PLEASE READ: This document contains information about the drugs we cover in this plan.

Transcription

1 01 Formulary (List of Covered s) CareMore Value Plus (H), CareMore Breathe (H SNP), CareMore Diabetes (H SNP), CareMore ESRD (H SNP), CareMore Heart (H SNP) CareMore Reliance (H SNP) PLEASE READ: This document contains information about the drugs we cover in this plan. This formulary was updated 10/01. For more recent information or other questions, please contact Member Services, at or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 1, and Monday to Friday (except holi from February 1 through September 0, or visit FORMPCSBNOCACVPSNP1_WEB Y011_1_0817A CHP CMS Accepted (09001) 00017_PT, V

2 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 CareMore Health Plan. When it refers to plan or our plan, it means CareMore Value Plus (H), CareMore Breathe (H SNP), CareMore Diabetes (H SNP), CareMore ESRD (H SNP), CareMore Heart (H SNP) CareMore Reliance (H SNP). This document includes a list of the drugs (formulary) for our plan which is current as of 10/01. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/ coinsurance may change on January 1, 017, and from time to time during the year. Effective Date November 1, 01 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

3 What is the CareMore Value Plus (H), CareMore Breathe (H SNP), CareMore Diabetes (H SNP), CareMore ESRD (H SNP), CareMore Heart (H SNP) CareMore Reliance (H SNP) formulary? A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary (drug list) change? Generally, if you are taking a drug on our 01 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 01 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step-therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 0 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 0-day supply of the drug. If the Food and Administration (FDA) 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 10/01. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (non-maintenance change) is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated formulary. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. 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, Antihypertensive Therapy. If you know what your drug is used for, look for the category name in the list that begins on page 7. 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. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan 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: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan Effective Date November 1, 01 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

4 before you fill your prescriptions. If you don't get approval, our plan may not cover the drug. Quantity : For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 0 tablets per month per prescription for JANUVIA 100. This may be in addition to a standard one-month or three-month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted on-line documents that explain our prior authorization restriction. 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 our plan 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 CareMore Value Plus (H), CareMore Breathe (H SNP), CareMore Diabetes (H SNP), CareMore ESRD (H SNP), CareMore Heart (H SNP) CareMore Reliance (H SNP)'s formulary? on page 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 Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan 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 CareMore Value Plus (H), CareMore Breathe (H SNP), CareMore Diabetes (H SNP), CareMore ESRD (H SNP), CareMore Heart (H SNP) CareMore Reliance (H SNP)'s formulary? You can ask our plan 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 predetermined 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, our plan 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, our plan 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 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. Effective Date November 1, 01 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

5 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term-care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. During the time when you are getting a temporary supply of a drug, you should talk to your prescriber or prescribing physician to decide what to do when your supply runs out. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you while you pursue a formulary exception. Please refer to the Evidence of Coverage for more information about exceptions. For more information For more detailed information about our plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, 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 ( ), hours a day/7 days a week. TTY users should call Or, visit Our plan s formulary The formulary that begins on page 7 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., NOVOLOG) and generic drugs are listed in lower-case italics (e.g., enalapril). The information in the column tells you if our plan has any special requirements for coverage of your drug. QLL - Quantity : Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. B/D - Part B vs. Part D: This drug may be covered under either your Part D prescripton drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Member Services at , 8 a.m. to 8 p.m., seven days a week (except Effective Date November 1, 01 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

6 Thanksgiving and Christmas) from October 1 through February 1, and Monday to Friday (except holi from February 1 through September 0. TTY users should call 711. CG - Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. INJ - Injectable: The drug is available in injectable form. - Mail Orders: Prescription drugs available through mail order. HI - Home Infusion: The drug may be covered through the medical benefit as a home-infusion medication. For more information, call Member Services at , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 1, and Monday to Friday (except holi from February 1 through September 0. TTY users should call 711. Cost-sharing for a one-month supply of a covered Part D prescription drug during the Initial Coverage Stage: Cost-Sharing 1: Preferred Generic Preferred Retail Cost-Sharing* (0-day supply) Standard Retail Cost-Sharing (0-day supply) Cost-Sharing Generic Preferred Retail Cost-Sharing* (0-day supply) Standard Retail Cost-Sharing (0-day supply) Cost-Sharing Preferred Brand Preferred Retail Cost-Sharing* (0-day supply) Standard Retail Cost-Sharing (0-day supply) Cost-Sharing Non-Preferred Brand Preferred Retail Cost-Sharing* (0-day supply) Standard Retail Cost-Sharing (0-day supply) Cost-Sharing Specialty Preferred Retail Cost-Sharing* (0-day supply) Standard Retail Cost-Sharing (0-day supply) Cost-Sharing Select Care s Preferred Retail Cost-Sharing* (0-day supply) Standard Retail Cost-Sharing (0-day supply) $0.00 $.00 $7.0 $1.0 $0.00 $.00 $8.00 $9.00 % % $0.00 $0.00 A 90-day supply of mail order drugs costs. times the amount of a 0-day supply. s designated with are available through mail order. Please refer to our Evidence of Coverage for more information for cost-sharing. *Preferred cost-sharing means lower cost-sharing for certain covered Part D drugs at certain network pharmacies. Effective Date November 1, 01 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

