Memorial Hermann Advantage HMO & PPO Abridged Formulary. (Partial List of Covered Drugs)

Transcription

1 Memorial Hermann Advantage H & PPO 2017 Abridged Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File , Version 11 This abridged formulary was updated on 12/01/2016. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact Memorial Hermann Advantage H & PPO at for H, for PPO or, for TTY users, 711, 24 hours a day, seven (7) days a week, or visit healthplan.memorialhermann.org/medicare. 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 Memorial Hermann Advantage H & PPO. When it refers to plan or our plan, it means Memorial Hermann Advantage H & PPO. This document includes a partial list of the drugs (formulary) for our plan which is current as of 12/01/2016. For a complete, updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. What is the Memorial Hermann Advantage H & PPO Abridged Formulary? A formulary is a list of covered drugs selected by Memorial Hermann Advantage H & PPO 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. Memorial Hermann Advantage H & PPO will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Memorial Hermann Advantage H & PPO network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a partial formulary and includes only some of the drugs covered by Memorial Hermann Advantage H & PPO. For a complete listing of all prescription drugs covered by Memorial Hermann Advantage H & PPO, 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. Y0110_PH_AbrFrmly CMS Accepted 09/05/2016 i

2 Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 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, 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 12/01/2016. To get updated information about the drugs covered by Memorial Hermann Advantage H & PPO, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid-year non-maintenance formulary change, we will provide details in the Medicare Part D Explanation of Benefits or through direct member mailings. To review and/or print formulary changes during the year, please visit our website at healthplan.memorialhermann.org/medicare and refer to the Formulary Addendum on the Find a Drug page. If you would like to request a copy of the Formulary Addendum to be mailed to your home, please call Memorial Hermann H & PPO Customer Services at for H or for PPO, 24 hours a day, seven days a week. TTY users should call 711. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 66. 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. ii

3 What are generic drugs? Memorial Hermann Advantage H & PPO 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: Memorial Hermann Advantage H & PPO requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Memorial Hermann Advantage H & PPO before you fill your prescriptions. If you don t get approval, Memorial Hermann Advantage H & PPO may not cover the drug. Quantity Limits: For certain drugs, Memorial Hermann Advantage H & PPO limits the amount of the drug that Memorial Hermann Advantage H & PPO will cover. For example, Memorial Hermann Advantage H & PPO provides 30 tablets per prescription for Digoxin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Memorial Hermann Advantage H & PPO 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, Memorial Hermann Advantage H & PPO may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Memorial Hermann Advantage H & PPO 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 1. 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 Memorial Hermann Advantage H & PPO 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 Memorial Hermann Advantage H & PPO s formulary? on page iv for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Services and ask if your drug is covered. This document includes only a partial list of covered drugs, so Memorial Hermann Advantage H & PPO may cover your drug. 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 Memorial Hermann Advantage H & PPO does not cover your drug, you have two options: iii

4 You can ask Customer Services for a list of similar drugs that are covered by Memorial Hermann Advantage H & PPO. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Memorial Hermann Advantage H & PPO. You can ask Memorial Hermann Advantage H & PPO 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 Memorial Hermann Advantage H & PPO s Formulary? You can ask Memorial Hermann Advantage H & PPO 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, Memorial Hermann Advantage H & PPO 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, Memorial Hermann Advantage H & PPO will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 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 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 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. iv

5 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 days) 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 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 93 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 93 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. As a current member of our plan, if you have a covered inpatient stay in the hospital or in a skilled nursing facility, the drugs you obtain during your stay will be covered under your medical benefit rather than your Medicare Part D prescription drug benefit. When you are discharged home or to a long-term care facility, many outpatient prescription drugs you obtain at a pharmacy may be covered under your Medicare Part D coverage. This transfer from one treatment setting to another is called a level-of-care change. Since your drug coverage is different depending on the setting where you obtain the drug, it is possible that a drug you were taking that was covered under your medical benefit might not be covered by Medicare Part D (for example, vitamins, or cough medicine). If this happens, you will have to pay full price for that drug unless you have other coverage (for example, employer-sponsored group coverage). For more information For more detailed information about your Memorial Hermann Advantage H & PPO prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Memorial Hermann Advantage H & PPO, 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 ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Memorial Hermann Advantage H & PPO s Formulary The abridged formulary that begins on the next page provides coverage information about some of the drugs covered by Memorial Hermann Advantage H & PPO. If you have trouble finding your drug in the list, turn to the Index that begins on page 66. Remember: This is only a partial list of drugs covered by Memorial Hermann Advantage H & PPO. If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g.,levothyroxine). The information in the Requirements/Limits column tells you if Memorial Hermann Advantage H & PPO has any special requirements for coverage of your drug. v

