Formulary (Drug List)

Transcription

1 Formulary (Drug List) CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) Los Angeles County, CA 2015 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on 10/27/2015. If you have questions, please call CareMore Cal MediConnect Plan Member Services at (TTY 711), Monday through Friday from 8 a.m. to 8 p.m. Pacific time. Y0071_H6229_15_21322_U_v2 CMS Accepted 11/02/2014 For more information, visit Formulary ID: Version: 16 duals.caremore.com. Issued 11/01/2015

2 H6229_15_24351_T_002_v16 CMS Approved 05/11/2015 CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) 2015 List of Covered Drugs (Formulary) County: Los Angeles PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 09/27/2015. If you have questions, please call CareMore Cal MediConnect Plan Member Services at (TTY: 711), After-hours messaging is available 24 hours a day, 7 days a week, including holidays. For more information, visit duals.caremore.com.? If you have questions, please call CareMore Cal MediConnect Plan at (TTY: 711). Monday through Friday from 8:00 am to 8:00 pm. After-hours messaging is available 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit duals.caremore.com.

3 H6229_15_24351_T_002v16 CMS Approved 05/11/2015 This is a list of drugs that members can get in CareMore Cal MediConnect Plan (Medicare-Medicaid Plan). CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. CareMore administers the contract on behalf of an affiliate of CareMore. CareMore is a registered trademark of CareMore Health System. Benefits, List of Covered Drugs, pharmacy and provider networks, and/or co-payments may change from time to time throughout the year and on January 1 of each year. You can always check CareMore Cal MediConnect Plan s up-to-date List of Covered Drugs online at duals.caremore.com or by calling (TTY: 711). You can ask for this information in other formats, such as Braille or large print. Call (TTY: 711). The call is free. Limitations, co-pays and restrictions may apply. For more information, call CareMore Cal MediConnect Plan Member Services at (TTY: 711). Co-pays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can get this information for free in other languages. Call (TTY: 711). The call is free. Puede recibir esta información sin cargo en otros idiomas. Llame al (línea TTY: 711). La llamada es gratuita. 您可免費獲得本資訊的其他語言版本 請致電免費電話 (TTY 專線 : 711) يمكنك الحصول ع هذه المع مجانا في لغات ا خرى. ىل وماتل.(711 (TTY: ا تصل على ا رقام الهواتف الاتصال سوف يكون مجانا. با شماره می توانيد اين اطلاعات را به طور رايگان به زبان های ديگر دريافت کنيد. اين تماس رايگان می باشد. تماس بگيريد. 711 TTY: Դուք կարող եք անվճար ստանալ այս տեղեկությունն այլ լեզուներով: Զանգահարեք հեռախոսահամարներով, (TTY` 711): Զանգն անվճար է: កអ ក ចទទ ល នព ត ន ន យឥតគ ត ថ ផ សៗ ស មទ រស ព មក លខ , ( ខ ទរស ពសស រ អ ក នរ ក ស រ រ ឬន យ(TTY): 711) រ ទ រស ព ន គ ឥតគ ត ថ 본정보를무료로다른언어로받아보실수있습니다 ( 청각장애인용전화 : 711). 번으로전화해주십시오. 통화는무료입니다.? If you have questions, please call CareMore Cal MediConnect Plan at (TTY: 711). Monday through Friday from 8:00 am to 8:00 pm. After-hours messaging is available 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit duals.caremore.com. 2

4 H6229_15_24351_T_002 CMS Approved 05/11/2015 Эту информацию вы можете получить бесплатно в переводе на другие языки. Позвоните по телефону (люди, страдающие нарушениями речи или слуха, могут звонить по линии TTY, телефон 711). Звонки по этому телефону бесплатные. Maaari ninyong makuha nang libre ang impormasyon na ito sa ibang mga wika. Tawagan ang (TTY: 711). Libre ang tawag. Quý vị có thể nhận thông tin này miễn phí bằng các ngôn ngữ khác. Hãy gọi, , (TTY: 711). Cuộc gọi này được miễn phí.? If you have questions, please call CareMore Cal MediConnect Plan at (TTY: 711). Monday through Friday from 8:00 am to 8:00 pm. After-hours messaging is available 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit duals.caremore.com. 3

5 Frequently Asked Questions (FAQ) H6229_15_24351_T_002v16 CMS Approved 05/11/2015 Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the Drug List are the drugs covered by CareMore Cal MediConnect Plan. The drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. CareMore Cal MediConnect Plan will cover all medically necessary drugs on the Drug List if: Your doctor or other prescriber says you need them to get better or stay healthy, and You fill the prescription at a CareMore Cal MediConnect Plan network pharmacy. In some cases, you have to do something before you can get a drug (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at duals.caremore.com, or call Member Services at (TTY: 711). 2. Does the Drug List ever change? Yes. CareMore Cal MediConnect Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: A cheaper drug comes along that works as well as a drug on the Drug List now, or We learn that a drug is not safe We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from CareMore Cal MediConnect Plan before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see pages 5-6.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4 and 7 below have more information on what happens when the Drug List changes.? If you have questions, please call CareMore Cal MediConnect Plan at (TTY: 711). Monday through Friday from 8:00 am to 8:00 pm. After-hours messaging is available 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit duals.caremore.com. 4

6 H6229_15_24351_T_002 CMS Approved 05/11/2015 You can always check CareMore Cal MediConnect Plan s up-to-date Drug List online at duals.caremore.com. You can also call Member Services to check the current Drug List at (TTY: 711). 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the drug is removed from the drug list. We will send you a letter about any non-maintenance changes made to the drug list throughout the year. We ll also post a copy of the letter on our website, duals.caremore.com. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you get a notice about an unsafe medicine, call your doctor right away. Your doctor can help you find another medicine that will work best for you. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases, you must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from CareMore Cal MediConnect Plan before you fill your prescription. If you don t get approval, CareMore Cal MediConnect Plan may not cover the drug. Quantity limits: Sometimes CareMore Cal MediConnect Plan limits the amount of a drug you can get. Step therapy: Sometimes CareMore Cal MediConnect Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second.? If you have questions, please call CareMore Cal MediConnect Plan at (TTY: 711). Monday through Friday from 8:00 am to 8:00 pm. After-hours messaging is available 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit duals.caremore.com. 5