7 Covered Medications by Therapeutic Category Legend Generic drugs are shown in lower-case italics (e.g. enalapril) Brand-name drugs are shown in capital letters (e.g. NOVOLOG) QLL - Quantity : Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Member Services at , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 1, and Monday to Friday (except holi from February 1 through September 0. TTY users should call 711. INJ - Injectable: The drug is available in injectable form. - Mail Order: Prescription drugs available through mail order. CG Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. HI - Home Infusion: The drug may be covered through the medical benefit as a home-infusion medication. For more information, call Member Services at , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 1, and Monday to Friday (except holi from February 1 through September 0. TTY users should call 711. Name Anti - Infectives abacavir abacavir-lamivudine-zidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 00 mg/ ml ; QLL (0 per ; QLL (0 per B/D; ; HI Name acyclovir oral tablet acyclovir sodium intravenous solution adefovir ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET B/D; ; ; QLL (180 per Effective Date November 1, 01 7 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

8 Name amantadine hcl oral capsule amantadine hcl oral tablet AMBISOME amikacin injection solution 1, 000 mg/ ml, 00 mg/ ml amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 1 mg, 0 mg amoxicillin-pot clavulanate amphotericin b ampicillin ampicillin sodium injection ampicillin sodium intravenous recon soln 1 gram ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln 1. gram, gram ampicillin-sulbactam injection recon soln 1 gram ampicillin-sulbactam intravenous recon soln gram APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atovaquone atovaquone-proguanil oral tablet mg ATRIPLA AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) azithromycin intravenous recon soln 00 mg azithromycin intravenous recon soln 00 mg ( mg/ml) azithromycin oral suspension for reconstitution B/D; B/D; ; ; HI HI ; HI HI ; QLL (10 per QLL (90 per 0 ; QLL (0 per ; HI HI Name azithromycin oral tablet baciim bacitracin intramuscular BARACLUDE ORAL SOLUTION BICILLIN C-R INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML(00K/00K) BILTRICIDE CANCIDAS CAPASTAT CAYSTON cefaclor oral capsule cefaclor oral suspension for reconstitution 1 mg/ ml cefaclor oral suspension for reconstitution 0 mg/ ml, 7 mg/ ml cefaclor oral tablet extended release 1 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 0 mg/ ml, 00 mg/ ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/0 ml cefazolin injection recon soln 1 gram cefazolin injection recon soln 10 gram, 100 gram, 0 gram, 00 g cefazolin injection recon soln 00 mg cefazolin intravenous cefdinir cefepime cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram ; QLL (00 per B/D; ; LA ; HI HI ; HI ; HI HI ; HI Effective Date November 1, 01 8 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

9 Name cefoxitin intravenous recon soln 10 gram, gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, gram ceftazidime injection recon soln gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, gram, 0 mg, 00 mg ceftriaxone injection recon soln 10 gram ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium intravenous vial injection recon soln 1. gram, 70 mg cefuroxime sodium intravenous vial intravenous recon soln 7. gram cephalexin oral capsule 0 mg, 00 mg cephalexin oral suspension for reconstitution cephalexin oral tablet chloramphenicol sod succinate chloroquine phosphate oral ciprofloxacin er ciprofloxacin hcl oral ciprofloxacin lactate intravenous solution 00 mg/0 ml ciprofloxacin lactate intravenous solution 00 mg/0 ml clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release hr clindamycin hcl clindamycin phosphate injection HI ; HI HI ; HI HI ; HI ; HI HI ; QLL (8 per Name clindamycin phosphate intravenous solution 00 mg/ ml, 900 mg/ ml clindamycin phosphate intravenous solution 00 mg/ ml clotrimazole mucous membrane COARTEM colistin (colistimethate na) COMPLERA CRIXIVAN ORAL CAPSULE 00 CRIXIVAN ORAL CAPSULE 00 CUBICIN dapsone daptomycin DARAPRIM demeclocycline DESCOVY dicloxacillin didanosine oral capsule,delayed release(dr/ec) 1 mg didanosine oral capsule,delayed release(dr/ec) 00 mg didanosine oral capsule,delayed release(dr/ec) 0 mg, 00 mg doxy-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline hyclate oral tablet 0 mg doxycycline hyclate oral tablet, delayed release (dr/ec) 100 mg, 10 mg, 7 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral tablet ; HI QLL (0 per 0 ; QLL (0 per ; QLL (180 per QLL (0 per 0 ; QLL (90 per ; QLL (0 per ; QLL (0 per Effective Date November 1, 01 9 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

10 Name EDURANT EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPCLUSA EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM ERAXIS(WATER DILUENT) ery-tab erythrocin (as stearate) oral tablet 0 mg ERYTHROCIN INTRAVENOUS RECON SOLN 00 erythromycin ethylsuccinate oral tablet erythromycin oral tablet ethambutol EVOTAZ famciclovir oral tablet 1 mg, 0 mg famciclovir oral tablet 00 mg fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/ 0 ml, 00 mg/00 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/ 100 ml flucytosine foscarnet QLL (0 per 0 ; QLL (0 per ; QLL (870 per ; QLL (0 per ; QLL (0 per ; QLL (90 per ; QLL (0 per ; QLL (0 per 0 ; QLL (0 per ; QLL (1 per 7 B/D; Name FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml gentamicin sulfate (pf) intravenous solution 0 mg/ ml, 80 mg/8 ml GENVOYA griseofulvin microsize oral suspension griseofulvin ultramicrosize HARVONI hydroxychloroquine oral imipenem-cilastatin INTELENCE ORAL TABLET 100 INTELENCE ORAL TABLET 00 INTELENCE ORAL TABLET INVANZ INJECTION INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET, CHEWABLE 100 ISENTRESS ORAL TABLET, CHEWABLE isoniazid oral itraconazole KALETRA ORAL SOLUTION QLL (0 per 0 QLL (0 per 0 ; QLL (8 per 8 ; HI ; QLL (10 per ; QLL (0 per ; QLL (80 per ; HI ; QLL (00 per ; QLL (10 per QLL (10 per 0 QLL (180 per 0 ; QLL (70 per ; QLL (80 per Effective Date November 1, FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