6 The Formulary may change at any time. You will receive notice when necessary. Memorial Hermann Advantage H and PPO are provided by Memorial Hermann Health Insurance Company and Memorial Hermann Health Plan, Inc., Medicare Advantage organizations with Medicare contracts. Enrollment in these plans depends on contract renewal. vi

7 ANALGESICS OPIOID ANALGESICS, LONG-ACTING fentanyl transdermal patch 72 hr 100 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr ST; ; QL (10 EA per 30 days) fentanyl transdermal patch 72 hr 12 mcg/hr ; QL (10 EA per 30 days) methadone hcl oral tablet 10 methadone hcl oral tablet 5 morphine sulfate er beads oral capsule extended release 24 hour 120, 30, 45, 60, 75, 90 morphine sulfate er oral capsule extended release 24 hour 10, 100, 20, 30, 50, 60, 80 morphine sulfate er oral tablet extendedrelease 100, 15, 30, 60 OXYCONTIN ORAL 10 MG, 20 MG, 40 MG, 80 MG ; QL (60 EA per 30 days) ; QL (60 EA per 30 days) ; QL (60 EA per 30 days) ; QL (60 EA per 30 days) OXYCONTIN ORAL 15 MG, 30 MG, 60 MG PA; ; QL (60 EA per 30 days) OPIOID ANALGESICS, SHORT-ACTING acetaminophen-codeine #2 oral tablet ; QL (400 EA per 30 days) acetaminophen-codeine #3 oral tablet ; QL (400 EA per 30 days) acetaminophen-codeine #4 oral tablet ; QL (400 EA per 30 days) ascomp-codeine oral capsule PA; ; HR; QL (180 EA per 30 days) butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule hydrocodone-acetaminophen oral solution /15ml PA; ; HR; QL (180 EA per 30 days) PA; ; HR; QL (180 EA per 30 days) ; QL (5500 ML per 30 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 1

8 hydrocodone-acetaminophen oral tablet , 5-325, hydrocodone-acetaminophen oral tablet hydrocodone-ibuprofen oral tablet , 5-200, hydromorphone hcl oral tablet 2, 4 hydromorphone hcl oral tablet 8 oxycodone hcl oral capsule 5 oxycodone hcl oral tablet 10, 20, 30, 5 ; QL (370 EA per 30 days) ; QL (370 EA per 30 days) ; QL (150 EA per 30 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 2 oxycodone hcl oral tablet 15 oxycodone-acetaminophen oral solution /5ml oxycodone-acetaminophen oral tablet , , 5-325, oxycodone-aspirin oral tablet oxycodone-ibuprofen oral tablet pentazocine-naloxone hcl oral tablet PA; ; HR ; QL (1800 ML per 30 days) ; QL (370 EA per 30 days) tramadol hcl oral tablet 50 ; QL (240 EA per 30 days) tramadol-acetaminophen oral tablet ; QL (240 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine-prilocaine external cream % ; QL (30 GM per 30 days) ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI-CRAVING ACAMPROSATE CALCIUM ORAL TABLET DELAYED RELEASE 333 MG disulfiram oral tablet 250, 500 naltrexone hcl oral tablet 50