7 H6229_15_24351_T_002v16 CMS Approved 05/11/2015 You can find out if your drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our website at duals.caremore.com. We have posted online documents that explain our prior authorization restriction. You may also ask us to send you a copy. You can also ask for an exception from these limits. Please see Question 11 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new CareMore Cal MediConnect Plan member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see Question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 12 has a column labeled Necessary actions, restrictions or limits on use. 7. What happens if we change our rules on how we cover some of the drugs? For example, if we add prior authorization (approval), quantity limits and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask your pharmacy for a refill. Then, you can get a 60-day supply of the drug before the change to the coverage rules is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition? If you have questions, please call CareMore Cal MediConnect Plan at (TTY: 711). Monday through Friday from 8:00 am to 8:00 pm. After-hours messaging is available 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit duals.caremore.com. 6

8 H6229_15_24351_T_002 CMS Approved 05/11/2015 To search alphabetically, go to the Alphabetical Listing section. You can find it using the first letter of the name of the drug. To search by medical condition, find the section labeled List of drugs by medical condition on page 12. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Member Services at (TTY: 711) and ask about it. If you learn that CareMore Cal MediConnect Plan will not cover the drug, you can do one of these things: Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new CareMore Cal MediConnect Plan member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of CareMore Cal MediConnect Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 30-day supply of your drug if: You are taking a drug that is not on our Drug List, or Health plan rules do not let you get the amount ordered by your prescriber, or The drug requires prior approval by CareMore Cal MediConnect Plan, or You are taking a drug that is part of a step therapy restriction If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as days. You may refill the drug multiple times during the 90 days. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception. If you experience a change in the level of care you re getting that requires you to transition from one facility or treatment center to another, you may be eligible for a one-time temporary fill of the prescription you have now. For example, if you were discharged from the hospital and given a? If you have questions, please call CareMore Cal MediConnect Plan at (TTY: 711). Monday through Friday from 8:00 am to 8:00 pm. After-hours messaging is available 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit duals.caremore.com. 7

9 H6229_15_24351_T_002v16 CMS Approved 05/11/2015 discharge list of medications based upon the hospital formulary, you may be able to get a onetime fill of the drug. You can get the temporary one-time fill exception regardless of whether or not you re in your first 90 days of program enrollment. Have your prescriber call us for details. 11. Can you ask for an exception to cover your drug? Yes. You can ask CareMore Cal MediConnect Plan to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, CareMore Cal MediConnect Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Member Services at (TTY: 711). Member Services will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand-name drug and their names are less commonly known. Generic drugs are approved by the Food and Drug Administration (FDA). CareMore Cal MediConnect Plan covers both brand-name drugs and generic drugs.? If you have questions, please call CareMore Cal MediConnect Plan at (TTY: 711). Monday through Friday from 8:00 am to 8:00 pm. After-hours messaging is available 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit duals.caremore.com. 8

10 H6229_15_24351_T_002 CMS Approved 05/11/ What are OTC drugs? OTC stands for over-the-counter. CareMore Cal MediConnect Plan covers some OTC drugs when they are written as prescriptions by your provider. You can read the CareMore Cal MediConnect Plan Drug List to see what OTC drugs are covered. The list of OTC drugs covered when written as a prescription by your provider can be found in Tier 4 of the Drug List. Tier 4 OTC drugs have a $0 copay. 16. What is your co-pay? You can read the CareMore Cal MediConnect Plan Drug List to learn about the co-pay for each drug. CareMore Cal MediConnect Plan members living in nursing homes or other long-term care facilities will have no co-pays. Some members getting long-term care in the community will also have no co-pays. Co-pays are listed by tiers. Tier 1 drugs are preferred generic and brand-name drugs. The co-pay for medications in this tier is $0 to $2.65. Tier 2 drugs have the highest co-pay. They are generic and brand-name drugs. The copay is from $0 to $6.60 depending on your income. Tier 3 drugs have a co-pay of $0. They are prescription generic and brand-name drugs that are covered by Medi-Cal. Tier 4 drugs have a co-pay of $0. They are over-the-counter (OTC) drugs that are covered by Medi-Cal.? If you have questions, please call CareMore Cal MediConnect Plan at (TTY: 711). Monday through Friday from 8:00 am to 8:00 pm. After-hours messaging is available 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit duals.caremore.com. 9

11 H6229_15_24351_T_002v16 CMS Approved 05/11/2015 List of Covered Drugs The list of covered drugs below gives you information about the drugs covered by CareMore Cal MediConnect Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 104. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., AZOPT) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Necessary actions, restrictions or limits on use column tells you if CareMore Cal MediConnect Plan has any rules for covering your drug. ABBREVIATION DESCRIPTION EXPLANATION B/D Part B vs. Part D determination This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. HI Home Infusion This prescription drug may be covered under our medical benefit. For more information, call Member Services (TTY: 711). LA Limited Availability This prescription may be available only at certain pharmacies. For more information, please call Member Services (TTY: 711). MO Mail-Order Drug This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your longterm (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PAR Prior Authorization Required The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval,? If you have questions, please call CareMore Cal MediConnect Plan at (TTY: 711). Monday through Friday from 8:00 am to 8:00 pm. After-hours messaging is available 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit duals.caremore.com. 10

12 H6229_15_24351_T_002 CMS Approved 05/11/2015 we may not cover the drug. QLL Quantity Limit For certain drugs, the Plan limits the amount of the drug that we will cover. Note: The asterisk (*) next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a decision we made about your coverage and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagrees with our decision, you can appeal. If you ever have a question, call Member Services at (TTY: 711). You can also read the Member Handbook to learn how to appeal a decision.? If you have questions, please call CareMore Cal MediConnect Plan at (TTY: 711). Monday through Friday from 8:00 am to 8:00 pm. After-hours messaging is available 24 hours a day, 7 days a week, including holidays. The call is free. For more information, visit duals.caremore.com. 11

