2017 Comprehensive Formulary

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1 Centers Plan for Medicare Advantage Care (HMO) 07 Comprehensive Formulary This formulary was updated on /07. 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 For More Information or to Enroll Call (toll free) TTY Users Seven days a week, 8am-8pm MemberServices@centersplan.com Heart. Health. Home. H6988_ENR085 Accepted 09006

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3 Language Assistance Services Notification ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: ). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: ). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: (. লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন ১ (TTY: ১ ) 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: ) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: ). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). i

4 ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). خبردار: اگر آپ اردو بولتے ہيں تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں کال کريں (TTY: ). אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר - אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט (TTY: ) ii

5 We're Here To Help And Serve You Centers Plan for Healthy Living is a culturally diverse company. We welcome all eligible individuals into our health care program. Anyone entitled to Medicare Parts A and B may apply. Discrimination is Against the Law Centers Plan for Healthy Living complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Centers Plan for Healthy Living does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Centers Plan for Healthy Living provides: Free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters. Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Member Services at (TTY users please call ( or 7). If you believe that Centers Plan for Healthy Living 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 our Grievances and Appeals Department: By Mail: Centers Plan for Healthy Living Attn: G&A Department 75 Vanderbilt Avenue Staten Island, NY By Phone: (TTY users call ) By Fax: By GandA@centersplan.com iii

6 You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Participant Services is available to help you seven days a week from 8am to 8pm. 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, D.C , (TDD) Complaint forms are available at iv

7 Centers Plan for Medicare Advantage Care (HMO) 07 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN CPHL 07 Formulary Formulary ID: Version: 7 This formulary was updated on /0/07. For more recent information or other questions, please contact Centers Plan for Centers Plan for Medicare Advantage Care (HMO) at or, for TTY users, , from 8 am to 8 pm seven days a week, 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 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 /0/07. 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, 07, and from time to time during the year. H6988_ENR085 Accepted CPHL 07 Formulary Formulary ID: Version: 7 v Effective: November 0, 07

8 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) 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) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Centers Plan for Medicare Advantage Care (HMO) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Centers Plan for Medicare Advantage Care (HMO). For a complete listing of all prescription drugs covered by Centers Plan for Medicare Advantage Care (HMO) please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 07 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 07 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 January, 07. To get updated information about the drugs covered by Centers Plan for Medicare Advantage Care (HMO) 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) 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 number. Then look under the category name for your drug. vi

9 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-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 Medicare Advantage Care (HMO) 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 Medicare Advantage Care (HMO) requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Centers Plan for Medicare Advantage Care (HMO) before you fill your prescriptions. If you don t get approval, Centers Plan for Medicare Advantage Care (HMO) may not cover the drug. Quantity Limits: For certain drugs, Centers Plan for Medicare Advantage Care (HMO) limits the amount of the drug that Centers Plan for Medicare Advantage Care (HMO) will cover. For example, Centers Plan for Medicare Advantage Care (HMO) 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) 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) 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) 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 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 Centers Plan for Medicare Advantage Care (HMO) 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) formulary? on page v for information about how to request an exception. vii

10 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 Healthy Living pays for certain OTC drugs Centers Plan for Healthy Living will provide these OTC drugs at no cost to you. The cost to Centers Plan for Healthy Living 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. For more information, 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 learn that Centers Plan for Medicare Advantage Care (HMO) 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). 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) You can ask Centers Plan for Medicare Advantage Care (HMO) 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) Formulary? You can ask Centers Plan for Medicare Advantage Care (HMO) 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) 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) 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. viii

11 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. 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 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. 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) 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 ix

12 Centers Plan for Medicare Advantage Care (HMO) Formulary The formulary that begins on the next page> provides coverage information about the drugs covered by Centers Plan for Medicare Advantage Care (HMO). 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., atorvastatin). The information in the Requirements/Limits column tells you if Centers Plan for Medicare Advantage Care (HMO) has any special requirements for coverage of your drug. ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA BvD PA NSO Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for New Starts Only You (or your physician) are required to get prior authorization from Centers Plan for Healthy Living before you fill your prescription for this drug. Without prior approval, Centers Plan for Healthy Living may not cover this drug. 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 Centers Plan for Healthy Living to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Centers Plan for Healthy Living may not cover this drug. If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from Centers Plan for Healthy Living before you fill your prescription for this drug. Without prior approval, Centers Plan for Healthy Living may not cover this drug. QL Quantity Limit Restriction Centers Plan for Healthy Living limits the amount of this drug that is covered per prescription, or within a specific time frame. ST Step Therapy Restriction Before Centers Plan for Healthy Living 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. x

13 Table of Contents Analgesics... 3 Anesthetics... 9 Anti-Addiction/Substance Abuse Treatment Agents... 9 Antianxiety Agents... 0 Antibacterials... Anticancer Agents... 9 Anticholinergic Agents... 8 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... 75

