LIST OF COVERED DRUGS

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1 LIST OF COVERED DRUGS Community Care Plus FIDA-MMP ICS H4465_ListofCoveredDrugs_2017_82216

2 Table of Contents Analgesics... 3 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders ICS Community Care Plus 2017 FIDA-MMP Formulary Formulary ID: Version: 7 Effective: January 01,

3 Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives Cough And Cold Products Dental And Oral Agents Dermatological Agents Devices Disinfectants (For Non-Dermatologic Use) Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals ICS Community Care Plus 2017 FIDA-MMP Formulary Formulary ID: Version: 7 Effective: January 01,

4 Analgesics Analgesics, Miscellaneous acephen 120 mg suppository outer 120 mg * acephen 325 mg suppository outer 325 mg * acephen 650 mg suppository outer 650 mg * acetaminophen 120 mg suppos outer 120 mg * acetaminophen 160 mg rapid tab 160 mg * acetaminophen 160 mg/5 ml elx 160 mg/5 ml * acetaminophen 325 mg liqui-gel 325 mg * acetaminophen 650 mg suppos 650 mg * acetaminophen 80 mg rapid tab children's 80 mg * acetaminophen-codeine 120 mg-12 mg/5 ml solution mg/5 ml acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) (Fiorinal with Codeine #3) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (2700 per 30 days) QL (2700 per 30 days) QL (360 per 30 days) QL (180 per 30 days) PA-HRM; QL (360 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) 3

5 BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0.3 mg/ml buprenorphine hcl injection syringe 0.3 mg/ml butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR (Buprenorphine HCl) (Buprenorphine HCl) (Fiorinal with Codeine #3) (Fioricet with Codeine) (Tencon) (Esgic) (Esgic) (Fiorinal) capacet oral capsule mg (Esgic) child non-aspirin 160 mg/5 ml children's 160 mg/5 ml * (Acetaminophen) QL (60 per 30 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (4 per 28 days) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (240 per 30 days) 4

6 child pain-fever 160 mg/5 ml a/f, QL (240 per 30 days) (Infants' Tylenol) asa/f, ibu/f 160 mg/5 ml * child tactinal 80 mg tab chw 80 mg QL (30 per 30 days) (Acetaminophen) * children's mapap 80 mg rapid 80 QL (30 per 30 days) (Acetaminophen) mg * codeine sulfate oral tablet 15 mg, 30 QL (180 per 30 days) (Codeine Sulfate) mg, 60 mg cvs acetaminophen 8-hr 650 mg QL (180 per 30 days) (Tylenol Arthritis) caplet 650 mg * cvs child non-asa 80 mg tb chw 80 QL (30 per 30 days) (Acetaminophen) mg * cvs non-aspirin jr tab chew 160 mg QL (30 per 30 days) (Acetaminophen) * cvs pain relief adult liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) endocet oral tablet mg (Xolox) QL (240 per 30 days) endocet oral tablet mg, 5- QL (360 per 30 days) (Xolox) 325 mg endocet oral tablet mg (Xolox) QL (300 per 30 days) (Oxycodone QL (360 per 30 days) endodan oral tablet mg HCl/Aspirin) fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour feverall 120 mg suppository children's, outer 120 mg * feverall 325 mg suppository junior str, outer 325 mg * feverall 650 mg suppository adult, inner 650 mg * (Actiq) (Duragesic) (Acetaminophen) (Acetaminophen) (Acetaminophen) PA; QL (120 per 30 days) QL (10 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) 5

7 hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/5 ml, mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml) hydromorphone (pf) injection solution 10 mg/ml hydromorphone 10 mg/ml vial p/f,sdv,latex-f 10 mg/ml hydromorphone injection solution 2 mg/ml, 4 mg/ml hydromorphone injection syringe 2 mg/ml (Hycet) (Norco) (Norco) (Ibudone) (Hydromorphone HCl/PF) (Dilaudid) QL (2700 per 30 days) QL (390 per 30 days) QL (360 per 30 days) QL (150 per 30 days) (Hydromorphone HCl/PF) (Hydromorphone HCl) (Hydromorphone HCl) hydromorphone oral liquid 1 mg/ml (Dilaudid) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 QL (180 per 30 days) (Dilaudid) mg, 8 mg HYSINGLA ER ORAL QL (30 per 30 days) TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG infant pain relv 80 mg/0.8 ml a/f, gluten-free 80 mg/0.8 ml * jr pain-fever 160 mg rapid tab junior,bubblegum 160 mg * junior mapap 160 mg rapid tab 160 mg * (Acetaminophen) (Acetaminophen) (Acetaminophen) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) 6

