Senior Care Plus Formulary. (List of Covered Drugs)

Transcription

1 Senior Care Plus 2016 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID: , Version: 7 This formulary was updated on 08/19/2015. For more recent information or other questions, please contact us, Senior Care Plus, at or toll-free at or, for TTY users, the State Relay Service at 711, 8 am to 8 pm Monday through Sunday (10/15-2/14) and 8 am to 8 pm Monday through Friday (2/15-10/14), or visit Senior Care Plus is a Medicare Advantage plan and a stand-alone Prescription Plan with a Medicare contract. Enrollment in Senior Care Plus depends on contract renewal. This information is available for free in other languages. Please call our customer service number at Senior Care Plus Customer Service at , toll-free at TTY users should call the State Relay Service at 711. We are open 8 a.m. to 8 p.m., Monday - Sunday (10/15-02/14) and 8 a.m. to 8 p.m. Monday - Friday (02/15-10/14). Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de servicio al cliente al Servicio al Cliente Senior Care Plus al , sin cargo al Los usuarios de TTY deben llamar al Servicio de Retransmisión del Estado al 711 Estamos de 8 am a 8 pm, Lunes -. Domingo (10.15 a 02.14) y 8 am a 8 pm de lunes - viernes (02.15 a 10.14). Material ID: Y0039_2016_FormularyHandbook CMS Accepted 1

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Senior Care Plus. When it refers to plan or our plan, it means Senior Care Plus. This document includes a list of the drugs (formulary) for our plan which is current as of 08/19/2015. For updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. What is the Senior Care Plus Formulary? A formulary is a list of covered drugs selected by Senior Care Plus in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Senior Care Plus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Senior Care Plus network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 08/19/2015. To get updated information about the drugs covered by Senior Care Plus, please contact us. Our contact information appears on the front and back cover pages. Senior Care Plus may choose to disseminate an errata sheet or addendum during the year to update members with respect to changes in providers or pharmacies; addresses and phone numbers, as well Material ID: Y0039_2016_FormularyHandbook CMS Accepted 2

3 as prescription drug coverage. Senior Care Plus may make any necessary formulary changes via errata sheets mailed to affected members. Senior Care Plus is required to provide information about contracted providers and pharmacies and formulary information upon request. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 14 The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 9. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 170. The Index provides an alphabetical list of all of the drugs included in this Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Senior Care Plus covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Senior Care Plus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Senior Care Plus before you fill your prescriptions. If you don t get approval, Senior Care Plus may not cover the drug. Quantity Limits: For certain drugs, Senior Care Plus limits the amount of the drug that Senior Care Plus will cover. For example, Senior Care Plus provides 30 tablets in 30 days per prescription for simvastatin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Senior Care Plus requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and Material ID: Y0039_2016_FormularyHandbook CMS Accepted 3

4 B both treat your medical condition, Senior Care Plus may not cover B unless you try A first. If A does not work for you, Senior Care Plus will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 14. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization restriction, step therapy restriction, prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Senior Care Plus to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Senior Care Plus s formulary? on page 4 for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Plan. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Senior Care Plus does not cover your drug, you have two options: You can ask Customer Services for a list of similar drugs that are covered by Senior Care Plus. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Senior Care Plus. You can ask Senior Care Plus to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Senior Care Plus Formulary? You can ask Senior Care Plus to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. Material ID: Y0039_2016_FormularyHandbook CMS Accepted 4

5 You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Senior Care Plus limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Senior Care Plus will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 91-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. Transition fills include the transition of new Enrollees into a Medicare Part D Plan following the annual coordinated election period; the transition of newly eligible Enrollees into a Medicare Part D Plan from other coverage; the transition of enrollees from one plan to another after the start of a plan year (i.e. after January 1); Enrollees residing in a Long-Term- Care (LTC) Facility; and current Enrollees in a Medicare Part D Plan affected by Formulary changes from one plan year to the next. Material ID: Y0039_2016_FormularyHandbook CMS Accepted 5

6 The transition period is the first 90 days of coverage under a Medicare Part D Plan following a transition, coverage will be extended across contract years if an Enrollee has an effective enrollment date of either November 1 or December 1 to allow for the full 90 days of coverage. During this time, Medicare Part D Plans must provide temporary fill of a Non Formulary to an Enrollee. For Enrollees who are residents of Long-Term Care Facilities and obtain their prescriptions from a Long- Term Care Network Pharmacy or who experience a transition characterized as a level of care change form one treatment setting to another, Senior Care Plus will provide up to a 31-day supply of Non Formulary. An override for up to a 31-day supply is entered to allow the Non Formulary claim to process. For more information For more detailed information about your Senior Care Plus prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Senior Care Plus, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Material ID: Y0039_2016_FormularyHandbook CMS Accepted 6

