2018 List of Covered Drugs (Formulary)

Transcription

1 208 List of Covered Drugs (Formulary) UCare s MSHO and UCare Connect + Medicare This is a list of drugs that members can get in UCare s MSHO and UCare Connect + Medicare. UCare s MSHO and UCare Connect + Medicare are health plans that contract with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in UCare s MSHO and UCare Connect + Medicare depends on contract renewal. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits and/or copays may change on January of each year. You can always check UCare s up-to-date List of Covered Drugs online at ucare.org.? Limitations, copays, and restrictions may apply. For more information, call UCare s MSHO/ UCare Connect + Medicare Customer Services at the number listed at the bottom of this page or read the MSHO Member Handbook or Evidence of Coverage for UCare Connect + Medicare. Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. You can get this document for free in other formats, such as large print, braille, or audio. Call Customer Services at the number listed at the bottom of this page. To make a standing request to always get your UCare materials in a language other than English or in an alternate format such as large print, please contact Customer Services at the number listed below. If you have questions, please call either UCare s MSHO Customer Services at / , or call UCare Connect + Medicare Customer Services at / , TTY / , 8 a.m. to 8 p.m., seven days a week. The call is free. For more information, visit ucare.org. H5937_08027 DHS Approved (088207) CMS Accepted ( ) H2456_08027 DHS/CMS Approved ( ) 8387, Version 7, Updated 0/8

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3 Civil Rights Notice Discrimination is against the law. UCare does not discriminate on the basis of any of the following: Race Sex (including sex stereotypes and Color gender identity) National Origin Marital Status Creed Political Beliefs Religion Medical Condition Sexual Orientation Health Status Public Assistance Status Receipt of Health Care Services Age Claims Experience Disability (including physical or Medical History mental impairment) Genetic Information Auxiliary Aids and Services. UCare provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner, to ensure an equal opportunity to participate in our health care programs. Contact UCare at (voice) or (voice), (TTY), or (TTY). Language Assistance Services. UCare provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact UCare at (voice) or (voice), (TTY), or (TTY). Civil Rights Complaints You have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by UCare. You may contact any of the following four agencies directly to file a discrimination complaint. U.S. Department of Health and Human Services Office for Civil Rights (OCR) You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following: Race Color National Origin Age Disability Sex (including sex stereotypes and gender identity)

4 Contact the OCR directly to file a complaint: Director U.S. Department of Health and Human Services Office for Civil Rights 200 Independence Avenue SW Room 509F HHH Building Washington, DC (Voice) (TDD) Complaint Portal Minnesota Department of Human Rights (MDHR) In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following: Race Sex Color Sexual Orientation National Origin Marital Status Religion Public Assistance Status Creed Disability Contact the MDHR directly to file a complaint: Minnesota Department of Human Rights Freeman Building, 625 North Robert Street St. Paul, MN (voice) (toll free) 7 or (MN Relay) (Fax) Info.MDHR@state.mn.us ( ) Minnesota Department of Human Services (DHS) You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following: Race Sex (including sex stereotypes and Color gender identity) National Origin Marital Status Creed Political Beliefs Religion Medical Condition Sexual Orientation Health Status Public Assistance Status Receipt of Health Care Services Age Claims Experience Disability (including physical or Medical History mental impairment) Genetic Information

5 Complaints must be in writing and filed within 80 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint. DHS will notify you in writing of the investigation s outcome. You have a right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome period. Be brief and state why you disagree with the decision. Include additional information you think is important. If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administration actions Contact DHS directly to file a discrimination complaint: ATTN: Civil Rights Coordinator Minnesota Department of Human Services Equal Opportunity and Access Division P.O. Box St. Paul, MN (voice) or use your preferred relay service UCare Complaint Notice You have the right to file a complaint with UCare if you believe you have been discriminated against in our health care programs because of any of the following: Race Color National Origin Creed Religion Sexual Orientation Public Assistance Status Age Disability (including physical or mental impairment) Phone: or toll free TTY: or toll free cag@ucare.org Fax: Sex (including sex stereotypes and gender identity) Marital Status Political Beliefs Medical Condition Health Status Receipt of Health Care Services Claims Experience Medical History Genetic Information Mailing address UCare Attn: Appeals and Grievances PO Box 52 Minneapolis, MN American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral.