8 LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet mg (Norco) PA; QL (30 per 30 days) QL (360 per 30 days) lorcet hd oral tablet mg (Norco) QL (360 per 30 days) lorcet plus oral tablet mg (Norco) QL (360 per 30 days) mapap 160 mg/5 ml liquid 160 mg/5 (Tylenol Sore QL (240 per 30 days) ml * Throat) mapap 160 mg/5 ml suspension 160 QL (240 per 30 days) (Infants' Tylenol) mg/5 ml * mapap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) mapap 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) mapap 500 mg tablet 500 mg * (Tylenol) QL (240 per 30 days) mapap 500 mg/15 ml liquid 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) mapap 80 mg tablet chew 80 mg * (Acetaminophen) QL (30 per 30 days) mapap arthritis er 650 mg cplt 650 QL (180 per 30 days) (Tylenol Arthritis) mg * margesic oral capsule mg (Esgic) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) methadone injection solution 10 mg/ml (Methadone HCl) methadone oral solution 10 mg/5 QL (1800 per 30 days) (Methadone HCl) ml, 5 mg/5 ml methadone oral tablet 10 mg (Diskets) QL (360 per 30 days) methadone oral tablet 5 mg (Diskets) QL (180 per 30 days) methadose oral tablet,soluble 40 mg (Diskets) QL (90 per 30 days) morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject outer, latex-f, p/f 2 mg/ml (Morphine Sulfate) morphine 4 mg/ml syringe p/f, latexfree 4 mg/ml (Morphine Sulfate) morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) 7

9 morphine concentrate oral solution QL (180 per 30 days) (Morphine Sulfate) 100 mg/5 ml (20 mg/ml) morphine intramuscular pen injector 10 mg/0.7 ml (Morphine Sulfate) morphine intravenous cartridge 15 mg/ml (Morphine Sulfate) morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Morphine Sulfate) QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) (Morphine Sulfate) (4 mg/ml) MORPHINE ORAL TABLET 15 QL (180 per 30 days) MG MORPHINE ORAL TABLET 30 QL (120 per 30 days) MG morphine oral tablet extended QL (60 per 30 days) (MS Contin) release 100 mg, 200 mg, 60 mg morphine oral tablet extended QL (180 per 30 days) (MS Contin) release 15 mg morphine oral tablet extended QL (120 per 30 days) (MS Contin) release 30 mg non-aspirin x-str 167 mg/5 ml 500 (Tylenol Sore QL (120 per 30 days) mg/15 ml * Throat) nortemp 80 mg/0.8 ml drop 80 QL (30 per 30 days) (Acetaminophen) mg/0.8 ml * NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 QL (181 per 30 days) MG, 50 MG, 75 MG oxycodone oral concentrate 20 QL (120 per 30 days) (Oxycodone HCl) mg/ml oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) QL (1300 per 30 days) oxycodone oral tablet 10 mg, 5 mg (Roxicodone) QL (180 per 30 days) 8

10 oxycodone oral tablet 15 mg, 20 mg, 30 mg oxycodone-acetaminophen oral solution mg/5 ml (Roxicodone) (Oxycodone HCl/Acetaminophe n) QL (120 per 30 days) QL (1800 per 30 days) oxycodone-acetaminophen oral QL (240 per 30 days) (Xolox) tablet mg oxycodone-acetaminophen oral QL (360 per 30 days) (Xolox) tablet mg, mg oxycodone-acetaminophen oral QL (300 per 30 days) (Xolox) tablet mg oxycodone-aspirin oral tablet (Oxycodone QL (360 per 30 days) mg HCl/Aspirin) OXYCONTIN ORAL QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg (Opana) QL (120 per 30 days) oxymorphone oral tablet 5 mg (Opana) QL (180 per 30 days) oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg (Opana ER) QL (60 per 30 days) pain relief 500 mg capsule 500 mg * (Acetaminophen) QL (240 per 30 days) pain reliever er 650 mg caplet 8 QL (180 per 30 days) (Tylenol Arthritis) hour, caplet 650 mg * pharbetol 325 mg tablet regular QL (360 per 30 days) (Tylenol) strength 325 mg * pharbetol 500 mg caplet extra-str, QL (240 per 30 days) (Tylenol) caplet 500 mg * pv non-aspirin 500 mg softgel exstr,liq filled 500 mg QL (240 per 30 days) (Acetaminophen) * 9

