icare Family Care Partnership (HMO SNP) (H ) 2019 Formulary (List of Covered Drugs)

Transcription

1 icare Family Care Partnership (HMO SNP) (H37-007) 09 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 9, Version Number 5 This formulary was updated on 08/4/08. For more recent information or other questions, please contact Independent Care Health Plan Customer Service at or, for TTY users, , 4 hours-a-day, 7 days-a-week, or visit H37_IC994_C 9/4/08

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 Independent Care Health Plan. When it refers to plan or our plan, it means icare Family Care Partnership (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of January, 09. 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, 09, and from time to time during the year. icare Family Care Partnership (HMO SNP) is a Coordinated Care plan with a Medicare Advantage contract and a contract with the State Medicaid program. Enrollment in icare Family Care Partnership depends on contract renewal.

3 What is the icare Family Care Partnership Formulary? A formulary is a list of covered drugs selected by icare Family Care Partnership 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. The icare Family Care Partnership 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 09 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 09 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.). 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. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the icare Family Care Partnership Formulary? Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier.) Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 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 30-day supply of the drug. The enclosed formulary is current as of January, 09. To get updated information about the drugs covered by icare Family Care Partnership please contact us. Our contact information appears on the front and back cover pages. 3

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 8. 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 I. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? The icare Family Care Partnership 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: The icare Family Care Partnership requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from icare Family Care Partnership before you fill your prescriptions. If you don t get approval, icare Family Care Partnership may not cover the drug. Quantity Limits: For certain drugs, icare Family Care Partnership limits the amount of the drug that icare Family Care Partnership will cover. For example, icare Family Care Partnership provides 60 capsules per prescription for Aggrenox. This may be in addition to a standard one-month or threemonth supply. Step Therapy: In some cases, icare Family Care Partnership requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, icare Family Care Partnership may not cover Drug B unless you try Drug A first. If Drug A does not work for you, icare Family Care Partnership will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain prior authorization and step therapy 4

5 restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask icare Family Care Partnership 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 icare Family Care Partnership formulary? on page 4 for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. icare Family Care Partnership pays for certain OTC drugs. icare Family Care Partnership will provide these OTC drugs at no cost to you. The cost to icare Family Care Partnership of these OTC drugs will not count toward your total Part D drug costs (that is, the cost of the OTC drugs does not count for the coverage gap.) What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that icare Family Care Partnership does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by icare Family Care Partnership. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by icare Family Care Partnership. You can ask icare Family Care Partnership 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 icare Family Care Partnership s Formulary? You can ask icare Family Care Partnership to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, icare Family Care Partnership 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. 5

6 Generally, icare Family Care Partnership will only approve your request for an exception if the alternative drugs included on the plan s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug while you pursue a formulary exception. As a current member in our plan, we will also cover an emergency supply of medication if you experience a level of care change. This may include unplanned changes in treatment settings such as being discharged from a hospital to return home. For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, you must utilize the exceptions and appeals process. However, we will cover up to a temporary 30-day supply, while an exception request is being processed. For more information For more detailed information about your icare Family Care Partnership prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about icare Family Care Partnership, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call Or, visit 6

7 The icare Family Care Partnership Formulary The formulary that begins on page 8 provides coverage information about the drugs covered by icare Family Care Partnership If you have trouble finding your drug in the list, turn to the Index that begins on page I. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ABILIFY) and generic drugs are listed in lower-case italics (e.g., diltiazem). The information in the Requirements/Limits column tells you if icare Family Care Partnership has any special requirements for coverage of your drug. 7

8 Co-pay Tiers This drug formulary includes three tiers described below. The co-payment you pay depends on the tier (or coverage level) assigned to your prescription drugs. Tier = Generic drug co-pay Tier = Brand drug co-pay Tier 3 = Brand drug co-pay or Generic drug copay as applicable (Specialty Tier) For co-pay amounts, please refer to your Summary of Benefits. 8

9 The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA BvD PA-HRM PA NSO QL ST Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction You (or your physician) are required to get prior authorization from icare Family Care Partnership before you fill your prescription for this drug. Without prior approval, icare Family Care Partnership may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from icare Family Care Partnership to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, icare Family Care Partnership may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 years or older are required to get prior authorization from icare Family Care Partnership before you fill your prescription for this drug. Without prior approval, i Care Family Care Partnership may not cover this drug. If you are a new member or if you have not taken this drug previously, you (or your physician) are required to get prior authorization from icare Family Care Partnership before you fill your prescription for this drug. Without prior approval, icare Family Care Partnership may not cover this drug. icare Family Care Partnership limits the amount of this drug that is covered per prescription, or within a specific time frame. Before icare Family Care Partnership will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. 9