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7 Frequently Asked Questions (FAQ) Find answers to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the Drug List that starts on page are the drugs covered by UCare s MSHO/ UCare Connect + Medicare. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. UCare s MSHO/UCare Connect + Medicare will cover all medically necessary drugs on the Drug List if: -- your doctor or other prescriber says you need them to get better or stay healthy, and -- you fill the prescription at a UCare s MSHO/ UCare Connect + Medicare network pharmacy. UCare s MSHO/UCare Connect + Medicare may have additional steps to access certain drugs (see question 5 below). You can also see an up-to-date list of drugs that we cover on our website at ucare.org or call Customer Services at the number listed at the bottom of this page. 2. Does the Drug List ever change? Yes. UCare s MSHO/UCare Connect + Medicare may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior authorization for a drug. (Prior authorization is permission from UCare s MSHO/ UCare Connect + Medicare before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see questions 5, 6 and 7.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check UCare s MSHO/ UCare Connect + Medicare s current Drug List online at ucare.org. You can also call Customer Services at the number listed at the bottom of this page to check the current Drug List. 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed from the Drug List because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a? If you have questions, please call either UCare s MSHO Customer Services at / , or call UCare Connect + Medicare Customer Services at / , TTY / , 8 a.m. to 8 p.m., seven days a week. The call is free. For more information, visit ucare.org. 208 UCare s MSHO and UCare Connect + Medicare Formulary i

8 60-day supply of the drug before the change to the Drug List is made. You will receive a letter notifying you of the change. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If this happens, you should contact your prescribing provider(s) to discuss a safer alternative. 5. Are there any restrictions or limits on drug coverage? Or are there any actions required to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you, your doctor, or other prescriber must do something before you can get the drug. For example: Prior Authorization: For some drugs, you, your doctor, or other prescriber must get authorization from UCare s MSHO/UCare Connect + Medicare before you fill your prescription. If you don t get authorization, UCare s MSHO/UCare Connect + Medicare may not cover the drug. Quantity Limits: Sometimes UCare s MSHO/ UCare Connect + Medicare limits the amount of a drug you can get. Step Therapy: Sometimes UCare s MSHO/UCare Connect + Medicare requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor or other prescriber thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages -24. You can also get more information by visiting our website at ucare.org. We have posted online documents that explain our prior authorization restrictions and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception to these limits. Please see questions 9-3 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 3-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new UCare s MSHO/UCare Connect + Medicare member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see questions 9-3 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are any actions required to get the drug? The Drug List on page has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization, quantity limits, and/ or step therapy restrictions on a drug. We will tell you if we add prior authorization, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. ii? If you have questions, please call either UCare s MSHO Customer Services at / , or call UCare Connect + Medicare Customer Services at / , TTY / , 8 a.m. to 8 p.m., seven days a week. The call is free. For more information, visit ucare.org. 208 UCare s MSHO and UCare Connect + Medicare Formulary

9 Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other provider about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by drug type. To search alphabetically, go to the Index. You can find it on page 3. The Index is an alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed in the Index. To search by drug type, find the section labeled List of drugs by drug type on page. The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the Antimigraine Agents category. That is where you will find drugs that treat migraines. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Customer Services at the number listed at the bottom of this page and ask about it. If you learn that UCare s MSHO/UCare Connect + Medicare will not cover the drug, you can do one of these things: Ask Customer Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see questions 0-3 for more information about exceptions. 0. What if you are a new UCare s MSHO or UCare Connect + Medicare member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UCare s MSHO/UCare Connect + Medicare. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior authorization by UCare s MSHO/UCare Connect + Medicare, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 9-98 days. You may refill the drug multiple times during your first 90 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. If your level of care changes (e.g. home to nursing home), we will authorize a one-time (3-day) transition supply.? If you have questions, please call either UCare s MSHO Customer Services at / , or call UCare Connect + Medicare Customer Services at / , TTY / , 8 a.m. to 8 p.m., seven days a week. The call is free. For more information, visit ucare.org. 208 UCare s MSHO and UCare Connect + Medicare Formulary iii

10 . Can you ask for an exception to cover your drug? Yes. You can ask UCare s MSHO/UCare Connect + Medicare to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, UCare s MSHO/UCare Connect + Medicare may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior authorization requirements. 2. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber s supporting statement. 3. How can you ask for an exception? To ask for an exception, call Customer Services. A Customer Services representative will work with you and your provider to help you ask for an exception. 4. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). UCare s MSHO/UCare Connect + Medicare covers both brand name drugs and generic drugs. 5. What are OTC drugs? OTC stands for over-the-counter. UCare s MSHO/UCare Connect + Medicare offers some OTC drugs through Medical Assistance (Medicaid) at no cost to you. You need a prescription for OTC drugs to be covered. These OTC drugs are listed in this Drug List, starting on page Does UCare s MSHO/UCare Connect + Medicare cover non-drug OTC products? UCare s MSHO/UCare Connect + Medicare covers some non-drug OTC products through Medical Assistance (Medicaid). These non-drug OTC products are listed in this Drug List. 7. Can I get my drugs through Mail-Order/Long-Term Supply? We offer a mail-order program that allows you to get up to a 90-day supply of your prescription drugs sent directly to your home. A 90-day supply has the same copay as a one-month supply. We offer a way to get a long-term supply of maintenance drugs on our plan s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.)? iv If you have questions, please call either UCare s MSHO Customer Services at / , or call UCare Connect + Medicare Customer Services at / , TTY / , 8 a.m. to 8 p.m., seven days a week. The call is free. For more information, visit ucare.org. 208 UCare s MSHO and UCare Connect + Medicare Formulary

