PHP (HMO SNP) 2018 Formulary (List of Covered Drugs)

Transcription

1 FLORIDA PHP (HMO SNP) 08 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on February, 08. For more recent information or other questions, please contact PHP Pharmacy Customer Service at (866) , 4 hours a day, seven days a week, or visit H33_ Accepted PHP (HMO SNP) 08 Part D Formulary Formulary ID: 00080, Version: Effective March, 08

2 Discrimination Is Against the Law PHP (HMO SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PHP: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Member Services. If you believe that PHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Member Services, P.O. Box 4660, Los Angeles, CA 90046, (888) , TTY 7, Fax (888) , php@positivehealthcare.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 00 Independence Avenue, SW Room 509F, HHH Building Washington, DC , (TDD) Complaint forms are available at

3 ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 7). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 7). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 7). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 7). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:7) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 7). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 7). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 7). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 7(. ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 7). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 7). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 7) 번으로전화해주십시오. UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 7). સ ચન : જ તમ ગ જર ત બ લત હ, ત નન:શ લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: 7). เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 7).

4 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 AHF MCO of Florida, Inc. When it refers to plan or our plan, it means PHP. This document includes a list of the drugs (formulary) for our plan which is current as of February, 08. For an updated formulary, please contact us. Our contract 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, 08, and from time to time during the year. PHP is an HMO plan with a Medicare contract. Enrollment in PHP depends on contract renewal The Formulary may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call our Member Services number at (888) , 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible de forma gratuita en otros idiomas. Por favor, llame a nuestro número del Departamento de servicios para miembros a (888) , 8:00 a.m. hasta 8:00 p.m., siete días a la semana.

5 What is the PHP Formulary? A formulary is a list of covered drugs selected by PHP 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. PHP will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a PHP 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 08 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 08 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 60 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 60-day supply of the drug. If the Food and Drug Administration 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 February, 08. To get updated information about the drugs covered by PHP, please contact us. Our contact information appears on the front and back cover pages. Should we make changes to the formulary during the year, we will notify you by sending a Notice of Changes to Your Formulary (List of Covered Drugs) in your Part D Explanation of Benefits (also called a Part D EOB ). We mail you a Part D Explanation of Benefits when you have had one or more prescriptions filled through the plan during the pervious month every month so you can track your Part D out-of-pocket costs and total drug costs for the year. For more information about the Part D Explanation of Benefits, please see your Evidence of Coverage, Chapter 6, Section 3.. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 3. 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 Agents. If you know - i -

6 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 I-. 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? PHP 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: PHP requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don t get approval, PHP may not cover the drug. Quantity Limits: For certain drugs, PHP limits the amount of the drug that the plan will cover. For example, the plan provides tables per prescription for MAXALT (0 ). This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, PHP requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, PHP will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 3. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. 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 PHP 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 PHP formulary? on page iii for information about how to request an exception. - ii -

7 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 Pharmacy Customer Service and ask if your drug is covered. If you learn that PHP does not cover your drug, you have two options: You can ask Pharmacy Customer Service for a list of similar drugs that are covered by the 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 the plan. You can ask PHP 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 PHP formulary? You can ask PHP 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 pre-determined 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 waive coverage restrictions or limits on your drug. For example, for certain drugs, PHP 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, PHP will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower-tiered 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 are requesting 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 4 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 - iii -

8 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 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 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-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 9-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 3-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you are a current member of our plan, an unexpected transition could occur if you experience a level-of-care change. For example, if you are hospitalized and given a drug that is not on our formulary, once you are discharged from the hospital to your home, you will need to talk to your doctor about continuing the drug. If you and your doctor decide you should continue taking the drug, you will need to request a formulary exception for us to cover it. Our plan may provide you a temporary 30-day transition supply of the drug while you decide what action to take. Please contact us about the availability of a transition supply of medication when you experience a level-of-care change. For more information For more detailed information about your PHP prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about PHP, please contact us. Our contact information, along with the date we last updated the formulary, appears on the fron and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at -800-MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call Or, visit - iv -