11 q-pap 160 mg/5 ml solution a/f, (Tylenol Sore QL (240 per 30 days) cherry 160 mg/5 ml * Throat) q-pap 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) q-pap 80 mg/0.8 ml drops 80 mg/0.8 QL (30 per 30 days) (Acetaminophen) ml * q-pap ex-str 500 mg tablet aspirin QL (240 per 30 days) (Tylenol) free 500 mg * reprexain oral tablet mg, QL (150 per 30 days) (Ibudone) mg, mg sm pain rel jr str tab chew 160 mg * (Acetaminophen) QL (30 per 30 days) sm pain reliever 80 mg tab QL (30 per 30 days) (Acetaminophen) children's 80 mg * tactinal 325 mg tablet 325 mg * (Tylenol) QL (360 per 30 days) tactinal 500 mg tablet extra-strength QL (240 per 30 days) (Tylenol) 500 mg * PA-HRM; QL (180 per tencon oral tablet mg (Tencon) 30 days); AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) QL (240 per 30 days) tramadol-acetaminophen oral tablet QL (240 per 30 days) (Ultracet) mg vicodin es oral tablet mg (Norco) QL (390 per 30 days) vicodin hp oral tablet mg (Norco) QL (390 per 30 days) vicodin oral tablet mg (Norco) QL (390 per 30 days) XTAMPZA ER ORAL QL (60 per 30 days) CAPSULE,SPRINKLE,ER 12HR TMPRR 13.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (120 per 30 days) CAPSULE,SPRINKLE,ER 12HR TMPRR 27 MG XTAMPZA ER ORAL QL (240 per 30 days) CAPSULE,SPRINKLE,ER 12HR TMPRR 36 MG xylon 10 oral tablet mg (Ibudone) QL (150 per 30 days) 10

12 zebutal oral capsule mg (Esgic) Nonsteroidal Anti- Inflammatory Agents ADVIL 100 MG TABLET JR STRENGTH,COATED 100 MG * ADVIL 200 MG TABLET 200 MG * ADVIL JR STR 100 MG TAB CHEW TB CHEW,8 HOUR,GRAPE 100 MG * aspirin 300 mg suppository 300 mg (Aspirin) * aspirin 325 mg tablet 325 mg * (Ecotrin) aspirin 600 mg suppository 600 mg (Aspirin) * aspirin 81 mg chewable tablet 81 (Bayer Chewable mg * Aspirin) aspirin buffered 325 mg tab 325 mg (Aspirin/Calcium * Carbonate/Mag) aspirin ec 325 mg tablet 325 mg * (Ecotrin) aspirin ec 500 mg tablet 500 mg * (Ecotrin) aspirin ec 81 mg tablet low dose 81 (Ecotrin) mg * aspir-low ec 81 mg tablet 81 mg * (Ecotrin) CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 (Celebrex) mg, 400 mg, 50 mg CHILDREN'S ADVIL 100 MG/5 ML (OTC) 100 MG/5 ML * bufferin 325 mg tablet coated 325 (Aspirin/Calcium mg * Carbonate/Mag) PA-HRM; QL (180 per 30 days); AGE (Max 64 Years) QL (60 per 30 days) 11

13 cvs ibuprofen 200 mg softgel liquid filled,softge 200 mg * (Advil) diclofenac potassium oral tablet 50 (Diclofenac mg Potassium) diclofenac sodium oral tablet extended release 24 hr 100 mg (Voltaren-XR) diclofenac sodium oral (Diclofenac tablet,delayed release (dr/ec) 25 mg, Sodium) 50 mg, 75 mg diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic (Arthrotec 50) mg-mcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) ecotrin ec 325 mg tablet saftey coated 325 mg * (Ecotrin) ecpirin ec 325 mg tablet 325 mg * (Ecotrin) etodolac oral capsule 200 mg, 300 mg (Etodolac) etodolac oral tablet 400 mg, 500 mg (Lodine) etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 (Etodolac) mg fenoprofen oral tablet 600 mg (Fenoprofen Calcium) FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg (Flurbiprofen) gnp ibuprofen jr str 100 mg tb 100 mg * (Advil) ibuprofen 100 mg/5 ml susp children's (otc) 100 mg/5 ml * (Children'S Advil) ibuprofen 200 mg tablet 200 mg * (Advil) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) PA 12

14 ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) indomethacin oral capsule 25 mg (Indomethacin) QL (240 per 30 days) indomethacin oral capsule 50 mg (Indomethacin) QL (120 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) (Indomethacin) release 75 mg indomethacin sodium intravenous (Indomethacin recon soln 1 mg Sodium) infant ibuprofen 50 mg/1.25 ml d/f,a/f,non-staining 50 mg/1.25 ml * (Infants' Motrin) ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac oral tablet 10 mg (Ketorolac QL (20 per 30 days) Tromethamine) mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 (Mobic) ml meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 (Nabumetone) mg naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 375 mg, 500 mg (Naprosyn) naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg (Ec-Naprosyn) naproxen sodium oral tablet 275 mg, 550 mg (Anaprox Ds) piroxicam oral capsule 10 mg, 20 mg (Feldene) ra aspirin tri-buffered tb 325 mg * (Aspirin/Calcium Carbonate/Mag) sm ibuprofen ib 100 mg tablet junior strength 100 mg * (Advil) 13