7 Senior Care Plus Formulary The formulary that begins on page 14 provides coverage information about the drugs covered by Senior Care Plus. If you have trouble finding your drug in the list, turn to the Index that begins on page 170. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the column tells you if Senior Care Plus has any special requirements for coverage of your drug. NOTES KEY The symbol [BvD] next to a drug name indicates that the drug is Part D vs Part B with prior authorization only. The symbol [LA] next to a drug name indicates that it has limited access. The symbol [PA] next to a drug name indicates that prior authorization may apply. The symbol [QL] next to a drug name indicates that quantities dispensed may be limited. The symbol [ST] next to a drug name indicates that Step Therapy may apply. The symbol [GC] next to a drug name indicates that Gap Coverage may apply. Only plans Value Rx Select- 018 and Freedom Rx Select-005 have Gap Coverage for drugs in tiers 1 (Preferred Generic) and 2 (Non- Preferred Generic). The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. You will be notified when a generic is available throughout the year for certain BRAND name drugs. We provide some coverage of Generic and Brand-name prescription drugs in the coverage gap. Please refer to our Summary of Benefits and the plan you have chosen or your Evidence of Coverage (EOC) for more information about this coverage. Certain prescription drugs related to Home Infusion Therapy that are normally covered under our outpatient prescription drug benefit may instead be covered under our medical benefit. For more information, please call Customer Service at or toll-free at TTY users should call the State Relay Service at 711. We are open 8 am to 8 pm Monday through Sunday (10/15-2/14) and 8 am to 8 pm Monday through Friday (2/15-10/14). Material ID: Y0039_2016_FormularyHandbook CMS Accepted 7

8 Key Preferred Generic Non- Preferred Generic Preferred Brand Non- Preferred Brand Specialty PLAN NAME Value RX (HMO)-012 <$6 $16 $45 $95 33% coinsurance Value RX Enhanced (HMO)-004 Value RX Select (HMO)-018 $ 5 $14 $45 $95 $3 $12 $45 $95 33% coinsurance 33% coinsurance Freedom RX (PPO)- 007 $8 $16 $45 $95 33% coinsurance Freedom RX Enhanced (PPO)- 006 Freedom RX Select (PPO)- 005 Prescription Plan Standard (PDP)-001 Prescription Plan Choice (PDP)-002 $6 $14 $45 $95 $3 $12 $45 $80 $3 $8 $45 $90 $3 $12 $45 $95 33% coinsurance 33% coinsurance 25 % coinsurance 33% coinsurance Material ID: Y0039_2016_PharmacyHandbook 8

9 DRUG CATEGORY GUIDE Senior Care Plus Formulary Handbook Analgesics 14 Analgesics, Miscellaneous 14 Nonsteroidal Anti- Inflammatory Agents 19 Anesthetics 21 Local Anesthetics 21 Anti- Addiction/Substance Abuse Treatment Agents 23 Anti- Addiction/Substance Abuse Treatment Agents 23 Antianxiety Agents 24 Benzodiazepines 24 Antibacterials 28 Aminoglycosides 28 Antibacterials, Miscellaneous 29 Cephalosporins 31 Macrolides 34 Miscellaneous B- Lactam Antibiotics 35 Penicillins 36 Quinolones 38 Sulfonamides 38 Tetracyclines 39 Anticancer Agents 40 Anticancer Agents 40 Anticholinergic Agents 50 Antimuscarinics/Antispasmodics 50 Anticonvulsants 50 Anticonvulsants 50 Antidementia Agents 55 Antidementia Agents 55 Antidepressants 55 Antidepressants 55 Antidiabetic Agents 58 Material ID: Y0039_2016_PharmacyHandbook 9