9 PHP s Formulary The formulary below provides coverage information about the drugs covered by PHP. If you have trouble finding your drug in the list, turn to the index that begins on page I-. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., KALETRA) and generic drugs are listed in lower-case italics (e.g., hydrochlorothiazide). The information in the Requirements/Limits columns tells you if PHP has any special requirements for coverage of your drug. The following abbreviations may be found within the body of this document. Coverage Notes Abbreviations Abbreviation Description Explanation Utilization Management Restrictions AGE Age Restriction Some drugs on our formulary are not appropriate for and may pose a risk to people of certain ages. If a drug has an age restriction, the maximum age of appropriateness is noted. Drugs that have an age restriction require prior authorization. PA Prior Authorization Restriction You (or your physician) are required to get prior authorization from PHP before you fill your prescription for this drug. Without prior approval, PHP may not cover this drug. PA BvD Prior Authorization Restriction for Part B vs Part D Determination This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from PHP to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, PHP may not cover this drug. PA NSO Prior Authorization Restriction for New Starts Only If you are a new member, you (or your physician) are required to get prior authorization from PHP before you fill your prescription for this drug. Without prior approval, PHP may not cover this drug. - v -

10 Abbreviation Description Explanation PA-HRM Prior Authorization Restriction for High- Risk Medication This drug is considered a high-risk medication for seniors. If you are age 65 or older, you (or your physician) are required to get prior authorization from PHP before you fill your prescription for this drug. PA NSO Prior Authorization Restriction for New Starts Only If you are a new member, you (or your physician) are required to get prior authorization from PHP before you fill your prescription for this drug. Without prior approval, PHP may not cover this drug. QL Quantity Limit Restriction PHP limits the amount of this drug that is covered per prescription, or within a specific time frame. ST Step Therapy Restriction Before PHP will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. Other Special Requirements for Coverage LA Limited Access Drug This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Pharmacy Customer Service at (866) , 4 hours a day, seven days a week. TTY users should call 7. NDS Non-Extended Day Supply This drug can be filled for a maximum 30-day supply. This drug is not eligible for extended day supply fills. If you would like an extended day supply of this drug, you will need to request a formulary exception. Please see Chapter 9, Section 6 of your Evidence of Coverage for information about requesting a formulary exception. - vi -

11 Standard Retail Cost Sharing by Tier Tier One-Month Supply Three-Month Supply Tier (Generic) 5% coinsurance 5% coinsurance Tier (Preferred Brand) 5% coinsurance 5% coinsurance Tier 3 (Non-Preferred Brand) 5% coinsurance Not Offered Tier 4 (Speciality Tier) 5% coinsurance Not Offered Strength and Dosage Form Abbreviations Abbreviation Description adh. patch adhesive patch aer br act aerosol, breath activated aer pow aerosol, powder aer pow ba aerosol powder, breath activated aer refill aerosol refill aer w/adap aerosol with adapter ampul Ampule blkbaginj bulk bag injection cap dr mp capsule, delayed release multiphasic cap ds pk capsule, dose pack cap er h capsule, hour extended release cap er 4h capsule, 4 hour extended release cap er deg capsule, extended release degradable cap er pel capsule, extended release pellets cap mphase capsule, multiphasic cap.sa 4h capsule, 4 hour sustained action cap.sr h capsule, hour sustained release cap.sr 4h capsule, 4 hour sustained release cap4h pct capsule, 4 hour controlled-onset pellets cap4h pel capsule, 4 hour sustained release pellets cap sprink capsule, sprinkle cap sr pel capsule sustained release pellets cap w/dev capsule with device capsule dr capsule, delayed release capsule er capsule, extended release capsule sa capsule, sustained action cmb cappad combination: capsule, pad cmb ont fm combination: ointment, foam cmb ont lt combination: ointment, lotion cmb tabpad combination: tablet, pad combo. pkg combination package cpmp hr capsule, hour multiphasic cpmp 4hr capsule, 4 hour multiphasic cpmp capsule, multiphasic, 30%-70% - vii -