11 For more information about getting drugs through mail-order or long-term supply, please call Customer Services at the number listed at the bottom of this page. 8. What is your copay? You can read the UCare s MSHO/UCare Connect + Medicare Drug List to learn about the copay for each drug. A copay is an amount you may be required to pay as your share of the cost of a prescription drug. A copay is usually a set amount, rather than a percentage. For example, you might pay $.25-$8.35 for a prescription drug. UCare s MSHO/UCare Connect + Medicare members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. The Drug List includes copays listed by tiers. Tier Generic drugs have the lowest copay. The copays will be from $.25 to $3.35, depending on your income and level of Medical Assistance (Medicaid) eligibility. Tier Brand drugs have a higher copay. The copay will be from $3.70 to $8.35, depending on your income and level of Medical Assistance (Medicaid) eligibility. OTCs have a $0 copay.? If you have questions, please call either UCare s MSHO Customer Services at / , or call UCare Connect + Medicare Customer Services at / , TTY / , 8 a.m. to 8 p.m., seven days a week. The call is free. For more information, visit ucare.org. 208 UCare s MSHO and UCare Connect + Medicare Formulary v

12 List of Covered Drugs The list of covered drugs that begins on the next page gives you information about the drugs covered by UCare s MSHO/UCare Connect + Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page 3. The first column of the table lists the name of the drug. Generic drugs are listed in lower-case italics (e.g., azathioprine), brand name drugs are capitalized (e.g., AZASAN), and OTC drugs and products are listed in lower case (e.g., aspirin). The information in the Necessary actions, restrictions, or limits on use column tells you if UCare s MSHO/UCare Connect + Medicare has any rules for covering your drug. Here are the meanings of the codes used in the Necessary actions, restrictions, or limits on use column: PA Prior authorization: You must have approval from the plan before you can get this drug. ST Step therapy: You must try another drug before you can get this one. BvsD Drugs requiring PA to determine coverage under Part B or Part D. ESRD Drugs requiring PA to determine coverage under Part D or dialysis benefit only applicable to members with End-Stage Renal Disease (ESRD). QLL Quantity limit. LA Limited Distribution drugs (drugs that may be available only at certain pharmacies). Part B Covered Covered under Part B benefit. List of Drugs by Drug Type The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the Antimigraine Agents category. That is where you will find drugs that treat migraines.? vi If you have questions, please call either UCare s MSHO Customer Services at / , or call UCare Connect + Medicare Customer Services at / , TTY / , 8 a.m. to 8 p.m., seven days a week. The call is free. For more information, visit ucare.org. 208 UCare s MSHO and UCare Connect + Medicare Formulary

13 Ucare's Minnesota Senior Health Options (MSHO) and UCare Connect + Medicare Formulary Name of Drug ANALGESICS acetaminophen-codeine oral solution 20-2 /5 ml QLL (4500 ML per 30 days) acetaminophen-codeine oral tablet 300-5, QLL (360 EA per 30 days) acetaminophen-codeine oral tablet QLL (80 EA per 30 days) buprenorphine hcl injection solution 0.3 /ml QLL (266 ML per 30 days) buprenorphine hcl injection syringe 0.3 /ml QLL (266 ML per 30 days) buprenorphine hcl sublingual tablet 2, 8 butorphanol tartrate injection solution /ml QLL (857 ML per 30 days) butorphanol tartrate injection solution 2 /ml QLL (428 ML per 30 days) butorphanol tartrate nasal spray,non-aerosol 0 /ml QLL (0 ML per 28 days) celecoxib oral capsule 00, 200, 400, 50 codeine sulfate oral tablet 5, 30, 60 QLL (80 EA per 30 days) diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended release 24 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 25, 50, 75 diclofenac sodium topical drops.5 % QLL (300 ML per 28 days) diclofenac sodium topical gel 3 % PA; QLL (00 GM per 28 days) diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mcg, mcg diflunisal oral tablet 500 DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML QLL (4000 ML per 30 days) DURAMORPH (PF) INJECTION SOLUTION MG/ML QLL (2000 ML per 30 days) ENDOCET ORAL TABLET MG, MG, MG QLL (360 EA per 30 days) etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 etodolac oral tablet extended release 24 hr 400, 500, UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208

