Lis Medikaman Ki Garanti (Fòmil) Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan (Medicare-Medicaid Plan)

Transcription

1 Lis Medikaman Ki Garanti (Fòmil) Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan (Medicare-Medicaid Plan) 2015 Sèvis Patisipan: (TTY 711) Lendi rive vandredi depi 8 è a.m. jiska 8 p.m. lè lokal ENYDMKT Formulary HC Fòmil: Vèsyon: 14 Fèt 11/01/2015

2 Empire FIDA Plan 2015 Lis Medikaman Ki Garanti (Fòmil) Sa a se yon lis medikaman Patisipan yo kapab jwenn nan Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA). Empire FIDA Plan FIDA se yon plan swen kowòdone ki gen kontra ak ni Medicare ak Depatman Sante Eta New York (Medicaid) pou ba moun k ap patisipe nan tou de pwogram yo avantaj yo atravè Demonstrasyon Fully Integrated Duals Advantage (FIDA) a. Empire BlueCross BlueShield HealthPlus se non komèsyal HealthPlus, LLC, yon konpayi endepandan ak lisans Blue Cross and Blue Shield Association. Avantaj, Lis Medikaman Ki Garanti, ak rezo famasi ak pwofesyonèl swen sante yo kapab chanje detanzantan pandan ane a ak 1ye janvye chak ane. Ou kapab toujou gade dènye Lis Medikaman Ki Garanti Empire FIDA Plan a sou entènèt nan adrès oswa ou kapab rele Sèvis Patisipan Empire FIDA Plan nan nimewo (TTY 711) lendi jiska vandredi kòmanse 8 a.m. jiska 8 p.m. Kapab genyen limit ak restriksyon. Pou plis enfòmasyon, rele Sèvis Patisipan Empire FIDA Plan a oswa li Liv Enfòmasyon Pou Patisipan Empire FIDA Plan a. Pa genyen okenn kotizasyon pou okenn nan medikaman ki garanti yo. Ou kapab resevwa enfòmasyon sa a gratis sou lòt fòma, tankou Bray pou moun avèg oswa sa ki ekri ak gwo lèt. Rele (TTY/TDD 711) lendi jiska vandredi 8am jiska 8pm. Koutfil la gratis. Ou kapab resevwa enfòmasyon sa a gratis nan lòt lang. Rele (TTY/TDD 711) lendi jiska vandredi 8am rive 8pm. Koutfil la gratis. Usted puede obtener esta información gratuitamente en otros idiomas. Llame al (TTY ) de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratuita. 您可以免費獲得此資訊的其他語言版本 請致電 (TTY 711) 當地時間週一至週五上午 8 點至晚上 8 點 此為免付費電話 Ou ka jwenn enfòmasyon sa a gratis nan lòt lang. Rele (TTY 711) lendi rive vandredi depi 8 è a.m. pou 8 è p.m. nan lè lokal. Koutfil sa a gratis.? Si ou genyen kesyon, tanpri rele Empire FIDA Plan (TTY 711) lendi jiska vandredi kòmanse 8 a.m. rive 8 p.m. lè lokal. Koutfil la gratis. Pou plis enfòmasyon, vizite ENYDMEM

3 Puoi ottenere quest informazione gratis anche in altre lingue. Chiamare (TTY 711) dal lunedì al venerdì, dalle 8:00 alle 20:00 ora locale. La chiamata è gratuita. 이정보는다른언어로무료로얻을수있습니다. 현지시간으로월요일부터금요일까지, 오전 8 시에서 오후 8 시사이에 (TTY 711) 번으로문의하십시오. 통화는무료입니다. Вы можете получить данную информацию бесплатно на любом языке. Звоните по номеру (TTY 711) с понедельника по пятницу с 8:00 до 20:00 по местному времени. Звонок бесплатный. Eta New York te kreye yon pwogram medyatè ki rele Independent Consumer Advocacy Network (ICAN) pou bay patisipan yo asistans gratis ak konfidansyèl sou nenpòt sèvis Empire FIDA Plan ofri. Ou kapab rele ICAN gratis nan nimewo oswa sou entènèt nan adrès Si ou genyen kesyon, tanpri rele Empire FIDA Plan (TTY 711) lendi jiska vandredi kòmanse 8 a.m. rive 8 p.m. lè lokal. Koutfil la gratis. Pou plis enfòmasyon, vizite ENYDMEM

4 Kesyon Moun Poze Souvan Jwenn repons la a sou kesyon ou genyen sou Lis Medikaman Ki Garanti. Ou kapab li tout Kesyon Moun Poze Souvan, oswa chèche yon kesyon ak repons. 1. Ki medikaman ki nan Lis Medikaman Ki Garanti a? (Nou rele Lis Medikaman Ki Garanti a "Lis Medikaman" pou bay li yon non kout.) Medikaman yo ki nan Lis Medikaman Ki Garanti ki kòmanse sou paj 11 la se medikaman Empire FIDA Plan garanti. Sa yo se medikaman ki disponib nan famasi ki fè pati rezo nou an. Yon famasi fè pati rezo nou an si nou dakò ak yo pou travay ak nou epi ba ou sèvis ou bezwen. Nou rele famasi sa yo "famasi nan rezo." Empire FIDA Plan ap garanti tout medikaman ni nan Lis Medikaman an si: doktè ou oswa lòt moun ki fè pati rezo a ki ekri yon preskripsyon pou ou di ou bezwen yo pou refè oswa rete an sante, medikaman an nesesè pou rezon medikal pou kondisyon ou a, epi ou ranpli preskripsyon an nan yon famasi nan rezo Empire FIDA Plan. Empire FIDA Plan kapab genyen plis eta pou jwenn sèten medikaman (gade kesyon #5 pi ba a). Nan kèk ka, ou kapab bezwen fè yon bagay avan ou kapab jwenn yon medikaman, tankou eseye lòt medikaman avan. Epi tou ou kapab gade dènye lis medikaman nou garanti yo sou sit entènèt nou nan adrès oswa rele Sèvis Patisipan nan nimewo (TTY 711) lendi rive vandredi depi 8 è a.m. pou 8 è p.m. 2. Èske Lis Medikaman an janm chanje? Wi. Empire FIDA Plan gendwa ajoute oswa retire medikaman nan Lis Medikaman an pandan ane a. Jeneralman, Lis Medikaman an ap chanje sèlman si: vin genyen yon medikaman ki mache byen menm jan ak yon medikaman ki nan Lis Medikaman an kounye a, ou nou aprann yon medikaman gen danje ladan. Epi tou nou kapab chanje règ nou sou medikaman yo. Pa egzanp, nou kapab:? Si ou genyen kesyon, tanpri rele Empire FIDA Plan (TTY 711) lendi jiska vandredi kòmanse 8 a.m. rive 8 p.m. lè lokal. Koutfil la gratis. Pou plis enfòmasyon, vizite ENYDMEM

5 Deside si ou oblije gen otorizasyon davans pou yon medikaman ou pa. (Otorizasyon davans se pèmisyon ou resevwa nan men Empire FIDA Plan oswa Ekip Entèdisiplinè ou avan w ap ka resevwa yon medikaman.) Ajoute oswa chanje kantite medikaman ou kapab resevwa (ki rele "limit sou kantite"). Ajoute oswa chanje restriksyon tretman pa etap sou yon medikaman. (Tretman pa etap vle di ou dwe itilize yon medikaman avan pou nou garanti yon lòt medikaman.) (Pou plis enfòmasyon sou règ pou medikaman sa yo, gade paj 11.) Nou ap di ou lè nou ap retire yon medikaman w ap pran sou Lis Medikaman an. Epi tou nou ap di ou lè nou chanje règ nou pou garanti yon medikaman. Kesyon 3, 4 ak 7 ki pi ba a genyen plis enfòmasyon sou sa k ap pase lè Lis Medikaman an chanje. Ou kapab toujou tcheke dènye Lis Medikaman Empire FIDA Plan sou entènèt nan Epi tou ou kapab rele Sèvis Patisipan pou tcheke dènye Lis Medikaman an nan nimewo (TTY 711) lendi rive vandredi depi 8 è a.m. pou 8 è p.m. 3. Kisa k ap pase lè vin genyen yon medikaman ki mache byen menm jan ak medikaman sa a sou Lis Medikaman an kounye a? Si vin genyen yon medikaman ki mache byen menm jan ak medikaman sa a sou Lis Medikaman an kounye a: Famasyen ou kapab ba ou medikaman ki pi bon mache a pwochèn fwa ou al ranpli preskripsyon ou. Si ou menm ak pwofesyonèl swen sante ou deside medikaman ki pi bon mache a pa apwopriye pou ou, pwofesyonèl swen sante ou kapab di famasyen an pou kontinye ba ou medikaman w ap pran kounye a. Empire FIDA Plan gendwa deside retire medikaman ki pi chè a sou Lis Medikaman an. Si w ap pran yon medikaman nou retire sou Lis Medikaman an paske vin genyen yon medikaman ki pi bon mache epi ki mache byen menm jan, n ap di ou sa omwen 60 jou avan nou retire li sou Lis Medikaman an oswa lè ou mande pou renouvle li. Apresa w ap kapab jwenn yon kantite medikaman pou 60 jou avan nou fè chanjman sou Lis Medikaman an. Si ou resevwa yon anons konsa, ou dwe pale ak pwofesyonèl swen sante ou pou kòmanse yon medikaman ki sou lis la oswa mande yon eksepsyon.? Si ou genyen kesyon, tanpri rele Empire FIDA Plan (TTY 711) lendi jiska vandredi kòmanse 8 a.m. rive 8 p.m. lè lokal. Koutfil la gratis. Pou plis enfòmasyon, vizite ENYDMEM