14 Dental And Oral Agents... 8 Dermatological Agents... 8 Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents... 9 Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents... 0 Inflammatory Bowel Disease Agents... 0 Irrigating Solutions... Metabolic Bone Disease Agents... Miscellaneous Therapeutic Agents... Ophthalmic Agents... 5 Replacement Preparations... 6 Respiratory Tract Agents... 9 Skeletal Muscle Relaxants... 3 Sleep Disorder Agents... 4 Vasodilating Agents... 5 Vitamins And Minerals... 6

15 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 0- QL (700 per 30 /5 ml, /5 ml (5 ml) acetaminophen-codeine oral tablet QL (360 per 30 acetaminophen-codeine oral tablet (Tylenol-Codeine #3) QL (360 per 30 acetaminophen-codeine oral tablet (Tylenol-Codeine #4) QL (80 per 30 ALLZITAL ORAL TABLET 5-35 MG PA-HRM; QL (360 per 30 ; AGE (Max 64 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 (Buprenex) Years) 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) (Tencon) 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) 3

16 butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet (Fiorinal) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) 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 endodan oral tablet QL (360 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 fentanyl transdermal patch 7 hour 37.5 QL (0 per 30 mcg/hour fentanyl transdermal patch 7 hour 6.5 mcg/hour, 87.5 mcg/hour ; QL (0 per 30 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 (Vicodin HP) QL (390 per hydrocodone-acetaminophen oral tablet (Norco) QL (360 per , 5-35, hydrocodone-acetaminophen oral tablet (Verdrocet) QL (360 per hydrocodone-acetaminophen oral tablet 5- (Xodol 5/300) QL (390 per hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (390 per hydrocodone-ibuprofen oral tablet 0-00, 5-00 (Ibudone) QL (50 per 30 4

17 hydrocodone-ibuprofen oral tablet QL (50 per 30 hydromorphone (pf) injection solution 0 (/ml) (5 ml) hydromorphone (pf) injection solution 0 /ml hydromorphone 0 /ml vial p/f,sdv,latex-f 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 HYSINGLA ER ORAL TABLET,ORAL QL (30 per 30 ONLY,EXT.REL.4 HR 00 MG, 0 MG, 0 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- 4 PA; NDS; QL (30 per 30 AEROSOL 00 MCG/SPRAY, 300 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 margesic oral capsule PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) 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 0 /ml carpuject outer, p/f, l/f, suv 0 /ml morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine 4 /ml syringe p/f, latexfree,suv 4 /ml morphine 8 /ml syringe 8 /ml morphine concentrate oral solution 00 QL (80 per 30 /5 ml (0 /ml) 5

18 morphine intramuscular pen injector 0 /0.7 ml morphine intravenous cartridge 5 /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 (80 per 30 morphine oral tablet extended release 30 (MS Contin) QL (0 per 30 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 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- (Percocet) 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 6

19 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 0-00,.5-00 QL (50 per 30, 5-00 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 vicodin es oral tablet QL (390 per 30 vicodin hp oral tablet QL (390 per 30 vicodin oral tablet QL (390 per 30 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 CAPSULE,SPRINKLE,ER HR QL (40 per 30 TMPRR 36 MG xylon 0 oral tablet 0-00 QL (50 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 release 4 hr 00 (Voltaren-XR) 7 3

20 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 etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 FLECTOR TRANSDERMAL PATCH PA HOUR.3 % flurbiprofen oral tablet 00, 50 ibuprofen oral suspension 00 /5 ml (Children's Profen IB) ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 5 QL (40 per 30 indomethacin oral capsule 50 QL (0 per 30 indomethacin oral capsule, extended QL (60 per 30 release 75 indomethacin sodium intravenous recon soln ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets 4 hr 00 ketorolac oral tablet 0 QL (0 per 30 mefenamic acid oral capsule 50 (Ponstel) 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 naproxen sodium oral tablet 75 naproxen sodium oral tablet 550 (Anaprox DS) 8

21 piroxicam oral capsule 0, 0 (Feldene) sulindac oral tablet 50, 00 tolmetin oral capsule 400 tolmetin oral tablet 00, 600 VOLTAREN TOPICAL GEL % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 0 /ml (Xylocaine-MPF) ( %), 5 /ml (.5 %), 0 /ml ( %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine (pf) injection solution 5 /ml (Xylocaine-MPF) (0.5 %) lidocaine hcl % vial inner,ltx-fr,p/f,sdv (Xylocaine-MPF) 0 /ml ( %) lidocaine hcl injection solution 0 /ml (Xylocaine) ( %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl injection syringe 0 /ml ( %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine hcl(pf) in 0.9% nacl injection syringe 00 /0 ml ( %) lidocaine topical adhesive (Lidoderm) PA patch,medicated 5 % lidocaine topical ointment 5 % PA NSO; 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 MG QL (30 per 30 9