12 Abbreviation Description cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package dehp fr bg di(-ethylhexyl)phthalate free bag dis needle disposable needle disk w/dev disk with inhalation device disp syrin disposable syringe drops susp drops, suspension drps hpvis drops, hyperviscous emul adhes emulsion adhesive emul packt emulsion packet emulsn(g) emulsion (grams) foam/appl. foam with applicator froz.piggy frozen piggyback g Gram gel/pf app gel with prefilled applicator gel (gm) gel (grams) gel (ml) gel (milliliters) gel md pmp gel in metered dose pump gel w/appl gel with applicator gel w/pump gel with pump gran pack granule pack hfa aer ad hfa aerosol adapter infus. btl infusion bottle insuln pen insulin pen ip soln intraperitoneal solution irrig soln irrigating solution iv soln. intravenous solution jel Jelly jelly/app jelly with applicator jel/pf app jelly with pre-filled applicator kit cl&crm kit: cleasner and cream kt crm le kit: cream, lotion emollient kt lotn ce kit: lotion, cream emollient kt oint le kit: ointment, lotion emollient lotion, er lotion, extended release lozenge hd lozenge handle m.ht patch medicated heated patch ma buc tab mucoadhesive buccal tablet mcg Microgram med. pad medicated pad - viii -

13 Abbreviation med. swab med. tape ml muc er h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td4 patch td7 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 4h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er h tab er 4h Description medicated swab medicated tape Milligram Milliliter mucoadhesive system, hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 4 hour transdermal patch, 7 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal Suppository suspension, 4 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, hour extended release tablet, 4 hour extended release - ix -

14 Abbreviation tab er prt tab er seq tab disper tab ds pk tab er 4 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr h tab.sr 4h tabergr4hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp hr tbmp 4hr u vag ring Description tablet, extended release particles tablet, extended release sequels tablet, dispersable tablet, dose pack tablet, 4 hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, hour sustained release tablet, 4 hour sustained release tablet, 4 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dosepack tablet, multiphasic dosepack tablet, rapid disintegrating dosepack tablet, 3-month dosepack tablet, hour multiphasic tablet, 4 hour multiphasic Unit vaginal ring - x -

15 Table of Contents Analgesics...3 Anesthetics... 8 Anti-Addiction/Substance Abuse Treatment Agents...9 Antianxiety Agents...0 Antibacterials... Anticancer Agents... 0 Anticholinergic Agents Anticonvulsants...30 Antidementia Agents...33 Antidepressants Antidiabetic Agents Antifungals...4 Antigout Agents... 4 Antihistamines...43 Anti-Infectives (Skin And Mucous Membrane)...43 Antimigraine Agents...43 Antimycobacterials...44 Antinausea Agents...45 Antiparasite Agents...46 Antiparkinsonian Agents...47 Antipsychotic Agents...48 Antivirals (Systemic)...53 Blood Products/Modifiers/Volume Expanders Caloric Agents...6 Cardiovascular Agents Central Nervous System Agents Contraceptives...80 Dental And Oral Agents...86 Dermatological Agents...87 Devices... 9 Enzyme Replacement/Modifiers...9 Eye, Ear, Nose, Throat Agents...93 Gastrointestinal Agents Genitourinary Agents... 0 Heavy Metal Antagonists... 0 Hormonal Agents, Stimulant/Replacement/Modifying...0

16 Immunological Agents...08 Inflammatory Bowel Disease Agents... 7 Irrigating Solutions...8 Metabolic Bone Disease Agents...8 Miscellaneous Therapeutic Agents...0 Ophthalmic Agents... Replacement Preparations... 3 Respiratory Tract Agents... 6 Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents...3 Vitamins And Minerals...3

17 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 0- /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet ascomp with codeine oral capsule BELBUCA BUCCAL FILM 50 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml buprenorphine transdermal patch weekly 0 mcg/hour, 5 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule , butalbital-acetaminophen oral tablet butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule QL (700 per 30 QL (360 per 30 (Tylenol-Codeine #3) QL (360 per 30 (Tylenol-Codeine #4) QL (80 per 30 (Buprenex) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) QL (60 per 30 (Butrans) QL (4 per 8 PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Marten-Tab) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Capacet) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Esgic) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Fiorinal) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) 3