11 Name KALETRA ORAL TABLET 100- KALETRA ORAL TABLET 00-0 ketoconazole oral lamivudine oral solution lamivudine oral tablet 100 mg lamivudine oral tablet 10 mg lamivudine oral tablet 00 mg lamivudine-zidovudine levofloxacin intravenous levofloxacin oral LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET linezolid oral suspension for reconstitution linezolid oral tablet MACRODANTIN ORAL CAPSULE, 0 mefloquine meropenem methenamine hippurate methenamine mandelate oral tablet 1 gram metro i.v. metronidazole in nacl (iso-os) metronidazole oral minocycline oral capsule minocycline oral tablet moderiba morgidox oral capsule 100 mg morgidox oral capsule 0 mg MYCOBUTIN nafcillin injection recon soln 1 gram, 10 gram ; QLL (00 per ; QLL (10 per ; QLL (900 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (1800 per ; QLL (10 per ; ; QLL (1800 per ; QLL (8 per ; HI ; HI Name nafcillin injection recon soln gram nafcillin intravenous recon soln gram NEBUPENT neomycin nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release hr 100 mg nevirapine oral tablet extended release hr 00 mg NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet ODEFSEY ofloxacin oral tablet 00 mg OLYSIO oxacillin injection recon soln 1 gram, gram oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 1 gram oxacillin intravenous recon soln gram paromomycin paser PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/0 ML B/D; ; ; QLL (100 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (80 per ; QLL (0 per QLL (0 per 0 QLL (0 per 0 ; HI HI Effective Date November 1, FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

12 Name PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK MILLION UNIT/0 ML, MILLION UNIT/0 ML penicillin g potassium injection recon soln 0 million unit penicillin g potassium injection recon soln million unit penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 00,000 unit/ml penicillin g sodium penicillin v potassium PENTAM piperacillin-tazobactam PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 10 PREZISTA ORAL TABLET 00, 800 PREZISTA ORAL TABLET 7 PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 10, 00 HI ; HI ; HI ; HI QLL (0 per 0 QLL (0 per 0 ; QLL (180 per ; QLL (0 per ; QLL (00 per ; ; QLL (0 per 180 ; QLL (180 per ; QLL (0 per ; QLL (0 per Name REYATAZ ORAL CAPSULE 00 REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg ribavirin oral capsule ribavirin oral tablet 00 mg rifampin RIFATER rimantadine SELZENTRY SIRTURO SOVALDI stavudine oral capsule 1 mg, 0 mg stavudine oral capsule 0 mg, 0 mg stavudine oral recon soln STREPTOMYCIN INTRAMUSCULAR STRIBILD STROMECTOL sulfadiazine oral sulfamethoxazole-trimethoprim SUSTIVA ORAL CAPSULE 00 SUSTIVA ORAL CAPSULE 0 SUSTIVA ORAL TABLET SYNAGIS SYNERCID TAMIFLU TECHNIVIE TEFLARO INTRAVENOUS RECON SOLN 00 TEFLARO INTRAVENOUS RECON SOLN 00 ; QLL (0 per ; QLL (0 per QLL (10 per 0 ; LA ; QLL (10 per ; QLL (0 per ; QLL (00 per ; QLL (0 per ; QLL (10 per ; QLL (0 per ; QLL (0 per ; LA ; QLL ( per 8 Effective Date November 1, 01 1 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

13 Name terbinafine hcl oral tetracycline TIVICAY ORAL TABLET 10 TIVICAY ORAL TABLET, 0 TOBI tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ TRIZIVIR TRUVADA ORAL TABLET , 1-00, 17-0 TRUVADA ORAL TABLET TYBOST TYGACIL TYZEKA valacyclovir valganciclovir oral tablet vancomycin in 0.9% sodium cl intravenous piggyback vancomycin in dextrose % intravenous piggyback 1 gram/ 00 ml vancomycin in dextrose % intravenous piggyback 00 mg/ 100 ml, 70 mg/10 ml vancomycin intravenous recon soln 1,000 mg, 10 gram, 00 mg, 70 mg ; QLL (0 per QLL (0 per 0 QLL (0 per 0 ; QLL (80 per 8 HI ; HI QLL (0 per 0 ; QLL (0 per QLL (0 per 0 ; QLL (0 per ; QLL (0 per HI ; QLL (0 per ; HI Name vancomycin intravenous recon soln gram vancomycin oral capsule 1 mg vancomycin oral capsule 0 mg VIDEX GRAM PEDIATRIC VIDEX GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR VIRACEPT ORAL TABLET 0 VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE HR 100 VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET VITEKTA voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 00 mg voriconazole oral tablet 0 mg XIFAXAN ORAL TABLET 0 ZEPATIER ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup ; QLL (0 per ; QLL (80 per ; QLL (100 per ; QLL (100 per ; QLL (00 per ; QLL (10 per ; QLL (0 per ; QLL (0 per QLL (0 per 0 ; QLL (00 per ; QLL (0 per ; QLL (10 per ; QLL (8 per 8 ; QLL (0 per ; QLL (90 per ; QLL (180 per ; QLL (190 per Effective Date November 1, 01 1 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