15 st. joseph aspirin 81 mg chew (Bayer Chewable orange 81 mg * Aspirin) st. joseph aspirin ec 81 mg tb enteric coated 81 mg * (Ecotrin) sulindac oral tablet 150 mg, 200 mg (Sulindac) tolmetin oral capsule 400 mg (Tolmetin Sodium) tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) VOLTAREN TOPICAL GEL 1 % wal-profen 200 mg softgel softgel 200 mg * (Advil) Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine (pf) injection solution 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) (Xylocaine-MPF) lidocaine 2% viscous soln 2 % lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 2 %, 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % (Pre-Attached Lta Kit) (Xylocaine) (Lidocaine HCl) (Pre-Attached Lta Kit) (Lidoderm) lidocaine topical ointment 5 % (Lidocaine) lidocaine-prilocaine topical cream % (EMLA) Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents PA 14

16 acamprosate oral tablet,delayed (Acamprosate release (dr/ec) 333 mg Calcium) BUNAVAIL BUCCAL FILM MG BUNAVAIL BUCCAL FILM MG, MG buprenorphine hcl sublingual tablet (Buprenorphine 2 mg, 8 mg HCl) (Buprenorphine buprenorphine-naloxone sublingual HCl/Naloxone tablet mg, 8-2 mg HCl) buproban oral tablet extended release 150 mg (Zyban) bupropion hcl (smoking deter) oral tablet extended release 150 mg (Zyban) CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0.4 mg/ml (Naloxone HCl) naloxone injection syringe 0.4 mg/ml, 1 mg/ml (Naloxone HCl) naltrexone oral tablet 50 mg (Revia) NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION nicorelief 2 mg gum 2 mg * (Nicorette) nicorelief 4 mg gum 4 mg * (Nicorette) nicorette 2 mg chewing gum white ice mint 2 mg * (Nicorette) QL (30 per 30 days) QL (60 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (168 per 84 days) QL (168 per 84 days) QL (53 per 28 days) QL (4 per 30 days) 15

17 nicotine 14 mg/24hr patch step 2 (otc) 14 mg/24 hr * (Nicoderm Cq) nicotine 2 mg chewing gum sugar free 2 mg * (Nicorette) nicotine 2 mg lozenge mint, 3 quittube 2 mg * (Nicorette) nicotine 21 mg/24hr patch outer, clear, step 1 (otc) 21 mg/24 hr * (Nicoderm Cq) nicotine 22 mg/24hr patch 1 week starter kit 22 mg/24 hr * (Nicoderm Cq) nicotine 4 mg chewing gum 4 mg * (Nicorette) nicotine 4 mg lozenge mint, 3 quittube 4 mg * (Nicorette) nicotine 7 mg/24hr patch step 3 (otc) 7 mg/24 hr * (Nicoderm Cq) NICOTROL INHALATION CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM 12-3 MG, 8-2 MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 QL (180 per 365 days) QL (168 per 365 days) QL (168 per 365 days) QL (180 per 365 days) QL (1008 per 90 days) QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (120 per 30 days) (Xanax) mg, 1 mg alprazolam oral tablet 2 mg (Xanax) QL (150 per 30 days) chlordiazepoxide hcl oral capsule (Chlordiazepoxide QL (120 per 30 days) 10 mg, 25 mg, 5 mg HCl) clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 days) clonazepam oral tablet 2 mg (Klonopin) QL (300 per 30 days) 16

18 clonazepam oral QL (90 per 30 days) tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) clonazepam oral QL (300 per 30 days) (Clonazepam) tablet,disintegrating 2 mg clorazepate dipotassium oral tablet QL (180 per 30 days) (Tranxene T-Tab) 15 mg, 3.75 mg, 7.5 mg diazepam injection solution 5 mg/ml (Diazepam) QL (10 per 28 days) diazepam intensol oral concentrate QL (1200 per 30 days) (Diazepam) 5 mg/ml diazepam oral solution 5 mg/5 ml (1 QL (1200 per 30 days) (Diazepam) mg/ml) diazepam oral tablet 10 mg, 2 mg, 5 QL (120 per 30 days) (Valium) mg diazepam rectal kit mg, 2.5 mg, mg (Diastat) lorazepam injection solution 2 QL (2 per 30 days) (Ativan) mg/ml lorazepam oral tablet 0.5 mg, 1 mg (Ativan) QL (90 per 30 days) lorazepam oral tablet 2 mg (Ativan) QL (150 per 30 days) ONFI ORAL SUSPENSION 2.5 PA NSO; QL (480 per MG/ML ONFI ORAL TABLET 10 MG, 20 MG Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 40 mg/ml (Gentamicin In Nacl, Iso-Osm) (Gentamicin Sulfate) 30 days) PA NSO; QL (60 per 30 days) 17