13 H6229_15_24351_T_002v16 CMS Approved 05/11/2015 List of drugs by medical condition Name of Drug ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET $ (Tier 2) B/D PAR; MO; HI AMBISOME $ (Tier 2) B/D PAR; MO amphotericin b $ (Tier 2) B/D PAR; MO CANCIDAS $ (Tier 2) B/D PAR; MO clotrimazole mucous membrane $ (Tier 2) MO ERAXIS(WATER DILUENT) $ (Tier 2) PAR; MO fluconazole $ (Tier 2) MO fluconazole in dextrose(iso-o) $ (Tier 2) B/D PAR fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml $ (Tier 2) B/D PAR; MO $ (Tier 2) B/D PAR flucytosine $ (Tier 2) MO griseofulvin microsize oral suspension $ (Tier 2) MO griseofulvin ultramicrosize $ (Tier 2) MO itraconazole $ (Tier 2) MO ketoconazole oral $ (Tier 2) MO NOXAFIL ORAL SUSPENSION $ (Tier 2) MO; QLL (630 per 30 days) nystatin oral suspension $ (Tier 2) MO nystatin oral tablet $ (Tier 2) MO terbinafine hcl oral $ (Tier 2) MO; QLL (30 per 30 days) voriconazole intravenous $ (Tier 2) MO voriconazole oral tablet 200 mg $ (Tier 2) PAR; MO; QLL (60 per 30 days) voriconazole oral tablet 50 mg $ (Tier 2) PAR; MO; QLL (120 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page

14 ANTIVIRALS H6229_15_24351_T_002 CMS Approved 05/11/2015 abacavir $ (Tier 2) MO abacavir-lamivudine-zidovudine $ (Tier 2) MO acyclovir oral capsule $ (Tier 2) MO acyclovir oral suspension 200 mg/5 ml $ (Tier 2) MO acyclovir oral tablet $ (Tier 2) MO acyclovir sodium intravenous recon soln 500 mg $ (Tier 2) B/D PAR acyclovir sodium intravenous solution $ (Tier 2) B/D PAR; MO adefovir $ (Tier 2) MO amantadine hcl oral capsule $ (Tier 2) MO amantadine hcl oral tablet $ (Tier 2) MO APTIVUS ORAL CAPSULE $ (Tier 2) MO APTIVUS ORAL SOLUTION $ (Tier 2) ATRIPLA $ (Tier 2) MO BARACLUDE ORAL SOLUTION $ (Tier 2) PAR; MO; QLL (600 per 30 days) BARACLUDE ORAL TABLET $ (Tier 2) PAR; MO; QLL (30 per 30 days) COMPLERA $ (Tier 2) MO CRIXIVAN ORAL CAPSULE 200 MG, 400 MG $ (Tier 2) MO didanosine $ (Tier 2) MO EDURANT $ (Tier 2) MO EMTRIVA $ (Tier 2) MO entecavir $ (Tier 2) PAR; MO; QLL (30 per 30 days) EPIVIR HBV ORAL SOLUTION $ (Tier 2) MO EPIVIR ORAL SOLUTION $ (Tier 2) MO EPZICOM $ (Tier 2) MO EVOTAZ $ (Tier 2) MO famciclovir oral tablet 125 mg, 250 mg $ (Tier 2) MO; QLL (60 per 30 days) famciclovir oral tablet 500 mg $ (Tier 2) MO; QLL (21 per 7 days) foscarnet $ (Tier 2) B/D PAR; MO FUZEON SUBCUTANEOUS RECON SOLN $ (Tier 2) MO; QLL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page

15 ganciclovir sodium $ (Tier 2) MO H6229_15_24351_T_002v16 CMS Approved 05/11/2015 HARVONI $ (Tier 2) PAR; MO; QLL (28 per 28 days) INTELENCE ORAL TABLET 100 MG, 200 MG $ (Tier 2) MO INTELENCE ORAL TABLET 25 MG $ (Tier 2) INVIRASE $ (Tier 2) MO ISENTRESS $ (Tier 2) MO KALETRA $ (Tier 2) MO lamivudine $ (Tier 2) MO lamivudine-zidovudine $ (Tier 2) MO LEXIVA $ (Tier 2) MO MODERIBA $ (Tier 2) MO nevirapine $ (Tier 2) MO NORVIR $ (Tier 2) MO OLYSIO $ (Tier 2) PAR; MO PREZCOBIX $ (Tier 2) MO PREZISTA ORAL SUSPENSION $ (Tier 2) MO PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG $ (Tier 2) MO RELENZA DISKHALER $ (Tier 2) MO; QLL (60 per 180 days) RESCRIPTOR $ (Tier 2) MO RETROVIR INTRAVENOUS $ (Tier 2) MO REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG $ (Tier 2) MO REYATAZ ORAL POWDER IN PACKET $ (Tier 2) MO ribasphere oral capsule $ (Tier 2) MO ribasphere oral tablet 200 mg $ (Tier 2) MO ribavirin oral capsule $ (Tier 2) MO ribavirin oral tablet 200 mg $ (Tier 2) MO rimantadine $ (Tier 2) MO SELZENTRY $ (Tier 2) MO SOVALDI $ (Tier 2) PAR; MO 14