10 ABBREVIATION DESCRIPTION EXPLANATION LA NM NDS Limited Access Drug Non-Mail Order Drug Non-extended Day Supply This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at , 4 hours-a-day, 7 days-a-week. TTY/TDD users should call You may be able to receive greater than a -month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. This drug is not eligible to be covered for an extended day supply. icare Family Care Partnership will only cover this drug for a maximum day supply of 30 days. 0

11 icare Family Care Partnership Additional Covered Drug -09 These prescription drugs are not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for these drugs does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs. Please call Customer Service for further information at , 8:00 am to 8:00 pm, 7 days a week. TTY/TDD users should call Drug Name Dosage Form Analgesics, Topical capsaicin cream, lotion Analgesics, Oral and Rectal acetaminophen aspirin ibuprofen naproxen sodium 0 tablet, suspension, suppository, chewable tablet, capsule tablet, chewable tablet, tablet DR, suppository tablet, suspension tablet Antacids aluminum hydroxide calcium carbonate magnesium carbonate/aluminum hydroxide magnesium hydroxide magnesium hydroxide/aluminum hydroxide magnesium hydroxide/calcium carbonate magnesium hydrox/aluminum hydrox/simethicone sodium bicarbonate suspension suspension, chewable tablet, tablet chewable tablet suspension suspension chewable tablet, suspension suspension tablet

12 Drug Name Dosage Form Antibiotics, Topical bacitracin bacitracin/neomycin/polymyxin bacitracin/polymyxin ointment ointment, packet ointment, packet Antifungals, Topical clotrimazole miconazole tolnaftate cream, solution, spray cream, ointment, aerosol powder aerosol powder, cream, packet, powder, solution Antifungals, Vaginal clotrimazole miconazole cream with applicator, tablet cream with applicator, suppository Antihistamines, Oral cetirizine cetirizine/pseudoephedrine diphenhydramine loratadine loratadine/pseudoephedrine tablet, solution, chewable tablet -hour tablet capsule, tablet, elixir, chewable tablet tablet, solution -hour tablet, 4-hour tablet Cough and Cold Products benzonatate brompheniramine/phenyleph/dihydrocodeine brompheniramine/pseudoeph/codeine brompheniramine/pseudoeph/dihydrocodeine capsule syrup syrup syrup

13 Drug Name Dosage Form Cough and Cold Products, continued chlorpheniramine/phenylephrine/dihydrocodeine dextromethorphan dm/phenyleph/chlorpheniramine guaifenesin guaifenesin/codeine guaifenesin/dextromethorphan guaifenesin/hydrocodone guaifenesin/pseudoephedrine/dihydrocodeine phenylephrine/promethazine/codeine promethazine/codeine pseudoephedrine pseudoephedrine/chlorpheniramine/dihydrocodeine syrup syrup syrup syrup syrup syrup syrup syrup syrup syrup tablet, syrup syrup Laxatives and other Gastrointestinal products bisacodyl docusate calcium docusate sodium magnesium citrate solution senna senna/docusate sodium simethicone tablet, suppository, enema capsule capsule, liquid liquid tablets tablets chewable tablet, suspension, capsule 3

14 Drug Name Dosage Form Vitamins calcitriol calcium + D calcium Carbonate/Citrate cyanocobalamin injection Dialyvite ferrous gluconate ferrous sulfate fish oil (Omega 3 fatty acid) folic acid Glucosamine/Condrontin magnesium oxide mephyton capsule tablet Tablet injection tablet tablet tablet, elixir capsule tablet tablet tablet tablet multivitamin vitamin B- vitamin B- vitamin C vitamin D 000units, 50,000 units tablet tablet tablet tablet capsule 4

15 Drug Name Dosage Form Miscellaneous Benzoyl peroxide hydrocortisone meclizine permethrin melatonin Florajen Cream, gel, wash cream, ointment, lotion tablet, chewable tablet lotion, spray tablet capsule Ophthalmic Agents carboxymethylcellulose sodium hypromellose ketotifen mineral oil/petrolatum polyvinyl alcohol polyvinyl alcohol/povidone propylene glycol/peg 400 eye drop eye drop, gel eye drop eye ointment eye drop eye drop eye drop Tobacco Cessation nicotine gum, patch, lozenges 5