14 fenoprofen oral tablet 600 fentanyl citrate buccal lozenge on a handle,200 mcg,,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr flurbiprofen oral tablet 00, 50 hydrocodone-acetaminophen oral solution /5 ml hydrocodone-acetaminophen oral tablet 0-300, 5-300, hydrocodone-acetaminophen oral tablet 0-325, , 5-325, hydrocodone-ibuprofen oral tablet 0-200, 5-200, hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml PA; QLL (20 EA per 30 days) PA; QLL (0 EA per 30 days) QLL (5550 ML per 30 days) QLL (390 EA per 30 days) QLL (360 EA per 30 days) QLL (50 EA per 30 days) QLL (240 ML per 30 days) hydromorphone injection syringe 2 /ml QLL (200 ML per 30 days) hydromorphone oral liquid /ml QLL (2400 ML per 30 days) hydromorphone oral tablet 2, 4, 8 QLL (80 EA per 30 days) hydromorphone oral tablet extended release 24 hr 2, 6, 32, 8 PA; QLL (60 EA per 30 days) ibuprofen oral suspension 00 /5 ml ibuprofen oral tablet 400, 600, 800 ibuprofen-oxycodone oral tablet QLL (28 EA per 30 days) ketoprofen oral capsule 75 ketoprofen oral capsule,ext rel. pellets 24 hr 200 levorphanol tartrate oral tablet 2 QLL (20 EA per 30 days) LORCET (HYDROCODONE) ORAL TABLET MG QLL (360 EA per 30 days) LORCET HD ORAL TABLET MG QLL (360 EA per 30 days) LORCET PLUS ORAL TABLET MG QLL (360 EA per 30 days) meclofenamate oral capsule 00, 50 mefenamic acid oral capsule 250 meloxicam oral tablet 5 meloxicam oral tablet 7.5 QLL (30 EA per 30 days) methadone injection solution 0 /ml QLL (50 ML per 30 days) 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 2

15 methadone oral solution 0 /5 ml PA; QLL (600 ML per 30 days) methadone oral solution 5 /5 ml PA; QLL (200 ML per 30 days) methadone oral tablet 0 PA; QLL (20 EA per 30 days) methadone oral tablet 5 PA; QLL (240 EA per 30 days) morphine concentrate oral solution 00 /5 ml (20 /ml) QLL (900 ML per 30 days) morphine injection syringe 5 /ml QLL (400 ML per 30 days) morphine intravenous syringe 0 /ml, 8 /ml morphine intravenous syringe 2 /ml QLL (000 ML per 30 days) morphine intravenous syringe 4 /ml QLL (500 ML per 30 days) morphine oral capsule, er multiphase 24 hr 20, 30, 45, 60, 75, 90 PA; QLL (60 EA per 30 days) morphine oral capsule,extend.release pellets 0, 00, 20, 30, 50, 60, 80 PA; QLL (90 EA per 30 days) morphine oral solution 0 /5 ml, 20 /5 ml (4 /ml) QLL (900 ML per 30 days) morphine oral tablet 5, 30 QLL (80 EA per 30 days) morphine oral tablet extended release 00 PA; QLL (60 EA per 30 days) morphine oral tablet extended release 5, 200, 30, 60 PA; QLL (20 EA per 30 days) nabumetone oral tablet 500, 750 nalbuphine injection solution 0 /ml QLL (200 ML per 30 days) nalbuphine injection solution 20 /ml QLL (00 ML per 30 days) naproxen oral suspension 25 /5 ml naproxen oral tablet 250, 375, 500 naproxen oral tablet,delayed release (dr/ec) 375, 500 naproxen sodium oral tablet 275, 550 naproxen sodium oral tablet, er multiphase 24 hr 375, 500 oxaprozin oral tablet 600 oxycodone oral capsule 5 QLL (360 EA per 30 days) oxycodone oral concentrate 20 /ml QLL (80 ML per 30 days) oxycodone oral solution 5 /5 ml QLL (200 ML per 30 days) oxycodone oral tablet 0, 5, 20, 30 QLL (80 EA per 30 days) oxycodone oral tablet 5 QLL (360 EA per 30 days) 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 3

16 oxycodone-acetaminophen oral tablet 0-325, , 5-325, QLL (360 EA per 30 days) oxycodone-aspirin oral tablet QLL (360 EA per 30 days) oxymorphone oral tablet 0 QLL (360 EA per 30 days) oxymorphone oral tablet 5 QLL (80 EA per 30 days) oxymorphone oral tablet extended release 2 hr 0, 5, 20, 30, 40, 5, 7.5 PA; QLL (90 EA per 30 days) piroxicam oral capsule 0, 20 PROFENO ORAL TABLET 600 MG sulindac oral tablet 50, 200 tolmetin oral capsule 400 tolmetin oral tablet 600 tramadol oral tablet 50 QLL (240 EA per 30 days) tramadol oral tablet extended release 24 hr 00, 200 PA; QLL (30 EA per 30 days) tramadol oral tablet, er multiphase 24 hr 00, 200, 300, 300 (matrix delivery) PA; QLL (30 EA per 30 days) tramadol-acetaminophen oral tablet QLL (240 EA per 30 days) VICODIN ES ORAL TABLET MG QLL (390 EA per 30 days) VICODIN HP ORAL TABLET MG QLL (390 EA per 30 days) VICODIN ORAL TABLET MG QLL (390 EA per 30 days) VOLTAREN TOPICAL GEL % ST; QLL (500 GM per 28 days) ANESTHETICS lidocaine (pf) injection solution 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl injection solution 20 /ml (2 %) lidocaine hcl mucous membrane jelly 2 % QLL (60 ML per 30 days) lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % PA lidocaine topical ointment 5 % QLL (36 GM per 30 days) LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 % lidocaine-prilocaine topical cream % QLL (30 GM per 30 days) 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 4

