Centers Plan for Medicare Advantage Care (HMO) 2018 Comprehensive Formulary

Transcription

1 Centers Plan for Medicare Advantage Care (HMO) 08 Comprehensive Formulary This formulary was updated on 0/08 For more recent information or other questions, please contact Centers Plan for Healthy Living at or, for TTY users, , seven days a week from 8 am 8 pm, or visit H6988_ENR085 Accepted

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3 Centers Plan for Medicaid Advantage Plan (HMO SNP) 08 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN CPHL 08 Formulary ID: 803 Version: 9 This formulary was updated on 0/0/08. For more recent information or other questions, please contact us, Centers Plan for Medicare Advantage Plan (HMO) at or, for TTY users, , seven days a week, 8:00 AM to 8:00 PM, or visit 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 Centers Plan for Medicare Advantage Care (HMO). When it refers to plan or our plan, it means Centers Plan for Medicare Advantage Care (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 0/0/08. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 08, and from time to time during the year. What is the Centers Plan for Medicare Advantage Care (HMO) Formulary? A formulary is a list of covered drugs selected by Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plan (HMO SNP) 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. Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plan (HMO SNP) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the H6988_ENR085 Accepted i

4 prescription is filled at a Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plan (HMO SNP) 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 0/0/08. To get updated information about the drugs covered by Centers Plan for Medicaid Advantage Care (HMO), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plan (HMO SNP) please contact us. Our contact information appears on the front and back cover pages. In the event of any mid-year non-maintenance formulary changes, Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plan (HMO SNP) will mail you an errata sheet to update your printed formulary. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page. Then look under the category name for your drug. H6988_ENR085 Accepted ii

5 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? Centers Plan for Medicaid Advantage Care (HMO), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plan (HMO SNP) 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: Centers Plan for Medicaid Advantage Plan (HMO), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP), and Centers Plan for Medicaid Advantage Plan (HMO SNP), requires your physician to get prior authorization for certain drugs. This means that you will need to get approval from Centers Plan for Medicaid Advantage Plan (HMO), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Medicaid Advantage Plan (HMO SNP), before you fill your prescriptions. If you don t get approval, Centers Plan for Medicaid Advantage Plan (HMO), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Advantage Care (HMO SNP) may not cover the drug. Quantity Limits: For certain drugs, Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Advantage Care (HMO) limits the amount of the drug that Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) and Centers Plan for Advantage Care (HMO) will cover. For example, Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) provides tablets per prescription for sumatriptan. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP), 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, Centers Plan for Medicare Advantage Care (HMO) Centers Plan H6988_ENR085 Accepted iii

6 for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP), may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) 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. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document 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 to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) formulary? on page v for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Centers Plan for Medicaid Advantage Care (HMO) pays for certain OTC drugs Centers Plan for Medicaid Advantage Care (HMO) will provide these OTC drugs at no cost to you. The cost to Centers Plan for Medicaid Advantage Care (HMO) of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap.) What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you learn that Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP), does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), and Centers Plan for Nursing Home Care (HMO SNP). H6988_ENR085 Accepted iv

7 You can ask Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) 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 Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) Formulary? You can ask Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), and Centers Plan for Nursing Home Care (HMO SNP) 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 cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), and Centers Plan for Nursing Home Care (HMO SNP) 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 Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary 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. H6988_ENR085 Accepted v

8 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course 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 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. Transition medications will be provided to members who change treatment settings due to changes in level of care (e.g. individuals who enter long term facilities from hospitals or enter an ambulatory setting from a hospital). For more information For more detailed information about your Centers Plan for Medicare Advantage Care (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about, Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call Or, visit H6988_ENR085 Accepted vi

9 Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), Centers Plan for Nursing Home Care (HMO SNP) Formulary The formulary below provides coverage information about the drugs covered by Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), and Centers Plan for Nursing Home Care (HMO SNP). 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., LIPITOR) and generic drugs are listed in lower-case italics (e.g., atorvastin). The information in the Requirements/Limits column tells you if Centers Plan for Medicare Advantage Care (HMO), Centers Plan for Medicaid Advantage Plan (HMO SNP), Centers Plan for Dual Coverage Care (HMO SNP), and Centers Plan for Nursing Home Care (HMO SNP) has any special requirements for coverage of your drug. H6988_ENR085 Accepted vii

10 Table of Contents Analgesics... 3 Anesthetics... 8 Anti-Addiction/Substance Abuse Treatment Agents... 8 Antianxiety Agents... 9 Antibacterials... Anticancer Agents... 9 Anticholinergic Agents... 7 Anticonvulsants... 8 Antidementia Agents... 3 Antidepressants... 3 Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials... 4 Antinausea Agents... 4 Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents... 7 Contraceptives... 74

11 Dental And Oral Agents Dermatological Agents Devices 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... 0 Ophthalmic Agents... Replacement Preparations... 3 Respiratory Tract Agents... 6 Skeletal Muscle Relaxants... 0 Sleep Disorder Agents... 0 Vasodilating Agents... Vitamins And Minerals...