10 Antidiabetic Agents, Miscellaneous 58 Insulins 61 Sulfonylureas 62 Antifungals 63 Antifungals 63 Antihistamines 66 Antihistamines 66 Anti- Infectives (Skin And Mucous Membrane) 66 Anti- Infectives (Skin And Mucous Membrane) 66 Antimigraine Agents 66 Antimigraine Agents 66 Antimycobacterials 68 Antimycobacterials 68 Antinausea Agents 68 Antinausea Agents 68 Antiparasite Agents 70 Antiparasite Agents 70 Antiparkinsonian Agents 71 Antiparkinsonian Agents 71 Antipsychotic Agents 72 Antipsychotic Agents 72 Antivirals (Systemic) 76 Antiretrovirals 76 Antivirals, Miscellaneous 79 Hcv Antivirals 80 Interferons 80 Nucleosides And Nucleotides 80 Blood Products/Modifiers/Volume Expanders 82 Anticoagulants 82 Blood Formation Modifiers 84 Hematologic Agents, Miscellaneous 85 Platelet- Aggregation Inhibitors 86 Material ID: Y0039_2016_PharmacyHandbook 10

11 Volume Expanders 86 Caloric Agents 87 Caloric Agents 87 Cardiovascular Agents 91 Alpha- Adrenergic Agents 91 Angiotensin Ii Receptor Antagonists 92 Angiotensin- Converting Enzyme Inhibitors 92 Antiarrhythmic Agents 94 Beta- Adrenergic Blocking Agents 95 Calcium- Channel Blocking Agents 96 Cardiovascular Agents, Miscellaneous 97 Dihydropyridines 99 Diuretics 100 Dyslipidemics 101 Renin- Angiotensin- Aldosterone System Inhibitors 103 Vasodilators 103 Central Nervous System Agents 104 Central Nervous System Agents 104 Contraceptives 106 Contraceptives 106 Dental And Oral Agents 114 Dental And Oral Agents 114 Dermatological Agents 114 Dermatological Agents, Other 114 Dermatological Antibacterials 116 Dermatological Anti- Inflammatory Agents 118 Dermatological Retinoids 122 Scabicides And Pediculicides 122 Devices 122 Devices 122 Enzyme Replacement/Modifiers 123 Enzyme Replacement/Modifiers 123 Material ID: Y0039_2016_PharmacyHandbook 11

12 Eye, Ear, Nose, Throat Agents 124 Eye, Ear, Nose, Throat Agents, Miscellaneous 124 Eye, Ear, Nose, Throat Anti- Infectives Agents 126 Eye, Ear, Nose, Throat Anti- Inflammatory Agents 128 Gastrointestinal Agents 130 Antiulcer Agents And Acid Suppressants 130 Gastrointestinal Agents, Other 131 Laxatives 133 Phosphate Binders 134 Genitourinary Agents 134 Antispasmodics, Urinary 134 Genitourinary Agents, Miscellaneous 135 Heavy Metal Antagonists 135 Heavy Metal Antagonists 135 Hormonal Agents, Stimulant/Replacement/Modifying 136 Androgens 136 Estrogens And Antiestrogens 137 Glucocorticoids/Mineralocorticoids 137 Pituitary 139 Progestins 140 Thyroid And Antithyroid Agents 141 Immunological Agents 141 Immunological Agents 141 Vaccines 144 Inflammatory Bowel Disease Agents 147 Inflammatory Bowel Disease Agents 147 Irrigating Solutions 148 Irrigating Solutions 148 Metabolic Bone Disease Agents 148 Metabolic Bone Disease Agents 148 Miscellaneous Therapeutic Agents 150 Miscellaneous Therapeutic Agents 150 Material ID: Y0039_2016_PharmacyHandbook 12

13 Ophthalmic Agents 155 Antiglaucoma Agents 155 Replacement Preparations 157 Replacement Preparations 157 Respiratory Tract Agents 162 Anti- Inflammatories, Inhaled Corticosteroids 162 Antileukotrienes 163 Bronchodilators 163 Respiratory Tract Agents, Other 165 Skeletal Muscle Relaxants 165 Skeletal Muscle Relaxants 165 Sleep Disorder Agents 166 Sleep Disorder Agents 166 Vasodilating Agents 167 Vasodilating Agents 167 Vitamins And Minerals 168 Vitamins And Minerals 168 Index of s 170 Material ID: Y0039_2016_PharmacyHandbook 13