17 ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS acamprosate oral tablet,delayed release (dr/ec) 333 buprenorphine hcl injection solution 0.3 /ml QLL (266 ML per 30 days) buprenorphine hcl injection syringe 0.3 /ml QLL (266 ML per 30 days) buprenorphine hcl sublingual tablet 2, 8 buprenorphine-naloxone sublingual tablet QLL (360 EA per 30 days) buprenorphine-naloxone sublingual tablet 8-2 QLL (90 EA per 30 days) bupropion hcl (smoking deter) oral tablet extended release 2 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 (42) disulfiram oral tablet 250, 500 naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION QLL (2 EA per 28 days) NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON-AEROSOL 0 MG/ML SUBOXONE SUBLINGUAL FILM 2-3 MG QLL (60 EA per 30 days) SUBOXONE SUBLINGUAL FILM MG QLL (360 EA per 30 days) SUBOXONE SUBLINGUAL FILM 4- MG, 8-2 MG QLL (90 EA per 30 days) VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG ANTIBACTERIALS acetic acid otic (ear) solution 2 % ALCOHOL PADS TOPICAL PADS, MEDICATED amikacin injection solution 500 /2 ml amoxicillin oral capsule 250, UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 5

18 amoxicillin oral suspension for reconstitution 25 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 25, 250 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet , , amoxicillin-pot clavulanate oral tablet extended release 2 hr, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 500 ampicillin sodium injection recon soln gram, 0 gram, 25 ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML azithromycin intravenous recon soln 500 azithromycin oral packet gram azithromycin oral suspension for reconstitution 00 /5 ml, 200 /5 ml azithromycin oral tablet 250, 250 (6 pack), 500, 500 (3 pack), 600 aztreonam injection recon soln gram BACIIM INTRAMUSCULAR RECON SOLN 50,000 UNIT bacitracin intramuscular recon soln 50,000 unit bacitracin ophthalmic (eye) ointment 500 unit/gram BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML BICILLIN C-R INTRAMUSCULAR SYRINGE,200,000 UNIT/ 2 ML(600K/600K),,200,000 UNIT/ 2 ML(900K/300K) B vs D; QLL (224 ML per 28 days) 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 6

19 BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML LA; QLL (84 ML per 28 days) cefaclor oral capsule 250, 500 cefaclor oral suspension for reconstitution 25 /5 ml, 250 /5 ml, 375 /5 ml cefaclor oral tablet extended release 2 hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin injection recon soln gram, 0 gram, 500 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefepime injection recon soln gram, 2 gram cefixime oral suspension for reconstitution 00 /5 ml, 200 /5 ml cefotaxime injection recon soln gram, 2 gram, 500 cefotetan injection recon soln gram, 2 gram cefoxitin intravenous recon soln gram, 0 gram, 2 gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 200 cefprozil oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 ceftazidime injection recon soln gram, 2 gram, 6 gram ceftriaxone injection recon soln gram, 0 gram, 2 gram, 250, 500 cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection recon soln UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 7

20 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 250, 500, 750 cephalexin oral suspension for reconstitution 25 /5 ml, 250 /5 ml cephalexin oral tablet 250, 500 chloramphenicol sod succinate intravenous recon soln gram ciprofloxacin (mixture) oral tablet, er multiphase 24 hr,000, 500 ciprofloxacin hcl ophthalmic (eye) drops 0.3 % ciprofloxacin hcl oral tablet 00, 250, 500, 750 ciprofloxacin hcl otic (ear) dropperette 0.2 % ciprofloxacin in 5 % dextrose intravenous piggyback 200 /00 ml ciprofloxacin oral suspension,microcapsule recon 250 /5 ml, 500 /5 ml clarithromycin oral suspension for reconstitution 25 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 clarithromycin oral tablet extended release 24 hr 500 CLINDACIN P TOPICAL SWAB % clindamycin hcl oral capsule 50, 300, 75 clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml), 50 /ml clindamycin phosphate intravenous solution 600 /4 ml clindamycin phosphate topical foam % clindamycin phosphate topical gel % clindamycin phosphate topical lotion % clindamycin phosphate topical solution % 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 8