16 stavudine $ (Tier 2) MO STRIBILD $ (Tier 2) MO SUSTIVA $ (Tier 2) MO H6229_15_24351_T_002 CMS Approved 05/11/2015 SYNAGIS $ (Tier 2) PAR; MO; LA TAMIFLU ORAL CAPSULE 30 MG $ (Tier 2) MO; QLL (84 per 1 day) TAMIFLU ORAL CAPSULE 45 MG $ (Tier 2) MO; QLL (42 per 1 day) TAMIFLU ORAL CAPSULE 75 MG $ (Tier 2) MO; QLL (56 per 365 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TIVICAY $ (Tier 2) MO TRIUMEQ $ (Tier 2) MO TRIZIVIR $ (Tier 2) MO TRUVADA $ (Tier 2) MO TYBOST $ (Tier 2) MO TYZEKA $ (Tier 2) MO $ (Tier 2) MO; QLL (360 per 180 days) valacyclovir $ (Tier 2) MO; QLL (30 per 1 day) VALCYTE ORAL TABLET $ (Tier 2) MO valganciclovir $ (Tier 2) MO VIDEX 2 GRAM PEDIATRIC $ (Tier 2) MO VIDEX 4 GRAM PEDIATRIC $ (Tier 2) MO VIEKIRA PAK $ (Tier 2) PAR; MO VIRACEPT ORAL TABLET $ (Tier 2) MO VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG $ (Tier 2) MO VIRAZOLE $ (Tier 2) PAR; MO VIREAD ORAL POWDER $ (Tier 2) MO; QLL (240 per 30 days) VIREAD ORAL TABLET $ (Tier 2) MO VITEKTA $ (Tier 2) MO ZIAGEN ORAL SOLUTION $ (Tier 2) MO zidovudine $ (Tier 2) MO You can find information on what the symbols and abbreviations in this table mean by going to page

17 CEPHALOSPORINS cefaclor oral capsule $ (Tier 2) MO cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml H6229_15_24351_T_002v16 CMS Approved 05/11/2015 $ (Tier 2) MO cefaclor oral tablet extended release 12 hr $ (Tier 2) MO cefadroxil oral capsule $ (Tier 2) MO cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml $ (Tier 2) MO cefadroxil oral tablet $ (Tier 2) MO cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml $ (Tier 2) B/D PAR; MO; HI cefazolin injection recon soln 1 gram, 500 mg $ (Tier 2) B/D PAR; MO; HI cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g $ (Tier 2) B/D PAR; HI cefazolin intravenous $ (Tier 2) B/D PAR cefdinir $ (Tier 2) MO cefepime $ (Tier 2) B/D PAR; MO; HI cefoxitin in dextrose, iso-osm $ (Tier 2) B/D PAR; HI cefoxitin intravenous recon soln 1 gram $ (Tier 2) B/D PAR; MO; HI cefoxitin intravenous recon soln 10 gram, 2 gram $ (Tier 2) B/D PAR; HI cefpodoxime $ (Tier 2) MO cefprozil $ (Tier 2) MO ceftazidime injection recon soln 1 gram, 2 gram $ (Tier 2) B/D PAR; MO; HI ceftazidime injection recon soln 6 gram $ (Tier 2) HI ceftriaxone in dextrose,iso-os $ (Tier 2) B/D PAR; MO ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg $ (Tier 2) B/D PAR; MO; HI ceftriaxone injection recon soln 10 gram $ (Tier 2) B/D PAR; HI ceftriaxone intravenous recon soln $ (Tier 2) B/D PAR; MO; HI cefuroxime axetil oral tablet $ (Tier 2) MO cefuroxime sodium injection recon soln 1.5 gram, 750 mg $ (Tier 2) B/D PAR; MO; HI 16

18 H6229_15_24351_T_002 CMS Approved 05/11/2015 cefuroxime sodium intravenous $ (Tier 2) B/D PAR; HI cephalexin oral capsule 250 mg, 500 mg $ (Tier 1) MO cephalexin oral suspension for reconstitution $ (Tier 1) MO cephalexin oral tablet $ (Tier 1) MO TEFLARO $ (Tier 2) MO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous $ (Tier 2) B/D PAR; MO azithromycin oral suspension for reconstitution $ (Tier 2) MO azithromycin oral tablet 250 mg (6 pack) $ (Tier 2) azithromycin oral tablet 250 mg, 500 mg, 600 mg $ (Tier 2) MO clarithromycin oral suspension for reconstitution $ (Tier 2) MO clarithromycin oral tablet $ (Tier 2) MO; QLL (28 per 1 day) clarithromycin oral tablet extended release 24 hr $ (Tier 2) MO; QLL (28 per 1 day) ery-tab $ (Tier 2) MO erythrocin (as stearate) oral tablet 250 mg $ (Tier 2) MO ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG $ (Tier 2) B/D PAR erythromycin ethylsuccinate oral tablet $ (Tier 2) MO erythromycin oral tablet $ (Tier 2) MO MISCELLANEOUS ANTIINFECTIVES ALBENZA $ (Tier 2) MO ALINIA ORAL SUSPENSION FOR RECONSTITUTION $ (Tier 2) MO; QLL (180 per 3 days) ALINIA ORAL TABLET $ (Tier 2) MO amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml $ (Tier 2) B/D PAR; MO atovaquone-proguanil oral tablet mg $ (Tier 2) MO AZACTAM $ (Tier 2) MO; HI AZACTAM IN DEXTROSE (ISO-OSM) $ (Tier 2) HI baciim $ (Tier 2) B/D PAR BILTRICIDE $ (Tier 2) MO You can find information on what the symbols and abbreviations in this table mean by going to page

19 H6229_15_24351_T_002v16 CMS Approved 05/11/2015 CAPASTAT $ (Tier 2) B/D PAR CAYSTON $ (Tier 2) PAR; MO; LA chloramphenicol sod succinate $ (Tier 2) chloroquine phosphate oral $ (Tier 2) MO clindamycin hcl $ (Tier 2) MO clindamycin phosphate injection $ (Tier 2) B/D PAR; MO clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml $ (Tier 2) B/D PAR $ (Tier 2) B/D PAR; MO COARTEM $ (Tier 2) MO colistin (colistimethate na) $ (Tier 2) B/D PAR; MO; HI CUBICIN $ (Tier 2) B/D PAR; MO DAPSONE $ (Tier 2) MO DARAPRIM $ (Tier 2) MO ethambutol $ (Tier 2) MO gentamicin injection $ (Tier 2) MO gentamicin sulfate (ped) (pf) $ (Tier 2) MO gentamicin sulfate (pf) intravenous solution 100 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml $ (Tier 2) MO $ (Tier 2) $ (Tier 2) hydroxychloroquine oral $ (Tier 2) MO imipenem-cilastatin $ (Tier 2) MO; HI INVANZ INJECTION $ (Tier 2) MO; HI isoniazid oral $ (Tier 1) MO linezolid oral $ (Tier 2) PAR; MO; QLL (28 per 1 day) mefloquine $ (Tier 2) MO MEPRON $ (Tier 2) MO meropenem $ (Tier 2) B/D PAR; MO; HI 18