16 Notice Informing Individuals About Nondiscrimination and Accessibility Requirements: Discrimination is Against the Law Independent Care Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Independent Care Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Independent Care Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o o Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o o Qualified interpreters Information written in other languages If you need these services, contact Customer Service at (TTY: ), 4 hours a day, 7 days a week (Office hours: Monday Friday, 8:30 a.m. 5:00 p.m.). If you believe that Independent Care Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: QAPI Nurse Ellen Wiesner, 555 N. RiverCenter Dr., Suite 06, Milwaukee, WI 53, (TTY: ), , ewiesner@icare-wi.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, QAPI Nurse Ellen Wiesner is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 00 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 00, , (TDD). Complaint forms are available at 6

17 English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: ). Spanish: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: ). Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Arabic: Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Pennsylvania Dutch: Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call (TTY: ). Laotian: ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: ). French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: ). Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). Hindi: ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: ) पर क ल कर Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: ). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). 7

18 Table of Contents Analgesics... 0 Anesthetics... 4 Anti-Addiction/Substance Abuse Treatment Agents... 4 Antianxiety Agents... 5 Antibacterials... 6 Anticancer Agents Anticholinergic Agents... 4 Anticonvulsants... 4 Antidementia Agents Antidepressants Antidiabetic Agents Antifungals... 5 Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic)... 6 Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents... 8 Contraceptives

19 Dental And Oral Agents Dermatological Agents... 9 Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents... 0 Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents... 7 Irrigating Solutions... 7 Metabolic Bone Disease Agents... 8 Miscellaneous Therapeutic Agents... 9 Ophthalmic Agents... 0 Replacement Preparations... Respiratory Tract Agents... 4 Skeletal Muscle Relaxants... 8 Sleep Disorder Agents... 8 Vasodilating Agents... 9 Vitamins And Minerals

20 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 0- /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet QL (700 per 30 days) QL (360 per 30 days) (Tylenol-Codeine #3) QL (360 per 30 days) (Tylenol-Codeine #4) QL (80 per 30 days) (Buprenex) (Esgic) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) (Fiorinal) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) QL (80 per 30 days) codeine sulfate oral tablet 5, 30, 60 endocet oral tablet 0-35 QL (80 per 30 days) endocet oral tablet.5-35, 5-35 QL (360 per 30 days) endocet oral tablet QL (40 per 30 days) fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution /5 ml hydrocodone-acetaminophen oral tablet 0-35 hydrocodone-acetaminophen oral tablet.5-35 hydrocodone-acetaminophen oral tablet 5-35 (Actiq) ; QL (0 per 30 days) (Duragesic) QL (0 per 30 days) (Hycet) QL (700 per 30 days) (Lorcet HD) QL (80 per 30 days) (Verdrocet) QL (40 per 30 days) (Lorcet (hydrocodone)) QL (40 per 30 days) 0

21 hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (80 per 30 days) hydrocodone-ibuprofen oral tablet QL (50 per 30 days) hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone oral liquid /ml (Dilaudid) QL (00 per 30 days) hydromorphone oral tablet, 4, 8 (Dilaudid) QL (80 per 30 days) HYSINGLA ER ORAL TABLET,ORAL QL (30 per 30 days) ONLY,EXT.REL.4 HR 00 MG, 0 MG, 0 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 300 ; QL (30 per 30 days) MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-35 QL (40 per 30 days) lorcet hd oral tablet 0-35 QL (80 per 30 days) lorcet plus oral tablet QL (80 per 30 days) methadone injection solution 0 /ml methadone oral solution 0 /5 ml QL (600 per 30 days) methadone oral solution 5 /5 ml QL (00 per 30 days) methadone oral tablet 0 (Dolophine) QL (0 per 30 days) methadone oral tablet 5 (Dolophine) QL (80 per 30 days) methadose oral tablet,soluble 40 QL (30 per 30 days) morphine 0 /ml isecure syrg l/f, p/f, suv, inner 0 /ml morphine concentrate oral solution 00 QL (80 per 30 days) /5 ml (0 /ml) morphine injection syringe 0 /ml morphine intravenous solution 0 /ml morphine oral solution 0 /5 ml QL (700 per 30 days) morphine oral solution 0 /5 ml (4 QL (300 per 30 days) /ml) MORPHINE ORAL TABLET 5 MG QL (80 per 30 days) MORPHINE ORAL TABLET 30 MG QL (0 per 30 days) morphine oral tablet extended release 00 (MS Contin) QL (60 per 30 days), 00, 60 morphine oral tablet extended release 5, 30 (MS Contin) QL (90 per 30 days)