18 butalbital-aspirin-caffeine oral tablet PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) QL (4 per 8 BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HOUR capacet oral capsule PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) codeine sulfate oral tablet 5, 30, QL (80 per endocet oral tablet 0-35 QL (40 per 30 endocet oral tablet.5-35, 5-35 QL (360 per 30 endocet oral tablet QL (300 per 30 fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, (Actiq) 4 PA; NDS; QL (0 per mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 (Duragesic) QL (0 per 30 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution QL (700 per /5 ml, 5-63 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) QL (700 per /5 ml hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (360 per hydrocodone-acetaminophen oral tablet (Verdrocet) QL (360 per hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) QL (360 per hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (360 per hydrocodone-ibuprofen oral tablet 7.5- QL (50 per hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone injection solution /ml, 4 /ml hydromorphone injection syringe (Dilaudid) /ml, 4 /ml hydromorphone oral liquid /ml (Dilaudid) QL (00 per 30 4

19 hydromorphone oral tablet, 4, 8 (Dilaudid) QL (80 per 30 HYSINGLA ER ORAL QL (30 per 30 TABLET,ORAL ONLY,EXT.REL.4 HR 00 MG, 0 MG, 0 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, PA; NDS; QL (30 per 30 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-35 QL (360 per 30 lorcet hd oral tablet 0-35 QL (360 per 30 lorcet plus oral tablet QL (360 per 30 methadone injection solution 0 /ml methadone oral solution 0 /5 ml, 5 QL (800 per 30 /5 ml methadone oral tablet 0 (Dolophine) QL (360 per 30 methadone oral tablet 5 (Dolophine) QL (80 per 30 methadose oral tablet,soluble 40 QL (90 per 30 morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine 4 /ml carpuject outer,l/f,p/f, sdv 4 /ml morphine 8 /ml carpuject sdv, l/f, outer 8 /ml morphine concentrate oral solution 00 QL (80 per 30 /5 ml (0 /ml) morphine intravenous syringe 0 /ml, /ml, 4 /ml, 8 /ml morphine oral solution 0 /5 ml QL (700 per 30 morphine oral solution 0 /5 ml (4 QL (300 per 30 /ml) MORPHINE ORAL TABLET 5 MG 3 NDS; QL (80 per 30 MORPHINE ORAL TABLET 30 MG 3 NDS; QL (0 per 30 morphine oral tablet extended release 00 (MS Contin) QL (60 per 30, 00, 60 morphine oral tablet extended release 5 (MS Contin) QL (90 per 30, 30 morphine sulfate 0 /ml vial 0 /ml 5

20 NUCYNTA ER ORAL TABLET QL (60 per 30 EXTENDED RELEASE HR 00 MG, 50 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 00 MG, QL (8 per MG, 75 MG oxycodone oral concentrate 0 /ml QL (0 per 30 oxycodone oral solution 5 /5 ml QL (300 per 30 oxycodone oral tablet 0 QL (80 per 30 oxycodone oral tablet 5, 30 (Roxicodone) QL (0 per 30 oxycodone oral tablet 0 QL (0 per 30 oxycodone oral tablet 5 (Roxicodone) QL (80 per 30 oxycodone oral tablet,oral only,ext.rel. (OxyContin) QL (60 per 30 hr 0, 5, 0, 30, 40, 60 oxycodone oral tablet,oral only,ext.rel. hr 80 (OxyContin) ; QL (0 per 30 oxycodone-acetaminophen oral solution QL (800 per /5 ml oxycodone-acetaminophen oral tablet 0- (Endocet) QL (40 per oxycodone-acetaminophen oral tablet (Endocet) QL (360 per , 5-35 oxycodone-acetaminophen oral tablet (Endocet) QL (300 per oxycodone-aspirin oral tablet QL (360 per 30 OXYCONTIN ORAL QL (60 per 30 TABLET,ORAL ONLY,EXT.REL. HR 0 MG, 5 MG, 0 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (0 per 30 TABLET,ORAL ONLY,EXT.REL. HR 80 MG oxymorphone oral tablet 0 (Opana) QL (0 per 30 oxymorphone oral tablet 5 (Opana) QL (80 per 30 oxymorphone oral tablet extended release QL (60 per 30 hr 0, 5, 0, 30, 40, 5, 7.5 reprexain oral tablet.5-00 QL (50 per 30 6