20 metro i.v. $ (Tier 2) MO metronidazole in nacl (iso-os) $ (Tier 2) MO metronidazole oral $ (Tier 2) MO MYCOBUTIN $ (Tier 2) MO H6229_15_24351_T_002 CMS Approved 05/11/2015 NEBUPENT $ (Tier 2) B/D PAR; MO neomycin $ (Tier 2) MO paromomycin $ (Tier 2) MO PASER $ (Tier 2) MO PENTAM $ (Tier 2) MO PRIFTIN $ (Tier 2) MO PRIMAQUINE $ (Tier 2) MO pyrazinamide $ (Tier 2) MO quinine sulfate $ (Tier 2) PAR; MO rifampin intravenous $ (Tier 2) B/D PAR; MO rifampin oral $ (Tier 2) MO RIFATER $ (Tier 2) MO STREPTOMYCIN INTRAMUSCULAR $ (Tier 2) MO STROMECTOL $ (Tier 2) MO SYNERCID $ (Tier 2) TOBI $ (Tier 2) PAR; MO; QLL (280 per 28 days) tobramycin sulfate injection recon soln $ (Tier 2) B/D PAR; HI tobramycin sulfate injection solution $ (Tier 2) B/D PAR; MO; HI TRECATOR $ (Tier 2) MO TYGACIL $ (Tier 2) MO; HI XIFAXAN ORAL TABLET 550 MG $ (Tier 2) PAR; MO; QLL (84 per 28 days) ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION $ (Tier 2) HI $ (Tier 2) MO; HI $ (Tier 2) PAR; MO You can find information on what the symbols and abbreviations in this table mean by going to page

21 H6229_15_24351_T_002v16 CMS Approved 05/11/2015 ZYVOX ORAL TABLET $ (Tier 2) PAR; MO; QLL (28 per 1 day) PENICILLINS amoxicillin oral capsule $ (Tier 1) MO amoxicillin oral suspension for reconstitution $ (Tier 1) MO amoxicillin oral tablet $ (Tier 1) MO amoxicillin oral tablet,chewable 125 mg, 250 mg $ (Tier 1) MO amoxicillin-pot clavulanate $ (Tier 2) MO ampicillin $ (Tier 2) MO ampicillin sodium injection $ (Tier 2) B/D PAR; MO; HI ampicillin sodium intravenous recon soln 1 gram $ (Tier 2) B/D PAR; HI ampicillin sodium intravenous recon soln 2 gram $ (Tier 2) B/D PAR ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram $ (Tier 2) B/D PAR; MO; HI ampicillin-sulbactam injection recon soln 15 gram $ (Tier 2) B/D PAR; HI ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K) $ (Tier 2) B/D PAR $ (Tier 2) B/D PAR; MO $ (Tier 2) MO dicloxacillin $ (Tier 2) MO nafcillin injection recon soln 1 gram, 10 gram $ (Tier 2) B/D PAR; MO; HI nafcillin injection recon soln 2 gram $ (Tier 2) B/D PAR; MO nafcillin intravenous recon soln 2 gram $ (Tier 2) B/D PAR; MO oxacillin injection $ (Tier 2) MO; HI oxacillin intravenous recon soln 1 gram $ (Tier 2) oxacillin intravenous recon soln 2 gram $ (Tier 2) HI PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML $ (Tier 2) B/D PAR $ (Tier 2) B/D PAR; HI 20

22 H6229_15_24351_T_002 CMS Approved 05/11/2015 penicillin g potassium $ (Tier 2) B/D PAR; MO; HI penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml $ (Tier 2) B/D PAR; MO $ (Tier 2) B/D PAR penicillin g sodium $ (Tier 2) B/D PAR; MO; HI penicillin v potassium $ (Tier 2) MO piperacillin-tazobactam $ (Tier 2) B/D PAR; MO; HI ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML, 4.5 GRAM/100 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML QUINOLONES $ (Tier 2) HI $ (Tier 2) MO; HI ciprofloxacin er $ (Tier 1) MO ciprofloxacin hcl oral $ (Tier 1) MO ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml $ (Tier 1) B/D PAR; MO $ (Tier 1) B/D PAR levofloxacin intravenous $ (Tier 2) MO levofloxacin oral $ (Tier 2) MO ofloxacin oral tablet 400 mg $ (Tier 2) SULFA'S / RELATED AGENTS sulfadiazine oral $ (Tier 2) MO sulfamethoxazole-trimethoprim intravenous $ (Tier 1) B/D PAR; MO sulfamethoxazole-trimethoprim oral $ (Tier 1) MO TETRACYCLINES demeclocycline oral $ (Tier 2) MO DOXY-100 $ (Tier 2) B/D PAR; MO doxycycline hyclate intravenous $ (Tier 2) B/D PAR You can find information on what the symbols and abbreviations in this table mean by going to page

23 doxycycline hyclate oral capsule $ (Tier 2) MO doxycycline hyclate oral tablet 100 mg, 20 mg $ (Tier 2) MO doxycycline hyclate oral tablet 50 mg $ (Tier 2) doxycycline hyclate oral tablet,delayed release (dr/ec) H6229_15_24351_T_002v16 CMS Approved 05/11/2015 $ (Tier 2) MO doxycycline monohydrate oral capsule $ (Tier 2) MO doxycycline monohydrate oral tablet $ (Tier 2) MO minocycline oral capsule $ (Tier 2) MO minocycline oral tablet $ (Tier 2) MO morgidox $ (Tier 2) MO tetracycline $ (Tier 2) MO URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 25 MG, 50 MG $ (Tier 2) MO methenamine hippurate $ (Tier 2) MO trimethoprim $ (Tier 2) MO VANCOMYCIN VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/200 ML VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 500 MG/100 ML $ (Tier 2) B/D PAR; MO $ (Tier 2) B/D PAR VANCOMYCIN IN DEXTROSE ISO-OSM $ (Tier 2) B/D PAR vancomycin intravenous $ (Tier 2) B/D PAR; MO; HI vancomycin oral capsule 125 mg $ (Tier 2) PAR; MO; QLL (40 per 1 day) vancomycin oral capsule 250 mg $ (Tier 2) PAR; MO; QLL (80 per 1 day) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline $ (Tier 2) B/D PAR; MO dexrazoxane hcl intravenous recon soln 250 mg $ (Tier 2) B/D PAR dexrazoxane hcl intravenous recon soln 500 mg $ (Tier 2) B/D PAR; MO ELITEK $ (Tier 2) PAR; MO 22

