ml (0 mg/ ml), gram/0 ml (100 mg/ml) cytarabine (pf) injection solution 0 mg/ml dacarbazine DACOGEN dactinomycin DARZALEX daunorubicin intravenous solution decitabine dexrazoxane hcl intravenous recon soln 0 mg dexrazoxane hcl intravenous recon soln 00 mg docetaxel intravenous solution 10 mg/1 ml (10 mg/ml), 0 mg/ ml (10 mg/ml) docetaxel intravenous solution 10 mg/8 ml (0 mg/ml), 0 mg/ml (1 ml), 80 mg/ ml (0 PAR; ; LA; QLL ( per 8 PAR; ; LA; QLL (11 per 8 PAR; ; LA; QLL (8 per 8 PAR; ; LA; QLL (90 B/D PAR; B/D PAR; B/D PAR; B/D PAR; PAR; ; LA B/D PAR; B/D PAR; B/D PAR; B/D PAR ; LA Name mg/ml), 80 mg/8 ml (10 mg/ ml) DOCETAXEL INTRA- VENOUS SOLUTION 0 MG/ML doxorubicin intravenous recon soln 10 mg doxorubicin intravenous recon soln 0 mg doxorubicin intravenous solution doxorubicin, peg-liposomal DROXIA ELITEK EMCYT EMPLICITI epirubicin intravenous solution 00 mg/100 ml epirubicin intravenous solution 0 mg/ ml ERBITUX INTRAVENOUS SOLUTION 100 MG/0 ML ERBITUX INTRAVENOUS SOLUTION 00 MG/100 ML ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 1 MG, 0 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE B/D PAR PAR; B/D PAR; B/D PAR; PAR; PAR; PAR; ; LA; QLL (0 ; QLL (0 ; QLL (0 per 0 PAR; ; LA; QLL (0 PAR; ; LA; QLL (0 PAR; ; QLL ( per Effective Date April 1, FORMCMAZP18_Classic

16 Name SUBCUTANEOUS RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN FUSILEV GAZYVA gemcitabine intravenous recon soln 1 gram, 00 mg gemcitabine intravenous recon soln gram gemcitabine intravenous solution 1 gram/. ml (8 mg/ml), 00 mg/. ml (8 mg/ml) gemcitabine intravenous solution gram/. ml (8 mg/ml) gengraf GILOTRIF GLEOSTINE HALAVEN HERCEPTIN INTRA- VENOUS RECON SOLN 10 MG HERCEPTIN INTRA- VENOUS RECON SOLN 0 MG HEXALEN hydroxyprogesterone caproate hydroxyurea IBRANCE ; QLL (1 per 8 B/D PAR; PAR; B/D PAR; PAR; ; LA; QLL (0 ; LA PAR; ; LA; QLL (0 Name ICLUSIG ORAL TABLET 1 MG ICLUSIG ORAL TABLET MG idarubicin IDHIFA ORAL TABLET 100 MG IDHIFA ORAL TABLET 0 MG ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg imatinib oral tablet 00 mg IMBRUVICA ORAL CAPSULE 10 MG IMFINZI INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET MG IRESSA irinotecan intravenous solution 100 mg/ ml, 0 mg/ ml irinotecan intravenous solution 00 mg/ ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 1 MG JAKAFI ORAL TABLET 0 MG JAKAFI ORAL TABLET MG JAKAFI ORAL TABLET MG JEVTANA KADCYLA INTRAVENOUS RECON SOLN 100 MG PAR; LA; QLL (0 PAR; ; LA; QLL (0 PAR; ; LA; QLL (0 PAR; ; LA; QLL (0 PAR; ; QLL (0 PAR; ; QLL (0 PAR; ; LA; QLL (10 PAR; PAR; ; LA; QLL (0 PAR; ; LA; QLL (10 ; LA PAR; ; LA; QLL (10 PAR; ; LA; QLL (100 PAR; ; LA; QLL (7 PAR; ; LA; QLL (0 PAR; ; LA; QLL (00 PAR; ; LA Effective Date April 1, FORMCMAZP18_Classic