14 Name zidovudine oral tablet ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK. GRAM/0 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK.7 GRAM/ 0 ML,. GRAM/100 ML ; HI ZYVOX INTRAVENOUS ENTERAL SOLUTION 00 /100 ML HI ZYVOX INTRAVENOUS ENTERAL SOLUTION 00 /00 ML ; HI ZYVOX ORAL SUSPENSION FOR RECONSTITUTION Antineoplastic / Immunosuppressant s ABRAXANE AFINITOR AFINITOR DISPERZ ALECENSA ALIMTA amifostine crystalline anastrozole ARRANON ARZERRA ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE HR 0., 1 ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE HR AVASTIN azacitidine azasan azathioprine azathioprine sodium BELEODAQ ; QLL (0 per HI ; ; QLL (1800 per ; QLL (0 per B/D; ; B/D; B/D; ; B/D; ; B/D; Name BENDEKA bexarotene bicalutamide BICNU bleo 1k bleomycin BLINCYTO BOSULIF ORAL TABLET 100 BOSULIF ORAL TABLET 00 BUSULFEX CABOMETYX ORAL TABLET 0 CABOMETYX ORAL TABLET 0, 0 CAPRELSA ORAL TABLET 100 CAPRELSA ORAL TABLET 00 carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine CLOLAR COMETRIQ ORAL CAPSULE 100 /DAY(80 X1-0 X1) COMETRIQ ORAL CAPSULE 10 /DAY(80 X1-0 X) COMETRIQ ORAL CAPSULE 0 /DAY (0 X /DAY) COTELLIC cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine QLL ( per ; QLL (00 per ; QLL (10 per ; QLL (0 per B/D; ; LA; QLL (90 per ; LA; QLL (0 per ; LA; QLL (90 per ; LA; QLL (0 per B/D; ; ; QLL ( per 8 ; QLL (11 per 8 ; QLL (8 per 8 ; LA; QLL (90 per B/D; ; B/D; B/D; ; B/D; ; Effective Date November 1, 01 1 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

15 Name cytarabine (pf) injection solution 100 mg/ ml (0 mg/ml), gram/0 ml (100 mg/ml) cytarabine (pf) injection solution 0 mg/ml dacarbazine DACOGEN DARZALEX daunorubicin intravenous solution decitabine dexrazoxane hcl intravenous recon soln 0 mg dexrazoxane hcl intravenous recon soln 00 mg DOCEFREZ INTRAVENOUS RECON SOLN 0 DOCETAXEL INTRAVENOUS SOLUTION 10 /ML, 10 /1 ML (10 /ML), 10 /8 ML (0 /ML), 0 / ML (10 /ML) docetaxel intravenous solution 0 mg/ml (1 ml), 80 mg/ ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous solution doxorubicin, peg-liposomal DROXIA ELITEK INTRAVENOUS RECON SOLN 1. elitek intravenous recon soln 7. mg EMCYT EMPLICITI epirubicin intravenous solution 00 mg/100 ml epirubicin intravenous solution 0 mg/ ml ERBITUX LA B/D; ; Name ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 10 FARYDAK ORAL CAPSULE 1, 0 FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN FUSILEV GAZYVA gemcitabine intravenous recon soln 1 gram, 00 mg gemcitabine intravenous recon soln gram gemcitabine intravenous solution 1 gram/. ml (8 mg/ml), 00 mg/. ml (8 mg/ml) gemcitabine intravenous solution gram/. ml (8 mg/ml) gengraf oral capsule 100 mg, mg gengraf oral capsule 0 mg ; QLL (0 per ; QLL (0 per QLL (0 per 0 ; QLL (0 per ; QLL (0 per B/D; ; B/D; Effective Date November 1, 01 1 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

16 Name gengraf oral solution GILOTRIF GLEEVEC ORAL TABLET 100 GLEEVEC ORAL TABLET 00 GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE ICLUSIG ORAL TABLET 1 ICLUSIG ORAL TABLET idarubicin ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg imatinib oral tablet 00 mg IMBRUVICA INLYTA ORAL TABLET 1 INLYTA ORAL TABLET IRESSA irinotecan intravenous solution 100 mg/ ml, 0 mg/ ml irinotecan intravenous solution 00 mg/ ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 JAKAFI ORAL TABLET 1 B/D; ; ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (10 per ; QLL (0 per ; QLL (10 per ; QLL (10 per ; QLL (100 per Name JAKAFI ORAL TABLET 0 JAKAFI ORAL TABLET JAKAFI ORAL TABLET JEVTANA KADCYLA KEPIVANCE KEYTRUDA LENVIMA ORAL CAPSULE 10 /DAY (10 X 1/ DAY) LENVIMA ORAL CAPSULE 1 /DAY(10 X 1- X 1), 0 /DAY (10 X ), 8 /DAY ( X ), 8 /DAY ( X ) (0 PACK) LENVIMA ORAL CAPSULE 18 /DAY (10 X 1- X), /DAY(10 X - X 1) letrozole leucovorin calcium injection recon soln 100 mg, 00 mg, 0 mg, 0 mg leucovorin calcium injection recon soln 00 mg leucovorin calcium oral LEUKERAN leuprolide subcutaneous kit levoleucovorin calcium intravenous recon soln LONSURF LUPRON DEPOT ( NTH) INTRAMUSCULAR SYRINGE KIT. LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.7 ; QLL (7 per ; QLL (0 per ; QLL (00 per ; QLL (0 per ; QLL (0 per ; QLL (90 per ; QLL (0 per ; QLL (1 per 8 Effective Date November 1, 01 1 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