9 OPIOID ANTAGONISTS buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG, 8-2 MG SKING CESSATION AGENTS buproban oral tablet extended release 12 hr 150 bupropion hcl er (smoking det) oral tablet extended release 12 hr 150 CHANTIX CONTINUING NTH PAK ORAL TABLET 1 MG ; QL (56 EA per 28 days) CHANTIX ORAL TABLET 0.5 MG ; QL (60 EA per 30 days) CHANTIX ORAL TABLET 1 MG ; QL (180 EA per 90 days) CHANTIX STARTING NTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 NICOTROL INHALATION INHALER 10 MG ANTIBACTERIALS AMINOGLYCOSIDES neomycin sulfate oral tablet 500 tobramycin inhalation nebulization solution 300 /5ml ANTIBACTERIALS, OTHER clindamycin hcl oral capsule 150, 300 dapsone oral tablet 100, 25 linezolid oral tablet 600 metronidazole oral tablet 250, 500 ; QL (53 EA per 28 days) ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 3

10 nitrofurantoin macrocrystal oral capsule 100, 25, 50 nitrofurantoin monohyd macro oral capsule 100 trimethoprim oral tablet 100 vancomycin hcl oral capsule 125, 250 XIFAXAN ORAL TABLET 550 MG BETA-LACTAM, CEPHALOSPORINS cefaclor oral capsule 250, 500 cefdinir oral capsule 300 cefprozil oral tablet 250, 500 cefuroxime axetil oral tablet 250, 500 cephalexin oral capsule 250 cephalexin oral capsule 500 SUPRAX ORAL CAPSULE 400 MG BETA-LACTAM, PENICILLINS amoxicillin oral capsule 250 amoxicillin oral capsule 500 amoxicillin oral tablet 875 amoxicillin-pot clavulanate oral tablet , amoxicillin-pot clavulanate oral tablet PA; ; HR PA; ; HR ampicillin oral capsule 250, 500 BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/ML dicloxacillin sodium oral capsule 250, 500 penicillin g sodium injection solution reconstituted unit pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 4

11 penicillin v potassium oral tablet 250, 500 MACROLIDES azithromycin oral packet 1 gm azithromycin oral tablet 250 (6 pack), 500, 600 clarithromycin oral tablet 250, 500 DIFICID ORAL TABLET 200 MG ST; erythromycin base oral capsule delayed release particles 250 QUINOLONES ciprofloxacin hcl oral tablet 100, 250, 750 ciprofloxacin hcl oral tablet 500 ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr 1000, 500 levofloxacin oral tablet 250, 500, 750 ofloxacin oral tablet 400 SULFONAMIDES sulfamethoxazole-trimethoprim oral tablet sulfamethoxazole-trimethoprim oral tablet TETRACYCLINES doxycycline monohydrate oral capsule 100, 50 minocycline hcl oral capsule 100, 75 minocycline hcl oral capsule 50 ANTICONVULSANTS ANTICONVULSANTS, OTHER pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 5

12 BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML PA; BRIVIACT ORAL SOLUTION 10 MG/ML PA; BRIVIACT ORAL TABLET 10 MG PA; BRIVIACT ORAL TABLET 100 MG, 25 MG, 50 MG, 75 MG levetiracetam er oral tablet extended release 24 hr 500, 750 LEVETIRACETAM IN NACL INTRAVENOUS SOLUTION 1000 MG/100ML, 1500 MG/100ML, 500 MG/100ML PA; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 6 levetiracetam intravenous solution 500 /5ml levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 750 levetiracetam oral tablet 250, 500 POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG roweepra oral tablet 500 SPRITAM ORAL 1000 MG ; QL (90 EA per 30 days) SPRITAM ORAL 250 MG, 500 MG, 750 MG ; QL (120 EA per 30 days) BARBITURATES phenobarbital oral elixir 20 /5ml PA; ; HR phenobarbital oral tablet 100, 15, 16.2, 30, 32.4, 60, 64.8, 97.2 BENZODIAZEPINES clonazepam oral tablet 0.5, 1, 2 clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 PA; ; HR diazepam gel 10, 2.5, 20 ONFI ORAL SUSPENSION 2.5 MG/ML

13 ONFI ORAL TABLET 10 MG, 20 MG CALCIUM CHANNEL DIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml LYRICA ORAL CAPSULE 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 7 LYRICA ORAL SOLUTION 20 MG/ML zonisamide oral capsule 100 zonisamide oral capsule 25, 50 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS divalproex sodium er oral tablet extended release 24 hr 250, 500 divalproex sodium oral tablet delayed release 250 divalproex sodium oral tablet delayed release 500 FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 GABITRIL ORAL TABLET 12 MG, 16 MG primidone oral tablet 250 primidone oral tablet 50 SABRIL ORAL PACKET 500 MG SABRIL ORAL TABLET 500 MG tiagabine hcl oral tablet 2, 4