17 Name KADCYLA INTRAVENOUS RECON SOLN 10 MG KEPIVANCE KEYTRUDA KISQALI FEMARA CO- PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-. MG KISQALI FEMARA CO- PACK ORAL TABLET 00 MG/DAY(00 MG X )-. MG KISQALI FEMARA CO- PACK ORAL TABLET 00 MG/DAY(00 MG X )-. MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1) KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) KYPROLIS LARTRUVO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/ DAY) LENVIMA ORAL CAPSULE 1 MG/DAY(10 MG X 1- MG X 1), 0 MG/DAY (10 MG X ), 8 MG/DAY ( MG X ) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1- MG X), MG/DAY(10 MG X - MG X 1) letrozole leucovorin calcium injection recon soln 100 mg, 00 mg, 0 mg, 0 mg leucovorin calcium injection recon soln 00 mg PAR; PAR; PAR; ; QLL (9 per 8 PAR; ; QLL (70 per 8 PAR; ; QLL (91 per 8 PAR; ; QLL (1 per 1 PAR; ; QLL ( per 1 PAR; ; QLL ( per 1 ; LA ; LA PAR; ; LA; QLL (0 PAR; ; LA; QLL (0 PAR; ; LA; QLL (90 ; QLL (0 Name leucovorin calcium oral LEUKERAN leuprolide subcutaneous kit levoleucovorin intravenous recon soln 0 mg levoleucovorin intravenous solution LONSURF LUPRON DEPOT LUPRON DEPOT ( NTH) LUPRON DEPOT-PED ( NTH) INTRAMUS- CULAR SYRINGE KIT 11. MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7. MG (PED) LYNPARZA ORAL CAPSULE LYNPARZA ORAL TABLET LYSODREN MARQIBO MATULANE megestrol oral suspension 00 mg/10 ml (10 ml), 800 mg/0 ml (0 ml) megestrol oral suspension 00 mg/10 ml (0 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0. MG MEKINIST ORAL TABLET MG melphalan hcl mercaptopurine mesna MESNEX ORAL methotrexate sodium (pf) injection recon soln PAR; PAR; ; QLL (1 per 8 PAR; ; QLL (1 per 8 PAR; ; QLL (1 per 8 PAR; ; QLL (1 per 8 PAR; ; LA; QLL (80 PAR; ; QLL (10 ; LA PAR; ; QLL (90 PAR; ; QLL (0 Effective Date April 1, FORMCMAZP18_Classic

18 Name methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium MYLOTARG NERLYNX NEXAVAR NILANDRON NINLARO NIPENT NULOJIX octreotide acetate injection solution 1,000 mcg/ml, 00 mcg/ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ ml, 0 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 0 mcg/ml (1 ml) octreotide acetate injection syringe 00 mcg/ml (1 ml) ODOMZO OPDIVO oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 0 mg B/D PAR; B/D PAR; B/D PAR; B/D PAR; PAR; ; LA PAR; ; LA; QLL (180 PAR; ; LA; QLL (10 ; QLL (0 per 0 PAR; ; QLL ( per 8 PAR; PAR; PAR; PAR; PAR; ; LA; QLL (0 PAR; Name oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE MG POMALYST ORAL CAPSULE MG, MG PORTRAZZA PROGRAF INTRA- VENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 1 MG,. MG, 0 MG, MG REVLIMID ORAL CAPSULE MG RITUXAN HYCELA RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ ML RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ ML (10 ML) RUBRACA ORAL TABLET 00 MG RUBRACA ORAL TABLET 0 MG RUBRACA ORAL TABLET 00 MG RYDAPT SANDIMMUNE ORAL SOLUTION SIGNIFOR SIMULECT INTRA- VENOUS RECON SOLN 10 MG ; LA PAR; ; LA; QLL (10 PAR; ; LA; QLL (0 PAR; ; LA; QLL (0 B/D PAR; PAR; ; LA B/D PAR; ; LA; QLL (0 ; LA; QLL (0 ; LA; QLL (10 B/D PAR; ; LA B/D PAR; PAR; ; LA; QLL (180 PAR; ; QLL (10 PAR; ; LA; QLL (10 PAR; ; QLL (0 B/D PAR; ; LA B/D PAR Effective Date April 1, FORMCMAZP18_Classic