22 NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE HR 00 MG, 50 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 00 MG, 50 QL (8 per 30 days) MG, 75 MG oxycodone oral solution 5 /5 ml QL (300 per 30 days) oxycodone oral tablet 0 QL (80 per 30 days) oxycodone oral tablet 5, 30 (Roxicodone) QL (0 per 30 days) oxycodone oral tablet 0 QL (0 per 30 days) oxycodone oral tablet 5 (Roxicodone) QL (80 per 30 days) oxycodone oral tablet,oral only,ext.rel. (OxyContin) QL (60 per 30 days) hr 0, 5, 0, 30, 40, 60, 80 oxycodone-acetaminophen oral solution 5- QL (800 per 30 days) 35 /5 ml oxycodone-acetaminophen oral tablet 0- (Endocet) QL (80 per 30 days) 35 oxycodone-acetaminophen oral tablet.5- (Endocet) QL (360 per 30 days) 35, 5-35 oxycodone-acetaminophen oral tablet 7.5- (Endocet) QL (40 per 30 days) 35 oxycodone-aspirin oral tablet QL (360 per 30 days) OXYCONTIN ORAL TABLET,ORAL QL (60 per 30 days) ONLY,EXT.REL. HR 0 MG, 5 MG, 0 MG, 30 MG, 40 MG, 60 MG, 80 MG SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 00 MG/0.5 ML, 300 MG/.5 ML tramadol oral tablet 50 (Ultram) QL (40 per 30 days) tramadol-acetaminophen oral tablet (Ultracet) QL (40 per 30 days) 35 XTAMPZA ER ORAL QL (60 per 30 days) CAPSULE,SPRINKLE,ER HR TMPRR 3.5 MG, 8 MG, 9 MG XTAMPZA ER ORAL QL (0 per 30 days) CAPSULE,SPRINKLE,ER HR TMPRR 7 MG XTAMPZA ER ORAL QL (40 per 30 days) CAPSULE,SPRINKLE,ER HR TMPRR 36 MG Nonsteroidal Anti-Inflammatory Agents

23 CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8 ML (00 MG/ML) celecoxib oral capsule 00, 00, 50 (Celebrex) QL (60 per 30 days) diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops.5 % QL (300 per 30 days) diclofenac sodium topical gel 3 % (Solaraze) PA; QL (00 per 8 days) etodolac oral capsule 00, 300 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 FLECTOR TRANSDERMAL PATCH PA HOUR.3 % flurbiprofen oral tablet 00, 50 ibu oral tablet 400, 600, 800 ibuprofen oral suspension 00 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, 800 (IBU) indomethacin oral capsule 5 PA-HRM; QL (40 per 30 days); AGE (Max 64 Years) indomethacin oral capsule 50 PA-HRM; QL (0 per 30 days); AGE (Max 64 Years) indomethacin sodium intravenous recon soln ketorolac oral tablet 0 PA-HRM; QL (0 per 30 days); AGE (Max 64 Years) mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral tablet 50, 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375, 500 sulindac oral tablet 50, 00 3

24 VOLTAREN TOPICAL GEL % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % QL (30 per 30 days) lidocaine (pf) injection solution 0 /ml (Xylocaine-MPF) ( %), 5 /ml (.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl injection solution 0 /ml ( %), 0 /ml ( %), 5 /ml (0.5 %) (Xylocaine) lidocaine hcl mucous membrane jelly % QL (30 per 30 days) lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive (Lidoderm) PA; QL (90 per 30 days) patch,medicated 5 % lidocaine topical ointment 5 % PA; QL (90 per 30 days) lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti -Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual tablet -0.5, 8- bupropion hcl (smoking deter) oral tablet extended release hr 50 CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) (Zyban) disulfiram oral tablet 50, 500 (Antabuse) PA; QL (30 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (336 per 365 days) QL (336 per 365 days) QL (06 per 365 days) 4