6 4. Kisa k ap pase lè nou aprann yon medikaman danjere? Si Administrasyon Manje ak Medikaman (FDA) di yon medikaman w ap danjere, n ap retire li sou Lis Medikaman an touswit. Epi tou n ap voye yon lèt ba ou ak rete ou pou fè ou konnen nou te retire medikaman danjere a sou Lis Medikaman an. Si ou resevwa yon anons sou yon medikaman ki danjere, rele doktè ou touswit. Doktè ou kapab ede ou jwenn yon lòt medikaman k ap mache pi byen pou ou. 5. Èske genyen okenn limit oswa restriksyon so pwoteksyon medikaman? Oswa èske genyen okenn bagay pou sipoze fè pou resevwa sèten medikaman? Wi, kèk medikaman gen règ sou pwoteksyon medikaman oswa genyen limit sou kantite ou kapab resevwa. Nan kèk ka, ou kapab dwe fè yon bagay avan ou kapab jwenn yon medikaman. Pa egzanp: Otorizasyon davans: Pou kèk medikaman, ou menm oswa doktè w oswa lòt moun ki ba ekri preskripsyon an pou ou dwe resevwa otorizasyon Empire FIDA Plan oswa Ekip Entèdisiplinè (IDT) ou anvan ou ranpli preskripsyon ou a. Si ou pa resevwa otorizasyon, Empire FIDA Plan ka pa garanti medikaman an. Limit sou kantite: Pafwa Empire FIDA Plan limite kantite nan medikaman an ou kapab jwenn. Tretman pa etap: Pafwa Empire FIDA Plan egzije pou ou fè tretman pa etap. Sa vle di w ap bezwen eseye medikaman nan yon sèten lòd pou pwoblèm medikal ou a. Ou kapab oblije itilize yon medikaman avan pou nou garanti yon lòt medikaman. Si doktè ou panse premye medikaman an pa mache pou ou, lè sa a n ap garanti dezyèm nan. Pou konnen si genyen plis egzijans oswa limit, gade nan tablo ki kòmanse sou paj 11 la. Epi tou pou jwenn plis enfòmasyon vizite sit entènèt nou nan adrès Nou te pibliye dokiman sou entènèt la ki eksplike restriksyon otorizasyon davans ak restriksyon tretman pa etap nou yo. Ou kapab mande nou voye yon kopi pou ou tou. Ou kapab mande yon "eksepsyon" pou limit sa yo. Tanpri gade kesyon 11 pou plis enfòmasyon sou eksepsyon.. Si ou nan yon mezon retrèt oswa lòt sant swen alontèm epi ou bezwen yon medikaman ki pa sou Lis Medikaman an, oswa si ou pa ka jwenn medikaman ou bezwen an fasil, nou kapab ede. Nou ap garanti yon kantite ijan medikaman ou bezwen an pou 31 jou (amwenske ou genyen yon preskripsyon pou pi piti kantite jou), kit ou se yon nouvo Patisipan Empire FIDA Plan ou pa. Sa ap ba ou tan pou pale ak doktè ou oswa lòt moun ki ekri preskripsyon pou ou a. Li kapab ede ou deside si genyen yon medikaman nan Lis Medikaman an si prèske menm jan ak li ou kapab pran pito oswa si pou ou mande yon eksepsyon. Tanpri gade kesyon 11 pou plis enfòmasyon sou eksepsyon..? Si ou genyen kesyon, tanpri rele Empire FIDA Plan (TTY 711) lendi jiska vandredi kòmanse 8 a.m. rive 8 p.m. lè lokal. Koutfil la gratis. Pou plis enfòmasyon, vizite ENYDMEM

7 6. Kijan w ap fè konnen si medikaman ou vle a genyen limitasyon oswa si genyen bagay ou sipoze fè pou jwenn medikaman an? Lis Medikaman Ki Garanti sou paj 11 la genyen yon ran ki rele "Aksyon ki nesesè, restriksyon, oswa limit sou fason pou itilize." 7. Kisa k ap pase si nou chanje rès nou sou jan ou garanti kèk medikaman? Pa egzanp, si nou ajoute otorizasyon davans, limit sou kantite, ak/ou restriksyon tretman pa etap sou yon medikaman. Nou ap di ou si nou ajoute otorizasyon davans, limit sou kantite, ak/ou restriksyon tretman pa etap sou yon medikaman. Nou ap di ou omwen 60 jou avan nou ajoute restriksyon an oswa pwochèn fwa ou mande renouvle medikaman ou. Apresa, w ap kapab jwenn yon kantite medikaman pou 60 jou avan nou fè chanjman sou Lis Medikaman an. Sa ap ba ou tan pou pale ak doktè ou oswa lòt moun ki ekri preskripsyon pou ou a sa pou ou fè apre. 8. Kijan pou w fè konnen si yon medikaman sou Lis Medikaman an? Genyen de fason pou jwenn yon medikaman: Ou kapab chèche li an òd alfabetik (si ou konnen jan pou ekri non medikaman an), oswa Ou kapab chèche li daprè pwoblèm medikal. Pou chèche an òd alfabetik, ale nan seksyon Lis Alfabetik sou paj nimewo. Apresa chèche non medikaman ou a sou lis la. Pou chèche daprè pwoblèm medikal, ale nan seksyon ki rele "Lis medikaman daprè pwoblèm medikal" sou paj paj nimewo. Apresa chèche pwoblèm medikal ou a. Pa egzanp, si ou gen yon pwoblèm kè, ou dwe gade nan kategori sa a. Se la w ap jwenn nouvo medikaman ki trete pwoblèm kè. 9. E si medikaman ou vle a pa sou Lis Medikaman an? Si ou pa wè medikaman ou a sou Lis Medikaman an, rele Sèvis Patisipan nan nimewo (TTY 711) lendi rive vandredi depi 8 è a.m. pou 8 è p.m. epi mande yo sou li. Si ou vin aprann Empire FIDA Plan p ap garanti medikaman ou a, ou kapab fè youn nan bagay sa yo: Mande Sèvis Patisipan pou yon lis medikaman ki tankou sa ou vle pran an. Apre sa montre doktè ou oswa lòt moun k ap ekri preskripsyon pou ou lis la. Li kapab preskri yon medikaman ki sou Lis Medikaman an ki menm jan ak sa ou vle pran an. Oswa? Si ou genyen kesyon, tanpri rele Empire FIDA Plan (TTY 711) lendi jiska vandredi kòmanse 8 a.m. rive 8 p.m. lè lokal. Koutfil la gratis. Pou plis enfòmasyon, vizite ENYDMEM