19 Name SIMULECT INTRA- VENOUS RECON SOLN 0 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 1. MG SUTENT ORAL CAPSULE MG, 7. MG, 0 MG SYNRIBO TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 0 MG TAGRISSO ORAL TABLET 80 MG tamoxifen TARCEVA ORAL TABLET 100 MG, 10 MG TARCEVA ORAL TABLET MG TARGRETIN ORAL TARGRETIN TOPICAL TASIGNA TECENTRIQ THALOMID ORAL CAPSULE 100 MG, 0 MG THALOMID ORAL CAPSULE 10 MG, 00 MG thiotepa toposar topotecan intravenous recon soln topotecan intravenous solution B/D PAR; B/D PAR; ; QLL (0 per 0 PAR; ; LA; QLL (10 ; QLL (90 per 0 ; QLL (0 per 0 B/D PAR; PAR; ; QLL (10 PAR; ; LA; QLL (0 PAR; ; LA; QLL (0 ; LA; QLL (0 ; LA; QLL (90 PAR; PAR; ; QLL (0 ; QLL (11 per 8 ; LA; QLL (0 per 1 ; QLL (0 per 0 ; QLL (0 per 0 Name TORISEL TREANDA INTRA- VENOUS RECON SOLN TRELSTAR INTRAMUS- CULAR SYRINGE 11. MG/ ML TRELSTAR INTRAMUS- CULAR SYRINGE. MG/ ML TRELSTAR INTRAMUS- CULAR SYRINGE.7 MG/ ML tretinoin (chemotherapy) trexall TRISENOX TYKERB UNITUXIN VECTIBIX INTRA- VENOUS SOLUTION 100 MG/ ML (0 MG/ML) VECTIBIX INTRA- VENOUS SOLUTION 00 MG/0 ML (0 MG/ML) VELCADE VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 0 MG VENCLEXTA STARTING PACK VERZENIO vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ml vincasar pfs intravenous solution mg/ ml vincristine vinorelbine ; QLL (1 per 8 ; QLL (1 per 18 ; QLL (1 per 8 ; QLL (180 per 0 PAR; PAR; PAR; ; LA; QLL (0 PAR; ; LA; QLL (10 PAR; ; LA; QLL (0 PAR; ; LA; QLL (8 per PAR; ; LA; QLL (0 B/D PAR; B/D PAR; B/D PAR; B/D PAR; Effective Date April 1, FORMCMAZP18_Classic

20 Name VOTRIENT VYXEOS XALKORI XATMEP XGEVA XTANDI YERVOY INTRAVENOUS SOLUTION 00 MG/0 ML ( MG/ML) YERVOY INTRAVENOUS SOLUTION 0 MG/10 ML ( MG/ML) yondelis ZALTRAP ZANOSAR ZEJULA ; QLL (10 per 0 B/D PAR; PAR; ; LA; QLL (0 PAR; ; QLL (1.7 per 8 PAR; ; LA; QLL (10 ; LA B/D PAR; ; LA PAR; PAR; ; QLL (90 ZELBORAF PAR; ; LA; QLL (0 ZOLINZA ; QLL (10 per 0 ZORTRESS ORAL TABLET B/D PAR; 0. MG ZORTRESS ORAL TABLET B/D PAR; 0. MG, 0.7 MG ZYDELIG PAR; ; LA; QLL (0 ZYKADIA PAR; ; LA; QLL (10 ZYTIGA ORAL TABLET PAR; ; LA; QLL 0 MG (10 ZYTIGA ORAL TABLET PAR; ; QLL (0 00 MG Autonomic / Cns s, Neurology / Psych ABILIFY MAINTENA ; QLL (1 per 8 ABSTRAL SUBLINGUAL PAR; ; QLL (10 TABLET 100 M Name ABSTRAL SUBLINGUAL TABLET 00 M, 00 M, 00 M, 00 M, 800 M acetaminophen-codeine oral solution 10 mg-1 mg / ml ( ml), 0 mg- mg /10 ml (10 ml), 00 mg-0 mg /1. ml acetaminophen-codeine oral solution 10-1 mg/ ml acetaminophen-codeine oral tablet 00-1 mg acetaminophen-codeine oral tablet 00-0 mg acetaminophen-codeine oral tablet 00-0 mg ADASUVE alprazolam oral tablet amitriptyline amoxapine AMPYRA AMRIX APOKYN APTIOM aripiprazole oral solution aripiprazole oral tablet 10 mg aripiprazole oral tablet 1 mg aripiprazole oral tablet mg aripiprazole oral tablet 0 mg, 0 mg aripiprazole oral tablet mg aripiprazole oral tablet, disintegrating 10 mg aripiprazole oral tablet, disintegrating 1 mg PAR; ; QLL (10 ; QLL (00 per 0 ; QLL (00 ; QLL (90 ; QLL (0 ; QLL (180 ; QLL (10 PAR; ; LA; QLL (0 PAR; PAR; ; LA ; QLL (900 per 0 ; QLL (90 ; QLL (0 ; QLL (0 ; QLL (0 ; QLL (180 ; QLL (90 ; QLL (0 Effective Date April 1, FORMCMAZP18_Classic