12 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

13 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, 400 mcg, 600 mcg, 800 mcg (Actiq) 4 PA; NDS; QL (0 per 30 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 5- (Lorcet (hydrocodone)) QL (360 per hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (360 per hydrocodone-ibuprofen oral tablet QL (50 per 30 hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone injection solution /ml, 4 /ml hydromorphone injection syringe /ml, (Dilaudid) 4 /ml hydromorphone oral liquid /ml (Dilaudid) QL (00 per 30 hydromorphone oral tablet, 4, 8 (Dilaudid) QL (80 per 30 4

14 HYSINGLA ER ORAL 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, 300 MCG/SPRAY, 400 MCG/SPRAY QL (30 per 30 4 PA; NDS; QL (30 per 30 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 syringe 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 QL (80 per 30 MORPHINE ORAL TABLET 30 MG 3 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 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, 50 QL (8 per 30 MG, 75 MG oxycodone oral concentrate 0 /ml QL (0 per 30 oxycodone oral solution 5 /5 ml QL (300 per 30 5

15 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 5- QL (800 per /5 ml oxycodone-acetaminophen oral tablet 0- (Endocet) QL (40 per oxycodone-acetaminophen oral tablet.5- (Endocet) QL (360 per 30 35, 5-35 oxycodone-acetaminophen oral tablet 7.5- (Endocet) QL (300 per oxycodone-aspirin oral tablet QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL QL (60 per 30 ONLY,EXT.REL. HR 0 MG, 5 MG, 0 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (0 per 30 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 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 CAPSULE,SPRINKLE,ER HR TMPRR 7 MG QL (0 per 30 6

16 XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER HR TMPRR 36 MG QL (40 per 30 zebutal oral capsule PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (00 MG/ML), 800 MG/8 ML (00 MG/ML) celecoxib oral capsule 00, 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 tablet,ir,delayed rel,biphasic mcg (Arthrotec 50) 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 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 PA-HRM; QL (60 per 30 ; AGE (Max 64 Years)

17 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 % 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 (Lidoderm) PA; QL (90 per 30 patch,medicated 5 % 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 8

18 Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 BUNAVAIL BUCCAL FILM.-0.3 MG QL (30 per 30 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 extended release hr 50 (Zyban) 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 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 3 QL (008 per 90 CARTRIDGE 0 MG SUBOXONE SUBLINGUAL FILM -3 QL (60 per 30 MG, 8- MG SUBOXONE SUBLINGUAL FILM -0.5 QL (30 per 30 MG, 4- MG ZUBSOLV SUBLINGUAL TABLET 0.7- QL (30 per MG, MG,.4-.9 MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG QL (60 per 30 Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, (Xanax) QL (0 per 30 9

19 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, 3.75 QL (80 per 30 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (80 per 30 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG 3 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 ( /ml) QL (00 per 30 diazepam oral tablet 0,, 5 (Valium) QL (0 per 30 diazepam rectal kit , 5- (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 0

20 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 SOLUTION 4 PA BvD; NDS 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 40 /ml 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 DEVICE ; QL (4 per 8 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 75 /5 ml soln 75 /5 ml (Cleocin Pediatric)

21 clindamycin hcl oral capsule 50, 300 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous (Cleocin in 5 % piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml dextrose) clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 50 /ml clindamycin phosphate intravenous (Cleocin) solution 600 /4 ml colistin (colistimethate na) injection recon (Coly-Mycin M soln 50 Parenteral) daptomycin intravenous recon soln 500 (Cubicin) linezolid intravenous parenteral solution 600 /300 ml (Zyvox) linezolid oral suspension for reconstitution (Zyvox) 00 /5 ml linezolid oral tablet 600 (Zyvox) linezolid-0.9% nacl 600 / /300 ml methenamine hippurate oral tablet gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /00 ml 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)

22 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 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) 3

23 CEFEPIME GM INJECTION 3 GRAM/50 ML CEFEPIME INJECTION RECON SOLN (Maxipime) 3 GRAM, GRAM CEFEPIME-DEXTROSE GM/50 ML 3 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 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 0 gram, 50, 500 ceftriaxone intravenous recon soln gram, gram 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) 4