14 Name 0BAnalgesics 47BAnalgesics, Miscellaneous acetaminophen-codeine oral solution mg/5 ml, 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg acetaminophen-codeine oral tablet mg (Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) ; QL (2700 per 30 ; QL (360 per 30 ; QL (180 per 30 buprenorphine hcl injection syringe (Buprenorphine HCl) butalbital-acetaminop-caf-cod butorphanol tartrate nasal (Fioricet with Codeine) (Butorphanol Tartrate) 2 PA-HRM; GC; QL (180 per 30 ; QL (5 per 28 BUTRANS 3 QL (4 per 28 codeine sulfate oral tablet (Codeine Sulfate) ; QL (180 per 30 EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL endocet oral tablet mg, mg, mg, mg 4 QL (60 per 30 (Xolox) ; QL (360 per 30 endodan (Percodan) ; QL (360 per 30 fentanyl (Duragesic) 2 PA; GC; QL (10 per 30 Material ID: Y0039_2016_PharmacyHandbook 14

15 Name fentanyl citrate (Actiq) 5 PA; QL (120 per 30 hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/5 ml, mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg (Hycet) ; QL (2700 per 30 (Norco) 2 (includes Vicodin, Vicodin ES and Vicodin HP); GC; QL (390 per 30 (Norco) ; QL (360 per 30 hydrocodone-ibuprofen (Ibudone) ; QL (150 per 30 hydromorphone (pf) injection solution 10 mg/ml (Hydromorphone HCl/PF) hydromorphone (pf) injection solution 4 mg/ml (Dilaudid) hydromorphone injection solution hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) (Hydromorphone HCl) hydromorphone oral liquid (Dilaudid) ; QL (1200 per 30 hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) ; QL (180 per 30 hydromorphone oral tablet 8 mg (Dilaudid) ; QL (240 per 30 Material ID: Y0039_2016_PharmacyHandbook 15

16 Name LAZANDA 5 PA; QL (30 per 30 lorcet (hydrocodone) (Norco) ; QL (360 per 30 lorcet hd (Norco) ; QL (360 per 30 lorcet plus oral tablet mg (Norco) ; QL (360 per 30 methadone injection (Methadone HCl) methadone oral solution (Methadone HCl) ; QL (1800 per 30 methadone oral tablet (Diskets) ; QL (360 per 30 methadose oral tablet,soluble (Diskets) ; QL (90 per 30 morphine concentrate oral solution (Morphine Sulfate) ; QL (200 per 30 morphine concentrate oral syringe (Morphine Sulfate) morphine injection solution 10 mg/ml, 15 mg/ml, 8 mg/ml (Morphine Sulfate) morphine injection syringe 2 mg/ml (Morphine Sulfate) morphine intramuscular (Morphine Sulfate) morphine intravenous cartridge (Morphine Sulfate) morphine intravenous solution 25 mg/ml, 50 mg/ml (Morphine Sulfate) Material ID: Y0039_2016_PharmacyHandbook 16

17 Name morphine intravenous syringe (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Morphine Sulfate) ; QL (700 per 30 morphine oral solution 20 mg/5 ml (Morphine Sulfate) ; QL (300 per 30 MORPHINE ORAL TABLET 4 QL (180 per 30 morphine oral tablet extended release 100 mg, 30 mg, 60 mg morphine oral tablet extended release 15 mg, 200 mg (MS Contin) ; QL (120 per 30 (MS Contin) ; QL (180 per 30 morphine rectal (Morphine Sulfate) NUCYNTA 3 QL (181 per 30 NUCYNTA ER 3 QL (60 per 30 oxycodone oral capsule (Oxycodone HCl) ; QL (180 per 30 oxycodone oral concentrate (Oxycodone HCl) ; QL (180 per 30 oxycodone oral solution (Oxycodone HCl) ; QL (1300 per 30 oxycodone oral tablet (Roxicodone) ; QL (180 per 30 oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-acetaminophen oral tablet mg (Xolox) ; QL (360 per 30 (Xolox) ; QL (180 per 30 Material ID: Y0039_2016_PharmacyHandbook 17

18 Name oxycodone-acetaminophen oral tablet mg (Xolox) ; QL (240 per 30 oxycodone-aspirin (Percodan) ; QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG 3 QL (60 per 30 3 QL (120 per 30 oxymorphone oral tablet (Opana) ; QL (180 per 30 oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 12 hr 30 mg, 40 mg (Opana ER) ; QL (60 per 30 (Opana ER) ; QL (120 per 30 reprexain (Ibudone) ; QL (150 per 30 roxicet oral solution (Oxycodone HCl/Acetaminophen ) ; QL (1800 per 30 tramadol oral tablet (Ultram) ; QL (240 per 30 tramadol-acetaminophen (Ultracet) ; QL (240 per 30 Material ID: Y0039_2016_PharmacyHandbook 18