21 Name ARISTADA INTRAMUS- CULAR SUSPENSION, EXTENDED REL SYRING 1,0 MG/.9 ML ARISTADA INTRAMUS- CULAR SUSPENSION, EXTENDED REL SYRING 1 MG/1. ML ARISTADA INTRAMUS- CULAR SUSPENSION, EXTENDED REL SYRING MG/. ML ARISTADA INTRAMUS- CULAR SUSPENSION, EXTENDED REL SYRING 88 MG/. ML atomoxetine oral capsule 10 mg, 18 mg, mg, 0 mg atomoxetine oral capsule 100 mg, 0 mg, 80 mg baclofen BANZEL ORAL SUSPEN- SION BANZEL ORAL TABLET 00 MG BANZEL ORAL TABLET 00 MG benztropine oral BRIVIACT INTRA- VENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 7 MG BRIVIACT ORAL TABLET MG BRIVIACT ORAL TABLET 0 MG bromocriptine buprenorphine hcl injection solution ; QLL (1. per 0 ; QLL (. per 0 ; QLL (. per 0 ; QLL (0 per 0 ; QLL (0 per 0 PAR; ; QLL (00 PAR; ; QLL (80 PAR; ; QLL (0 PAR PAR; ; QLL (00 PAR; ; QLL (00 PAR; ; QLL (0 PAR; ; QLL (0 PAR; ; QLL (10 ; QLL (90 Name buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet mg buprenorphine hcl sublingual tablet 8 mg buprenorphine-naloxone sublingual tablet -0. mg buprenorphine-naloxone sublingual tablet 8- mg bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 7 mg bupropion hcl oral tablet extended release 1 hr 100 mg bupropion hcl oral tablet extended release 1 hr 10 mg, 00 mg bupropion hcl oral tablet extended release hr 10 mg bupropion hcl oral tablet extended release hr 00 mg buspirone butalbital-acetaminop-caf-cod oral capsule mg butorphanol tartrate injection butorphanol tartrate nasal carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 mg/ ml carbamazepine oral suspension 00 mg/10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr carbamazepine oral tablet, chewable carbidopa-levodopa celecoxib oral capsule 100 mg, 00 mg, 0 mg ; QLL (10 per 0 ; QLL (0 ; QLL (0 ; QLL (0 ; QLL (90 ; QLL (1 ; QLL (180 ; QLL (10 ; QLL (0 ; QLL (90 ; QLL (0 ; QLL (180 ; QLL ( per 8 ; QLL (0 per 0 Effective Date April 1, FORMCMAZP18_Classic