8 Ou kapab mande plan an oswa Ekip Entèdisiplinè (IDT) ou yon eksepsyon pou garanti medikaman ou a. Tanpri gade kesyon 11 pou plis enfòmasyon sou eksepsyon E si ou se yon nouvo manm Empire FIDA Plan epi ou pa ka jwenn medikaman ou a sou Lis Medikaman an oswa gen yon pwoblèm pou jwenn medikaman ou a? Nou kapab ede. N ap garanti yon kantite tanporè medikaman ou an pou jiska 90 jou, daprè sa ou bezwen, pandan premye 90 jou ou se yon Patisipan Empire FIDA Plan. Sa ap ba ou tan pou pale ak doktè ou oswa lòt moun ki ekri preskripsyon pou ou a. Li kapab ede ou deside si genyen yon medikaman nan Lis Medikaman an si prèske menm jan ak li ou kapab pran pito oswa si pou ou mande yon eksepsyon. N ap garanti yon kantite tanporè medikaman ou a pou jiska 90 jou si: w ap pran yon medikaman ki pa sou Lis Medikaman ou a, oswa règ plan sante a pa kite ou jwenn kantite moun ki ekri preskripsyon pou ou a kòmande a, oswa medikaman an bezwen otorizasyon davans nan men Empire FIDA Plan oswa Ekip Entèdisiplinè (IDT) ou, oswa w ap pran yon medikaman ki pa fè pati yon restriksyon tretman pa etap. Si w ap viv nan yon mezon retrèt oswa lòt sant swen alontèm, ou kapab renouvle preskripsyon ou a pou jiska 98 jou. Ou kapab renouvle medikaman an plizyè fwa pandan peryòd 98 jou a. Sa bay moun ki ekri preskripsyon ba ou a tan pou chanje medikaman ou sou sa yo ki sou Lis Medikaman an oswa mande yon eksepsyon. Si ou genyen yon chanjman nan nivo swen w ap resevwa ki fè ou oblije soti nan yon sant oswa sant tretman pou ale nan yon lòt, ou kapab kalifye pou resevwa yon kantite tanporè preskripsyon ou genyen kounye a. Pa egzanp, si ou kite lopital epi yo ba ou yon lis medikaman pou pran lakay ou daprè fòmil lopital la, gen posiblite pou ou resevwa medikaman an yon fwa. Ou kapab jwenn medikaman tanporè sa a yon fwa san gade sou si ou nan premye 90 jou ou enskri nan pwogram nan ou pa. Fè moun k ap ekri preskripsyon pou ou a rele pou plis detay. 11. Èske ou kapab mande yon eksepsyon pou garanti medikaman ou a? Wi. Ou kapab mande Empire FIDA Plan oswa Ekip Entèdisiplinè (IDT) ou a pou fè yon eksepsyon epi garanti yon medikaman ki pa sou Lis Medikaman an.? Si ou genyen kesyon, tanpri rele Empire FIDA Plan (TTY 711) lendi jiska vandredi kòmanse 8 a.m. rive 8 p.m. lè lokal. Koutfil la gratis. Pou plis enfòmasyon, vizite ENYDMEM

9 Epi tou ou kapab mande Empire FIDA Plan pou chanje règ sou medikaman ou a. Pa egzanp, Empire FIDA Plan kapab limite kantite nan medikaman n ap garanti. Si medikaman ou a genyen yon limit, ou kapab mande nou menm oswa IDT ou a pou chanje limit la epi garanti plis. Lòt egzanp: Ou kapab mande nou menm oswa IDT ou a pou elimine restriksyon tretman pa etap oswa egzijans pou otorizasyon davans. 12. Konbyen tan l ap pran pou jwenn yon eksepsyon? Premyèman, moun ki ba ou preskripsyon an dwe bay Empire FIDA Plan oswa Ekip entèdisiplinè ou (IDT) yon deklarasyon ki sipòte demann ou pou eksepsyon an.. Apre nou resevwa deklarasyon an, w ap jwenn yon desizyon sou demann pou eksepsyon ou a avan 72 èdtan. Si ou menm oswa moun ki ekri preskripsyon an panse li kapab yon danje pou sante ou si ou tann 72 èdtan pou yon desizyon, ou kapab mande yon eksepsyon rapid. Sa a se yon desizyon ki pi rapid.. Si moun ki ekri preskripsyon an pou ou a sipòte demann ou a, w ap jwenn yon desizyon avan 24 èdtan apre nou resevwa deklarasyon moun ki preskri a ap sipòte ou a. 13. Kijan ou kapab mande yon eksepsyon? Pou mande yon eksepsyon, relekowòdonatè Swen ou a. Kowòdonatè Swen ou a ap travay ak ou menm ansanm ak pwofesyonèl swen sante ou pou ede ou mande yon eksepsyon. 14. Kisa medikaman jenerik ye? Medikaman jenerik yo gen menm engredyan ank medikaman mak komèsyal yo. Nòmalman yo koute pi piti pase medikaman mak komèsyal la epi nòmalman yo pa gen non ki popilè. Administrasyon Manje ak Medikaman (FDA) otorize medikaman jenerik yo. Empire FIDA Plan ap garanti ni medikaman mak komèsyal ak medikaman jenerik. 15. Kisa medikaman OTC ye? OTC siyifi over-the-counter (pwodwi ou kapab achte san preskripsyon). Empire FIDA Plan ap garanti kèk medikaman OTC lè pwofesyonèl swen sante ou ekri yo tankou preskripsyon.? Si ou genyen kesyon, tanpri rele Empire FIDA Plan (TTY 711) lendi jiska vandredi kòmanse 8 a.m. rive 8 p.m. lè lokal. Koutfil la gratis. Pou plis enfòmasyon, vizite ENYDMEM

10 Ou kapab li Lis Medikaman Empire FIDA Plan a pou wè ki medikaman OTC ki garanti. 16. Èske Empire FIDA Plan pwodwi OTC ki pa medikaman? Empire FIDA Plan ap garanti kèk pwodwi OTC ki pa medikaman lè pwofesyonèl swen sante ou ekri yo tankou preskripsyon. Empire FIDA Plan ap garanti pwodi ki pa medikaman tankou vitamin ak mineral. Ou kapab li Lis Medikaman Empire FIDA Plan a pou wè ki pwodwi OTC ki pa medikaman ki garanti. 17. Konbyen kotizasyon ou ye? Ou p ap bezwen peye yon kotizasyon pou medikaman ki sou Lis Medikaman an. 18. Kisa nivo medikaman ye? Nivo medikaman se yon gwoup medikaman diferan kalite ak diferan règ. Tout nivo Empire FIDA Plan pa genyen kotizasyon. Medikaman nivo 1 se medikaman jenerik ak mak komèsyal Pati D prefere. Medikaman nivo 2 se medikaman mak komèsyal ak jenerik Pati D yo pa prefere ou kapab bezwen otorizasyon davans. Medikaman nivo 3 se medikaman ki pa Pati D (ni medikaman mak komèsyal ak medikaman jenerik). Ou bezwen otorizasyon davans pou kèk medikaman. Medikaman nivo 4 genyen ladan yo medikaman ou kapab achte san preskripsyon men ou genyen yon preskripsyon. Lis Medikaman ki Garanti Lis medikaman ki garanti yo kòmanse sou pwochen paj ki ba ou enfòmasyon sou medikaman Empire FIDA Plan garanti yo. Si ou genyen difikilte pou jwenn medikaman ou an sou lis la, ale sou Endèks ki kòmanse sou paj 190. Premye ran tablo a gen non medikaman an. Non medikaman mak komèsyal yo an majiskil (pa egzanp., ABELCET), epi medikaman jenerik yo an miniskil ak italik (pa egzanp, fluconazole). Enfòmasyon ki nan ran aksyon ki nesesè, restriksyon, oswa limit sou fason pou itilize a di ou si Empire FIDA Plan genyen nenpòt règ pou garanti medikaman ou a. Men sa kèk kòd nou itilize nan ran "Aksyon ki nesesè, restriksyon, oswa limit sou fason pou itilize" an siyifi:? Si ou genyen kesyon, tanpri rele Empire FIDA Plan (TTY 711) lendi jiska vandredi kòmanse 8 a.m. rive 8 p.m. lè lokal. Koutfil la gratis. Pou plis enfòmasyon, vizite ENYDMEM