21 clindamycin phosphate topical swab % clindamycin phosphate vaginal cream 2 % colistin (colistimethate na) injection recon soln 50 daptomycin intravenous recon soln 500 demeclocycline oral tablet 50, 300 dicloxacillin oral capsule 250, 500 DOXY-00 INTRAVENOUS RECON SOLN 00 MG doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00, 50, 20, 75 doxycycline hyclate oral tablet,delayed release (dr/ec) 00, 50, 200, 50, 75 doxycycline monohydrate oral capsule 00, 50, 50, 75 doxycycline monohydrate oral suspension for reconstitution 25 /5 ml doxycycline monohydrate oral tablet 00, 50, 50, 75 E.E.S. 400 ORAL TABLET 400 MG ERY PADS TOPICAL SWAB 2 % ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG, 500 MG ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 /5 ml erythromycin ethylsuccinate oral tablet 400 erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) erythromycin oral capsule,delayed release(dr/ec) 250 erythromycin oral tablet 250, 500 erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 9

22 gatifloxacin ophthalmic (eye) drops 0.5 % GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM) gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 60 /50 ml, 80 /00 ml, 80 /50 ml gentamicin injection solution 40 /ml gentamicin ophthalmic (eye) drops 0.3 % gentamicin topical cream 0. % gentamicin topical ointment 0. % imipenem-cilastatin intravenous recon soln 250, 500 INVANZ INJECTION RECON SOLN GRAM levofloxacin in d5w intravenous piggyback 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 25 /ml levofloxacin ophthalmic (eye) drops 0.5 % levofloxacin oral solution 250 /0 ml levofloxacin oral tablet 250, 500, 750 lincomycin injection solution 300 /ml linezolid in dextrose 5% intravenous piggyback 600 /300 ml linezolid oral suspension for reconstitution 00 /5 ml linezolid oral tablet 600 meropenem intravenous recon soln gram, 500 methenamine hippurate oral tablet gram metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml metronidazole oral capsule 375 metronidazole oral tablet 250, 500 metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % minocycline oral capsule 00, 50, UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 0

23 minocycline oral tablet 00, 50, 75 minocycline oral tablet extended release 24 hr 35, 45, 90 MORGIDOX ORAL CAPSULE 50 MG moxifloxacin in nacl (iso-osm) intravenous piggyback 400 /250 ml moxifloxacin ophthalmic (eye) drops 0.5 % moxifloxacin oral tablet 400 mupirocin calcium topical cream 2 % mupirocin topical ointment 2 % nafcillin injection recon soln gram, 0 gram neomycin oral tablet 500 neomycin-polymyxin b gu irrigation solution ,000 unit/ml nitrofurantoin macrocrystal oral capsule 00, 25, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 nitrofurantoin oral suspension 25 /5 ml ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin oral tablet 400 ofloxacin otic (ear) drops 0.3 % oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, 2 gram/50 ml oxacillin injection recon soln gram, 0 gram, 2 gram paromomycin oral capsule 250 penicillin g potassium injection recon soln 20 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 25 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208

24 polymyxin b sulfate injection recon soln 500,000 unit silver sulfadiazine topical cream % SIVEXTRO INTRAVENOUS RECON SOLN 200 MG SSD TOPICAL CREAM % streptomycin intramuscular recon soln gram sulfacetamide sodium (acne) topical suspension 0 % sulfacetamide sodium ophthalmic (eye) drops 0 % sulfacetamide sodium ophthalmic (eye) ointment 0 % sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral suspension /5 ml sulfamethoxazole-trimethoprim oral tablet , SULFAMYLON TOPICAL CREAM 85 MG/G SULFAMYLON TOPICAL PACKET 50 GRAM SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 00 MG, 200 MG SYNERCID INTRAVENOUS RECON SOLN 500 MG TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG tetracycline oral capsule 250, 500 tigecycline intravenous recon soln 50 tinidazole oral tablet 250, 500 tobramycin in % nacl inhalation solution for nebulization 300 /5 ml tobramycin ophthalmic (eye) drops 0.3 % B vs D; QLL (280 ML per 28 days) 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 2

25 tobramycin sulfate injection solution 0 /ml, 40 /ml trimethoprim oral tablet 00 TYGACIL INTRAVENOUS RECON SOLN 50 MG vancomycin intravenous recon soln,000, 0 gram, 500 vancomycin oral capsule 25, 250 VANDAZOLE VAGINAL GEL 0.75 % XIFAXAN ORAL TABLET 200 MG QLL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG QLL (90 EA per 30 days) ZANOSAR INTRAVENOUS RECON SOLN GRAM B vs D ANTICONVULSANTS APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG carbamazepine oral suspension 00 /5 ml carbamazepine oral tablet 200 carbamazepine oral tablet extended release 2 hr 00, 200, 400 carbamazepine oral tablet,chewable 00 CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5,, 2 PA clonazepam oral tablet,disintegrating 0.25, 0.25, 0.5,, 2 PA clorazepate dipotassium oral tablet 5, 3.75, 7.5 PA DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT 2.5 MG DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML PA 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 3