25 LUCEMYRA ORAL TABLET 0.8 MG ; QL (4 per 4 days) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL (4 per 30 days) AEROSOL 4 MG/ACTUATION NICOTROL INHALATION QL (008 per 90 days) CARTRIDGE 0 MG SUBOXONE SUBLINGUAL FILM -3 QL (60 per 30 days) MG, 8- MG SUBOXONE SUBLINGUAL FILM -0.5 QL (30 per 30 days) MG, 4- MG ZUBSOLV SUBLINGUAL TABLET MG, MG,.4-.9 MG,.9- QL (30 per 30 days) 0.7 MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, QL (60 per 30 days) (Xanax) QL (0 per 30 days) alprazolam oral tablet (Xanax) QL (50 per 30 days) buspirone oral tablet 0, 5, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 0, QL (0 per 30 days) 5, 5 clonazepam oral tablet 0.5, (Klonopin) QL (90 per 30 days) clonazepam oral tablet (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating QL (90 per 30 days) 0.5, 0.5, 0.5, clonazepam oral tablet,disintegrating QL (300 per 30 days) clorazepate dipotassium oral tablet 5, 3.75 QL (80 per 30 days) clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (80 per 30 days) DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG diazepam injection solution 5 /ml QL (0 per 8 days) diazepam injection syringe 5 /ml QL (0 per 8 days) 5

26 diazepam intensol oral concentrate 5 QL (00 per 30 days) /ml diazepam oral solution 5 /5 ml ( QL (00 per 30 days) /ml) diazepam oral tablet 0,, 5 (Valium) QL (0 per 30 days) diazepam rectal kit , 5- (Diastat AcuDial) diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml, 4 (Ativan) QL ( per 30 days) /ml lorazepam injection syringe /ml, 4 QL ( per 30 days) /ml lorazepam oral tablet 0.5, (Ativan) QL (90 per 30 days) lorazepam oral tablet (Ativan) QL (50 per 30 days) ONFI ORAL SUSPENSION.5 MG/ML 3 PA NSO; NM; NDS; QL (480 per 30 days) ONFI ORAL TABLET 0 MG, 0 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) temazepam oral capsule 5, 30 (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 days); AGE (Max 64 Years) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION 3 PA BvD; NM; NDS FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 00 /50 ml, 0 /00 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin injection solution 0 / ml, 40 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 00 /0 ml, 60 /6 ml, 80 /8 ml 6

27 neomycin oral tablet 500 streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE ; QL (4 per 8 days) 8 MG tobramycin in 0.5 % nacl inhalation (Tobi) 3 PA BvD; NM; NDS solution for nebulization 300 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 0 /ml, 40 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln (BACiiM) 50,000 unit chloramphenicol sod succinate intravenous recon soln gram clindamycin hcl oral capsule 50, 300 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml (Cleocin in 5 % dextrose) clindamycin phosphate injection solution 50 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 50 /ml clindamycin phosphate intravenous (Cleocin) solution 600 /4 ml colistin (colistimethate na) injection recon (Coly-Mycin M 3 PA BvD; NM; NDS soln 50 Parenteral) daptomycin intravenous recon soln 500 (Cubicin) FIRVANQ ORAL RECON SOLN 5 MG/ML, 50 MG/ML linezolid 600 /300 ml-0.9% nacl 600 /300 ml linezolid in dextrose 5% intravenous piggyback 600 /300 ml (Zyvox) linezolid oral suspension for reconstitution (Zyvox) 00 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet gram (Hiprex) 7

28 metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /00 ml metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 00, 5, 50 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (0 per 30 days); AGE nitrofurantoin monohyd/m-cryst oral capsule 00 (Max 64 Years) (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 days); AGE (Max 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 vancomycin intravenous recon soln,000, 0 gram, 5 gram, 500, 750 PA BvD vancomycin oral capsule 5 (Vancocin) vancomycin oral capsule 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG ; QL (9 per 30 days) XIFAXAN ORAL TABLET 550 MG Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 5 /5 ml, 50 /5 ml, 375 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml 8