11 B/D: HI: LA: MO: Medikaman sou preskripsyon sa a kapab garanti sou Medicare Pati B (pa egzanp, sa vle di ou kapab jwenn medikaman an nan biwo pwofesyonèl swen sante ou) oswa Pati D (ki vle di ou kapab jwenn li nan famasi ou). Li depannde sikonstans yo. Ou kapab bezwen soumèt enfòmasyon ki dekri fason ak sikonstans ki fè y ap itilize medikaman an pou pran desizyon an. Nan tout ka, ou toujou p ap peye anyen pou medikaman an. Pèfizyon Nan Kay. Medikaman sou preskripsyon sa a kapab garanti sou avantaj medikal nou an. Pou plis enfòmasyon, tanpri rele Sèvis Manm. Disponiblite Limite. Medikaman sou preskripsyon sa a kapab disponib sèlman nan sèten famasi. Pou plis enfòmasyon, tanpri rele depatman Sèvis Manm. Medikaman Kòmand Pa Lapòs. Medikaman sou preskripsyon sa a disponib nan sèvis kòmand pa lapòs nou an, ansanm ak nan famasi rezo ki vann an detay nou yo. Panse itilize kòmand pa lapòs pou medikaman alontèm (pou antretyen) ou yo (tankou medikaman pou tansyon wo). Famasi rezo ki vann an detay yo kapab pi apwopriye pou medikaman akoutèm (tankou antibyotik). PAR: Otorizasyon Davans obligatwa. Plan sa a egzije pou ou menm oswa doktè ou genyen otorizasyon davans pou sèten medikaman. Sa vle di w ap bezwen resevwa otorizasyon avan pou ou ranpli preskripsyon ou yo. Si ou pa jwenn otorizasyon, nou ka pa garanti medikaman an. QLL: Limit Sou Kantite. Pou sèten medikaman, nou limite kantite nan medikaman an n ap garanti. ST: Tretman Pa Etap. Nan kèk ka, plan an egzije pou ou eseye sèten medikaman avan pou trete pwoblèm medikal ou a avan pou nou garanti yon lòt medikaman pou pwoblèm sa a. Pa egzanp, si medikaman A ak Medikaman B trete pwoblèm medikal ou a, nou kapab pa garanti Medikaman B amwenske ou eseye Medikaman A avan. Si medikaman A pa travay pou ou, lè sa a n ap garanti medikaman B. Remak: Etwal (*) ki akote medikaman an vle di medikaman an pa yon "Medikaman Pati D." Medikaman sak yo genyen diferan règ pou apèl tou. Yon apèl se yon fason fòmèl pou mande nou revize yon desizyon sou pwoteksyon epi u chanje li si w panse nou te fè yon erè. Pa egzanp, Empire FIDA Plan oswa Ekip Entèdisiplinè (IDT) ou kapab deside Medicare oswa Medicaid p ap garanti yon medikaman ou vle oswa pa garanti li ankò. Si ou menm oswa moun ki ba ou preskripsyon an pa dakò ak desizyon an, nou kapab fè yon apèl. Pou mande enstriksyon sou jan pou fè yon apèl, rele Sèvis Patisipan nan nimewo (TTY 711) oswa Medyatè Patisipan FIDA a nan nimewo Ou kapab li Liv Enfòmasyon Pou Patisipan an pou aprann jan pou fè apèl kont yon desiziyon tou.? Si ou genyen kesyon, tanpri rele Empire FIDA Plan (TTY 711) lendi jiska vandredi kòmanse 8 a.m. rive 8 p.m. lè lokal. Koutfil la gratis. Pou plis enfòmasyon, vizite ENYDMEM

12 Name of ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 2 $0 B/D PAR; MO AMBISOME 2 $0 B/D PAR; MO amphotericin b 2 $0 B/D PAR; MO CANCIDAS 2 $0 B/D PAR; MO clotrimazole mucous membrane 2 $0 MO ERAXIS(WATER DILUENT) 2 $0 PAR; MO fluconazole 2 $0 MO fluconazole in dextrose(iso-o) 2 $0 fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml 2 $0 MO 2 $0 flucytosine 2 $0 MO griseofulvin microsize oral suspension 2 $0 MO griseofulvin ultramicrosize 2 $0 MO itraconazole 2 $0 PAR; MO ketoconazole oral 2 $0 MO NOXAFIL ORAL SUSPENSION 2 $0 PAR; MO; QLL (630 per 30 days) nystatin oral suspension 2 $0 MO nystatin oral tablet 2 $0 MO terbinafine hcl oral 2 $0 MO; QLL (30 per 30 days) voriconazole intravenous 2 $0 MO voriconazole oral suspension for reconstitution 2 $0 PAR; MO; QLL (300 per 30 days) voriconazole oral tablet 200 mg 2 $0 PAR; MO; QLL (60 per 30 days) voriconazole oral tablet 50 mg 2 $0 PAR; MO; QLL (120 per 30 days) ANTIVIRALS abacavir 2 $0 MO ENYDMEM

13 Name of abacavir-lamivudine-zidovudine 2 $0 MO acyclovir oral capsule 2 $0 MO acyclovir oral suspension 200 mg/5 ml 2 $0 MO acyclovir oral tablet 2 $0 MO acyclovir sodium intravenous recon soln 500 mg 2 $0 B/D PAR acyclovir sodium intravenous solution 2 $0 B/D PAR; MO adefovir 2 $0 MO amantadine hcl oral capsule 2 $0 MO amantadine hcl oral tablet 2 $0 MO APTIVUS ORAL CAPSULE 2 $0 MO APTIVUS ORAL SOLUTION 2 $0 ATRIPLA 2 $0 MO BARACLUDE 2 $0 PAR; MO cidofovir 2 $0 B/D PAR; MO COMPLERA 2 $0 MO CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 $0 MO DAKLINZA 2 $0 PAR; MO; QLL (30 per 30 days) didanosine 2 $0 MO EDURANT 2 $0 MO EMTRIVA 2 $0 MO entecavir 2 $0 PAR; MO EPIVIR HBV ORAL SOLUTION 2 $0 MO EPIVIR ORAL SOLUTION 2 $0 MO EPZICOM 2 $0 MO EVOTAZ 2 $0 MO famciclovir oral tablet 125 mg, 250 mg 2 $0 MO; QLL (60 per 30 days) famciclovir oral tablet 500 mg 2 $0 MO; QLL (21 per 7 days) foscarnet 2 $0 B/D PAR; MO FUZEON SUBCUTANEOUS RECON SOLN 2 $0 MO; QLL (60 per 30 days) ENYDMEM

14 Name of ganciclovir sodium 2 $0 MO HARVONI 2 $0 PAR; MO; QLL (28 per 28 days) INTELENCE ORAL TABLET 100 MG, 200 MG 2 $0 MO INTELENCE ORAL TABLET 25 MG 2 $0 INVIRASE 2 $0 MO ISENTRESS 2 $0 MO KALETRA 2 $0 MO lamivudine 2 $0 MO lamivudine-zidovudine 2 $0 MO LEXIVA 2 $0 MO nevirapine 2 $0 MO NORVIR 2 $0 MO OLYSIO 2 $0 PAR; MO PREZCOBIX 2 $0 MO PREZISTA ORAL SUSPENSION 2 $0 MO PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 2 $0 MO RELENZA DISKHALER 2 $0 MO; QLL (60 per 180 days) RESCRIPTOR 2 $0 MO RETROVIR INTRAVENOUS 2 $0 MO REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 2 $0 MO REYATAZ ORAL POWDER IN PACKET 2 $0 MO ribasphere oral capsule 2 $0 PAR; MO ribasphere oral tablet 200 mg 2 $0 PAR; MO ribavirin oral capsule 2 $0 PAR; MO ribavirin oral tablet 200 mg 2 $0 PAR; MO rimantadine 2 $0 MO SELZENTRY 2 $0 MO ENYDMEM

15 Name of SOVALDI 2 $0 PAR; MO stavudine 2 $0 MO STRIBILD 2 $0 MO SUSTIVA 2 $0 MO SYNAGIS 2 $0 PAR; MO; LA TAMIFLU ORAL CAPSULE 30 MG 2 $0 MO; QLL (84 per 1 day) TAMIFLU ORAL CAPSULE 45 MG 2 $0 MO; QLL (42 per 1 day) TAMIFLU ORAL CAPSULE 75 MG 2 $0 MO; QLL (56 per 365 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TIVICAY 2 $0 MO TRIUMEQ 2 $0 MO TRIZIVIR 2 $0 MO TRUVADA 2 $0 MO TYBOST 2 $0 MO 2 $0 MO; QLL (360 per 180 days) TYZEKA 2 $0 PAR; MO valacyclovir 2 $0 MO; QLL (30 per 1 day) VALCYTE ORAL TABLET 2 $0 MO valganciclovir 2 $0 MO VIDEX 2 GRAM PEDIATRIC 2 $0 MO VIDEX 4 GRAM PEDIATRIC 2 $0 MO VIEKIRA PAK 2 $0 PAR; MO VIRACEPT ORAL TABLET 2 $0 MO VIRAMUNE XR 2 $0 MO VIRAZOLE 2 $0 PAR; MO VIREAD ORAL POWDER 2 $0 MO; QLL (240 per 30 days) VIREAD ORAL TABLET 2 $0 MO VITEKTA 2 $0 MO ZIAGEN ORAL SOLUTION 2 $0 MO ENYDMEM