19 Name vicodin es oral tablet mg (Norco) 2 (includes Vicodin, Vicodin ES and Vicodin HP); GC; QL (390 per 30 vicodin hp oral tablet mg (Norco) 2 (includes Vicodin, Vicodin ES and Vicodin HP); GC; QL (390 per 30 vicodin oral tablet mg (Norco) 2 (includes Vicodin, Vicodin ES and Vicodin HP); GC; QL (390 per 30 XARTEMIS XR 3 QL (360 per 30 xylon 10 (Ibudone) ; QL (150 per 30 48BNonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) 4 celecoxib (Celebrex) ; QL (60 per 30 choline,magnesium salicylate diclofenac potassium (Choline Sal/Mag Salicylate) (Diclofenac Potassium) diclofenac sodium oral tablet extended release 24 hr (Voltaren-XR) Material ID: Y0039_2016_PharmacyHandbook 19

20 Name diclofenac sodium oral tablet,delayed release (dr/ec) (Diclofenac Sodium) diclofenac sodium topical gel (Solaraze) 5 diclofenac-misoprostol (Arthrotec 50) diflunisal (Diflunisal) etodolac (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR 2 PA; GC flurbiprofen (Flurbiprofen) ibuprofen oral suspension (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 mg (Ibuprofen) 1 GC ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg (Ketoprofen) ketorolac injection cartridge 15 mg/ml ketorolac injection cartridge 30 mg/ml ketorolac injection solution 15 mg/ml ketorolac injection solution 30 mg/ml (1 ml) (Ketorolac Tromethamine) (Ketorolac Tromethamine) (Ketorolac Tromethamine) (Ketorolac Tromethamine) ; QL (40 per 30 ; QL (20 per 30 ; QL (40 per 30 ; QL (20 per 30 Material ID: Y0039_2016_PharmacyHandbook 20

21 Name ketorolac intramuscular solution ketorolac oral (Ketorolac Tromethamine) (Ketorolac Tromethamine) ; QL (20 per 30 ; QL (20 per 30 mefenamic acid (Ponstel) meloxicam oral suspension (Mobic) meloxicam oral tablet (Mobic) 1 GC nabumetone (Nabumetone) naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) 1 GC naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg (Ec-Naprosyn) (Anaprox) 1 GC piroxicam (Feldene) salsalate (Salsalate) sulindac oral (Sulindac) tolmetin (Tolmetin Sodium) VOLTAREN TOPICAL 3 1BAnesthetics 49BLocal Anesthetics glydo (Lidocaine HCl) Material ID: Y0039_2016_PharmacyHandbook 21

22 Name lidocaine (pf) injection solution 15 mg/ml (1.5 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %) (Xylocaine-MPF) 2 PA BvD; (PA for ESRD Only); GC (Lidocaine HCl/PF) (Xylocaine) 2 PA BvD; (PA for ESRD Only); GC lidocaine hcl laryngotracheal (Xylocaine) lidocaine hcl mucous membrane gel (Lidocaine HCl) lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution (Lidocaine HCl) (Xylocaine) lidocaine hcl urethral (Lidocaine HCl) lidocaine topical adhesive patch,medicated (Lidoderm) 2 PA; GC lidocaine topical ointment (Lidocaine) 2 PA BvD; (PA for ESRD Only); GC lidocaine viscous (Xylocaine) lidocaine-prilocaine topical cream (EMLA) 2 PA BvD; (PA for ESRD Only); GC lidocaine-prilocaine topical kit (Lidocaine/Prilocain e) 2 PA BvD; GC Material ID: Y0039_2016_PharmacyHandbook 22

23 Name 2BAnti-Addiction/Substance Abuse Treatment Agents 50BAnti-Addiction/Substance Abuse Treatment Agents acamprosate (Acamprosate Calcium) buprenorphine hcl sublingual (Subutex) 2 PA; GC; QL (90 per 30 buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) 2 PA; GC; QL (90 per 30 bupropion hcl sr 150 mg tablet f/c (Zyban) CHANTIX 3 QL (168 per 84 CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX 3 QL (56 per 28 3 QL (56 per 28 3 QL (53 per 28 depade (Revia) disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone oral (Revia) NICOTROL 4 QL (1008 per 90 ZUBSOLV 3 PA; QL (90 per 30 Material ID: Y0039_2016_PharmacyHandbook 23