21 tencon oral tablet PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) tramadol oral tablet 50 (Ultram) QL (40 per 30 tramadol-acetaminophen oral tablet (Ultracet) QL (40 per XTAMPZA ER ORAL QL (60 per 30 CAPSULE,SPRINKLE,ER HR TMPRR 3.5 MG, 8 MG, 9 MG XTAMPZA ER ORAL QL (0 per 30 CAPSULE,SPRINKLE,ER HR TMPRR 7 MG XTAMPZA ER ORAL QL (40 per 30 CAPSULE,SPRINKLE,ER HR TMPRR 36 MG zebutal oral capsule PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS 3 NDS RECON SOLN 400 MG/4 ML (00 MG/ML), 800 MG/8 ML (00 MG/ML) celecoxib oral capsule 00, 00, (Celebrex) QL (60 per , 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 etodolac oral capsule 00, 300 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 7

22 etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 (ProFeno) flurbiprofen oral tablet 00, 50 ibuprofen oral suspension 00 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 5 PA-HRM; QL (40 per 30 ; AGE (Max 64 Years) indomethacin oral capsule 50 PA-HRM; QL (0 per 30 ; AGE (Max 64 Years) indomethacin oral capsule, extended release 75 PA-HRM; QL (60 per 30 ; AGE (Max 64 Years) indomethacin sodium intravenous recon soln ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets 4 hr 00 ketorolac oral tablet 0 PA-HRM; QL (0 per 30 ; AGE (Max 64 Years) mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral suspension 5 /5 ml (Naprosyn) naproxen oral tablet 50, 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375, 500 piroxicam oral capsule 0, 0 (Feldene) sulindac oral tablet 50, 00 Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % 8

23 lidocaine (pf) injection solution 0 /ml (Xylocaine-MPF) ( %), 5 /ml (.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl injection solution 0 /ml (Xylocaine) ( %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 30 lidocaine topical ointment 5 % PA; QL (90 per 30 lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 BUNAVAIL BUCCAL FILM.-0.3 QL (30 per 30 MG BUNAVAIL BUCCAL FILM QL (60 per 30 MG, 6.3- MG buprenorphine hcl sublingual tablet, QL (90 per 30 8 buprenorphine-naloxone sublingual tablet -0.5, 8- QL (90 per 30 bupropion hcl (smoking deter) oral tablet (Zyban) extended release hr 50 CHANTIX CONTINUING MONTH QL (68 per 84 BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, QL (68 per 84 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) QL (53 per 8 9

24 disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL (4 per 30 AEROSOL MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION CARTRIDGE 0 MG 3 NDS; QL (008 per 90 SUBOXONE SUBLINGUAL FILM QL (60 per 30-3 MG, 8- MG SUBOXONE SUBLINGUAL FILM - QL (30 per MG, 4- MG ZUBSOLV SUBLINGUAL TABLET QL (30 per MG, MG,.4-.9 MG, MG, MG ZUBSOLV SUBLINGUAL TABLET QL (60 per MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, (Xanax) QL (0 per 30 alprazolam oral tablet (Xanax) QL (50 per 30 buspirone oral tablet 0, 5, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 0, QL (0 per 30 5, 5 clonazepam oral tablet 0.5, (Klonopin) QL (90 per 30 clonazepam oral tablet (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating QL (90 per , 0.5, 0.5, clonazepam oral tablet,disintegrating QL (300 per 30 clorazepate dipotassium oral tablet 5 QL (80 per 30, 3.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (80 per 30 DIASTAT ACUDIAL RECTAL KIT 3 NDS MG, MG DIASTAT RECTAL KIT.5 MG 3 NDS 0