17 Name LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7. LYNZA LYSODREN MARQIBO MATULANE megestrol oral suspension 00 mg/10 ml (10 ml), 800 mg/0 ml (0 ml) megestrol oral suspension 00 mg/10 ml (0 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0. MEKINIST ORAL TABLET melphalan hcl mercaptopurine mesna MESNEX ORAL methotrexate sodium methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium NEXAVAR NILANDRON NINLARO NIPENT ; QLL (80 per ; QLL (90 per ; QLL (0 per B/D; ; B/D; B/D; ; B/D; ; ; LA; QLL (10 per QLL (0 per 0 ; QLL ( per 8 Name NULOJIX octreotide acetate injection solution 1,000 mcg/ml, 00 mcg/ ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ ml, 0 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 0 mcg/ml (1 ml) OCTREOTIDE ACETATE INJECTION SYRINGE 00 MCG/ML (1 ML) ODOMZO ONCAS OPDIVO oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 0 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 POMALYST ORAL CAPSULE POMALYST ORAL CAPSULE, PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE REVLIMID ORAL CAPSULE 10 REVLIMID ORAL CAPSULE 1,., 0, REVLIMID ORAL CAPSULE RITUXAN B/D; ; ; ; LA; QLL (0 per ; QLL (10 per ; QLL (0 per ; QLL (0 per B/D; ; B/D; ; LA; QLL (0 per 0 LA; QLL (0 per 0 LA; QLL (10 per Effective Date November 1, FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

18 Name SANDIMMUNE ORAL SOLUTION SIGNIFOR SIMULECT sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 1. SUTENT ORAL CAPSULE, 7., 0 SYNRIBO TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 0 TAGRISSO ORAL TABLET 80 tamoxifen TARCEVA ORAL TABLET 100, 10 TARCEVA ORAL TABLET TARGRETIN ORAL TARGRETIN TOPICAL TASIGNA TECENTRIQ THALOMID ORAL CAPSULE 100, 0 THALOMID ORAL CAPSULE 10, 00 thiotepa toposar topotecan intravenous recon soln B/D; ; B/D; B/D; ; QLL (0 per 0 ; QLL (10 per QLL (90 per 0 QLL (0 per 0 B/D; ; ; QLL (10 per ; LA; QLL (0 per ; LA; QLL (0 per QLL (0 per 0 QLL (90 per 0 ; QLL (00 per QLL (10 per 0 LA; QLL (0 per 1 QLL (0 per 0 QLL (0 per 0 Name TOPOTECAN INTRAVENOUS SOLUTION TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR DEPOT TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE 11. / ML,.7 / ML TRELSTAR INTRAMUSCULAR SYRINGE. / ML TRELSTAR LA tretinoin (chemotherapy) trexall TRISENOX TYKERB UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 10 VENCLEXTA ORAL TABLET 100 VENCLEXTA ORAL TABLET 0 VENCLEXTA STARTING PACK vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ml vincasar pfs intravenous solution mg/ ml vincristine vinorelbine QLL (1 per 18 QLL (1 per 18 LA; QLL (180 per ; ; LA; QLL (0 per ; LA; QLL (10 per ; LA; QLL (0 per ; LA; QLL ( per Effective Date November 1, FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

19 Name VOTRIENT QLL (10 per 0 XALKORI ; QLL (0 per XGEVA ; QLL (1.7 per 8 XTANDI ; QLL (10 per YERVOY YONDELIS ZALTRAP ZANOSAR ZELBORAF ; QLL (0 per ZOLINZA QLL (10 per 0 ZORTRESS ORAL TABLET 0. B/D; ; ZORTRESS ORAL TABLET 0., 0.7 B/D; ZYDELIG ; QLL (0 per ZYKADIA ; QLL (10 per ZYTIGA ; QLL (10 per Autonomic / Cns s, Neurology / Psych ABILIFY MAINTENA QLL (1 per 8 ABSTRAL SUBLINGUAL TABLET 100 MCG ; ; QLL (10 per ABSTRAL SUBLINGUAL TABLET 00 MCG, 00 MCG, 00 MCG, 00 MCG, ; QLL (10 per 800 MCG acetaminophen-codeine oral solution 10 mg-1 mg / ml ( ml), 0 mg- mg /10 ml (10 ml), 00 mg-0 mg /1. ml acetaminophen-codeine oral solution 10-1 mg/ ml acetaminophen-codeine oral tablet 00-1 mg QLL (00 per 0 ; QLL (00 per ; QLL (90 per Name acetaminophen-codeine oral tablet 00-0 mg acetaminophen-codeine oral tablet 00-0 mg ADASUVE alprazolam oral tablet amitriptyline amoxapine AMPYRA AMRIX APOKYN APTIOM aripiprazole oral solution aripiprazole oral tablet 10 mg aripiprazole oral tablet 1 mg aripiprazole oral tablet mg aripiprazole oral tablet 0 mg, 0 mg aripiprazole oral tablet mg aripiprazole oral tablet, disintegrating 10 mg aripiprazole oral tablet, disintegrating 1 mg ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1 /1. ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING /. ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED ; QLL (0 per ; QLL (180 per ; QLL (90 per ; LA; QLL (0 per ; LA QLL (900 per 0 ; QLL (90 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (180 per ; QLL (90 per ; QLL (0 per ; QLL (1. per ; QLL (. per ; QLL (. per Effective Date November 1, FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