24 Name 3BAntianxiety Agents 51BBenzodiazepines alprazolam oral tablet (Xanax) ; QL (120 per 30 alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg alprazolam oral tablet extended release 24 hr 3 mg (Xanax XR) ; QL (120 per 30 (Xanax XR) ; QL (90 per 30 chlordiazepoxide hcl (Chlordiazepoxide HCl) ; QL (120 per 30 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) ; QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) ; QL (300 per 30 clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating 2 mg clorazepate dipotassium oral tablet 15 mg clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg (Clonazepam) ; QL (90 per 30 (Clonazepam) ; QL (300 per 30 (Tranxene T-Tab) ; QL (120 per 30 (Tranxene T-Tab) ; QL (60 per 30 diazepam injection solution (Diazepam) ; QL (10 per 28 diazepam intensol (Diazepam) ; QL (1200 per 30 Material ID: Y0039_2016_PharmacyHandbook 24

25 Name diazepam oral solution 5 mg/5 ml (Diazepam) ; QL (1200 per 30 diazepam oral tablet (Valium) ; QL (120 per 30 diazepam rectal (Diastat) estazolam oral tablet 1 mg (Estazolam) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); GC; QL (60 per 30 estazolam oral tablet 2 mg (Estazolam) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); GC; QL (30 per 30 Material ID: Y0039_2016_PharmacyHandbook 25

26 Name flurazepam oral capsule 15 mg (Flurazepam HCl) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); GC; QL (60 per 30 flurazepam oral capsule 30 mg (Flurazepam HCl) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); GC; QL (30 per 30 lorazepam intensol (Ativan) ; QL (150 per 30 lorazepam oral tablet (Ativan) ; QL (90 per 30 midazolam oral syrup 2 mg/ml (Midazolam HCl) ; QL (10 per 30 Material ID: Y0039_2016_PharmacyHandbook 26

27 Name temazepam oral capsule 15 mg, 22.5 mg, 30 mg (Restoril) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); GC; QL (30 per 30 temazepam oral capsule 7.5 mg (Restoril) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); GC; QL (120 per 30 triazolam oral tablet mg (Halcion) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); GC; QL (120 per 30 Material ID: Y0039_2016_PharmacyHandbook 27

28 Name triazolam oral tablet 0.25 mg (Halcion) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); GC; QL (60 per 30 4BAntibacterials 52BAminoglycosides BETHKIS 5 PA BvD gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml (Gentamicin In Nacl, Iso-Osm) gentamicin injection solution 40 mg/ml (Gentamicin Sulfate) gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 80 mg/8 ml (Gentamicin Sulfate/PF) (Gentamicin Sulfate/PF) neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) Material ID: Y0039_2016_PharmacyHandbook 28

29 Name TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 5 QL (224 per 28 tobramycin in % nacl (Tobi) 5 PA BvD tobramycin in 0.9 % nacl tobramycin sulfate injection solution (Tobramycin/Sodiu m Chloride) (Tobramycin Sulfate) 53BAntibacterials, Miscellaneous baciim (Bacitracin) bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod Succ) clindamycin hcl (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate In D5w) clindamycin palmitate hcl (Cleocin Palmitate) clindamycin pediatric (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) clindamycin phosphate intravenous solution 600 mg/4 ml (Cleocin Phosphate) colistin (colistimethate na) (Coly-Mycin M Parenteral) 5 CUBICIN 5 Material ID: Y0039_2016_PharmacyHandbook 29

30 Name linezolid (Zyvox) 5 methenamine hippurate (Hiprex) methenamine mandelate metronidazole in nacl (iso-os) (Methenamine Mandelate) (Metronidazole/Sodi um Chloride) metronidazole oral (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg nitrofurantoin macrocrystal oral capsule 50 mg (Macrodantin/Macro bid) (Macrodantin/Macro bid) 2 PA-HRM; GC; QL (120 per 30 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (120 per 30 nitrofurantoin monohyd/m-cryst (Macrobid) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (120 per 30 Material ID: Y0039_2016_PharmacyHandbook 30

31 Name nitrofurantoin oral (Furadantin) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (2400 per 30 polymyxin b sulfate (Polymyxin B Sulfate) SYNERCID 5 trimethoprim (Trimethoprim) vancomycin in d5w intravenous piggyback 1 gram/200 ml vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg (Vancomycin HCl/D5W) (Vancomycin HCl) vancomycin intravenous recon soln (Vancomycin 500 mg HCl/D5W) vancomycin oral capsule (Vancocin HCl) 5 XIFAXAN ORAL TABLET 200 MG 5 PA; QL (9 per 30 ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 5 54BCephalosporins cefaclor oral capsule (Cefaclor) Material ID: Y0039_2016_PharmacyHandbook 31