16 Name of zidovudine 2 $0 MO CEPHALOSPORINS cefaclor oral capsule 2 $0 MO cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml 2 $0 MO cefaclor oral tablet extended release 12 hr 2 $0 MO cefadroxil oral capsule 2 $0 MO cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 2 $0 MO cefadroxil oral tablet 2 $0 MO cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 2 $0 MO cefazolin injection recon soln 1 gram, 500 mg 2 $0 MO cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g 2 $0 cefazolin intravenous 2 $0 cefdinir 2 $0 MO cefepime 2 $0 MO cefoxitin in dextrose, iso-osm 2 $0 cefoxitin intravenous recon soln 1 gram 2 $0 MO cefoxitin intravenous recon soln 10 gram, 2 gram 2 $0 cefpodoxime 2 $0 MO cefprozil 2 $0 MO ceftazidime injection recon soln 1 gram, 2 gram 2 $0 MO ceftazidime injection recon soln 6 gram 2 $0 ceftriaxone in dextrose,iso-os 2 $0 MO ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg 2 $0 MO ceftriaxone injection recon soln 10 gram 2 $0 ceftriaxone intravenous recon soln 2 $0 MO ENYDMEM

17 Name of cefuroxime axetil oral tablet 2 $0 MO cefuroxime sodium injection recon soln 1.5 gram, 750 mg 2 $0 MO cefuroxime sodium intravenous 2 $0 cephalexin oral capsule 250 mg, 500 mg 1 $0 MO cephalexin oral suspension for reconstitution 1 $0 MO cephalexin oral tablet 1 $0 MO TEFLARO 2 $0 MO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous 2 $0 MO azithromycin oral suspension for reconstitution 2 $0 MO azithromycin oral tablet 250 mg (6 pack) 2 $0 azithromycin oral tablet 250 mg, 500 mg, 600 mg 2 $0 MO clarithromycin oral suspension for reconstitution 2 $0 MO clarithromycin oral tablet 2 $0 MO clarithromycin oral tablet extended release 24 hr 2 $0 MO; QLL (28 per 1 day) ery-tab 2 $0 MO erythrocin (as stearate) oral tablet 250 mg 2 $0 MO ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG 2 $0 erythromycin ethylsuccinate oral tablet 2 $0 MO erythromycin oral tablet 2 $0 MO MISCELLANEOUS ANTIINFECTIVES ALBENZA 2 $0 MO ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET 2 $0 MO amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml 2 $0 MO; QLL (180 per 3 days) 2 $0 MO atovaquone 2 $0 PAR; MO ENYDMEM

18 Name of atovaquone-proguanil 2 $0 MO AZACTAM IN DEXTROSE (ISO-OSM) 2 $0 aztreonam 2 $0 MO baciim 2 $0 BILTRICIDE 2 $0 MO CAPASTAT 2 $0 CAYSTON 2 $0 PAR; MO; LA chloramphenicol sod succinate 2 $0 chloroquine phosphate oral 2 $0 MO clindamycin hcl 2 $0 MO clindamycin phosphate injection 2 $0 MO clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml 2 $0 2 $0 MO colistin (colistimethate na) 2 $0 MO DAPSONE 2 $0 MO DARAPRIM 2 $0 MO ethambutol 2 $0 MO gentamicin injection 2 $0 MO gentamicin sulfate (ped) (pf) 2 $0 MO gentamicin sulfate (pf) intravenous solution 100 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml 2 $0 MO 2 $0 2 $0 hydroxychloroquine oral 1 $0 MO imipenem-cilastatin 2 $0 MO INVANZ INJECTION 2 $0 MO ENYDMEM

19 Name of isoniazid oral 1 $0 MO ivermectin oral 2 $0 MO linezolid intravenous 2 $0 linezolid oral 2 $0 PAR; MO; QLL (28 per 1 day) linezolid-0.9% sodium chloride 2 $0 mefloquine 2 $0 MO MEPRON 2 $0 PAR; MO meropenem 2 $0 MO metro i.v. 2 $0 MO metronidazole in nacl (iso-os) 2 $0 MO metronidazole oral 2 $0 MO MYCOBUTIN 2 $0 MO NEBUPENT 2 $0 B/D PAR; MO neomycin 2 $0 MO paromomycin 2 $0 MO PASER 2 $0 MO PENTAM 2 $0 MO pin-x oral suspension 4 $0 [*] PIN-X ORAL TABLET,CHEWABLE 4 $0 MO; [*] PRIFTIN 2 $0 MO PRIMAQUINE 2 $0 MO pyrazinamide 2 $0 MO reese's pinworm medicine 4 $0 [*] rifabutin 2 $0 MO rifampin intravenous 2 $0 MO rifampin oral 2 $0 MO RIFATER 2 $0 MO STREPTOMYCIN INTRAMUSCULAR 2 $0 MO STROMECTOL 2 $0 MO ENYDMEM

20 Name of SYNERCID 2 $0 tobramycin in % nacl 2 $0 B/D PAR; MO; QLL (280 per 28 days) tobramycin sulfate injection recon soln 2 $0 tobramycin sulfate injection solution 2 $0 MO TRECATOR 2 $0 MO TYGACIL 2 $0 MO XIFAXAN ORAL TABLET 550 MG 2 $0 MO ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 2 $0 2 $0 MO 2 $0 PAR; MO; QLL (1800 per 1 day) ZYVOX ORAL TABLET 2 $0 PAR; MO; QLL (28 per 1 day) PENICILLINS amoxicillin oral capsule 1 $0 MO amoxicillin oral suspension for reconstitution 1 $0 MO amoxicillin oral tablet 1 $0 MO amoxicillin oral tablet,chewable 125 mg, 250 mg 1 $0 MO amoxicillin-pot clavulanate 2 $0 MO ampicillin 2 $0 MO ampicillin sodium injection 2 $0 MO ampicillin sodium intravenous 2 $0 ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram 2 $0 MO ampicillin-sulbactam injection recon soln 15 gram 2 $0 ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram 2 $0 2 $0 MO ENYDMEM

21 Name of BICILLIN C-R 2 $0 MO BICILLIN L-A 2 $0 MO dicloxacillin 2 $0 MO nafcillin injection 2 $0 MO nafcillin intravenous recon soln 2 gram 2 $0 MO oxacillin injection 2 $0 MO oxacillin intravenous 2 $0 PENICILLIN G POT IN DEXTROSE 2 $0 penicillin g potassium 2 $0 MO penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml 2 $0 MO 2 $0 penicillin g sodium 2 $0 MO penicillin v potassium 2 $0 MO piperacillin-tazobactam 2 $0 MO QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg 1 $0 MO; QLL (14 per 1 day) 1 $0 MO; QLL (3 per 1 day) ciprofloxacin hcl oral tablet 1 $0 MO ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml 1 $0 MO 1 $0 levofloxacin intravenous 2 $0 MO levofloxacin oral tablet 2 $0 MO; QLL (14 per 1 day) moxifloxacin 2 $0 MO; QLL (21 per 1 day) ofloxacin oral tablet 400 mg 2 $0 SULFA'S / RELATED AGENTS ENYDMEM