20 Name REL SYRING 88 /. ML AZILECT baclofen BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 00 BANZEL ORAL TABLET 00 benztropine oral BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 briviact oral tablet 100 mg BRIVIACT ORAL TABLET BRIVIACT ORAL TABLET 0 BRIVIACT ORAL TABLET 7 bromocriptine buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet mg buprenorphine hcl sublingual tablet 8 mg buprenorphine-naloxone sublingual tablet -0. mg buprenorphine-naloxone sublingual tablet 8- mg bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 7 mg bupropion hcl oral tablet extended release 100 mg ; QLL (00 per ; ; QLL (80 per ; QLL (0 per ; QLL (00 per ; QLL (00 per ; QLL (0 per ; QLL (0 per ; QLL (10 per ; QLL (0 per ; QLL (10 per QLL (10 per 0 ; ; QLL (0 per ; ; QLL (0 per ; ; QLL (0 per ; ; QLL (90 per ; QLL (1 per ; QLL (180 per ; QLL (10 per Name bupropion hcl oral tablet extended release 10 mg, 00 mg bupropion hcl oral tablet extended release hr 10 mg bupropion hcl oral tablet extended release hr 00 mg buspirone butalbital-acetaminop-caf-cod oral capsule mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution mg/ml butorphanol tartrate nasal carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 mg/ ml carbamazepine oral suspension 00 mg/10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr 100 mg carbamazepine oral tablet extended release 1 hr 00 mg, 00 mg carbamazepine oral tablet, chewable carbidopa-levodopa CELONTIN ORAL CAPSULE 00 chlorpromazine citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 0 mg citalopram oral tablet 0 mg clomipramine ; QLL (0 per ; QLL (90 per ; QLL ( per ; QLL (180 per ; QLL (0 per ; QLL (10 per ; QLL ( per 8 ; QLL (00 per ; QLL (10 per ; QLL (0 per ; QLL (0 per Effective Date November 1, 01 0 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

21 Name clonazepam oral tablet 0. mg clonazepam oral tablet 1 mg clonazepam oral tablet mg clonazepam oral tablet, disintegrating 0.1 mg clonazepam oral tablet, disintegrating 0. mg clonazepam oral tablet, disintegrating 0. mg clonazepam oral tablet, disintegrating 1 mg clonazepam oral tablet, disintegrating mg clorazepate dipotassium clozapine oral tablet 100 mg clozapine oral tablet 00 mg clozapine oral tablet mg clozapine oral tablet 0 mg clozapine oral tablet, disintegrating 100 mg clozapine oral tablet, disintegrating 1. mg clozapine oral tablet, disintegrating 10 mg clozapine oral tablet, disintegrating 00 mg clozapine oral tablet, disintegrating mg COPAXONE SUBCUTANEOUS SYRINGE 0 /ML COPAXONE SUBCUTANEOUS SYRINGE 0 /ML dantrolene ; QLL (100 per ; QLL (00 per ; QLL (00 per ; QLL (800 per ; QLL (00 per ; QLL (100 per ; QLL (00 per ; QLL (00 per ; QLL (10 per ; QLL (70 per ; QLL (1 per ; QLL (1080 per ; QLL (0 per QLL (70 per 0 QLL (10 per 0 QLL (180 per 0 QLL (1 per 0 QLL (1080 per 0 ; QLL (0 per ; QLL (1 per 8 Name desipramine oral DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE HR 100 DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE HR 0 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 100 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 desvenlafaxine oral tablet extended release hr 100 mg desvenlafaxine oral tablet extended release hr 0 mg dextroamphetamine oral capsule, extended release 10 mg, mg dextroamphetamine oral capsule, extended release 1 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet mg dextroamphetamineamphetamine oral tablet 10 mg, 1. mg, 1 mg, 0 mg, mg, 7. mg dextroamphetamineamphetamine oral tablet 0 mg diazepam injection solution diazepam injection syringe diazepam intensol diazepam oral concentrate diazepam oral solution mg/ ml (1 mg/ml) diazepam oral solution mg/ ml (1 mg/ml, ml) ; QLL (10 per ; QLL (0 per ; QLL (10 per ; QLL (0 per QLL (10 per 0 QLL (0 per 0 ; QLL (0 per ; QLL (10 per ; ; QLL (180 per ; ; QLL (90 per ; QLL (90 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (100 per QLL (100 per 0 Effective Date November 1, 01 1 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