14 valproate sodium intravenous solution 500 /5ml valproic acid oral capsule 250 valproic acid oral syrup 250 /5ml GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 /5ml felbamate oral tablet 400, 600 lamotrigine er oral tablet extended release 24 hr 100 lamotrigine er oral tablet extended release 24 hr 200, 25, 250, 300, 50 lamotrigine oral tablet 100, 150, 200 lamotrigine oral tablet 25 lamotrigine oral tablet chewable 25, 5 lamotrigine oral tablet dispersible 100, 200, 25, 50 topiramate er oral 100, 150, 200, 25, 50 topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 200, 25, 50 TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG carbamazepine er oral capsule extended release 12 hour 200, 300 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 8

15 carbamazepine er oral tablet extended release 12 hr 100, 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 epitol oral tablet 200 fosphenytoin sodium injection solution 100 pe/2ml oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 600 oxcarbazepine oral tablet 300 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenytoin oral suspension 125 /5ml phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 100, 200, 300 phenytoin sodium injection solution 50 /ml VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates oral tablet 1 PA; ; HR CHOLINESTERASE INHIBITORS donepezil hcl oral tablet 10, 5 donepezil hcl oral tablet dispersible 10, 5 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 9

16 EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR galantamine hydrobromide er oral capsule extended release 24 hour 16, 8 galantamine hydrobromide er oral capsule extended release 24 hour 24 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 10 galantamine hydrobromide oral tablet 4, 8 rivastigmine tartrate oral capsule 1.5, 3, 4.5, 6 N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl oral tablet 10, 5 ; QL (60 EA per 30 days) NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG bupropion hcl er (sr) oral tablet extended release 12 hr 100, 200 bupropion hcl er (sr) oral tablet extended release 12 hr 150 bupropion hcl er (xl) oral tablet extended release 24 hr 150, 300 bupropion hcl oral tablet 100, 75 FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG maprotiline hcl oral tablet 25, 50, 75 mirtazapine oral tablet 15, 30, 7.5 mirtazapine oral tablet 45 mirtazapine oral tablet dispersible 15

17 mirtazapine oral tablet dispersible 30, 45 nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 50 trazodone hcl oral tablet 300 TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG NOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR ST; ; QL (30 EA per 30 days) MARPLAN ORAL TABLET 10 MG phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS BRISDELLE ORAL CAPSULE 7.5 MG citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10, 20, 40 DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 50 MG duloxetine hcl oral capsule delayed release particles 20, 30, 40, 60 escitalopram oxalate oral solution 5 /5ml escitalopram oxalate oral tablet 10, 20, 5 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 11

18 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG FETZIMA TITRATION ORAL 20 & 40 MG fluoxetine hcl oral capsule 10 fluoxetine hcl oral capsule 20, 40 fluoxetine hcl oral capsule delayed release 90 fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10 fluoxetine hcl oral tablet 20 FLUOXETINE HCL ORAL TABLET 60 MG fluvoxamine maleate er oral capsule extended release 24 hour 100, 150 fluvoxamine maleate oral tablet 100, 25, 50 olanzapine-fluoxetine hcl oral capsule 12-25, 12-50, 3-25, 6-25, 6-50 paroxetine hcl er oral tablet extended release 24 hr 12.5, 25, 37.5 paroxetine hcl oral tablet 10, 20 paroxetine hcl oral tablet 30, 40 PAXIL ORAL SUSPENSION 10 MG/5ML PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100, 25, 50 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 12

19 venlafaxine hcl er oral tablet extended release 24 hr 150, 225, 37.5, 75 venlafaxine hcl oral tablet 100, 75 venlafaxine hcl oral tablet 25, 37.5, 50 TRICYCLICS amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 chlordiazepoxide-amitriptyline oral tablet 10-25, clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 imipramine pamoate oral capsule 100, 125, 150, 75 nortriptyline hcl oral capsule 10, 25 nortriptyline hcl oral capsule 50, 75 nortriptyline hcl oral solution 10 /5ml protriptyline hcl oral tablet 10, 5 trimipramine maleate oral capsule 100, 25, 50 ANTIEMETICS ANTIEMETICS, OTHER meclizine hcl oral tablet 12.5, 25 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 13