32 Name cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr (Cefaclor) (Cefaclor) cefadroxil oral capsule (Cefadroxil) cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml (Cefadroxil) cefadroxil oral tablet (Cefadroxil) cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml (Cefazolin Sodium/Dextrose, Iso) cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 300 g, 500 mg (Cefazolin Sodium) cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % 4 CEFEPIME IN DEXTROSE,ISO- OSM INTRAVENOUS PIGGYBACK 2 GRAM/100 ML 4 cefixime (Suprax) cefotaxime (Claforan) cefoxitin (Cefoxitin Sodium) Material ID: Y0039_2016_PharmacyHandbook 32

33 Name cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml cefpodoxime (Cefoxitin Sodium/Dextrose, Iso) (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime (Fortaz) ceftibuten (Cedax) ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML (Ceftriaxone Na/Dextrose, Iso) ceftriaxone injection recon soln 1 gram, 10 gram, 250 mg, 500 mg (Rocephin) ceftriaxone intravenous recon soln 1 gram CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM (Ceftriaxone Na/Dextrose, Iso) cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln 1.5 gram, 750 mg (Zinacef) cefuroxime sodium intravenous (Zinacef) cefuroxime-dextrose (iso-osm) (Cefuroxime Sodium/Dextrose, Iso) Material ID: Y0039_2016_PharmacyHandbook 33

34 Name cephalexin oral capsule (Keflex) 1 GC cephalexin oral suspension for reconstitution (Cephalexin) 1 GC cephalexin oral tablet (Cephalexin) 1 GC MEFOXIN IN DEXTROSE (ISO- OSM) SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE tazicef injection recon soln 2 gram, 6 gram (Fortaz) tazicef intravenous (Ceftazidime) TEFLARO 4 55BMacrolides azithromycin (Zithromax) clarithromycin oral suspension for reconstitution (Biaxin) clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended release 24 hr (Clarithromycin) DIFICID 5 QL (20 per 10 e.e.s. 400 oral tablet (Erythromycin Ethylsuccinate) Material ID: Y0039_2016_PharmacyHandbook 34

35 Name e.e.s. granules (Eryped 200) ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG (Erythromycin Base) 4 ERYTHROCIN 4 erythrocin (as stearate) oral tablet 250 mg (Erythromycin Stearate) erythromycin ethylsuccinate oral suspension for reconstitution (Eryped 200) erythromycin ethylsuccinate oral tablet (Erythromycin Ethylsuccinate) erythromycin oral capsule,delayed release(dr/ec) (Erythromycin Base) erythromycin oral tablet (Erythromycin Base) 56BMiscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram (Azactam) CAYSTON 5 LA imipenem-cilastatin (Primaxin) INVANZ 4 meropenem (Merrem) Material ID: Y0039_2016_PharmacyHandbook 35

36 Name 57BPenicillins amoxicillin oral capsule (Amoxicillin) 1 GC amoxicillin oral suspension for reconstitution (Amoxicillin) 1 GC amoxicillin oral tablet (Amoxicillin) 1 GC amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution (Amoxicillin) 1 GC (Augmentin) amoxicillin-pot clavulanate oral tablet (Augmentin) amoxicillin-pot clavulanate oral tablet extended release 12 hr (Augmentin XR) amoxicillin-pot clavulanate oral tablet,chewable ampicillin (Amoxicillin/Potassi um Clav) (Ampicillin Trihydrate) 1 GC ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 15 gram, 3 gram (Ampicillin Sodium) (Ampicillin Sodium) (Unasyn) ampicillin-sulbactam intravenous (Unasyn) BICILLIN C-R 4 Material ID: Y0039_2016_PharmacyHandbook 36

37 Name BICILLIN L-A 4 dicloxacillin (Dicloxacillin Sodium) nafcillin injection (Nafcillin Sodium) nafcillin intravenous recon soln 2 gram (Nafcillin Sodium) oxacillin in dextrose(iso-osm) (Oxacillin Sodium/Dextrose, Iso) oxacillin injection recon soln 10 gram (Oxacillin Sodium) oxacillin intravenous (Oxacillin Sodium) penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium pfizerpen-g injection recon soln 20 million unit (Pen G Pot/Dextrose-Water) (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin V Potassium) (Penicillin G Potassium) piperacillin-tazobactam intravenous recon soln gram, 4.5 gram, 40.5 gram (Zosyn) Material ID: Y0039_2016_PharmacyHandbook 37