22 Name diazepam oral tablet 10 mg diazepam oral tablet mg diazepam oral tablet mg diazepam rectal kit mg diazepam rectal kit. mg, mg diclofenac potassium diclofenac sodium oral diflunisal DILANTIN DILANTIN EXTENDED ORAL CAPSULES 100 DILANTIN INFATABS divalproex donepezil oral tablet 10 mg donepezil oral tablet mg donepezil oral tablet, disintegrating 10 mg donepezil oral tablet, disintegrating mg doxepin oral duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg duramorph (pf) injection solution 0. mg/ml duramorph (pf) injection solution 1 mg/ml EMSAM endocet oral tablet 10- mg, - mg, 7.- mg entacapone ; QLL (10 per ; QLL (00 per ; QLL (0 per ; QLL ( per ; QLL (0 per ; QLL (0 per ; QLL (180 per ; QLL (10 per ; QLL (90 per ; QLL (0 per ; QLL (180 per QLL (180 per 0 QLL (0 per 0 ; QLL (0 per Name epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 100 EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 00 EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 00 ergoloid ergomar escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet mg ethosuximide etodolac EXELON TRANSDERMAL FANAPT ORAL TABLET 1 FANAPT ORAL TABLET 10 FANAPT ORAL TABLET 1 FANAPT ORAL TABLET FANAPT ORAL TABLET FANAPT ORAL TABLET FANAPT ORAL TABLET 8 FANAPT ORAL TABLETS, DOSE PACK ; QLL (80 per ; QLL (0 per ; QLL (180 per ; QLL (00 per ; QLL (0 per ; QLL (0 per ; QLL (10 per ; QLL (0 per QLL (70 per 0 QLL (7 per 0 ; QLL (0 per ; QLL (0 per ; QLL (180 per ; QLL (10 per ; QLL (90 per ; QLL (1 per Effective Date November 1, 01 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

23 Name FAZACLO ORAL TABLET, DISINTEGRATING 100 FAZACLO ORAL TABLET, DISINTEGRATING 1. FAZACLO ORAL TABLET, DISINTEGRATING felbamate fenoprofen oral tablet fentanyl citrate fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, mcg/hr, 0 mcg/hr, 7 mcg/hr FENTORA FETZIMA ORAL CAPSULE, EXT REL HR DOSE PACK FETZIMA ORAL CAPSULE, EXTENDED RELEASE HR 10, 80 FETZIMA ORAL CAPSULE, EXTENDED RELEASE HR 0 FETZIMA ORAL CAPSULE, EXTENDED RELEASE HR 0 fluoxetine oral capsule 10 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule 0 mg fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 0 mg fluphenazine decanoate fluphenazine hcl flurbiprofen QLL (70 per 0 QLL (10 per 0 QLL (1080 per 0 ; QLL (10 per ; QLL (1 per ; QLL (10 per ; ; QLL ( per ; ; QLL (0 per ; ; QLL (180 per ; ; QLL (90 per ; QLL (0 per ; QLL (10 per ; QLL (0 per ; QLL (00 per ; QLL (0 per ; QLL (10 per Name fluvoxamine oral tablet 100 mg fluvoxamine oral tablet mg fluvoxamine oral tablet 0 mg fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 10, 1 FYCOMPA ORAL TABLET FYCOMPA ORAL TABLET FYCOMPA ORAL TABLET FYCOMPA ORAL TABLET 8 gabapentin oral capsule 100 mg gabapentin oral capsule 00 mg gabapentin oral capsule 00 mg gabapentin oral solution 0 mg/ ml gabapentin oral solution 0 mg/ ml ( ml), 00 mg/ ml ( ml) gabapentin oral tablet 00 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 1, 1 galantamine oral capsule,ext rel. pellets hr galantamine oral solution galantamine oral tablet GEODON INTRAMUSCULAR ; QLL (90 per ; QLL (0 per ; QLL (180 per QLL (70 per 0 ; QLL (0 per ; QLL (180 per ; QLL (90 per ; QLL (0 per ; QLL ( per ; QLL (1080 per ; QLL (0 per ; QLL (70 per ; QLL (10 per QLL (10 per 0 ; QLL (180 per ; QLL (1 per ; QLL (0 per ; QLL (180 per ; QLL (0 per Effective Date November 1, 01 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

24 Name GILENYA GLATOPA guanidine haloperidol haloperidol decanoate haloperidol lactate HETLIOZ hydrocodone-acetaminophen oral solution 10- mg/1 ml(1 ml),.-17 mg/ ml, -1 mg/7.ml(7.ml) hydrocodone-acetaminophen oral solution 7.- mg/1 ml hydrocodone-acetaminophen oral tablet mg, -00 mg, mg hydrocodone-acetaminophen oral tablet 10- mg, - mg, 7.- mg hydrocodone-ibuprofen oral tablet mg hydromorphone oral tablet mg, mg hydromorphone oral tablet 8 mg ibuprofen oral suspension ibuprofen oral tablet 00 mg, 00 mg, 800 mg imipramine hcl INTUNIV ER INVEGA ORAL TABLET EXTENDED RELEASE HR 1. INVEGA ORAL TABLET EXTENDED RELEASE HR INVEGA ORAL TABLET EXTENDED RELEASE HR ; QLL (0 per ; QLL (0 per ; QLL (0 per QLL (700 per 0 ; QLL (700 per ; QLL (90 per ; QLL (0 per ; QLL (80 per ; QLL (0 per ; QLL (180 per ; QLL (0 per ; QLL (0 per ; QLL (10 per ; QLL (0 per Name INVEGA ORAL TABLET EXTENDED RELEASE HR 9 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 /0.7 ML, 1 /ML, /1. ML, 78 /0. ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 9 /0. ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 7 /0.87 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 10 /1.1 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE /1.7 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 /. ML KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 100 KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 0 lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible LATUDA ORAL TABLET 10 LATUDA ORAL TABLET 0 LATUDA ORAL TABLET 0 LATUDA ORAL TABLET 0 LATUDA ORAL TABLET 80 ; QLL (0 per QLL ( per 8 ; QLL ( per 8 QLL (0.87 per 90 QLL (1.1 per 90 QLL (1.7 per 90 QLL (. per 90 ; QLL (10 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (10 per ; QLL (7 per ; QLL (0 per Effective Date November 1, 01 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