19 gentamicin ped 20 mg/2 ml vial (Gentamicin latex-free, sdv 20 mg/2 ml Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution 80 mg/8 ml Sulfate/PF) neomycin oral tablet 500 mg (Neomycin Sulfate) streptomycin intramuscular recon (Streptomycin soln 1 gram Sulfate) TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization (Tobi) 300 mg/5 ml tobramycin in 0.9 % nacl (Tobramycin/Sodiu intravenous piggyback 60 mg/50 ml m Chloride) tobramycin sulfate injection solution (Tobramycin 10 mg/ml, 40 mg/ml Sulfate) Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit (Bacitracin) chloramphenicol sod succinate (Chloramphenicol intravenous recon soln 1 gram Sod Succinate) clindamycin 75 mg/5 ml soln 75 mg/5 ml (Cleocin Palmitate) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate intravenous piggyback 300 mg/50 In D5w) ml, 600 mg/50 ml, 900 mg/50 ml clindamycin pediatric oral recon (Cleocin Palmitate) soln 75 mg/5 ml clindamycin phosphate injection solution 150 (mg/ml) (6 ml), 150 mg/ml (Cleocin Phosphate) QL (224 per 28 days) 18

20 clindamycin phosphate intravenous (Cleocin solution 600 mg/4 ml Phosphate) colistin (colistimethate na) injection (Coly-Mycin M recon soln 150 mg Parenteral) CUBICIN INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 mg (Cubicin) linezolid intravenous parenteral solution 600 mg/300 ml (Zyvox) linezolid oral suspension for reconstitution 100 mg/5 ml (Zyvox) linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) (Metronidazole/So intravenous piggyback 500 mg/100 dium Chloride) ml metronidazole oral capsule 375 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days); AGE (Max 64 Years) 19

21 nitrofurantoin monohyd/m-cryst oral capsule 100 mg (Macrobid) polymyxin b sulfate injection recon (Polymyxin B soln 500,000 unit Sulfate) SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg (Trimethoprim) vancomycin hcl 1g/200 ml bag 1 (Vancomycin Hcl gram/200 ml In Dextrose 5 %) vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl) vancomycin intravenous recon soln (Vancomycin Hcl 500 mg In Dextrose 5 %) vancomycin oral capsule 125 mg, 250 mg (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 (Cefaclor) mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 (Cefadroxil) mg/5 ml PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 days); AGE (Max 64 Years) PA; QL (9 per 30 days) PA 20

22 cefadroxil oral tablet 1 gram (Cefadroxil) cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 (Cefazolin Sodium/Dextrose, ml, 2 gram/50 ml Iso) cefazolin injection recon soln 1 gram, 10 gram, 500 mg (Cefazolin Sodium) cefdinir oral capsule 300 mg (Cefdinir) cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 (Cefdinir) mg/5 ml cefditoren pivoxil oral tablet 200 mg, 400 mg (Spectracef) CEFEPIME 1 GM INJECTION 1 GRAM/50 ML cefepime hcl 1 gm vial 10's, sdv 1 gram (Cefepime HCl) cefepime hcl 2 gram vial latex/f, sdv, outer 2 gram (Cefepime HCl) CEFEPIME INJECTION RECON SOLN 1 GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 ML 2 GRAM/50 ML cefotaxime injection recon soln 1 gram, 10 gram, 2 gram, 500 mg cefoxitin 2 gm piggyback bag 2 gram/50 ml cefoxitin 2 gm vial latex/f, outer 2 gram cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln 2 gram (Claforan) (Cefoxitin Sodium/Dextrose, Iso) (Cefoxitin Sodium) (Cefoxitin Sodium) (Cefoxitin Sodium/Dextrose, Iso) 21

23 cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cefpodoxime Proxetil) (Cefpodoxime Proxetil) (Cefprozil) cefprozil oral tablet 250 mg, 500 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 gram (Fortaz) ceftibuten oral capsule 400 mg (Cedax) ceftibuten oral suspension for reconstitution 180 mg/5 ml (Cedax) ceftriaxone 1 gm piggyback latexfree 1 gram/50 ml Na/Dextrose, Iso) (Ceftriaxone ceftriaxone 2 gm piggyback latexfree 2 gram/50 ml Na/Dextrose, Iso) (Ceftriaxone ceftriaxone injection recon soln 1 (Ceftriaxone gram, 10 gram, 250 mg, 500 mg Sodium) ceftriaxone intravenous recon soln 1 (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) cefuroxime axetil oral tablet 250 mg, 500 mg (Ceftin) cefuroxime sodium injection recon soln 1.5 gram, 750 mg (Zinacef) cefuroxime sodium intravenous recon soln 7.5 gram (Zinacef) cephalexin oral capsule 250 mg, 500 mg, 750 mg (Keflex) cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cephalexin) cephalexin oral tablet 250 mg, 500 mg (Cephalexin) 22