20 transderm-scop (1.5 ) transdermal patch 72 hr 1 /3days EMETOGENIC THERAPY ADJUNCTS dronabinol oral capsule 10 PA; ; QL (60 EA per 30 days) dronabinol oral capsule 2.5, 5 PA; ; QL (60 EA per 30 days) EMEND ORAL CAPSULE 80 & 125 MG ; BvD; QL (12 EA per 30 days) granisetron hcl oral tablet 1 ; BvD; QL (60 EA per 30 days) ondansetron hcl oral tablet 4 ; BvD; QL (60 EA per 30 days) ondansetron hcl oral tablet 8 ; BvD; QL (60 EA per 30 days) ondansetron oral tablet dispersible 4, 8 ; BvD; QL (60 EA per 30 days) ANTIFUNGALS ANTIFUNGALS amphotericin b injection solution reconstituted 50 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 14 clotrimazole mouth/throat troche 10 fluconazole oral tablet 100, 150, 200, 50 ; BvD griseofulvin microsize oral suspension 125 /5ml itraconazole oral capsule 100 ketoconazole oral tablet 200 nystatin oral tablet unit terbinafine hcl oral tablet 250 voriconazole oral tablet 200 ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol oral tablet 100, 300 colchicine oral tablet 0.6 probenecid oral tablet 500

21 ULORIC ORAL TABLET 40 MG, 80 MG ST; ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib oral capsule 100, 200, 400 ; QL (60 EA per 30 days) diclofenac sodium er oral tablet extended release 24 hr 100 diclofenac sodium oral tablet delayed release 75 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 15 diflunisal oral tablet 500 ibuprofen oral tablet 400 ibuprofen oral tablet 600, 800 indomethacin er oral capsule extended release 75 PA; ; HR indomethacin oral capsule 25, 50 PA; ; HR ketorolac tromethamine injection solution 15 /ml, 30 /ml ketorolac tromethamine intramuscular solution 60 /2ml PA; ; HR PA; ; HR ketorolac tromethamine oral tablet 10 PA; ; HR meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen oral tablet 500 naproxen sodium oral tablet 550 oxaprozin oral tablet 600 sulindac oral tablet 200 tencon oral tablet PA; ; HR; QL (180 EA per 30 days) ANTIMIGRAINE AGENTS ANTIMIGRAINE AGENTS, PROPHYLACTIC

22 divalproex sodium oral 125 divalproex sodium oral tablet delayed release 125 topiramate oral tablet 100 SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS RELPAX ORAL TABLET 20 MG, 40 MG ST; ; QL (9 EA per 30 days) sumatriptan nasal solution 20 /act, 5 /act sumatriptan succinate oral tablet 100 ; QL (9 EA per 30 days) sumatriptan succinate oral tablet 25, 50 ; QL (9 EA per 30 days) sumatriptan succinate subcutaneous 6 /0.5ml ; QL (4.5 ML per 30 days) sumatriptan succinate subcutaneous solution 6 /0.5ml ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS pyridostigmine bromide oral tablet 60 ANTIMYCOBACTERIALS ANTITUBERCULARS ethambutol hcl oral tablet 400 isoniazid oral tablet 100, 300 rifampin oral capsule 150, 300 ANTINEOPLASTICS ALKYLATING AGENTS cyclophosphamide oral capsule 25, 50 ; BvD GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG ; QL (4.5 ML per 30 days) HEXALEN ORAL CAPSULE 50 MG LEUKERAN ORAL TABLET 2 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 16