22 Name of sulfadiazine oral 2 $0 MO sulfamethoxazole-trimethoprim 1 $0 MO TETRACYCLINES demeclocycline oral 2 $0 MO DOXY $0 MO doxycycline hyclate intravenous 2 $0 doxycycline hyclate oral capsule 2 $0 MO doxycycline hyclate oral tablet 100 mg, 20 mg 2 $0 MO doxycycline hyclate oral tablet 50 mg 2 $0 doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg 2 $0 MO 2 $0 MO doxycycline monohydrate oral capsule 75 mg 2 $0 MO; QLL (60 per 1 day) doxycycline monohydrate oral tablet 2 $0 MO minocycline oral capsule 2 $0 MO minocycline oral tablet 2 $0 MO tetracycline 2 $0 MO URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 50 MG 2 $0 PAR; MO methenamine hippurate 2 $0 MO nitrofurantoin macrocrystal oral capsule 50 mg 2 $0 PAR; MO trimethoprim 2 $0 MO VANCOMYCIN VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/200 ML VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 500 MG/100 ML 2 $0 B/D PAR; MO 2 $0 B/D PAR VANCOMYCIN IN DEXTROSE ISO-OSM 2 $0 B/D PAR vancomycin intravenous 2 $0 B/D PAR; MO ENYDMEM

23 Name of vancomycin oral capsule 125 mg 2 $0 PAR; MO; QLL (40 per 1 day) vancomycin oral capsule 250 mg 2 $0 PAR; MO; QLL (80 per 1 day) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline 2 $0 PAR; MO dexrazoxane hcl intravenous recon soln 250 mg 2 $0 B/D PAR dexrazoxane hcl intravenous recon soln 500 mg 2 $0 B/D PAR; MO ELITEK 2 $0 PAR; MO FUSILEV 2 $0 B/D PAR; MO KEPIVANCE 2 $0 leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg 2 $0 B/D PAR; MO leucovorin calcium injection recon soln 500 mg 2 $0 B/D PAR leucovorin calcium oral 2 $0 MO mesna 2 $0 B/D PAR; MO MESNEX ORAL 2 $0 MO XGEVA 2 $0 PAR; MO; QLL (1.7 per 28 days) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 2 $0 B/D PAR; MO AFINITOR 2 $0 PAR; MO AFINITOR DISPERZ 2 $0 PAR; MO ALIMTA 2 $0 PAR; MO anastrozole 2 $0 MO ARRANON 2 $0 B/D PAR ARZERRA 2 $0 B/D PAR; MO ASTAGRAF XL 2 $0 B/D PAR; MO AVASTIN INTRAVENOUS SOLUTION 25 MG/ML 2 $0 PAR; MO ENYDMEM

24 Name of AVASTIN INTRAVENOUS SOLUTION 25 MG/ML (16 ML) 2 $0 PAR azacitidine 2 $0 PAR; MO azathioprine 2 $0 B/D PAR; MO BELEODAQ 2 $0 PAR; MO bexarotene 2 $0 PAR; MO bicalutamide 2 $0 MO BICNU 2 $0 B/D PAR; MO bleomycin 2 $0 B/D PAR; MO BLINCYTO 2 $0 PAR; MO BOSULIF 2 $0 PAR; MO BUSULFEX 2 $0 B/D PAR CAPRELSA 2 $0 PAR; MO; LA carboplatin intravenous solution 2 $0 B/D PAR; MO CELLCEPT INTRAVENOUS 2 $0 B/D PAR; MO CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 2 $0 B/D PAR; MO cisplatin 2 $0 B/D PAR; MO cladribine 2 $0 B/D PAR; MO CLOLAR 2 $0 B/D PAR; MO COMETRIQ 2 $0 PAR; MO COSMEGEN 2 $0 B/D PAR; MO cyclophosphamide oral capsule 2 $0 B/D PAR; MO cyclosporine intravenous 2 $0 B/D PAR cyclosporine modified 2 $0 B/D PAR; MO cyclosporine oral capsule 2 $0 B/D PAR; MO CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML (50 ML) 2 $0 PAR; MO 2 $0 PAR ENYDMEM

25 Name of cytarabine 2 $0 B/D PAR; MO cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) 2 $0 B/D PAR; MO cytarabine (pf) injection solution 20 mg/ml 2 $0 B/D PAR dacarbazine 2 $0 B/D PAR; MO daunorubicin intravenous solution 2 $0 B/D PAR DAUNOXOME 2 $0 B/D PAR; MO decitabine 2 $0 B/D PAR; MO DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ml, 140 mg/7 ml (20 mg/ml), 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) 2 $0 B/D PAR 2 $0 B/D PAR 2 $0 B/D PAR; MO DOXIL 2 $0 B/D PAR; MO doxorubicin intravenous recon soln 2 $0 B/D PAR doxorubicin intravenous solution 2 $0 B/D PAR; MO DROXIA 2 $0 MO EMCYT 2 $0 MO epirubicin intravenous solution 200 mg/100 ml 2 $0 B/D PAR epirubicin intravenous solution 50 mg/25 ml 2 $0 B/D PAR; MO ERBITUX 2 $0 PAR; MO ERIVEDGE 2 $0 PAR; MO ERWINAZE 2 $0 B/D PAR; MO ETOPOPHOS 2 $0 B/D PAR; MO etoposide intravenous 2 $0 B/D PAR; MO exemestane 2 $0 MO FARESTON 2 $0 MO FARYDAK ORAL CAPSULE 10 MG 2 $0 PAR; MO; QLL (60 per 30 days) ENYDMEM

26 Name of FARYDAK ORAL CAPSULE 15 MG, 20 MG 2 $0 PAR; MO; QLL (30 per 30 days) FASLODEX 2 $0 PAR; MO FIRMAGON KIT W DILUENT SYRINGE 2 $0 B/D PAR; MO fludarabine intravenous recon soln 2 $0 B/D PAR; MO fludarabine intravenous solution 2 $0 B/D PAR fluorouracil intravenous 2 $0 B/D PAR; MO flutamide 2 $0 MO FOLOTYN 2 $0 B/D PAR; MO GAZYVA 2 $0 PAR; MO gemcitabine intravenous recon soln 1 gram, 200 mg 2 $0 B/D PAR; MO gemcitabine intravenous recon soln 2 gram 2 $0 B/D PAR gemcitabine intravenous solution 2 $0 B/D PAR gengraf 2 $0 B/D PAR; MO GILOTRIF 2 $0 PAR; MO GLEEVEC 2 $0 PAR; MO GLEOSTINE 2 $0 MO HALAVEN 2 $0 PAR; MO HERCEPTIN 2 $0 PAR; MO HEXALEN 2 $0 MO hydroxyurea 2 $0 MO IBRANCE 2 $0 PAR; MO; QLL (30 per 30 days) ICLUSIG 2 $0 PAR; MO idarubicin 2 $0 B/D PAR IFEX 2 $0 B/D PAR; MO ifosfamide intravenous recon soln 1 gram 2 $0 B/D PAR; MO ifosfamide intravenous recon soln 3 gram 2 $0 B/D PAR ifosfamide intravenous solution 2 $0 B/D PAR IMBRUVICA 2 $0 PAR; MO ENYDMEM

27 Name of INLYTA 2 $0 PAR; MO irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml 2 $0 B/D PAR; MO irinotecan intravenous solution 500 mg/25 ml 2 $0 B/D PAR ISTODAX 2 $0 PAR; MO IXEMPRA 2 $0 B/D PAR; MO JAKAFI 2 $0 PAR; MO JEVTANA 2 $0 B/D PAR; MO KADCYLA 2 $0 PAR; MO KEYTRUDA 2 $0 PAR; MO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY) LENVIMA ORAL CAPSULE 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY) LENVIMA ORAL CAPSULE 24 MG (10 MG[2] -4 MG[1])/DAY letrozole 2 $0 MO LEUKERAN 2 $0 MO 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (60 per 30 days) 2 $0 PAR; MO; QLL (90 per 30 days) leuprolide 2 $0 PAR; MO LOMUSTINE 2 $0 MO LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) 2 $0 PAR; MO 2 $0 PAR; MO LYNPARZA 2 $0 PAR; MO; QLL (480 per 30 days) LYSODREN 2 $0 MO MATULANE 2 $0 MO megestrol oral suspension 400 mg/10 ml (10 ml) 2 $0 PAR megestrol oral suspension 400 mg/10 ml (40 mg/ml) 2 $0 PAR; MO megestrol oral tablet 2 $0 PAR; MO ENYDMEM