24 H6229_15_24351_T_002 CMS Approved 05/11/2015 FUSILEV $ (Tier 2) B/D PAR; MO KEPIVANCE $ (Tier 2) B/D PAR leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg $ (Tier 2) B/D PAR; MO leucovorin calcium injection recon soln 500 mg $ (Tier 2) B/D PAR leucovorin calcium oral $ (Tier 2) MO mesna $ (Tier 2) B/D PAR; MO MESNEX ORAL $ (Tier 2) MO XGEVA $ (Tier 2) PAR; MO; QLL (1.7 per 28 days) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE $ (Tier 2) B/D PAR; MO AFINITOR $ (Tier 2) PAR; MO AFINITOR DISPERZ $ (Tier 2) PAR; MO ALIMTA $ (Tier 2) B/D PAR; MO anastrozole $ (Tier 2) MO ARRANON $ (Tier 2) B/D PAR ARZERRA $ (Tier 2) B/D PAR; MO ASTAGRAF XL $ (Tier 2) B/D PAR; MO AVASTIN INTRAVENOUS SOLUTION 25 MG/ML AVASTIN INTRAVENOUS SOLUTION 25 MG/ML (16 ML) $ (Tier 2) B/D PAR; MO $ (Tier 2) B/D PAR azacitidine $ (Tier 2) B/D PAR; MO AZASAN $ (Tier 2) B/D PAR; MO azathioprine $ (Tier 2) B/D PAR; MO BELEODAQ $ (Tier 2) PAR; MO bexarotene $ (Tier 2) PAR; MO bicalutamide $ (Tier 2) MO BICNU $ (Tier 2) B/D PAR; MO bleomycin $ (Tier 2) B/D PAR; MO BLINCYTO $ (Tier 2) PAR; MO You can find information on what the symbols and abbreviations in this table mean by going to page

25 H6229_15_24351_T_002v16 CMS Approved 05/11/2015 BOSULIF $ (Tier 2) PAR; MO BUSULFEX $ (Tier 2) B/D PAR CAPRELSA $ (Tier 2) PAR; MO; LA carboplatin intravenous solution $ (Tier 2) B/D PAR; MO CELLCEPT INTRAVENOUS $ (Tier 2) B/D PAR; MO CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION $ (Tier 2) B/D PAR; MO cisplatin $ (Tier 2) B/D PAR; MO cladribine $ (Tier 2) B/D PAR; MO CLOLAR $ (Tier 2) B/D PAR; MO COMETRIQ $ (Tier 2) PAR; MO cyclophosphamide oral capsule $ (Tier 2) B/D PAR; MO cyclosporine intravenous $ (Tier 2) B/D PAR cyclosporine modified $ (Tier 2) B/D PAR; MO cyclosporine oral capsule $ (Tier 2) B/D PAR; MO CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML (50 ML) $ (Tier 2) PAR; MO $ (Tier 2) PAR cytarabine $ (Tier 2) B/D PAR; MO cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) $ (Tier 2) B/D PAR; MO cytarabine (pf) injection solution 20 mg/ml $ (Tier 2) B/D PAR dacarbazine $ (Tier 2) B/D PAR; MO DACOGEN $ (Tier 2) B/D PAR; MO daunorubicin intravenous solution $ (Tier 2) B/D PAR DAUNOXOME $ (Tier 2) B/D PAR; MO decitabine $ (Tier 2) B/D PAR; MO DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ml, 140 mg/7 ml (20 mg/ml), 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml) $ (Tier 2) B/D PAR $ (Tier 2) B/D PAR 24

26 docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) H6229_15_24351_T_002 CMS Approved 05/11/2015 $ (Tier 2) B/D PAR; MO doxorubicin intravenous recon soln $ (Tier 2) B/D PAR doxorubicin intravenous solution $ (Tier 2) B/D PAR; MO DROXIA $ (Tier 2) MO EMCYT $ (Tier 2) MO epirubicin intravenous solution 200 mg/100 ml $ (Tier 2) B/D PAR epirubicin intravenous solution 50 mg/25 ml $ (Tier 2) B/D PAR; MO ERBITUX $ (Tier 2) PAR; MO ERIVEDGE $ (Tier 2) PAR; MO ERWINAZE $ (Tier 2) B/D PAR; MO ETOPOPHOS $ (Tier 2) MO etoposide intravenous $ (Tier 2) B/D PAR; MO exemestane $ (Tier 2) MO FARESTON $ (Tier 2) MO FARYDAK ORAL CAPSULE 10 MG $ (Tier 2) PAR; MO; QLL (60 per 30 days) FARYDAK ORAL CAPSULE 15 MG, 20 MG $ (Tier 2) PAR; MO; QLL (30 per 30 days) FASLODEX $ (Tier 2) B/D PAR; MO FIRMAGON KIT W DILUENT SYRINGE $ (Tier 2) B/D PAR; MO fludarabine intravenous recon soln $ (Tier 2) B/D PAR; MO fludarabine intravenous solution $ (Tier 2) B/D PAR fluorouracil intravenous $ (Tier 2) B/D PAR; MO flutamide $ (Tier 2) MO FOLOTYN $ (Tier 2) B/D PAR; MO GAZYVA $ (Tier 2) PAR; MO gemcitabine intravenous recon soln 1 gram, 200 mg $ (Tier 2) B/D PAR; MO gemcitabine intravenous recon soln 2 gram $ (Tier 2) B/D PAR gemcitabine intravenous solution $ (Tier 2) B/D PAR gengraf $ (Tier 2) B/D PAR; MO GILOTRIF $ (Tier 2) PAR; MO You can find information on what the symbols and abbreviations in this table mean by going to page