22 BUNAVAIL BUCCAL FILM QL (60 per 30 MG, 6.3- MG buprenorphine hcl sublingual tablet, PA; QL (90 per 30 8 buprenorphine-naloxone sublingual tablet QL (90 per , 8- buproban oral tablet extended release hr 50 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 (Revia) 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 alprazolam oral tablet (Xanax) QL (50 per 30 chlordiazepoxide hcl oral capsule 0, QL (0 per 30 5, 5 0

23 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 (Ativan) 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 Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION 4 PA BvD; NDS FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 00 /50 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin injection solution 40 /ml gentamicin ped 0 / ml vial latex-free, sdv 0 / ml gentamicin sulfate (pf) intravenous solution 00 /0 ml neomycin oral tablet 500

24 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) 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) methenamine hippurate oral tablet gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /00 ml metronidazole oral capsule 375 (Flagyl)

25 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 hcl g/00 ml bag gram/00 ml vancomycin intravenous recon soln,000, 0 gram, 750 vancomycin intravenous recon soln 500 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 3

26 cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, gram/50 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 GRAM/50 ML cefepime hcl gm vial 0's, sdv gram (Maxipime) cefepime hcl gram vial latex/f, sdv, outer (Maxipime) gram CEFEPIME INJECTION RECON SOLN (Maxipime) GRAM, GRAM CEFEPIME-DEXTROSE GM/50 ML GRAM/50 ML cefotaxime injection recon soln gram, 0 (Claforan) gram, gram cefotaxime injection recon soln 500 cefoxitin gm piggyback bag gram/50 ml cefoxitin gm vial l/f, outer, sdv gram 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 (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) 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 4

27 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 750 /50 ml cephalexin oral capsule 50, 500, (Keflex) 750 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, 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 (Zithromax Z-Pak) azithromycin oral tablet 50 (6 pack), 500 (3 pack) azithromycin oral tablet 500 (Zithromax TRI-PAK) azithromycin oral tablet 600 (Zithromax) clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 5

28 DIFICID ORAL TABLET 00 MG ; QL (0 per 0 e.e.s. 400 oral tablet 400 e.e.s. granules oral suspension for reconstitution 00 /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 ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG, 500 MG 3 erythromycin ethylsuccinate oral (EryPed 00) suspension for reconstitution 00 /5 ml 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 6

29 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 (Augmentin XR) extended release hr, amoxicillin-pot clavulanate oral tablet,chewable , 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 0's, latex-free gram nafcillin injection recon soln gram, 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 7

30 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 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous recon (Zosyn) soln.5 gram, gram, 4.5 gram, 40.5 gram Quinolones 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 8

31 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) sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) (dr/ec) 500 sulfatrim oral suspension /5 ml Tetracyclines doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon (Doxy-00) soln 00 doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 0 doxycycline monohydrate oral capsule 00 (Mondoxyne NL), 75 doxycycline monohydrate oral capsule 50 doxycycline monohydrate oral capsule 50 (Monodox) 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 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents 9

32 ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous solution /ml, 0 /0 ml adrucil,500 /50 ml vial outer, latexfree.5 gram/50 ml 4 PA NSO; NDS; QL (4 per PA BvD PA BvD adrucil intravenous solution 500 /0 ml PA BvD 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 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 4 PA NSO; NDS; QL (40 MCG per 365 0

33 BOSULIF ORAL TABLET 00 MG 4 PA NSO; NDS; QL (0 per 30 BOSULIF ORAL TABLET 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 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 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 00 /00 ml vial latex-free (Adriamycin) PA BvD /ml doxorubicin intravenous solution 50 (Adriamycin) PA BvD /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 QL ( per 84 SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG 3 QL ( per

34 ELIGARD (6 MONTH) 3 QL ( per 68 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 SOLN 00 MG 3 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 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

35 IDHIFA ORAL TABLET 00 MG, 50 MG 4 PA NSO; NDS; QL (30 per 30 ifosfamide gm/0 ml vial sdv,p/f,latexfree PA BvD gram/0 ml ifosfamide intravenous recon soln gram (Ifex) PA BvD 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 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 4 PA NSO; NDS SOLN 50 MG KEYTRUDA INTRAVENOUS 4 PA NSO; NDS SOLUTION 5 MG/ML KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG 4 PA NSO; NDS; QL (49 per 8 KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X 3)-.5 MG 4 PA NSO; NDS; QL (70 per 8 4 PA NSO; NDS; QL (9 per 8 3

36 KISQALI ORAL TABLET 00 MG/DAY (00 MG X ), 400 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 30 MG KYPROLIS INTRAVENOUS RECON SOLN 60 MG LARTRUVO INTRAVENOUS 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 4 PA NSO; NDS; QL (63 per 8 4 PA NSO; NDS; QL ( per 8 4 PA NSO; NDS; QL (6 per 8 4 PA NSO; LA; NDS 4 PA NSO; NDS X ) 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 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 ; QL ( per 84 ; QL ( per 84 ; QL ( per 68 LYNPARZA ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (480 per 30 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 MEKINIST ORAL TABLET 0.5 MG 4 PA NSO; NDS; QL (90 per 30 4

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