25 diazepam injection solution 5 /ml QL (0 per 8 diazepam intensol oral concentrate 5 QL (00 per 30 /ml diazepam oral solution 5 /5 ml ( QL (00 per 30 /ml) diazepam oral tablet 0,, 5 (Valium) QL (0 per 30 diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml, 4 (Ativan) QL ( per 30 /ml lorazepam injection syringe /ml QL ( per 30 lorazepam oral tablet 0.5, (Ativan) QL (90 per 30 lorazepam oral tablet (Ativan) QL (50 per 30 ONFI ORAL SUSPENSION.5 MG/ML 4 PA NSO; NDS; QL (480 per 30 ONFI ORAL TABLET 0 MG, 0 MG 4 PA NSO; NDS; QL (60 per 30 temazepam oral capsule 5, 30 (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) Antibacterials Aminoglycosides BETHKIS INHALATION 4 PA BvD; NDS SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin 0 /ml vial sdv 60 /6 ml gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 00 /50 ml, 0 /00 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin injection solution 0 / ml, 40 /ml

26 gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 00 /0 ml neomycin oral tablet 500 streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION ; QL (4 per 8 DEVICE 8 MG tobramycin in 0.5 % nacl inhalation (Tobi) 4 PA BvD; NDS solution for nebulization 300 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 0 /ml, 40 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln (BACiiM) 50,000 unit chloramphenicol sod succinate intravenous recon soln gram clindamycin hcl oral capsule 50, 300, 75 (Cleocin HCl) clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) clindamycin phosphate injection solution 50 /ml clindamycin phosphate intravenous solution 600 /4 ml colistin (colistimethate na) injection recon soln 50 daptomycin intravenous recon soln 500 linezolid intravenous parenteral solution 600 /300 ml (Cleocin in 5 % dextrose) (Cleocin Pediatric) (Cleocin) (Cleocin) (Coly-Mycin M Parenteral) (Cubicin) (Zyvox)

27 linezolid oral suspension for (Zyvox) reconstitution 00 /5 ml linezolid oral tablet 600 (Zyvox) linezolid-0.9% nacl 600 / /300 ml methenamine hippurate oral tablet (Hiprex) gram metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml (Metro I.V.) metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 00, 5, 50 (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 (0 per 30 ; AGE (Max 64 Years) nitrofurantoin monohyd/m-cryst oral capsule 00 (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 ; AGE (Max 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 vancomycin in dextrose 5 % intravenous piggyback gram/00 ml, 500 /00 ml, 750 /50 ml vancomycin intravenous recon soln,000, 0 gram, 5 gram, 500, 750 vancomycin oral capsule 5, 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG 4 PA; NDS; QL (9 per 30 3

28 XIFAXAN ORAL TABLET 550 MG 4 PA; NDS Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 5 /5 ml, 50 /5 ml, 375 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin in 0.9% sod chloride intravenous solution gram/00 ml cefazolin in dextrose (iso-os) intravenous piggyback gram/00 ml cefazolin injection recon soln gram, 0 gram, 500 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 400 (Spectracef) CEFEPIME GM INJECTION 3 NDS GRAM/50 ML CEFEPIME INJECTION RECON (Maxipime) 3 NDS SOLN GRAM, GRAM CEFEPIME-DEXTROSE GM/50 3 NDS ML GRAM/50 ML cefotaxime injection recon soln gram, 500 cefotaxime injection recon soln 0 gram, (Claforan) gram cefoxitin gm piggyback bag gram/50 ml cefoxitin intravenous recon soln gram, 0 gram cefoxitin intravenous recon soln gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml 4