23 THIOTEPA INJECTION SOLUTION RECONSTITUTED 15 MG ANTIANGIOGENIC AGENTS DEPEN TITRATABS ORAL TABLET 250 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG REVLIMID ORAL CAPSULE 2.5 MG, 20 MG SYPRINE ORAL CAPSULE 250 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG ANTIMETABOLITES ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 500 MG azacitidine injection suspension reconstituted 100 decitabine intravenous solution reconstituted 50 fludarabine phosphate intravenous solution reconstituted 50 GEMCITABINE HCL INTRAVENOUS SOLUTION RECONSTITUTED 1 GM ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 17 LA mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 ; BvD methotrexate sodium (pf) injection solution 1 gm/40ml methotrexate sodium injection solution reconstituted 1 gm PURIXAN ORAL SUSPENSION 2000 MG/100ML ; BvD ; BvD TABLOID ORAL TABLET 40 MG ANTINEOPLASTICS

24 ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG ; BvD ALECENSA ORAL CAPSULE 150 MG PA; amifostine intravenous solution reconstituted 500 ARRANON INTRAVENOUS SOLUTION 5 MG/ML AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML AVASTIN INTRAVENOUS SOLUTION 400 MG/16ML BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 18 LA ; BvD PA; bexarotene oral capsule 75 PA; bicalutamide oral tablet 50 BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG bleomycin sulfate injection solution reconstituted 30 unit ; BvD ; BvD BOSULIF ORAL TABLET 100 MG, 500 MG PA; BUSULFEX INTRAVENOUS SOLUTION 6 MG/ML CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG CAPRELSA ORAL TABLET 100 MG, 300 MG ; BvD PA; carboplatin intravenous solution 150 /15ml ; BvD

25 cisplatin intravenous solution 100 /100ml ; BvD cladribine intravenous solution 10 /10ml ; BvD CLOLAR INTRAVENOUS SOLUTION 1 MG/ML COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 19 ; BvD COTELLIC ORAL TABLET 20 MG PA; LA CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML ; BvD cytarabine (pf) injection solution 100 /ml ; BvD cytarabine injection solution 20 /ml ; BvD dacarbazine intravenous solution reconstituted 200 DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML ; BvD PA; LA daunorubicin hcl intravenous injectable 5 /ml ; BvD DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML dexrazoxane intravenous solution reconstituted 250 DOCEFREZ INTRAVENOUS SOLUTION RECONSTITUTED 20 MG DOCETAXEL INTRAVENOUS CONCENTRATE 80 MG/4ML DOCETAXEL INTRAVENOUS SOLUTION 80 MG/8ML ; BvD ; BvD

26 doxorubicin hcl intravenous solution 2 /ml ; BvD DOXORUBICIN HCL LIPOSOMAL INTRAVENOUS INJECTABLE 2 MG/ML ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 7.5 MG ; BvD ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 20 EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG, 400 MG ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML ERIVEDGE ORAL CAPSULE 150 MG ERWINAZE INJECTION SOLUTION RECONSTITUTED UNIT ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG PA; ; BvD PA; ; BvD etoposide intravenous solution 500 /25ml ; BvD FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG PA; fluorouracil external solution 2 %, 5 % fluorouracil intravenous solution 2.5 gm/50ml ; BvD flutamide oral capsule 125

27 FOLOTYN INTRAVENOUS SOLUTION 40 MG/2ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEEVEC ORAL TABLET 100 MG, 400 MG HALAVEN INTRAVENOUS SOLUTION 1 MG/2ML HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 440 MG HYDROXYPROGESTERONE CAPROATE INTRAMUSCULAR SOLUTION 1.25 GM/5ML ; BvD PA; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 21 hydroxyurea oral capsule 500 IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ; BvD PA; PA; ICLUSIG ORAL TABLET 15 MG, 45 MG PA; idarubicin hcl intravenous solution 10 /10ml ; BvD ifosfamide intravenous solution reconstituted 1 gm ; BvD IMBRUVICA ORAL CAPSULE 140 MG PA; INLYTA ORAL TABLET 1 MG, 5 MG INTRON A INJECTION SOLUTION UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT intron a injection solution reconstituted unit, unit IRESSA ORAL TABLET 250 MG irinotecan hcl intravenous solution 100 /5ml ; BvD ISTODAX INTRAVENOUS SOLUTION RECONSTITUTED 10 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG

28 JEVTANA INTRAVENOUS SOLUTION 60 MG/1.5ML KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4ML KEYTRUDA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 22 LENVIMA 10 MG DAILY DOSE ORAL 10 MG LENVIMA 14 MG DAILY DOSE ORAL 10 & 4 MG LENVIMA 18 MG DAILY DOSE ORAL 10 & 4 (2) MG LENVIMA 20 MG DAILY DOSE ORAL 10 (2) MG LENVIMA 24 MG DAILY DOSE ORAL 10 (2) & 4 MG ; BvD PA; PA; LENVIMA 8 MG DAILY DOSE ORAL 4 (2) MG leucovorin calcium injection solution reconstituted 100, 350 leucovorin calcium oral tablet 10, 15, 25, 5 leuprolide acetate injection kit 1 /0.2ml levoleucovorin calcium intravenous solution 175 /17.5ml LONSURF ORAL TABLET MG, MG LUPRON DEPOT INTRAMUSCULAR KIT MG, 22.5 MG LUPRON DEPOT INTRAMUSCULAR KIT 3.75 MG, 30 MG ; BvD PA; PA; PA;

29 LUPRON DEPOT INTRAMUSCULAR KIT 45 MG PA; LYNPARZA ORAL CAPSULE 50 MG PA; LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol acetate oral suspension 40 /ml PA; ; HR megestrol acetate oral tablet 20, 40 PA; ; HR MEKINIST ORAL TABLET 0.5 MG, 2 MG LA melphalan hcl intravenous solution reconstituted 50 ; BvD mesna intravenous solution 100 /ml ; BvD MESNEX ORAL TABLET 400 MG mitomycin intravenous solution reconstituted 20, 40, 5 mitoxantrone hcl intravenous concentrate 25 /12.5ml MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG NEXAVAR ORAL TABLET 200 MG LA ; BvD NILANDRON ORAL TABLET 150 MG nilutamide oral tablet 150 NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ; BvD PA; ODOMZO ORAL CAPSULE 200 MG PA; LA OPDIVO INTRAVENOUS SOLUTION 40 MG/4ML PA; oxaliplatin intravenous solution 100 /20ml ; BvD paclitaxel intravenous concentrate 300 /50ml ; BvD PERJETA INTRAVENOUS SOLUTION 420 MG/14ML pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 23

30 POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED UNIT RITUXAN INTRAVENOUS SOLUTION 500 MG/50ML pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 24 LA SOLTAX ORAL SOLUTION 10 MG/5ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG PA; SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG LA TAGRISSO ORAL TABLET 40 MG, 80 MG PA; LA tamoxifen citrate oral tablet 10 tamoxifen citrate oral tablet 20 TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CAPSULE 150 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML ; BvD toposar intravenous solution 1 gm/50ml ; BvD topotecan hcl intravenous solution reconstituted 4 TORISEL INTRAVENOUS SOLUTION 25 MG/ML TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG ; BvD ; BvD ; BvD

31 TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED MG, 22.5 MG, 3.75 MG tretinoin oral capsule 10 TRISENOX INTRAVENOUS SOLUTION 10 MG/10ML TYKERB ORAL TABLET 250 MG UVADEX INJECTION SOLUTION 20 MCG/ML ; BvD VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG ; BvD VENCLEXTA ORAL TABLET 10 MG, 50 MG PA; LA VENCLEXTA ORAL TABLET 100 MG PA; LA VENCLEXTA STARTING PACK ORAL 10 & 50 & 100 MG PA; LA vinblastine sulfate intravenous solution 1 /ml ; BvD vincasar pfs intravenous solution 1 /ml ; BvD vincristine sulfate intravenous solution 1 /ml ; BvD vinorelbine tartrate intravenous solution 50 /5ml VOTRIENT ORAL TABLET 200 MG ; BvD XALKORI ORAL CAPSULE 200 MG, 250 MG PA; XTANDI ORAL CAPSULE 40 MG ST; YERVOY INTRAVENOUS SOLUTION 50 MG/10ML YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 MG ZALTRAP INTRAVENOUS SOLUTION 100 MG/4ML PA; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 25