22 Name celecoxib oral capsule 00 mg CELONTIN ORAL CAPSULE 00 MG chlorpromazine citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 0 mg citalopram oral tablet 0 mg clomipramine clonazepam oral tablet 0. mg clonazepam oral tablet 1 mg clonazepam oral tablet mg clonazepam oral tablet, disintegrating 0.1 mg clonazepam oral tablet, disintegrating 0. mg clonazepam oral tablet, disintegrating 0. mg clonazepam oral tablet, disintegrating 1 mg clonazepam oral tablet, disintegrating mg clorazepate dipotassium clozapine oral tablet 100 mg clozapine oral tablet 00 mg clozapine oral tablet mg clozapine oral tablet 0 mg clozapine oral tablet, disintegrating 100 mg clozapine oral tablet, disintegrating 1. mg ; QLL (0 per 0 ; QLL (00 ; QLL (10 ; QLL (0 ; QLL (0 ; QLL (100 ; QLL (00 ; QLL (00 ; QLL (800 ; QLL (00 ; QLL (100 ; QLL (00 ; QLL (00 ; QLL (70 ; QLL (10 ; QLL (1080 ; QLL (0 ; QLL (70 per 0 ; QLL (10 per 0 Name clozapine oral tablet, disintegrating 10 mg clozapine oral tablet, disintegrating 00 mg clozapine oral tablet, disintegrating mg COPAXONE SUBCUTA- NEOUS SYRINGE 0 MG/ ML COPAXONE SUBCUTA- NEOUS SYRINGE 0 MG/ ML dantrolene desipramine desvenlafaxine oral tablet extended release hr 100 mg DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG desvenlafaxine succinate oral tablet extended release hr 100 mg desvenlafaxine succinate oral tablet extended release hr mg desvenlafaxine succinate oral tablet extended release hr 0 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet mg dextroamphetamineamphetamine oral tablet 10 mg, 1. mg, 1 mg, 0 mg, mg, 7. mg QLL (180 per 0 QLL (10 per 0 ; QLL (1080 per 0 PAR; ; QLL (0 PAR; ; QLL (1 per 8 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (80 per 0 ; QLL (0 per 0 PAR; ; QLL (180 PAR; ; QLL (90 ; QLL (90 Effective Date April 1, FORMCMAZP18_Classic

23 Name dextroamphetamineamphetamine oral tablet 0 mg DIASTAT DIASTAT ACUDIAL RECTAL KIT MG DIASTAT ACUDIAL RECTAL KIT MG diazepam injection solution diazepam injection syringe diazepam intensol diazepam oral concentrate diazepam oral solution mg/ ml (1 mg/ml) diazepam oral tablet 10 mg diazepam oral tablet mg diazepam oral tablet mg diazepam rectal kit mg diazepam rectal kit. mg, mg diclofenac potassium diclofenac sodium oral diclofenac sodium topical gel 1 % diflunisal DILANTIN DILANTIN EXTENDED DILANTIN INFATABS divalproex donepezil oral tablet 10 mg donepezil oral tablet mg doxepin oral duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg ; QLL (0 ; QLL (0 ; QLL (0 ; QLL (100 ; QLL (10 ; QLL (00 ; QLL (0 ; QLL (1000 ; QLL (0 ; QLL (180 ; QLL (10 Name duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg duramorph (pf) injection solution 0. mg/ml duramorph (pf) injection solution 1 mg/ml EMSAM endocet oral tablet 10- mg, - mg, 7.- mg entacapone epitol EQUETRO ORAL CAPSULE, ER MULTI- PHASE 1 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTI- PHASE 1 HR 00 MG EQUETRO ORAL CAPSULE, ER MULTI- PHASE 1 HR 00 MG ergoloid ergomar escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet mg ethosuximide FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG, 1 MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET MG ; QLL (90 ; QLL (0 ; QLL (180 per 0 QLL (180 per 0 ; QLL (0 per 0 ; QLL (0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (00 ; QLL (0 ; QLL (0 ; QLL (10 ; QLL (70 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (180 per 0 Effective Date April 1, 018 FORMCMAZP18_Classic