26 diazepam oral solution 5 /5 ml ( /ml) PA diazepam oral tablet 0, 2, 5 PA DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel sprinkle 25 divalproex oral tablet extended release 24 hr 250, 500 divalproex oral tablet,delayed release (dr/ec) 25, 250, 500 EPITOL ORAL TABLET 200 MG ethosuximide oral capsule 250 ethosuximide oral solution 250 /5 ml felbamate oral suspension 600 /5 ml felbamate oral tablet 400, 600 fosphenytoin injection solution 00 pe/2 ml FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 00 QLL (080 EA per 30 days) gabapentin oral capsule 300 QLL (360 EA per 30 days) gabapentin oral capsule 400 QLL (270 EA per 30 days) gabapentin oral solution 250 /5 ml QLL (260 ML per 30 days) gabapentin oral tablet 600 QLL (80 EA per 30 days) gabapentin oral tablet 800 QLL (35 EA per 30 days) GABITRIL ORAL TABLET 2 MG, 6 MG lamotrigine oral tablet 00, 50, 200, 25 lamotrigine oral tablet extended release 24hr 00, 200, 25, 250, 300, 50 lamotrigine oral tablet, chewable dispersible 25, 5 lamotrigine oral tablet,disintegrating 00, 200, 25, 50 lamotrigine oral tablets,dose pack 25 (35), 25 (42) -00 (7), 25 (84) -00 (4) levetiracetam in nacl (iso-os) intravenous piggyback,000 /00 ml,,500 /00 ml, 500 /00 ml 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 4

27 levetiracetam intravenous solution 500 /5 ml levetiracetam oral solution 00 /ml levetiracetam oral tablet,000, 250, 500, 750 levetiracetam oral tablet extended release 24 hr 500, 750 lorazepam oral concentrate 2 /ml PA lorazepam oral tablet 0.5,, 2 PA LYRICA ORAL CAPSULE 00 MG PA; QLL (80 EA per 30 days) LYRICA ORAL CAPSULE 50 MG PA; QLL (20 EA per 30 days) LYRICA ORAL CAPSULE 200 MG PA; QLL (90 EA per 30 days) LYRICA ORAL CAPSULE 225 MG PA; QLL (8 EA per 30 days) LYRICA ORAL CAPSULE 25 MG PA; QLL (720 EA per 30 days) LYRICA ORAL CAPSULE 300 MG PA; QLL (60 EA per 30 days) LYRICA ORAL CAPSULE 50 MG PA; QLL (360 EA per 30 days) LYRICA ORAL CAPSULE 75 MG PA; QLL (240 EA per 30 days) LYRICA ORAL SOLUTION 20 MG/ML PA; QLL (900 ML per 30 days) ONFI ORAL SUSPENSION 2.5 MG/ML PA ONFI ORAL TABLET 0 MG, 20 MG PA oxcarbazepine oral suspension 300 /5 ml (60 /ml) oxcarbazepine oral tablet 50, 300, 600 PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 /5 ml (4 /ml) PA phenobarbital oral tablet 00, 5, 6.2, 30, 32.4, 60, 64.8, 97.2 PA phenytoin oral suspension 25 /5 ml phenytoin oral tablet,chewable 50 phenytoin sodium extended oral capsule 00, 200, 300 phenytoin sodium intravenous solution 50 /ml primidone oral tablet 250, 50 ROWEEPRA ORAL TABLET,000 MG, 500 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG, 750 MG 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 5

28 SABRIL ORAL POWDER IN PACKET 500 MG LA SABRIL ORAL TABLET 500 MG LA SPRITAM ORAL TABLET FOR SUSPENSION,000 MG, 250 MG, 500 MG, 750 MG tiagabine oral tablet 2, 6, 2, 4 topiramate oral capsule, sprinkle 5, 25 PA topiramate oral tablet 00, 200, 25, 50 PA valproate sodium intravenous solution 500 /5 ml (00 /ml) valproic acid (as sodium salt) oral solution 500 /0 ml (0 ml) valproic acid oral capsule 250 vigabatrin oral powder in packet 500 VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG zonisamide oral capsule 00, 25, 50 PA ANTIDEMENTIA AGENTS donepezil oral tablet 0, 23, 5 donepezil oral tablet,disintegrating 0, 5 ergoloid oral tablet galantamine oral capsule,ext rel. pellets 24 hr 6, 24, 8 galantamine oral solution 4 /ml galantamine oral tablet 2, 4, 8 memantine oral capsule,sprinkle,er 24hr 4, 2, 28, 7 PA memantine oral solution 2 /ml PA memantine oral tablet 0, 5 PA NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK MG PA NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 4 MG, 2 MG, 28 MG, 7 MG PA NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/4/2/28 MG-0 MG PA 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 6