32 ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 1 GM ZELBORAF ORAL TABLET 240 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet 1 exemestane oral tablet 25 letrozole oral tablet 2.5 ANTIPARASITICS ANTHELMINTICS ivermectin oral tablet 3 ANTIPROTOZOALS atovaquone-proguanil hcl oral tablet chloroquine phosphate oral tablet 250, 500 DARAPRIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG ; BvD quinine sulfate oral capsule 324 PA; ANTIPARKINSON AGENTS ANTICHOLINERGICS pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 26 benztropine mesylate injection solution 1 /ml benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml

33 trihexyphenidyl hcl oral tablet 2, 5 ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 100 entacapone oral tablet 200 tolcapone oral tablet 100 DOPAMINE AGONISTS bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 pramipexole dihydrochloride er oral tablet extended release 24 hr 3 pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 1 pramipexole dihydrochloride oral tablet 0.75, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 4, 5 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 27 ropinirole hcl oral tablet 1, 2, 3 DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa er oral tablet extendedrelease carbidopa-levodopa er oral tablet extendedrelease carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet , carbidopa-levodopa oral tablet dispersible , , NOAMINE OXIDASE B (MAO-B) INHIBITORS AZILECT ORAL TABLET 0.5 MG, 1 MG selegiline hcl oral capsule 5

34 selegiline hcl oral tablet 5 ANTIPSYCHOTICS 1ST GENERATION/TYPICAL chlorpromazine hcl injection solution 50 /2ml ; BvD chlorpromazine hcl oral tablet 10 ; BvD chlorpromazine hcl oral tablet 100, 200, 25, 50 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 28 compro suppository 25 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 haloperidol decanoate intramuscular solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 loxapine succinate oral capsule 10, 25, 5, 50 molindone hcl oral tablet 10, 25, 5 perphenazine oral tablet 16, 2, 4, 8 perphenazine-amitriptyline oral tablet 2-10, 2-25, 4-10, 4-25, 4-50 pimozide oral tablet 1, 2 prochlorperazine edisylate injection solution 5 /ml

35 prochlorperazine maleate oral tablet 10, 5 prochlorperazine suppository 25 thioridazine hcl oral tablet 10, 100, 25, 50 thiothixene oral capsule 1, 10, 2, 5 trifluoperazine hcl oral tablet 1, 10, 2, 5 2ND GENERATION/ATYPICAL ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 300 MG (1.5ML SYRINGE) aripiprazole oral tablet 10, 15, 2, 5 aripiprazole oral tablet 20, 30 ARIPIPRAZOLE ORAL TABLET DISPERSIBLE 10 MG, 15 MG ARISTADA INTRAMUSCULAR 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.25ML, 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML ST; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 29

36 LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG NUPLAZID ORAL TABLET 17 MG PA; olanzapine intramuscular solution reconstituted 10 olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 olanzapine oral tablet dispersible 10, 15, 20, 5 paliperidone er oral tablet extended release 24 hr 1.5, 3, 6, 9 quetiapine fumarate oral tablet 100, 25, 50 quetiapine fumarate oral tablet 200, 300, 400 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 37.5 MG, 50 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 30 ST; risperidone oral solution 1 /ml risperidone oral tablet 0.25, 2, 3, 4 risperidone oral tablet 0.5, 1 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG

37 VRAYLAR ORAL 1.5 & 3 MG ST; VRAYLAR ORAL CAPSULE 1.5 MG ST; ; QL (120 EA per 30 days) VRAYLAR ORAL CAPSULE 3 MG ST; ; QL (60 EA per 30 days) VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG ST; ; QL (30 EA per 30 days) ziprasidone hcl oral capsule 20, 40, 60, 80 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG TREATMENT-RESISTANT clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 100, 12.5, 150, 25 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 31 clozapine oral tablet dispersible 200 FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5 MG, 25 MG VERSACLOZ ORAL SUSPENSION 50 MG/ML ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS valganciclovir hcl oral tablet 450 ANTIHEPATITIS AGENTS adefovir dipivoxil oral tablet 10 BARACLUDE ORAL SOLUTION 0.05 MG/ML DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG entecavir oral tablet 0.5, 1 EPIVIR HBV ORAL SOLUTION 5 MG/ML PA; HARVONI ORAL TABLET MG PA; lamivudine oral tablet 100