24 MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 gram (Fortaz) TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln (Zithromax) 500 mg azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 (Zithromax) mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 600 mg (Zithromax) azithromycin oral tablet 500 mg (Zithromax) clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 (Biaxin) mg/5 ml clarithromycin oral tablet 250 mg, 500 mg (Biaxin) clarithromycin oral tablet extended release 24 hr 500 mg (Clarithromycin) DIFICID ORAL TABLET 200 MG QL (20 per 10 days) (Erythromycin e.e.s. 400 oral tablet 400 mg Ethylsuccinate) e.e.s. granules oral suspension for reconstitution 200 mg/5 ml (Eryped 200) 23

25 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, 2 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 mg Penicillins amoxicillin oral capsule 250 mg, 500 mg (Erythromycin Base) (Erythromycin Stearate) (Eryped 200) (Erythromycin Ethylsuccinate) (Erythromycin Base) (Erythromycin Base) (Azactam) (Primaxin) (Merrem) (Amoxicillin) LA 24

26 amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam 1.5 gm vl 10's,sdv,latex-free 1.5 gram ampicillin-sulbactam injection recon soln 15 gram, 3 gram ampicillin-sulbactam intravenous recon soln 1.5 gram (Amoxicillin) (Amoxicillin) (Amoxicillin) (Augmentin) (Augmentin) (Augmentin XR) (Amoxicillin/Potas sium Clav) (Ampicillin Trihydrate) (Ampicillin Trihydrate) (Ampicillin Sodium) (Ampicillin Sodium) (Unasyn) (Unasyn) (Unasyn) 25

27 BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial 10's, latex-free 2 gram nafcillin injection recon soln 1 gram, 10 gram nafcillin intravenous recon soln 2 gram oxacillin 2 gm vial 10's,outer 2 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 2 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml (Dicloxacillin Sodium) (Nafcillin Sodium) (Nafcillin Sodium) (Nafcillin Sodium) (Oxacillin Sodium) (Oxacillin Sodium/Dextrose, Iso) (Oxacillin Sodium) (Oxacillin Sodium) (Pen G Pot/Dextrose- Water) (Penicillin G Potassium) (Penicillin G Procaine) 26

28 penicillin gk 20 million unit 20 (Penicillin G million unit Potassium) penicillin v potassium oral recon (Penicillin V soln 125 mg/5 ml, 250 mg/5 ml Potassium) penicillin v potassium oral tablet (Penicillin V 250 mg, 500 mg Potassium) pfizerpen-g injection recon soln 20 (Penicillin G million unit Potassium) piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, (Zosyn) 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 100 mg, (Cipro) 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml, 400 mg/200 ml (Cipro I.V.) ciprofloxacin lactate intravenous (Ciprofloxacin solution 200 mg/20 ml, 400 mg/40 Lactate) ml ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml (Cipro) levofloxacin in d5w intravenous (Levofloxacin/D5 piggyback 250 mg/50 ml, 500 W) mg/100 ml, 750 mg/150 ml levofloxacin intravenous solution 25 (Levofloxacin) mg/ml levofloxacin oral solution 250 mg/10 ml (Levofloxacin) levofloxacin oral tablet 250 mg, 500 (Levaquin) mg, 750 mg moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 300 mg, 400 mg (Ofloxacin) Sulfonamides 27

29 sulfadiazine oral tablet 500 mg (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/ intravenous solution mg/5 Trimethoprim) ml sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/ suspension mg/5 ml Trimethoprim) sulfamethoxazole-trimethoprim oral tablet mg, mg (Bactrim) sulfasalazine oral tablet 500 mg (Azulfidine) sulfasalazine oral tablet,delayed (Azulfidine) release (dr/ec) 500 mg sulfatrim oral suspension mg/5 ml Tetracyclines doxy-100 intravenous recon soln 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg tetracycline oral capsule 250 mg, 500 mg (Sulfamethoxazole/ Trimethoprim) (Doxycycline Hyclate) (Doxycycline Hyclate) (Morgidox) (Doryx) (Adoxa) (Vibramycin) (Avidoxy) (Minocin) (Minocycline HCl) (Tetracycline HCl) 28

30 TYGACIL INTRAVENOUS RECON SOLN 50 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG (Fluorouracil) (Fluorouracil) AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG anastrozole oral tablet 1 mg (Arimidex) AVASTIN INTRAVENOUS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 25 MG/ML (Vidaza) bexarotene oral capsule 75 mg (Targretin) PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) PA NSO; QL (240 per 30 days) PA NSO PA NSO PA NSO PA NSO; QL (420 per 30 days) 29

31 bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 15 (Bleomycin unit, 30 unit Sulfate) BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG CABOMETYX ORAL TABLET 20 MG, 60 MG CABOMETYX ORAL TABLET 40 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous (Cyclophosphamid recon soln 1 gram, 2 gram, 500 mg e) CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg (Dacogen) PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) PA NSO; LA; QL (63 per 28 days) ; ST PA NSO PA NSO; LA 30