28 Name of MEKINIST 2 $0 PAR; MO melphalan hcl 2 $0 B/D PAR mercaptopurine 2 $0 MO methotrexate sodium 2 $0 MO methotrexate sodium (pf) injection recon soln 2 $0 methotrexate sodium (pf) injection solution 2 $0 MO mitomycin 2 $0 B/D PAR; MO mitoxantrone 2 $0 MO MUSTARGEN 2 $0 B/D PAR; MO mycophenolate mofetil 2 $0 B/D PAR; MO mycophenolate sodium 2 $0 B/D PAR; MO NEXAVAR 2 $0 PAR; MO; LA; QLL (120 per 30 days) NILANDRON 2 $0 MO NIPENT 2 $0 B/D PAR; MO NULOJIX 2 $0 B/D PAR; MO octreotide acetate 2 $0 PAR; MO ONCASPAR 2 $0 B/D PAR; MO OPDIVO 2 $0 PAR; MO oxaliplatin intravenous recon soln 100 mg 2 $0 B/D PAR; MO oxaliplatin intravenous recon soln 50 mg 2 $0 B/D PAR oxaliplatin intravenous solution 2 $0 B/D PAR; MO paclitaxel 2 $0 B/D PAR; MO PERJETA 2 $0 PAR; MO POMALYST 2 $0 PAR; MO PROGRAF INTRAVENOUS 2 $0 B/D PAR; MO PURIXAN 2 $0 PAR; MO RAPAMUNE 2 $0 B/D PAR; MO REVLIMID ORAL CAPSULE 10 MG 2 $0 PAR; MO; LA; QLL (60 per 30 days) ENYDMEM

29 Name of REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG 2 $0 PAR; MO; LA; QLL (30 per 30 days) REVLIMID ORAL CAPSULE 5 MG 2 $0 PAR; MO; LA; QLL (150 per 30 days) RITUXAN 2 $0 PAR; MO SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG 2 $0 B/D PAR 2 $0 B/D PAR; MO sirolimus 2 $0 B/D PAR; MO SOLTAMOX 2 $0 MO SOMATULINE DEPOT 2 $0 MO SPRYCEL 2 $0 PAR; MO STIVARGA 2 $0 PAR; MO; QLL (120 per 30 days) SUTENT 2 $0 PAR; MO SYNRIBO 2 $0 PAR; MO TABLOID 2 $0 MO tacrolimus oral 2 $0 B/D PAR; MO TAFINLAR 2 $0 PAR; MO tamoxifen 2 $0 MO TARCEVA 2 $0 PAR; MO TARGRETIN 2 $0 PAR; MO TASIGNA 2 $0 PAR; MO THALOMID ORAL CAPSULE 100 MG, 50 MG 2 $0 PAR; MO; QLL (30 per 30 days) THALOMID ORAL CAPSULE 150 MG, 200 MG 2 $0 PAR; MO; QLL (60 per 30 days) thiotepa 2 $0 B/D PAR; MO toposar 2 $0 B/D PAR; MO topotecan 2 $0 B/D PAR; MO TORISEL 2 $0 B/D PAR; MO TREANDA 2 $0 B/D PAR; MO ENYDMEM

30 Name of TRELSTAR 2 $0 MO TRELSTAR DEPOT 2 $0 TRELSTAR LA 2 $0 tretinoin (chemotherapy) 2 $0 MO TREXALL 2 $0 MO TRISENOX 2 $0 B/D PAR; MO TYKERB 2 $0 PAR; MO; LA UNITUXIN 2 $0 MO VECTIBIX 2 $0 PAR; MO VELCADE 2 $0 PAR; MO vinblastine intravenous solution 2 $0 B/D PAR; MO vincasar pfs intravenous solution 1 mg/ml 2 $0 B/D PAR vincasar pfs intravenous solution 2 mg/2 ml 2 $0 B/D PAR; MO vincristine 2 $0 B/D PAR; MO vinorelbine 2 $0 B/D PAR; MO VOTRIENT 2 $0 PAR; MO XALKORI 2 $0 PAR; MO XTANDI 2 $0 PAR; MO YERVOY 2 $0 PAR; MO ZALTRAP 2 $0 PAR; MO ZANOSAR 2 $0 B/D PAR; MO ZELBORAF 2 $0 PAR; MO ZOLINZA 2 $0 PAR; MO ZORTRESS 2 $0 B/D PAR; MO ZYDELIG 2 $0 PAR; MO; QLL (60 per 30 days) ZYKADIA 2 $0 PAR; MO ZYTIGA 2 $0 PAR; MO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ENYDMEM

31 Name of ANTICONVULSANTS APTIOM 2 $0 ST; MO BANZEL ORAL SUSPENSION 2 $0 PAR; MO; QLL (2400 per 30 days) BANZEL ORAL TABLET 200 MG 2 $0 PAR; MO; QLL (480 per 30 days) BANZEL ORAL TABLET 400 MG 2 $0 PAR; MO; QLL (240 per 30 days) carbamazepine oral capsule, er multiphase 12 hr 2 $0 MO carbamazepine oral suspension 100 mg/5 ml 2 $0 MO carbamazepine oral tablet 2 $0 MO carbamazepine oral tablet extended release 12 hr 2 $0 MO carbamazepine oral tablet,chewable 2 $0 MO CELONTIN ORAL CAPSULE 300 MG 2 $0 MO clonazepam oral tablet 0.5 mg 2 $0 PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet 1 mg 2 $0 PAR; MO; QLL (600 per 30 days) clonazepam oral tablet 2 mg 2 $0 PAR; MO; QLL (300 per 30 days) clonazepam oral tablet,disintegrating mg 2 $0 PAR; MO; QLL (4800 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg 2 $0 PAR; MO; QLL (2400 per 30 days) clonazepam oral tablet,disintegrating 0.5 mg 2 $0 PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet,disintegrating 1 mg 2 $0 PAR; MO; QLL (600 per 30 days) clonazepam oral tablet,disintegrating 2 mg 2 $0 PAR; MO; QLL (300 per 30 days) diazepam rectal 2 $0 MO; QLL (2 per 1 day) DILANTIN CAPSULES 2 $0 MO DILANTIN EXTENDED CAPSULES 2 $0 MO DILANTIN INFATABS 2 $0 MO divalproex 2 $0 MO epitol 2 $0 MO EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG 2 $0 MO; QLL (480 per 30 days) 2 $0 MO; QLL (240 per 30 days) ENYDMEM

32 Name of EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ethosuximide 2 $0 MO felbamate 2 $0 MO 2 $0 MO; QLL (180 per 30 days) fosphenytoin 2 $0 B/D PAR; MO FYCOMPA ORAL TABLET 10 MG, 12 MG 2 $0 MO; QLL (30 per 30 days) FYCOMPA ORAL TABLET 2 MG 2 $0 MO; QLL (180 per 30 days) FYCOMPA ORAL TABLET 4 MG 2 $0 MO; QLL (90 per 30 days) FYCOMPA ORAL TABLET 6 MG 2 $0 MO; QLL (60 per 30 days) FYCOMPA ORAL TABLET 8 MG 2 $0 MO; QLL (45 per 30 days) gabapentin oral capsule 100 mg 2 $0 MO; QLL (1080 per 30 days) gabapentin oral capsule 300 mg 2 $0 MO; QLL (360 per 30 days) gabapentin oral capsule 400 mg 2 $0 MO; QLL (270 per 30 days) gabapentin oral solution 250 mg/5 ml 2 $0 MO; QLL (2160 per 30 days) gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) 2 $0 QLL (2160 per 30 days) gabapentin oral tablet 600 mg 2 $0 MO; QLL (180 per 30 days) gabapentin oral tablet 800 mg 2 $0 MO; QLL (135 per 30 days) GABITRIL 2 $0 MO lamotrigine oral tablet 2 $0 MO lamotrigine oral tablet, chewable dispersible 2 $0 MO levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml 2 $0 B/D PAR 2 $0 B/D PAR; MO levetiracetam intravenous 2 $0 B/D PAR; MO levetiracetam oral solution 100 mg/ml 2 $0 MO levetiracetam oral solution 500 mg/5 ml (5 ml) 2 $0 levetiracetam oral tablet 2 $0 MO ENYDMEM