29 cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram, 6 (Fortaz) gram ceftibuten oral capsule 400 (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 80 /5 ml ceftriaxone gm piggyback l/g, single use gram/50 ml ceftriaxone gm piggyback l/f, single use gram/50 ml ceftriaxone injection recon soln gram, gram ceftriaxone injection recon soln 0 gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln (Zinacef) 750 cefuroxime sodium intravenous recon soln (Zinacef).5 gram, 7.5 gram cefuroxime-dextrose (iso-osm) intravenous piggyback.5 gram/50 ml, 750 /50 ml cephalexin oral capsule 50, 500 (Keflex) cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 MEFOXIN IN DEXTROSE (ISO- 3 NDS OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG 3 NDS SUPRAX ORAL 3 NDS TABLET,CHEWABLE 00 MG, 00 MG tazicef injection recon soln gram, gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG 3 NDS 5

30 Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 (3 pack) azithromycin oral tablet 50, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 DIFICID ORAL TABLET 00 MG 4 ST; NDS; QL (0 per 0 e.e.s. 400 oral tablet NDS E.E.S. GRANULES ORAL 3 NDS SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 00 ORAL SUSPENSION 3 NDS FOR RECONSTITUTION 00 MG/5 ML ERYPED 400 ORAL SUSPENSION 3 NDS FOR RECONSTITUTION 400 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL 3 NDS TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG, 500 MG 3 NDS erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 erythromycin oral capsule,delayed release(dr/ec) 50 6

31 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram, gram (Azactam) CAYSTON INHALATION 4 LA; NDS SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon soln 500 (Primaxin IV) INVANZ INJECTION RECON SOLN GRAM 3 NDS meropenem intravenous recon soln (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet 50-5 amoxicillin-pot clavulanate oral tablet (Augmentin) 500-5, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, 500 ampicillin oral suspension for reconstitution 5 /5 ml, 50 /5 ml 7

32 ampicillin sodium injection recon soln gram, 0 gram, 5, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram (Unasyn) BICILLIN C-R INTRAMUSCULAR 3 NDS SYRINGE,00,000 UNIT/ ML(600K/600K),,00,000 UNIT/ ML(900K/300K) BICILLIN L-A INTRAMUSCULAR 3 NDS SYRINGE,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln gram nafcillin injection recon soln 0 gram nafcillin intravenous recon soln gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, gram/50 ml oxacillin injection recon soln 0 gram, gram oxacillin intravenous recon soln gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe. million unit/ ml, 600,000 unit/ml penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit 8

33 piperacillin-tazobactam intravenous (Zosyn) recon soln.5 gram, gram, 4.5 gram, 40.5 gram Quinolones BAXDELA ORAL TABLET 450 MG 4 PA; NDS; QL (8 per 4 ciprofloxacin hcl oral tablet 00, 750 ciprofloxacin hcl oral tablet 50, 500 (Cipro) ciprofloxacin in 5 % dextrose intravenous piggyback 00 /00 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50, 500, (Levaquin) 750 moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 300, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) tablet sulfatrim oral suspension /5 ml 9

34 Tetracyclines doxy-00 intravenous recon soln 00 doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 0 doxycycline monohydrate oral capsule (Mondoxyne NL) 00, 50, 75 doxycycline monohydrate oral capsule 50 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 00 (Avidoxy) doxycycline monohydrate oral tablet 50, 50, 75 minocycline oral capsule 00, 50, (Minocin) 75 minocycline oral tablet 00, 50, 75 tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG adriamycin intravenous solution 0 /5 PA BvD ml, 0 /0 ml adrucil intravenous solution.5 gram/50 PA BvD ml, 500 /0 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 3 4 PA NSO; NDS; QL ( per 8 MG, 5 MG AFINITOR ORAL TABLET 0 MG 4 PA NSO; NDS; QL (56 per 8 AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 4 PA NSO; NDS; QL (8 per 8 ALECENSA ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (40 per 30 ALIMTA INTRAVENOUS RECON SOLN 00 MG, 500 MG 0