27 H6229_15_24351_T_002v16 CMS Approved 05/11/2015 GLEEVEC $ (Tier 2) PAR; MO GLEOSTINE $ (Tier 2) MO HALAVEN $ (Tier 2) B/D PAR; MO HERCEPTIN $ (Tier 2) PAR; MO HEXALEN $ (Tier 2) MO hydroxyurea $ (Tier 2) MO IBRANCE $ (Tier 2) PAR; MO; QLL (30 per 30 days) ICLUSIG $ (Tier 2) PAR; MO idarubicin $ (Tier 2) B/D PAR ifosfamide intravenous recon soln 1 gram $ (Tier 2) B/D PAR; MO ifosfamide intravenous recon soln 3 gram $ (Tier 2) B/D PAR ifosfamide intravenous solution $ (Tier 2) B/D PAR IMBRUVICA $ (Tier 2) PAR; MO INLYTA $ (Tier 2) PAR; MO irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml $ (Tier 2) B/D PAR; MO irinotecan intravenous solution 500 mg/25 ml $ (Tier 2) B/D PAR ISTODAX $ (Tier 2) B/D PAR; MO IXEMPRA $ (Tier 2) B/D PAR; MO JAKAFI $ (Tier 2) PAR; MO JEVTANA $ (Tier 2) B/D PAR; MO KADCYLA $ (Tier 2) PAR; MO KEYTRUDA $ (Tier 2) MO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY) LENVIMA ORAL CAPSULE 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY) LENVIMA ORAL CAPSULE 24 MG (10 MG[2] -4 MG[1])/DAY letrozole $ (Tier 2) MO LEUKERAN $ (Tier 2) MO leuprolide $ (Tier 2) MO $ (Tier 2) PAR; MO; QLL (30 per 30 days) $ (Tier 2) PAR; MO; QLL (60 per 30 days) $ (Tier 2) PAR; MO; QLL (90 per 30 days) 26

28 LOMUSTINE $ (Tier 2) MO LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG H6229_15_24351_T_002 CMS Approved 05/11/2015 $ (Tier 2) PAR; MO $ (Tier 2) PAR; MO LYNPARZA $ (Tier 2) PAR; MO; QLL (480 per 30 days) LYSODREN $ (Tier 2) MO MATULANE $ (Tier 2) MO megestrol oral suspension 400 mg/10 ml (10 ml) $ (Tier 2) megestrol oral suspension 400 mg/10 ml (40 mg/ml) $ (Tier 2) MO megestrol oral tablet $ (Tier 2) MO MEKINIST $ (Tier 2) PAR; MO melphalan hcl $ (Tier 2) B/D PAR mercaptopurine $ (Tier 2) MO methotrexate sodium (pf) injection recon soln $ (Tier 2) B/D PAR methotrexate sodium (pf) injection solution $ (Tier 2) B/D PAR; MO methotrexate sodium injection $ (Tier 2) B/D PAR; MO methotrexate sodium oral $ (Tier 2) MO mitomycin $ (Tier 2) B/D PAR; MO mitoxantrone $ (Tier 2) MO MUSTARGEN $ (Tier 2) B/D PAR; MO mycophenolate mofetil $ (Tier 2) B/D PAR; MO mycophenolate sodium $ (Tier 2) B/D PAR; MO NEXAVAR $ (Tier 2) PAR; MO; LA; QLL (120 per 30 days) NILANDRON $ (Tier 2) MO NIPENT $ (Tier 2) B/D PAR; MO NULOJIX $ (Tier 2) B/D PAR; MO octreotide acetate $ (Tier 2) PAR; MO ONCASPAR $ (Tier 2) B/D PAR; MO You can find information on what the symbols and abbreviations in this table mean by going to page

29 H6229_15_24351_T_002v16 CMS Approved 05/11/2015 OPDIVO $ (Tier 2) PAR; MO oxaliplatin intravenous recon soln 100 mg $ (Tier 2) B/D PAR; MO oxaliplatin intravenous recon soln 50 mg $ (Tier 2) B/D PAR oxaliplatin intravenous solution $ (Tier 2) B/D PAR; MO paclitaxel $ (Tier 2) B/D PAR; MO PERJETA $ (Tier 2) B/D PAR; MO POMALYST $ (Tier 2) PAR; MO PROGRAF INTRAVENOUS $ (Tier 2) B/D PAR; MO PURIXAN $ (Tier 2) PAR; MO RAPAMUNE $ (Tier 2) B/D PAR; MO REVLIMID ORAL CAPSULE 10 MG $ (Tier 2) MO; LA; QLL (60 per 30 days) REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG $ (Tier 2) MO; LA; QLL (30 per 30 days) REVLIMID ORAL CAPSULE 5 MG $ (Tier 2) MO; LA; QLL (150 per 30 days) RITUXAN $ (Tier 2) B/D PAR; MO SANDIMMUNE ORAL SOLUTION $ (Tier 2) B/D PAR; MO SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG $ (Tier 2) B/D PAR $ (Tier 2) B/D PAR; MO sirolimus $ (Tier 2) B/D PAR; MO SOLTAMOX $ (Tier 2) MO SOMATULINE DEPOT $ (Tier 2) MO SPRYCEL $ (Tier 2) MO STIVARGA $ (Tier 2) PAR; MO; QLL (120 per 30 days) SUTENT $ (Tier 2) MO SYNRIBO $ (Tier 2) B/D PAR; MO TABLOID $ (Tier 2) MO tacrolimus oral $ (Tier 2) B/D PAR; MO TAFINLAR $ (Tier 2) PAR; MO tamoxifen $ (Tier 2) MO 28