29 cefazolin injection recon soln gram, 0 gram, 500 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 400 (Spectracef) cefepime injection recon soln gram, (Maxipime) gram cefotaxime injection recon soln gram, 500 cefotaxime injection recon soln 0 gram, (Claforan) gram cefoxitin intravenous recon soln gram, 0 gram, gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram (Fortaz) ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftibuten oral capsule 400 ceftibuten oral suspension for reconstitution 80 /5 ml ceftriaxone injection recon soln gram, 0 gram, gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex) cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml SUPRAX ORAL CAPSULE 400 MG tazicef injection recon soln gram, gram, 6 gram 9

30 TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 (3 pack) azithromycin oral tablet 50, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 DIFICID ORAL TABLET 00 MG 3 ST; NM; NDS; QL (0 per 0 days) erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram, gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 3 NM; LA; NDS ertapenem injection recon soln gram (Invanz) imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50 30

31 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) 500-5, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, 500 ampicillin sodium injection recon soln gram, 0 gram, 5, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn).5 gram, 5 gram, 3 gram BICILLIN L-A INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln gram nafcillin injection recon soln 0 gram nafcillin intravenous recon soln gram oxacillin gm add-vantage vl addvantage, inner gram oxacillin injection recon soln gram, 0 gram, gram penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe. million unit/ ml, 600,000 unit/ml penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit 3

32 piperacillin-tazobactam intravenous recon (Zosyn) PA BvD soln.5 gram, gram, 4.5 gram, 40.5 gram Quinolones BAXDELA ORAL TABLET 450 MG ; QL (8 per 4 days) ciprofloxacin hcl oral tablet 50, 500 (Cipro) ciprofloxacin hcl oral tablet 750 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /00 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50 levofloxacin oral tablet 500, 750 (Levaquin) moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 300, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) sulfatrim oral suspension /5 ml Tetracyclines doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon soln 00 (Doxy-00) 3

33 doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00, 0 doxycycline monohydrate oral capsule 00, 50 doxycycline monohydrate oral suspension for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 00 doxycycline monohydrate oral tablet 50 (Morgidox) (Mondoxyne NL) (Vibramycin) (Avidoxy) minocycline oral capsule 00, 50 (Minocin) minocycline oral capsule 75 mondoxyne nl oral capsule 00, 50 okebo oral capsule 00 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG adriamycin intravenous solution 0 /5 PA BvD ml, /ml, 0 /0 ml, 50 /5 ml adrucil intravenous solution.5 gram/50 PA BvD ml, 500 /0 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 3 MG, 5 MG 3 PA NSO; NM; NDS; QL ( per 8 days) AFINITOR ORAL TABLET 0 MG 3 PA NSO; NM; NDS; QL (56 per 8 days) AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 3 PA NSO; NM; NDS; QL (8 per 8 days) ALECENSA ORAL CAPSULE 50 MG 3 PA NSO; NM; NDS; QL (40 per 30 days) ALIMTA INTRAVENOUS RECON SOLN 00 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG 3 PA NSO; NM; NDS; QL (3 per 8 days) ALUNBRIG ORAL TABLET 80 MG, 90 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) 33

34 ALUNBRIG ORAL TABLET 30 MG 3 PA NSO; NM; NDS; QL (0 per 30 days) ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG (3) 3 PA NSO; NM; NDS; QL (30 per 30 days) anastrozole oral tablet (Arimidex) AVASTIN INTRAVENOUS SOLUTION 3 PA NSO; NM; NDS 5 MG/ML azacitidine injection recon soln 00 (Vidaza) BAVENCIO INTRAVENOUS 3 PA NSO; NM; NDS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON 3 PA NSO; NM; NDS SOLN 500 MG BENDEKA INTRAVENOUS 3 PA NSO; NM; NDS SOLUTION 5 MG/ML BESPONSA INTRAVENOUS RECON 3 PA NSO; NM; NDS SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 3 PA NSO; NM; NDS; QL (40 per 30 days) bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 5 unit, 30 PA BvD unit BLINCYTO INTRAVENOUS KIT 35 3 PA NSO; NM; NDS MCG BORTEZOMIB INTRAVENOUS 3 PA NSO; NM; NDS RECON SOLN 3.5 MG BOSULIF ORAL TABLET 00 MG 3 PA NSO; NM; NDS; QL (90 per 30 days) BOSULIF ORAL TABLET 400 MG, 500 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) BRAFTOVI ORAL CAPSULE 50 MG 3 PA NSO; NM; NDS; QL (0 per 30 days) BRAFTOVI ORAL CAPSULE 75 MG 3 PA NSO; NM; NDS; QL (80 per 30 days) CABOMETYX ORAL TABLET 0 MG, 60 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) CABOMETYX ORAL TABLET 40 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) CALQUENCE ORAL CAPSULE 00 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) CAPRELSA ORAL TABLET 00 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) CAPRELSA ORAL TABLET 300 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) 34