32 doxorubicin, peg-liposomal intravenous suspension 2 mg/ml (Doxil) DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml (Etoposide) exemestane oral tablet 25 mg (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram (Floxuridine) fluorouracil 5,000 mg/100 ml latexfree 5 gram/100 ml (Fluorouracil) QL (1 per 84 days) QL (1 per 112 days) QL (1 per 168 days) PA NSO PA NSO; QL (30 per 30 days) PA NSO 31

33 fluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 500 mg/10 ml (Fluorouracil) flutamide oral capsule 125 mg (Flutamide) GAZYVA INTRAVENOUS SOLUTION 1,000 MG/40 ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON SOLN 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG ifosfamide 1 gm/20 ml vial sdv,p/f,latex-free 1 gram/20 ml ifosfamide intravenous recon soln 1 gram ifosfamide-mesna intravenous kit 1-1 gram, 3,000-1,000 mg (Ifex) (Ifex) (Ifosfamide/Mesna ) imatinib oral tablet 100 mg (Gleevec) imatinib oral tablet 400 mg (Gleevec) IMBRUVICA ORAL CAPSULE 140 MG IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML PA NSO PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO; QL (4 per 365 days) 32

34 IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 (Leuprolide mg/0.2 ml Acetate) PA NSO; QL (8 per 28 days) PA NSO; QL (180 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (12 per 28 days) PA NSO; QL (6 per 28 days) PA NSO; LA PA NSO 33

35 LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG (Megestrol Acetate) MEKINIST ORAL TABLET 2 MG mercaptopurine oral tablet 50 mg (Mercaptopurine) methotrexate sodium (pf) injection (Methotrexate recon soln 1 gram Sodium/PF) methotrexate sodium (pf) injection (Methotrexate solution 25 mg/ml Sodium/PF) methotrexate sodium injection (Methotrexate solution 25 mg/ml Sodium) PA NSO; QL (100 per 28 days) PA NSO; QL (80 per 28 days) QL (1 per 84 days) QL (1 per 84 days) QL (1 per 168 days) PA NSO; QL (480 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) 34

36 methotrexate sodium oral tablet 2.5 (Methotrexate mg Sodium) mitoxantrone intravenous (Mitoxantrone concentrate 2 mg/ml HCl) NEXAVAR ORAL TABLET 200 MG NILANDRON ORAL TABLET 150 MG nilutamide oral tablet 150 mg (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ODOMZO ORAL CAPSULE 200 MG ONCASPAR INJECTION SOLUTION 750 UNIT/ML OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML SOLTAMOX ORAL SOLUTION 10 MG/5 ML ; ST PA NSO; QL (120 per 30 days) PA NSO; QL (3 per 28 days) PA NSO; LA PA NSO PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (100 per 21 days) PA NSO; LA PA NSO 35

37 SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG tamoxifen oral tablet 10 mg, 20 mg (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG TARGRETIN ORAL CAPSULE 75 MG TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG thiotepa injection recon soln 15 mg (Thiotepa) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) PA NSO; QL (20 per 21 days) PA NSO 36

38 toposar intravenous solution 20 mg/ml (Etoposide) TREANDA INTRAVENOUS RECON SOLN 100 MG TRELSTAR 22.5 MG SYRINGE OUTER, L/F, SDV 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 10 mg (Tretinoin) TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG vinorelbine intravenous solution 10 mg/ml, 50 mg/5 ml (Navelbine) QL (1 per 168 days) QL (1 per 168 days) QL (1 per 84 days) ; ST PA NSO PA NSO PA NSO; LA; QL (60 per 30 days) PA NSO; LA; QL (120 per 30 days) PA NSO; LA; QL (30 per 30 days) PA NSO; LA; QL (42 per 28 days) 37

39 VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG XTANDI ORAL CAPSULE 40 MG YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG ZELBORAF ORAL TABLET 240 MG ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG Anticholinergic Agents Antimuscarinics/Antispasm odics atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline oral tablet 15 mg Anticonvulsants Anticonvulsants (Atropine Sulfate) (Propantheline Bromide) PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL (1 per 84 days) QL (1 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) 38

40 APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, (Carbatrol) 300 mg carbamazepine oral suspension 100 mg/5 ml (Tegretol) carbamazepine oral tablet 200 mg (Tegretol) carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 (Tegretol XR) mg carbamazepine oral tablet,chewable (Carbamazepine) 100 mg CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, sprinkle (Depakote 125 mg Sprinkle) divalproex oral tablet extended release 24 hr 250 mg, 500 mg (Depakote ER) divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 (Depakote) mg epitol oral tablet 200 mg (Tegretol) ST ST ST QL (80 per 30 days) QL (600 per 30 days) QL (60 per 30 days) 39