24 Name FANAPT ORAL TABLET MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS, DOSE PACK FAZACLO ORAL TABLET, DISINTEGRATING 100 MG FAZACLO ORAL TABLET, DISINTEGRATING 1. MG FAZACLO ORAL TABLET, DISINTEGRATING MG felbamate fenoprofen oral tablet fentanyl citrate fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, mcg/hr, 0 mcg/hr, 7 mcg/ hr FENTORA FETZIMA ORAL CAPSULE,EXT REL HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 10 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG fluoxetine oral capsule 10 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule 0 mg ; QLL (10 per 0 ; QLL (90 per 0 ; QLL (1 per QLL (70 per 0 QLL (10 per 0 QLL (1080 per 0 PAR; ; QLL (10 ; QLL (1 PAR; ; QLL (10 PAR; ; QLL ( per PAR; ; QLL (0 PAR; ; QLL (180 PAR; ; QLL (90 ; QLL (0 ; QLL (10 ; QLL (0 Name fluoxetine oral solution fluphenazine decanoate fluphenazine hcl flurbiprofen fluvoxamine oral tablet 100 mg fluvoxamine oral tablet mg fluvoxamine oral tablet 0 mg fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10 MG, 1 MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 100 mg gabapentin oral capsule 00 mg gabapentin oral capsule 00 mg gabapentin oral solution 0 mg/ ml gabapentin oral solution 0 mg/ ml ( ml), 00 mg/ ml ( ml) gabapentin oral tablet 00 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 1 MG, 1 MG GEODON INTRAMUS- CULAR ; QLL (00 ; QLL (90 ; QLL (0 ; QLL (180 ; QLL (70 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (90 per 0 ; QLL (0 per 0 ; QLL ( per 0 ; QLL (1080 ; QLL (0 ; QLL (70 ; QLL (10 ; QLL (10 per 0 ; QLL (180 ; QLL (10 Effective Date April 1, 018 FORMCMAZP18_Classic

25 Name GILENYA glatiramer subcutaneous syringe 0 mg/ml glatiramer subcutaneous syringe 0 mg/ml GLATOPA SUBCUTA- NEOUS SYRINGE 0 MG/ ML guanfacine oral tablet extended release hr GUANIDINE haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate oral HETLIOZ hycet hydrocodone-acetaminophen oral solution 7.- mg/1 ml hydrocodone-acetaminophen oral tablet 10- mg, - mg, 7.- mg hydrocodone-ibuprofen oral tablet mg hydromorphone oral tablet mg, mg hydromorphone oral tablet 8 mg ibuprofen oral suspension ibuprofen oral tablet 00 mg, 00 mg, 800 mg imipramine hcl INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.7 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 1 MG/ML PAR; ; QLL (0 PAR; QLL (0 per 0 PAR; ; QLL (1 per 8 PAR; ; QLL (0 PAR; ; QLL (0 PAR; ; LA; QLL (0 ; QLL (700 per 0 ; QLL (700 ; QLL (0 ; QLL (0 ; QLL (0 ; QLL (180 ; QLL (0.7 per 8 ; QLL (1 per 8 Name INVEGA SUSTENNA INTRAMUSCULAR SYRINGE MG/1. ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 9 MG/0. ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0. ML INVEGA TRINZA INTRA- MUSCULAR SYRINGE 7 MG/0.87 ML INVEGA TRINZA INTRA- MUSCULAR SYRINGE 10 MG/1.1 ML INVEGA TRINZA INTRA- MUSCULAR SYRINGE MG/1.7 ML INVEGA TRINZA INTRA- MUSCULAR SYRINGE 819 MG/. ML KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 0 MG lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible LATUDA ORAL TABLET 10 MG, 0 MG LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 80 MG levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,00 mg/100 ml ; QLL (1. per 8 ; QLL (0. per 8 ; QLL (0. per 8 ; QLL (0.87 per 90 ; QLL (1.1 per 90 ; QLL (1.7 per 90 ; QLL (. per 90 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (0 per 0 Effective Date April 1, 018 FORMCMAZP18_Classic