24 cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 MEFOXIN IN DEXTROSE (ISO-OSM) 3 INTRAVENOUS PIGGYBACK GRAM/50 ML, GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG 3 SUPRAX ORAL TABLET,CHEWABLE 3 00 MG, 00 MG tazicef injection recon soln gram, gram, 6 gram TEFLARO INTRAVENOUS RECON 3 SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 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 e.e.s. granules oral suspension for 3 reconstitution 00 /5 ml ERYPED 00 ORAL SUSPENSION FOR 3 RECONSTITUTION 00 MG/5 ML ERYPED 400 ORAL SUSPENSION FOR 3 RECONSTITUTION 400 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL TABLET,DELAYED 3 RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 50 5

25 ERYTHROCIN INTRAVENOUS 3 RECON SOLN,000 MG, 500 MG erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram, gram (Azactam) CAYSTON INHALATION SOLUTION 4 LA; NDS FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN 3 GRAM 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 ,

26 ampicillin oral capsule 50, 500 ampicillin oral suspension for reconstitution 5 /5 ml, 50 /5 ml ampicillin sodium injection recon soln gram, 0 gram, 5, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn).5 gram, 5 gram, 3 gram BICILLIN C-R INTRAMUSCULAR 3 SYRINGE,00,000 UNIT/ ML(600K/600K),,00,000 UNIT/ ML(900K/300K) BICILLIN L-A INTRAMUSCULAR 3 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) 5 million unit penicillin g procaine intramuscular syringe. million unit/ ml, 600,000 unit/ml penicillin gk 0 million unit 0 million unit (Pfizerpen-G) penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 7

27 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous recon (Zosyn) 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 tablet (Bactrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) sulfatrim oral suspension /5 ml Tetracyclines 8

28 doxy-00 intravenous recon soln 00 doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 0 doxycycline monohydrate oral capsule 00 (Mondoxyne NL), 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 4 PA NSO; NDS; QL ( FOR SUSPENSION MG, 3 MG, 5 MG per 8 AFINITOR ORAL TABLET 0 MG 4 PA NSO; NDS; QL (56 per 8 AFINITOR ORAL TABLET.5 MG, 5 4 PA NSO; NDS; QL (8 MG, 7.5 MG per 8 ALECENSA ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (40 per 30 ALIMTA INTRAVENOUS RECON SOLN 00 MG, 500 MG ALIQOPA INTRAVENOUS RECON 4 PA NSO; NDS; QL (3 SOLN 60 MG per 8 ALUNBRIG ORAL TABLET 30 MG 4 PA NSO; NDS; QL (80 per 30 9

29 anastrozole oral tablet (Arimidex) AVASTIN INTRAVENOUS SOLUTION 4 PA NSO; NDS 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 RECON 4 PA NSO; NDS SOLN 500 MG BENDEKA INTRAVENOUS 4 PA NSO; NDS SOLUTION 5 MG/ML BESPONSA INTRAVENOUS RECON 4 PA NSO; NDS 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 (Bleo 5K) PA BvD bleomycin injection recon soln 30 unit PA BvD BLINCYTO INTRAVENOUS KIT 35 MCG 4 PA NSO; NDS; QL (40 per 365 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 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 4 PA NSO; NDS; QL ( per 8 MG/DAY(80 MG X-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) COTELLIC ORAL TABLET 0 MG 4 PA NSO; LA; NDS; QL cyclophosphamide intravenous recon soln gram, gram, 500 (63 per 8 4 PA BvD; NDS 0

30 CYCLOPHOSPHAMIDE ORAL 3 PA BvD; ST 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 SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) 3 SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) 3 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON 4 PA NSO; NDS SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (30 per 30 ETOPOPHOS INTRAVENOUS RECON 3 SOLN 00 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 4 PA NSO; NDS MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil 5,000 /00 ml latex-free 5 (Adrucil) PA BvD gram/00 ml fluorouracil intravenous solution PA BvD gram/0 ml fluorouracil intravenous solution.5 (Adrucil) PA BvD gram/50 ml, 500 /0 ml