33 Name of levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg 2 $0 MO; QLL (180 per 30 days) 2 $0 MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 100 MG 2 $0 PAR; MO; QLL (180 per 30 days) LYRICA ORAL CAPSULE 150 MG 2 $0 PAR; MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 200 MG 2 $0 PAR; MO; QLL (90 per 30 days) LYRICA ORAL CAPSULE 225 MG, 300 MG 2 $0 PAR; MO; QLL (60 per 30 days) LYRICA ORAL CAPSULE 25 MG 2 $0 PAR; MO; QLL (720 per 30 days) LYRICA ORAL CAPSULE 50 MG 2 $0 PAR; MO; QLL (360 per 30 days) LYRICA ORAL CAPSULE 75 MG 2 $0 PAR; MO; QLL (240 per 30 days) LYRICA ORAL SOLUTION 2 $0 PAR; MO; QLL (900 per 30 days) ONFI ORAL SUSPENSION 2 $0 PAR; MO; QLL (480 per 30 days) ONFI ORAL TABLET 10 MG 2 $0 PAR; MO; QLL (120 per 30 days) ONFI ORAL TABLET 20 MG 2 $0 PAR; MO; QLL (60 per 30 days) oxcarbazepine 2 $0 MO OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG PEGANONE 2 $0 MO 2 $0 MO; QLL (480 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (120 per 30 days) phenobarbital oral elixir 2 $0 PAR; MO; QLL (3000 per 30 days) phenobarbital oral tablet 100 mg 2 $0 PAR; QLL (120 per 30 days) phenobarbital oral tablet 15 mg 2 $0 PAR; MO; QLL (800 per 30 days) phenobarbital oral tablet 16.2 mg 2 $0 PAR; MO; QLL (741 per 30 days) phenobarbital oral tablet 30 mg 2 $0 PAR; MO; QLL (400 per 30 days) phenobarbital oral tablet 32.4 mg 2 $0 PAR; MO; QLL (370 per 30 days) phenobarbital oral tablet 60 mg 2 $0 PAR; MO; QLL (200 per 30 days) ENYDMEM

34 Name of phenobarbital oral tablet 64.8 mg 2 $0 PAR; MO; QLL (185 per 30 days) phenobarbital oral tablet 97.2 mg 2 $0 PAR; MO; QLL (123 per 30 days) phenytoin oral suspension 100 mg/4 ml 2 $0 phenytoin oral suspension 125 mg/5 ml 2 $0 MO phenytoin oral tablet,chewable 2 $0 MO phenytoin sodium extended 2 $0 MO phenytoin sodium intravenous solution 2 $0 B/D PAR; MO phenytoin sodium intravenous syringe 2 $0 B/D PAR POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG 2 $0 MO; QLL (90 per 30 days) POTIGA ORAL TABLET 50 MG 2 $0 MO; QLL (270 per 30 days) primidone 2 $0 MO SABRIL 2 $0 PAR; MO; LA; QLL (180 per 30 days) tiagabine 2 $0 MO topiramate oral capsule, sprinkle 2 $0 PAR; MO topiramate oral tablet 2 $0 PAR; MO valproate sodium 2 $0 B/D PAR; MO valproic acid 2 $0 MO valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) 2 $0 MO 2 $0 VIMPAT INTRAVENOUS 2 $0 B/D PAR; QLL (1200 per 30 days) VIMPAT ORAL SOLUTION 2 $0 MO; QLL (1200 per 30 days) VIMPAT ORAL TABLET 100 MG 2 $0 MO; QLL (120 per 30 days) VIMPAT ORAL TABLET 150 MG 2 $0 MO; QLL (80 per 30 days) VIMPAT ORAL TABLET 200 MG 2 $0 MO; QLL (60 per 30 days) VIMPAT ORAL TABLET 50 MG 2 $0 MO; QLL (240 per 30 days) zonisamide 2 $0 MO ENYDMEM

35 Name of ANTIPARKINSONISM AGENTS APOKYN 2 $0 PAR; MO; LA AZILECT 2 $0 MO benztropine oral 2 $0 PAR; MO bromocriptine 2 $0 MO carbidopa-levodopa 2 $0 MO entacapone 2 $0 MO NEUPRO 2 $0 PAR; MO; QLL (30 per 30 days) pramipexole oral tablet 2 $0 MO ropinirole oral tablet 2 $0 MO selegiline hcl 2 $0 MO TASMAR ORAL TABLET 100 MG 2 $0 MO tolcapone 2 $0 MO MIGRAINE / CLUSTER HEADACHE THERAPY ERGOMAR 2 $0 MO MIGRANAL 2 $0 MO; QLL (8 per 28 days) rizatriptan 2 $0 MO; QLL (12 per 30 days) sumatriptan succinate oral 2 $0 MO; QLL (9 per 30 days) sumatriptan succinate subcutaneous cartridge 2 $0 MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml (auto-injector) 2 $0 MO; QLL (4 per 30 days) 2 $0 QLL (4 per 30 days) sumatriptan succinate subcutaneous solution 2 $0 MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml 2 $0 QLL (4 per 30 days) zolmitriptan 2 $0 MO; QLL (9 per 30 days) ZOMIG NASAL 2 $0 MO; QLL (6 per 30 days) MISCELLANEOUS NEUROLOGICAL THERAPY ENYDMEM

36 Name of AMPYRA 2 $0 PAR; MO; LA; QLL (60 per 30 days) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (12 per 28 days) donepezil oral tablet 10 mg, 5 mg 2 $0 MO; QLL (30 per 30 days) donepezil oral tablet,disintegrating 2 $0 MO; QLL (30 per 30 days) EXELON TRANSDERMAL 2 $0 MO; QLL (30 per 30 days) galantamine oral capsule,ext rel. pellets 24 hr 2 $0 MO; QLL (30 per 30 days) galantamine oral solution 2 $0 MO; QLL (180 per 30 days) galantamine oral tablet 2 $0 MO; QLL (60 per 30 days) GILENYA 2 $0 PAR; MO; QLL (30 per 30 days) GLATOPA 2 $0 PAR; MO; QLL (30 per 30 days) NAMENDA ORAL SOLUTION 2 $0 PAR; MO; QLL (300 per 30 days) NAMENDA ORAL TABLET 10 MG 2 $0 MO; QLL (60 per 30 days) NAMENDA ORAL TABLET 5 MG 2 $0 MO; QLL (90 per 30 days) NAMENDA TITRATION PAK 2 $0 MO; QLL (60 per 30 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC 2 $0 MO 2 $0 PAR; MO; QLL (28 per 365 days) 2 $0 PAR; MO; QLL (30 per 30 days) NUEDEXTA 2 $0 MO; QLL (60 per 30 days) rivastigmine tartrate oral capsule 2 $0 MO; QLL (60 per 30 days) rivastigmine transdermal patch 2 $0 MO; QLL (30 per 30 days) TECFIDERA 2 $0 PAR; MO tetrabenazine oral tablet 12.5 mg 2 $0 PAR; MO; QLL (240 per 30 days) tetrabenazine oral tablet 25 mg 2 $0 PAR; MO; QLL (120 per 30 days) TYSABRI 2 $0 MO; LA ENYDMEM

37 Name of XENAZINE ORAL TABLET 12.5 MG 2 $0 PAR; MO; LA; QLL (240 per 30 days) XENAZINE ORAL TABLET 25 MG 2 $0 PAR; MO; LA; QLL (120 per 30 days) MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen 2 $0 MO cyclobenzaprine oral tablet 2 $0 PAR; MO dantrolene 2 $0 MO MESTINON ORAL SYRUP 2 $0 MO MESTINON TIMESPAN 2 $0 MO pyridostigmine bromide 2 $0 MO tizanidine oral tablet 2 $0 MO NARCOTIC ANALGESICS ABSTRAL 2 $0 PAR; MO; QLL (120 per 30 days) acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral solution mg/5 ml 2 $0 QLL (4500 per 30 days) 2 $0 MO; QLL (4500 per 30 days) acetaminophen-codeine oral tablet mg 2 $0 MO; QLL (390 per 30 days) acetaminophen-codeine oral tablet mg 2 $0 MO; QLL (360 per 30 days) acetaminophen-codeine oral tablet mg 2 $0 MO; QLL (180 per 30 days) ACTIQ 2 $0 PAR; MO; QLL (120 per 30 days) buprenorphine hcl injection solution 2 $0 MO buprenorphine hcl injection syringe 2 $0 buprenorphine hcl sublingual tablet 2 mg 2 $0 PAR; MO; QLL (240 per 30 days) buprenorphine hcl sublingual tablet 8 mg 2 $0 PAR; MO; QLL (60 per 30 days) butalbital compound w/codeine 2 $0 PAR; MO duramorph (pf) injection solution 0.5 mg/ml 2 $0 B/D PAR; MO duramorph (pf) injection solution 1 mg/ml 2 $0 B/D PAR ENYDMEM