41 ethosuximide oral capsule 250 mg (Zarontin) ethosuximide oral solution 250 mg/5 (Zarontin) ml felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 400 mg, 600 mg (Felbatol) fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 300 mg, 400 mg (Neurontin) gabapentin oral solution 250 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg (Lamictal) lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 (Lamictal XR) mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg (Lamictal) lamotrigine oral tablets,dose pack 25 mg (35) (Lamictal (Blue)) levetiracetam intravenous solution 500 mg/5 ml (Keppra) levetiracetam oral solution 100 mg/ml (Keppra) ST ST ST 40

42 levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg (Roweepra) levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg (Keppra XR) LYRICA ORAL CAPSULE 100 QL (90 per 30 days) MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 30 days) MG/ML oxcarbazepine oral suspension 300 mg/5 ml (Trileptal) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg (Trileptal) OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml QL (1500 per 30 days) (Phenobarbital) (4 mg/ml) phenobarbital oral tablet 100 mg, QL (90 per 30 days) 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg (Phenobarbital) phenobarbital oral tablet 30 mg (Phenobarbital) QL (200 per 30 days) phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral tablet,chewable 50 mg (Dilantin) phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg (Dilantin) phenytoin sodium intravenous (Phenytoin solution 50 mg/ml Sodium) phenytoin sodium intravenous (Phenytoin syringe 50 mg/ml Sodium) POTIGA ORAL TABLET 200 MG, ST; QL (90 per MG, 400 MG days) 41

43 POTIGA ORAL TABLET 50 MG primidone oral tablet 250 mg, 50 mg (Mysoline) ROWEEPRA ORAL TABLET 500 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, 4 mg (Gabitril) topiramate oral capsule, sprinkle 15 (Topamax) mg, 25 mg topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 (Qudexy XR) mg, 50 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) (Depacon) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depakene) valproic acid oral capsule 250 mg (Depakene) VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG ST; QL (270 per 30 days) ST; QL (60 per 30 days) ST; QL (120 per 30 days) ST ST; QL (200 per 5 days) ST; QL (1200 per 30 days) ST; QL (60 per 30 days) 42

44 zonisamide oral capsule 100 mg, 25 mg, 50 mg Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 23 mg, (Zonegran) QL (30 per 30 days) (Aricept) 5 mg donepezil oral tablet,disintegrating QL (30 per 30 days) (Donepezil HCl) 10 mg, 5 mg galantamine oral capsule,ext rel. QL (30 per 30 days) (Razadyne ER) pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml (Galantamine Hbr) QL (200 per 30 days) galantamine oral tablet 12 mg, 4 QL (60 per 30 days) (Razadyne) mg, 8 mg memantine oral solution 2 mg/ml (Namenda) QL (360 per 30 days) memantine oral tablet 10 mg, 5 mg (Namenda) QL (60 per 30 days) memantine oral tablets,dose pack 5- QL (49 per 28 days) (Namenda) 10 mg NAMENDA XR ORAL QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG NAMZARIC ORAL QL (56 per 365 days) CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG NAMZARIC ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR MG, MG, MG, 7-10 MG rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr Antidepressants (Exelon) (Exelon) QL (60 per 30 days) QL (30 per 30 days) 43

45 Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg citalopram oral solution 10 mg/5 ml (Amitriptyline HCl) (Amoxapine) (Wellbutrin) (Wellbutrin SR) (Wellbutrin XL) (Citalopram Hydrobromide) citalopram oral tablet 10 mg, 20 mg, 40 mg (Celexa) clomipramine oral capsule 25 mg, 50 mg, 75 mg (Anafranil) desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg (Norpramin) doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg (Doxepin HCl) doxepin oral concentrate 10 mg/ml (Doxepin HCl) duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg (Irenka) duloxetine oral capsule,delayed release(dr/ec) 30 mg (Irenka) duloxetine oral capsule,delayed release(dr/ec) 40 mg (Irenka) EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml (Lexapro) ST QL (600 per 30 days) QL (30 per 30 days) (Cymbalta); QL (60 per 30 days) (Cymbalta); QL (30 per 30 days) (Irenka); QL (30 per 30 days) QL (30 per 30 days) 44

46 escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg (Lexapro) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 40 mg (Prozac) fluoxetine oral capsule,delayed release(dr/ec) 90 mg (Prozac Weekly) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) fluvoxamine oral capsule,extended (Fluvoxamine release 24hr 100 mg, 150 mg Maleate) fluvoxamine oral tablet 100 mg, 25 (Fluvoxamine mg, 50 mg Maleate) imipramine hcl oral tablet 10 mg, 25 (Tofranil) mg, 50 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg (Tofranil-Pm) maprotiline oral tablet 25 mg, 50 mg, 75 mg (Maprotiline HCl) MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg (Remeron) mirtazapine oral tablet,disintegrating 15 mg, 30 mg, (Remeron) 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg (Nefazodone HCl) ST ST 45

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