31 flutamide oral capsule 5 GAZYVA INTRAVENOUS SOLUTION 4 PA NSO; NDS,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 MG, 3 00 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON 4 PA NSO; NDS 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 - 4 PA BvD; NDS gram, 3,000-,000 imatinib oral tablet 00 (Gleevec) 4 PA NSO; NDS; QL (90 per 30 imatinib oral tablet 400 (Gleevec) 4 PA NSO; NDS; QL (60 per 30 IMBRUVICA ORAL CAPSULE 40 MG 4 PA NSO; NDS IMFINZI INTRAVENOUS SOLUTION 4 PA NSO; NDS 50 MG/ML, 50 MG/ML (0 ML) IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML 4 PA NSO; NDS; QL (4 per 365 IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML 4 PA NSO; NDS; QL (8 per 8 INLYTA ORAL TABLET MG 4 PA NSO; NDS; QL (80 per 30 INLYTA ORAL TABLET 5 MG 4 PA NSO; NDS; QL (60 per 30 IRESSA ORAL TABLET 50 MG 4 PA NSO; NDS; QL (60 per 30

32 IXEMPRA INTRAVENOUS RECON SOLN 5 MG, 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG 4 PA NSO; NDS; QL (60 per 30 KEYTRUDA INTRAVENOUS RECON SOLN 50 MG 4 PA NSO; NDS; QL (4 per KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML 4 PA NSO; NDS; QL (8 per KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 4 PA NSO; NDS; QL (49 per 8 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(00 MG X )-.5 4 PA NSO; NDS; QL (70 per 8 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X 3)-.5 4 PA NSO; NDS; QL (9 per 8 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X ), 400 MG/DAY (00 MG X 4 PA NSO; NDS; QL (63 per 8 ), 600 MG/DAY (00 MG X 3) KYPROLIS INTRAVENOUS RECON 4 PA NSO; NDS SOLN 30 MG, 60 MG LARTRUVO INTRAVENOUS 4 PA NSO; LA; NDS SOLUTION 0 MG/ML LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X), 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (4 MG X ) 4 PA NSO; NDS letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG 3 leuprolide subcutaneous kit /0. ml LONSURF ORAL TABLET MG 4 PA NSO; NDS; QL (00 per 8 LONSURF ORAL TABLET MG 4 PA NSO; NDS; QL (80 per 8 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG,.5 MG 3

33 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 4 PA NSO; NDS; QL (448 per 8 LYNPARZA ORAL TABLET 00 MG, 50 MG 4 PA NSO; NDS; QL (0 per 30 LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 40 PA NSO-HRM; AGE (Max 64 Years) MEKINIST ORAL TABLET 0.5 MG 4 PA NSO; NDS; QL (90 per 30 MEKINIST ORAL TABLET MG 4 PA NSO; NDS; QL (30 per 30 mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon PA BvD soln gram methotrexate sodium (pf) injection PA BvD solution 5 /ml methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST mitoxantrone intravenous concentrate /ml MYLOTARG INTRAVENOUS RECON 4 PA NSO; NDS SOLN 4.5 MG ( MG/ML INITIAL CONC) NERLYNX ORAL TABLET 40 MG 4 PA NSO; NDS; QL (80 per 30 NEXAVAR ORAL TABLET 00 MG 4 PA NSO; NDS; QL (0 per 30 nilutamide oral tablet 50 (Nilandron) NINLARO ORAL CAPSULE.3 MG, 3 MG, 4 MG 4 PA NSO; NDS; QL (3 per 8 ODOMZO ORAL CAPSULE 00 MG 4 PA NSO; LA; NDS ONCASPAR INJECTION SOLUTION 750 UNIT/ML 4 PA NSO; NDS 4

34 ONIVYDE INTRAVENOUS 4 PA BvD; NDS DISPERSION 4.3 MG/ML OPDIVO INTRAVENOUS SOLUTION 4 PA NSO; NDS 00 MG/0 ML, 40 MG/4 ML POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG 4 PA NSO; NDS; QL ( per 8 PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (6 MG/ML) 4 PA NSO; NDS; QL (00 per PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 0 MG, 5 4 PA NSO; LA; NDS MG,.5 MG, 0 MG, 5 MG, 5 MG RITUXAN HYCELA SUBCUTANEOUS 4 PA NSO; NDS SOLUTION 400 MG/.7 ML (0 MG/ML), 600 MG/3.4 ML (0 MG/ML) RITUXAN INTRAVENOUS 4 PA NSO; NDS CONCENTRATE 0 MG/ML RUBRACA ORAL TABLET 00 MG, 50 MG, 300 MG 4 PA NSO; NDS; QL (0 per 30 RYDAPT ORAL CAPSULE 5 MG 4 PA NSO; NDS; QL (4 per 8 SOLTAMOX ORAL SOLUTION 0 3 MG/5 ML SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG 4 PA NSO; NDS; QL (30 per 30 SPRYCEL ORAL TABLET 0 MG 4 PA NSO; NDS; QL (60 per 30 STIVARGA ORAL TABLET 40 MG 4 PA NSO; NDS; QL (84 per 8 SUTENT ORAL CAPSULE.5 MG, 5 MG, 37.5 MG, 50 MG 4 PA NSO; NDS; QL (30 per 30 SYLVANT INTRAVENOUS RECON 4 PA NSO; NDS SOLN 00 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG 4 PA NSO; NDS; QL (8 per 8 TABLOID ORAL TABLET 40 MG 3 TAFINLAR ORAL CAPSULE 50 MG, 75 MG 4 PA NSO; NDS; QL (0 per 30 TAGRISSO ORAL TABLET 40 MG, 80 MG 4 PA NSO; LA; NDS; QL (30 per 30 5