25 Name LAZANDA levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral solution 00 mg/ ml ( ml) levetiracetam oral tablet levetiracetam oral tablet extended release hr 00 mg levetiracetam oral tablet extended release hr 70 mg levorphanol tartrate lithium carbonate lithium citrate oral solution 8 meq/ ml LODOSYN lorazepam intensol lorazepam oral tablet lorcet (hydrocodone) lorcet hd lorcet plus oral tablet 7.- mg lortab 10- lortab - lortab 7.- loxapine succinate LUNESTA LYRICA ORAL CAPSULE 100 LYRICA ORAL CAPSULE 10 LYRICA ORAL CAPSULE 00 ; QLL (0 per ; QLL (180 per ; QLL (10 per ; QLL (180 per ; QLL (90 per ; QLL (90 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (180 per ; QLL (10 per ; QLL (90 per Name LYRICA ORAL CAPSULE, 00 LYRICA ORAL CAPSULE LYRICA ORAL CAPSULE 0 LYRICA ORAL CAPSULE 7 LYRICA ORAL SOLUTION maprotiline oral tablet mg maprotiline oral tablet 0 mg maprotiline oral tablet 7 mg MARPLAN meclofenamate oral meloxicam oral suspension meloxicam oral tablet memantine oral solution memantine oral tablet 10 mg memantine oral tablet mg MESTINON ORAL SYRUP MESTINON TIMESPAN metadate er methadone injection methadone intensol methadone oral concentrate methadone oral solution 10 mg/ ml methadone oral solution mg/ ml methadone oral tablet 10 mg 1 ; QLL (0 per ; QLL (70 per ; QLL (0 per ; QLL (0 per ; QLL (900 per ; QLL (70 per ; QLL (1 per ; QLL (00 per ; QLL (0 per ; QLL (00 per ; QLL (0 per ; QLL (90 per ; QLL (90 per QLL (10 per 0 ; QLL (180 per ; QLL (180 per ; QLL (900 per ; QLL (1800 per ; QLL (180 per Effective Date November 1, 01 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V

26 Name methadone oral tablet mg methadose oral concentrate methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule, er biphasic mg methylphenidate oral capsule,er biphasic mg methylphenidate oral capsule,er biphasic mg methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release hr 18 mg MIGRANAL mirtazapine oral tablet 1 mg mirtazapine oral tablet 0 mg mirtazapine oral tablet mg mirtazapine oral tablet 7. mg mirtazapine oral tablet, disintegrating 1 mg mirtazapine oral tablet, disintegrating 0 mg mirtazapine oral tablet, disintegrating mg modafinil oral tablet 100 mg modafinil oral tablet 00 mg molindone morphine (pf) injection solution 0. mg/ml morphine (pf) injection solution 1 mg/ml ; QLL (0 per ; QLL (180 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (0 per ; QLL (90 per ; QLL (90 per ; QLL (8 per 8 ; QLL (90 per ; QLL ( per ; QLL (0 per ; QLL (180 per ; QLL (90 per ; QLL ( per ; QLL (0 per ; ; QLL (0 per ; ; QLL (0 per ; QLL (180 per Name morphine (pf) intravenous patient control.analgesia soln 10 mg/0 ml morphine (pf) intravenous patient control.analgesia soln 0 mg/0 ml morphine concentrate oral solution morphine intravenous cartridge mg/ml, 8 mg/ml morphine intravenous solution 10 mg/ml, 0 mg/ml morphine intravenous solution 100 mg/ ml, mg/ml, 0 mg/10 ml morphine intravenous solution mg/ml, 8 mg/ml morphine intravenous syringe mg/ml, mg/ml morphine oral capsule, er multiphase hr 0 mg, 0 mg morphine oral capsule, extend.release pellets 100 mg, 0 mg, 0 mg, 0 mg, 0 mg, 80 mg morphine oral solution 10 mg/ ml morphine oral solution 0 mg/ ml ( mg/ml) morphine oral tablet 1 mg morphine oral tablet 0 mg morphine oral tablet extended release 100 mg, 1 mg, 0 mg, 0 mg morphine oral tablet extended release 00 mg nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 0 mg/ml ; QLL (10 per B/D; ; QLL (180 per ; QLL (70 per QLL (10 per 0 ; QLL (10 per QLL (10 per 0 ; QLL (180 per QLL (10 per 0 ; QLL (0 per ; QLL (0 per ; QLL (700 per ; QLL (10 per ; QLL (0 per ; QLL (180 per ; QLL (90 per ; QLL (0 per ; QLL (180 per ; QLL (90 per Effective Date November 1, 01 FORMPCSBNOCACVPSNP1_WEB 00017_PT, V