35 clofarabine intravenous solution 0 /0 (Clolar) ml COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 3 PA NSO; NM; NDS; QL ( per 8 days) MG/DAY(80 MG X-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) COTELLIC ORAL TABLET 0 MG 3 PA NSO; NM; LA; NDS; QL (63 per 8 days) cyclophosphamide intravenous recon soln 3 PA BvD; NM; NDS gram, gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 3 PA NSO; NM; NDS SOLUTION 0 MG/ML DARZALEX INTRAVENOUS 3 PA NSO; NM; LA; NDS SOLUTION 0 MG/ML decitabine intravenous recon soln 50 (Dacogen) doxorubicin intravenous solution 0 /5 (Adriamycin) PA BvD ml, /ml, 0 /0 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) 3 PA BvD; NM; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON 3 PA NSO; NM; NDS SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) ERLEADA ORAL TABLET 60 MG 3 PA NSO; NM; NDS; QL (0 per 30 days) ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) 35

36 FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 3 PA NSO; NM; NDS MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil intravenous solution PA BvD gram/0 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/00 ml, 500 /0 ml flutamide oral capsule 5 GAZYVA INTRAVENOUS SOLUTION 3 PA NSO; NM; NDS,000 MG/40 ML GILOTRIF ORAL TABLET 0 MG, 30 MG, 40 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) GLEOSTINE ORAL CAPSULE 0 MG, 40 MG, 5 MG GLEOSTINE ORAL CAPSULE 00 MG HERCEPTIN INTRAVENOUS RECON 3 PA NSO; NM; NDS SOLN 50 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG 3 PA NSO; NM; NDS; QL ( per 8 days) ICLUSIG ORAL TABLET 5 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) ICLUSIG ORAL TABLET 45 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) IDHIFA ORAL TABLET 00 MG, 50 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) ifosfamide intravenous recon soln gram (Ifex) PA BvD ifosfamide intravenous solution gram/0 PA BvD ml, 3 gram/60 ml ifosfamide-mesna intravenous kit - 3 PA BvD; NM; NDS gram, 3,000-,000 imatinib oral tablet 00 (Gleevec) 3 PA NSO; NM; NDS; QL (90 per 30 days) imatinib oral tablet 400 (Gleevec) 3 PA NSO; NM; NDS; QL (60 per 30 days) IMBRUVICA ORAL CAPSULE 40 MG, 70 MG 3 PA NSO; NM; NDS; QL (8 per 8 days) IMBRUVICA ORAL TABLET 40 MG, 80 MG, 40 MG, 560 MG 3 PA NSO; NM; NDS; QL (8 per 8 days) 36

37 IMFINZI INTRAVENOUS SOLUTION 3 PA NSO; NM; NDS 50 MG/ML IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML 3 PA NSO; NM; NDS; QL (4 per 365 days) IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML 3 PA NSO; NM; NDS; QL (8 per 8 days) INLYTA ORAL TABLET MG 3 PA NSO; NM; NDS; QL (80 per 30 days) INLYTA ORAL TABLET 5 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) IRESSA ORAL TABLET 50 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) IXEMPRA INTRAVENOUS RECON SOLN 5 MG, 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) KEYTRUDA INTRAVENOUS 3 PA NSO; NM; NDS; QL SOLUTION 5 MG/ML KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X 3)-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) KISQALI ORAL TABLET 400 MG/DAY (00 MG X ) KISQALI ORAL TABLET 600 MG/DAY (00 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 0 MG/ML (8 per days) 3 PA NSO; NM; NDS; QL (49 per 8 days) 3 PA NSO; NM; NDS; QL (70 per 8 days) 3 PA NSO; NM; NDS; QL (9 per 8 days) 3 PA NSO; NM; NDS; QL ( per 8 days) 3 PA NSO; NM; NDS; QL (4 per 8 days) 3 PA NSO; NM; NDS; QL (63 per 8 days) 3 PA NSO; NM; NDS 3 PA NSO; NM; LA; NDS 37