35 tamoxifen oral tablet 0, 0 TARCEVA ORAL TABLET 00 MG, 5 MG 4 PA NSO; NDS; QL (60 per 30 TARCEVA ORAL TABLET 50 MG 4 PA NSO; NDS; QL (90 per 30 TARGRETIN TOPICAL GEL % 4 PA NSO; NDS; QL (60 per 8 TASIGNA ORAL CAPSULE 50 MG, 00 MG 4 PA NSO; NDS; QL ( per 8 TECENTRIQ INTRAVENOUS SOLUTION,00 MG/0 ML (60 4 PA NSO; NDS; QL (0 per MG/ML) TEMODAR INTRAVENOUS RECON 4 PA NSO; NDS SOLN 00 MG thiotepa injection recon soln 5 (Tepadina) toposar intravenous solution 0 /ml TREANDA INTRAVENOUS RECON SOLN 00 MG, 5 MG TRELSTAR.5 MG VIAL INNER, ; QL ( per 84 SDV.5 MG TRELSTAR.5 MG VIAL INNER,SDV.5 MG ; QL ( per 68 TRELSTAR 3.75 MG VIAL INNER, SDV 3.75 MG TRELSTAR INTRAMUSCULAR ; QL ( per 84 SYRINGE.5 MG/ ML TRELSTAR INTRAMUSCULAR SYRINGE.5 MG/ ML ; QL ( per 68 TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/ ML tretinoin (chemotherapy) oral capsule 0 TREXALL ORAL TABLET 0 MG, 5 3 PA BvD; ST MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 50 MG UNITUXIN INTRAVENOUS 4 PA NSO; NDS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 4 PA NSO; NDS 3.5 MG VENCLEXTA ORAL TABLET 0 MG PA NSO; LA; QL (60 per 30 6

36 VENCLEXTA ORAL TABLET 00 MG 4 PA NSO; LA; NDS; QL (0 per 30 VENCLEXTA ORAL TABLET 50 MG PA NSO; LA; QL (30 per 30 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG VERZENIO ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG vinorelbine intravenous solution 0 /ml, 50 /5 ml 4 PA NSO; LA; NDS; QL (4 per 8 4 PA NSO; NDS; QL (56 per 8 (Navelbine) VOTRIENT ORAL TABLET 00 MG 4 PA NSO; NDS; QL (0 per 30 VYXEOS INTRAVENOUS RECON 4 PA BvD; NDS SOLN MG XALKORI ORAL CAPSULE 00 MG, 50 MG 4 PA NSO; NDS; QL (60 per 30 XATMEP ORAL SOLUTION.5 3 PA BvD; ST MG/ML XTANDI ORAL CAPSULE 40 MG 4 PA NSO; NDS; QL (0 per 30 YERVOY INTRAVENOUS SOLUTION 00 MG/40 ML (5 MG/ML), 50 MG/0 ML (5 MG/ML) 4 PA NSO; NDS YONDELIS INTRAVENOUS RECON 4 PA NSO; NDS SOLN MG ZEJULA ORAL CAPSULE 00 MG 4 PA NSO; NDS; QL (90 per 30 ZELBORAF ORAL TABLET 40 MG 4 PA NSO; NDS; QL (40 per 30 ZOLADEX SUBCUTANEOUS 3 QL ( per 84 IMPLANT 0.8 MG ZOLADEX SUBCUTANEOUS 3 QL ( per 8 IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG 4 PA NSO; NDS; QL (60 per 30 ZYKADIA ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (40 per 8 ZYTIGA ORAL TABLET 50 MG, 500 MG 4 PA NSO; NDS; QL (0 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics 7