29 NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 4-0 MG, 2-0 MG, 28-0 MG, 7-0 MG PA rivastigmine tartrate oral capsule.5, 3, 4.5, 6 rivastigmine transdermal patch 24 hour 3.3 /24 hour, 4.6 /24 hr, 9.5 /24 hr ANTIDEPRESSANTS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG amitriptyline oral tablet 0, 00, 50, 25, 50, 75 PA amoxapine oral tablet 00, 50, 25, 50 aripiprazole oral tablet 0 QLL (90 EA per 30 days) aripiprazole oral tablet 5, 20 QLL (60 EA per 30 days) aripiprazole oral tablet 2 QLL (450 EA per 30 days) aripiprazole oral tablet 30 QLL (30 EA per 30 days) aripiprazole oral tablet 5 QLL (80 EA per 30 days) aripiprazole oral tablet,disintegrating 0 QLL (90 EA per 30 days) aripiprazole oral tablet,disintegrating 5 QLL (60 EA per 30 days) bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended release 2 hr 00 QLL (20 EA per 30 days) bupropion hcl oral tablet extended release 2 hr 50 QLL (90 EA per 30 days) bupropion hcl oral tablet extended release 2 hr 200 QLL (60 EA per 30 days) bupropion hcl oral tablet extended release 24 hr 50 QLL (90 EA per 30 days) bupropion hcl oral tablet extended release 24 hr 300 QLL (60 EA per 30 days) citalopram oral solution 0 /5 ml citalopram oral tablet 0 QLL (20 EA per 30 days) citalopram oral tablet 20 QLL (60 EA per 30 days) 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 7

30 citalopram oral tablet 40 QLL (30 EA per 30 days) clomipramine oral capsule 25, 50, 75 PA desipramine oral tablet 0, 00, 50, 25, 50, 75 desvenlafaxine succinate oral tablet extended release 24 hr 00 QLL (20 EA per 30 days) desvenlafaxine succinate oral tablet extended release 24 hr 25 QLL (480 EA per 30 days) desvenlafaxine succinate oral tablet extended release 24 hr 50 QLL (240 EA per 30 days) doxepin oral capsule 0, 00, 50, 25, 50, 75 PA doxepin oral concentrate 0 /ml PA duloxetine oral capsule,delayed release(dr/ec) 20 QLL (80 EA per 30 days) duloxetine oral capsule,delayed release(dr/ec) 30 QLL (20 EA per 30 days) duloxetine oral capsule,delayed release(dr/ec) 40 QLL (90 EA per 30 days) duloxetine oral capsule,delayed release(dr/ec) 60 QLL (60 EA per 30 days) EMSAM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 0 QLL (60 EA per 30 days) escitalopram oxalate oral tablet 20 QLL (30 EA per 30 days) escitalopram oxalate oral tablet 5 QLL (20 EA per 30 days) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) QLL (28 EA per 28 days) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG QLL (30 EA per 30 days) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG QLL (80 EA per 30 days) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG QLL (90 EA per 30 days) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 80 MG QLL (45 EA per 30 days) fluoxetine oral capsule 0 QLL (240 EA per 30 days) fluoxetine oral capsule UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 8

31 fluoxetine oral capsule 40 QLL (60 EA per 30 days) fluoxetine oral capsule,delayed release(dr/ec) 90 QLL (4 EA per 28 days) fluoxetine oral solution 20 /5 ml (4 /ml) fluoxetine oral tablet 0 QLL (240 EA per 30 days) fluoxetine oral tablet 20, 60 fluvoxamine oral capsule,extended release 24hr 00 QLL (90 EA per 30 days) fluvoxamine oral capsule,extended release 24hr 50 QLL (60 EA per 30 days) fluvoxamine oral tablet 00 QLL (90 EA per 30 days) fluvoxamine oral tablet 25 QLL (360 EA per 30 days) fluvoxamine oral tablet 50 QLL (80 EA per 30 days) imipramine hcl oral tablet 0, 25, 50 PA imipramine pamoate oral capsule 00, 25, 50, 75 PA KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 00 MG QLL (20 EA per 30 days) KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG QLL (240 EA per 30 days) maprotiline oral tablet 25, 50, 75 MARPLAN ORAL TABLET 0 MG mirtazapine oral tablet 5, 30, 45, 7.5 mirtazapine oral tablet,disintegrating 5, 30, 45 nefazodone oral tablet 00, 50, 200, 250, 50 nortriptyline oral capsule 0, 25, 50, 75 nortriptyline oral solution 0 /5 ml olanzapine-fluoxetine oral capsule 2-25, 2-50, 3-25, 6-25, 6-50 paroxetine hcl oral tablet 0 QLL (80 EA per 30 days) paroxetine hcl oral tablet 20 QLL (90 EA per 30 days) paroxetine hcl oral tablet 30 QLL (60 EA per 30 days) paroxetine hcl oral tablet 40 QLL (45 EA per 30 days) 208 UCare's MSHO and UCare Connect + Medicare Formulary Updated: October, 208 9