35 ALIQOPA INTRAVENOUS RECON SOLN 60 MG 4 PA NSO; NDS; QL (3 per 8 ALUNBRIG ORAL TABLET 80 MG, 90 MG 4 PA NSO; NDS; QL (30 per 30 ALUNBRIG ORAL TABLET 30 MG 4 PA NSO; NDS; QL (80 per 30 ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG (3) 4 PA NSO; NDS; QL (30 per 30 anastrozole oral tablet (Arimidex) AVASTIN INTRAVENOUS 4 PA NSO; NDS SOLUTION 5 MG/ML, 5 MG/ML (6 ML) azacitidine injection recon soln 00 (Vidaza) BAVENCIO INTRAVENOUS 4 PA NSO; NDS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS 4 PA NSO; NDS RECON SOLN 500 MG BENDEKA INTRAVENOUS 4 PA NSO; NDS SOLUTION 5 MG/ML BESPONSA INTRAVENOUS 4 PA NSO; NDS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 4 PA NSO; NDS; QL (40 per 30 bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 5 unit, 30 PA BvD unit BLINCYTO INTRAVENOUS KIT 35 MCG 4 PA NSO; NDS; QL (5 per 365 BORTEZOMIB INTRAVENOUS 4 PA NSO; NDS RECON SOLN 3.5 MG BOSULIF ORAL TABLET 00 MG 4 PA NSO; NDS; QL (0 per 30 BOSULIF ORAL TABLET 400 MG, 500 MG 4 PA NSO; NDS; QL (30 per 30 CABOMETYX ORAL TABLET 0 MG, 60 MG 4 PA NSO; NDS; QL (30 per 30 CABOMETYX ORAL TABLET 40 MG 4 PA NSO; NDS; QL (60 per 30 CALQUENCE ORAL CAPSULE 00 MG 4 PA NSO; NDS; QL (60 per 30

36 CAPRELSA ORAL TABLET 00 MG 4 PA NSO; NDS; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG 4 PA NSO; NDS; QL (30 per 30 clofarabine intravenous solution 0 /0 (Clolar) ml COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 MG/DAY(80 MG X-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) 4 PA NSO; NDS; QL ( per 8 COTELLIC ORAL TABLET 0 MG 4 PA NSO; LA; NDS; QL (63 per 8 cyclophosphamide intravenous recon soln 4 PA BvD; NDS gram, gram, 500 CYCLOPHOSPHAMIDE ORAL 3 PA BvD; ST; NDS CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 4 PA NSO; NDS SOLUTION 0 MG/ML, 0 MG/ML (50 ML) DARZALEX INTRAVENOUS 4 PA NSO; LA; NDS SOLUTION 0 MG/ML decitabine intravenous recon soln 50 (Dacogen) doxorubicin intravenous solution 0 /5 (Adriamycin) PA BvD ml, /ml, 0 /0 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) 4 PA BvD; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, 300 MG, 400 MG ELIGARD (3 MONTH) 3 NDS SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) 3 NDS SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) 3 NDS SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS 3 NDS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG 4 PA NSO; NDS

37 ERIVEDGE ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (30 per 30 ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG 3 NDS etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 4 PA NSO; NDS MG, 5 MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil intravenous solution PA BvD gram/0 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/00 ml, 500 /0 ml flutamide oral capsule 5 GAZYVA INTRAVENOUS 4 PA NSO; NDS SOLUTION,000 MG/40 ML GILOTRIF ORAL TABLET 0 MG, 30 MG, 40 MG 4 PA NSO; NDS; QL (30 per 30 GLEOSTINE ORAL CAPSULE 0 3 NDS MG, 00 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS 4 PA NSO; NDS RECON SOLN 50 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG 4 PA NSO; NDS; QL ( per 8 ICLUSIG ORAL TABLET 5 MG 4 PA NSO; NDS; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG 4 PA NSO; NDS; QL (30 per 30 IDHIFA ORAL TABLET 00 MG, 50 MG 4 PA NSO; NDS; QL (30 per 30 ifosfamide intravenous recon soln gram, (Ifex) PA BvD 3 gram ifosfamide intravenous solution gram/0 PA BvD ml, 3 gram/60 ml ifosfamide-mesna intravenous kit - gram, 3,000-,000 4 PA BvD; NDS 3