30 H6229_15_24351_T_002 CMS Approved 05/11/2015 TARCEVA $ (Tier 2) MO TARGRETIN $ (Tier 2) PAR; MO TASIGNA $ (Tier 2) MO THALOMID ORAL CAPSULE 100 MG, 50 MG $ (Tier 2) MO; QLL (30 per 30 days) THALOMID ORAL CAPSULE 150 MG, 200 MG $ (Tier 2) MO; QLL (60 per 30 days) thiotepa $ (Tier 2) B/D PAR; MO toposar $ (Tier 2) B/D PAR; MO topotecan $ (Tier 2) B/D PAR; MO TORISEL $ (Tier 2) B/D PAR; MO TREANDA $ (Tier 2) B/D PAR; MO TRELSTAR $ (Tier 2) MO TRELSTAR DEPOT $ (Tier 2) TRELSTAR LA $ (Tier 2) tretinoin (chemotherapy) $ (Tier 2) MO TREXALL $ (Tier 2) MO TRISENOX $ (Tier 2) B/D PAR; MO TYKERB $ (Tier 2) MO; LA UNITUXIN $ (Tier 2) MO VECTIBIX $ (Tier 2) PAR; MO VELCADE $ (Tier 2) B/D PAR; MO vinblastine intravenous solution $ (Tier 2) B/D PAR; MO vincasar pfs intravenous solution 1 mg/ml $ (Tier 2) B/D PAR vincasar pfs intravenous solution 2 mg/2 ml $ (Tier 2) B/D PAR; MO vincristine $ (Tier 2) B/D PAR; MO vinorelbine $ (Tier 2) B/D PAR; MO VOTRIENT $ (Tier 2) MO XALKORI $ (Tier 2) PAR; MO XTANDI $ (Tier 2) PAR; MO YERVOY $ (Tier 2) B/D PAR; MO ZALTRAP $ (Tier 2) PAR; MO You can find information on what the symbols and abbreviations in this table mean by going to page

31 H6229_15_24351_T_002v16 CMS Approved 05/11/2015 ZANOSAR $ (Tier 2) B/D PAR; MO ZELBORAF $ (Tier 2) PAR; MO ZOLINZA $ (Tier 2) MO ZORTRESS $ (Tier 2) B/D PAR; MO ZYDELIG $ (Tier 2) PAR; MO; QLL (60 per 30 days) ZYKADIA $ (Tier 2) PAR; MO ZYTIGA $ (Tier 2) PAR; MO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM $ (Tier 2) MO BANZEL ORAL SUSPENSION $ (Tier 2) PAR; MO; QLL (2400 per 30 days) BANZEL ORAL TABLET 200 MG $ (Tier 2) PAR; MO; QLL (480 per 30 days) BANZEL ORAL TABLET 400 MG $ (Tier 2) PAR; MO; QLL (240 per 30 days) carbamazepine oral capsule, er multiphase 12 hr $ (Tier 2) MO carbamazepine oral suspension 100 mg/5 ml $ (Tier 2) MO carbamazepine oral tablet $ (Tier 2) MO carbamazepine oral tablet extended release 12 hr $ (Tier 2) MO carbamazepine oral tablet,chewable $ (Tier 2) MO CELONTIN ORAL CAPSULE 300 MG $ (Tier 2) MO clonazepam oral tablet 0.5 mg $ (Tier 2) MO; QLL (1200 per 30 days) clonazepam oral tablet 1 mg $ (Tier 2) MO; QLL (600 per 30 days) clonazepam oral tablet 2 mg $ (Tier 2) MO; QLL (300 per 30 days) clonazepam oral tablet,disintegrating mg $ (Tier 2) MO; QLL (4800 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg $ (Tier 2) MO; QLL (2400 per 30 days) clonazepam oral tablet,disintegrating 0.5 mg $ (Tier 2) MO; QLL (1200 per 30 days) clonazepam oral tablet,disintegrating 1 mg $ (Tier 2) MO; QLL (600 per 30 days) clonazepam oral tablet,disintegrating 2 mg $ (Tier 2) MO; QLL (300 per 30 days) diazepam rectal $ (Tier 2) MO; QLL (2 per 1 day) DILANTIN $ (Tier 2) MO DILANTIN EXTENDED $ (Tier 2) MO 30

32 DILANTIN INFATABS $ (Tier 2) MO divalproex $ (Tier 2) MO epitol $ (Tier 2) MO EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG H6229_15_24351_T_002 CMS Approved 05/11/2015 $ (Tier 2) MO; QLL (480 per 30 days) $ (Tier 2) MO; QLL (240 per 30 days) $ (Tier 2) MO; QLL (180 per 30 days) ethosuximide $ (Tier 2) MO felbamate $ (Tier 2) MO fosphenytoin $ (Tier 2) B/D PAR; MO FYCOMPA ORAL TABLET 10 MG, 12 MG $ (Tier 2) MO; QLL (30 per 30 days) FYCOMPA ORAL TABLET 2 MG $ (Tier 2) MO; QLL (180 per 30 days) FYCOMPA ORAL TABLET 4 MG $ (Tier 2) MO; QLL (90 per 30 days) FYCOMPA ORAL TABLET 6 MG $ (Tier 2) MO; QLL (60 per 30 days) FYCOMPA ORAL TABLET 8 MG $ (Tier 2) MO; QLL (45 per 30 days) gabapentin oral capsule 100 mg $ (Tier 2) MO; QLL (1080 per 30 days) gabapentin oral capsule 300 mg $ (Tier 2) MO; QLL (360 per 30 days) gabapentin oral capsule 400 mg $ (Tier 2) MO; QLL (270 per 30 days) gabapentin oral solution 250 mg/5 ml $ (Tier 2) MO; QLL (2160 per 30 days) gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) $ (Tier 2) QLL (2160 per 30 days) gabapentin oral tablet 600 mg $ (Tier 2) MO; QLL (180 per 30 days) gabapentin oral tablet 800 mg $ (Tier 2) MO; QLL (135 per 30 days) GABITRIL ORAL TABLET 12 MG, 16 MG $ (Tier 2) MO lamotrigine oral tablet $ (Tier 2) MO lamotrigine oral tablet, chewable dispersible $ (Tier 2) MO levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml $ (Tier 2) B/D PAR $ (Tier 2) B/D PAR; MO You can find information on what the symbols and abbreviations in this table mean by going to page