26 Name levetiracetam in nacl (iso-os) intravenous piggyback 00 mg/ 100 ml levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 00 mg/ ml ( ml) levetiracetam oral tablet levetiracetam oral tablet extended release hr 00 mg levetiracetam oral tablet extended release hr 70 mg levorphanol tartrate lithium carbonate lithium citrate oral solution 8 meq/ ml LODOSYN lorazepam intensol lorazepam oral lorcet (hydrocodone) lorcet hd lorcet plus oral tablet 7.- mg loxapine succinate LUNESTA LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 10 MG LYRICA ORAL CAPSULE 00 MG LYRICA ORAL CAPSULE MG, 00 MG LYRICA ORAL CAPSULE MG LYRICA ORAL CAPSULE 0 MG ; QLL (180 ; QLL (10 ; QLL (180 ; QLL (0 ; QLL (0 ; QLL (0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (10 per 0 ; QLL (90 per 0 ; QLL (0 per 0 ; QLL (70 per 0 ; QLL (0 per 0 Name LYRICA ORAL CAPSULE 7 MG LYRICA ORAL SOLUTION maprotiline oral tablet mg maprotiline oral tablet 0 mg maprotiline oral tablet 7 mg MARPLAN meclofenamate meloxicam oral suspension meloxicam oral tablet memantine oral solution memantine oral tablet 10 mg memantine oral tablet mg MESTINON ORAL SYRUP metadate er methadone injection solution methadone intensol methadone oral concentrate methadone oral solution 10 mg/ ml methadone oral solution mg/ ml methadone oral tablet 10 mg methadone oral tablet mg methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release 1 ; QLL (0 per 0 ; QLL (900 per 0 ; QLL (70 ; QLL (1 ; QLL (00 per 0 ; QLL (0 ; QLL (00 ; QLL (0 ; QLL (90 ; QLL (90 QLL (10 per 0 ; QLL (0 ; QLL (0 ; QLL (900 ; QLL (1800 ; QLL (180 ; QLL (0 ; QLL (90 ; QLL (90 Effective Date April 1, 018 FORMCMAZP18_Classic

27 Name MIGRANAL mirtazapine oral tablet 1 mg mirtazapine oral tablet 0 mg mirtazapine oral tablet mg mirtazapine oral tablet 7. mg mirtazapine oral tablet, disintegrating 1 mg mirtazapine oral tablet, disintegrating 0 mg mirtazapine oral tablet, disintegrating mg modafinil oral tablet 100 mg modafinil oral tablet 00 mg morphine (pf) injection solution 0. mg/ml morphine (pf) injection solution 1 mg/ml morphine (pf) intravenous patient control.analgesia soln 10 mg/0 ml morphine (pf) intravenous patient control.analgesia soln 0 mg/0 ml morphine concentrate oral solution morphine injection syringe 10 mg/ml morphine injection syringe mg/ml, mg/ml morphine injection syringe 8 mg/ml morphine intravenous cartridge mg/ml, 8 mg/ml morphine intravenous cartridge mg/ml ; QLL (8 per 8 ; QLL (90 ; QLL ( ; QLL (0 ; QLL (180 ; QLL (90 ; QLL ( ; QLL (0 PAR; ; QLL (0 PAR; ; QLL (0 ; QLL (180 per 0 ; QLL (180 ; QLL (0 B/D PAR; ; QLL (180 ; QLL (70 ; QLL (10 ; QLL (180 per 0 ; QLL (180 per 0 ; QLL (180 per 0 QLL (180 per 0 Name morphine intravenous solution 10 mg/ml morphine intravenous solution mg/ml, 8 mg/ml morphine intravenous syringe mg/ml, mg/ml morphine oral solution 10 mg/ ml morphine oral solution 0 mg/ ml ( mg/ml) morphine oral tablet 1 mg morphine oral tablet 0 mg morphine oral tablet extended release 100 mg, 1 mg, 0 mg, 0 mg morphine oral tablet extended release 00 mg nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 0 mg/ml naloxone naltrexone NAMENDA XR ORAL CAP, SPRINKLE,ER HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER HR naproxen oral tablet NARCAN NASAL SPRAY, NON-AEROSOL MG/ ACTUATION nefazodone oral tablet 100 mg nefazodone oral tablet 10 mg nefazodone oral tablet 00 mg ; QLL (10 ; QLL (180 QLL (180 per 0 ; QLL (700 per 0 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (90 ; QLL (0 ; QLL (180 ; QLL (90 ; QLL ( per ; QLL (0 per 0 ; QLL (180 ; QLL (10 ; QLL (90 Effective Date April 1, 018 FORMCMAZP18_Classic

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