38 Name 58BQuinolones ciprofloxacin (Cipro) ciprofloxacin (mixture) (Cipro XR) ciprofloxacin hcl oral (Cipro) 1 GC ciprofloxacin in 5 % dextrose (Cipro I.V.) ciprofloxacin lactate (Ciprofloxacin Lactate) levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral solution (Levaquin) levofloxacin oral tablet (Levaquin) 1 GC moxifloxacin (Avelox) ofloxacin oral tablet 400 mg (Ofloxacin) 59BSulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim intravenous sulfamethoxazole-trimethoprim oral suspension (Sulfamethoxazole/T rimethoprim) (Sulfamethoxazole/T rimethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) 1 GC Material ID: Y0039_2016_PharmacyHandbook 38

39 Name sulfasalazine (Azulfidine) sulfatrim (Sulfamethoxazole/T rimethoprim) sulfazine (Azulfidine) sulfazine ec (Azulfidine) 60BTetracyclines demeclocycline oral doxy-100 (Demeclocycline HCl) (Doxycycline Hyclate) doxycycline hyclate 100 mg cap (Morgidox) doxycycline hyclate 100 mg t ab f/c (Doryx) doxycycline hyclate intravenous doxycycline hyclate oral capsule 100 mg doxycycline hyclate oral capsule 50 mg (Doxycycline Hyclate) (Adoxa) (Morgidox) doxycycline hyclate oral tabl et 100 (Avidoxy) mg, 50 mg doxycycline hyclate oral tabl et 20 mg (Doryx) doxycycline hyclate oral tabl et,delayed (Doryx) release (dr/ec) doxycycline monohydrate oral capsule (Adoxa) Material ID: Y0039_2016_PharmacyHandbook 39

40 Name doxycycline monohydrate oral suspension for reconstitution (Vibramycin) doxycycline monohydrate oral tablet (Avidoxy) MINOCIN INTRAVENOUS 5 minocycline oral capsule (Minocin) minocycline oral tablet (Minocycline HCl) minocycline oral tablet extended release 24 hr (Minocycline HCl) tetracycline (Tetracycline HCl) TYGACIL 5 5BAnticancer Agents 61BAnticancer Agents ABRAXANE 5 ADCETRIS 5 PA NSO; QL (4 per 21 adriamycin intravenous recon soln 10 mg (Doxorubicin HCl) 2 PA BvD; GC adrucil intravenous solution 2.5 gram/50 ml, 500 mg/10 ml (Fluorouracil) 2 PA BvD; GC AFINITOR DISPERZ 5 PA NSO; QL (112 per 28 AFINITOR ORAL TABLET 10 MG 5 PA NSO; QL (56 per 28 Material ID: Y0039_2016_PharmacyHandbook 40

41 Name AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG 5 PA NSO; QL (28 per 28 5 anastrozole (Arimidex) AVASTIN 5 PA NSO azacitidine (Vidaza) 5 BELEODAQ 5 PA NSO bicalutamide (Casodex) bleomycin (Bleomycin Sulfate) 2 PA BvD; GC BLINCYTO 5 PA NSO; QL (140 per 365 BOSULIF ORAL TABLET 100 MG 5 PA NSO; QL (120 per 30 BOSULIF ORAL TABLET 500 MG 5 PA NSO; QL (30 per 30 CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG 5 PA NSO; QL (60 per 30 5 PA NSO; QL (30 per 30 carboplatin intravenous solution (Carboplatin) cladribine (Cladribine) 2 PA BvD; GC COMETRIQ 5 PA NSO; QL (112 per 28 Material ID: Y0039_2016_PharmacyHandbook 41

42 Name cyclophosphamide intravenous recon soln 2 gram CYCLOPHOSPHAMIDE ORAL CAPSULE (Cyclophosphamide) 2 PA BvD; GC 4 PA BvD; ST cyclophosphamide oral tablet (Cyclophosphamide) 2 PA BvD; ST; GC CYRAMZA 5 PA NSO dactinomycin (Dactinomycin) DAUNOXOME 3 decitabine (Dacogen) 5 docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (final), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) (Taxotere) 5 doxorubicin, peg-liposomal (Doxil) 5 PA BvD DROXIA 3 ELIGARD SUBCUTANEOUS SYRINGE 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 45 MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) 4 QL (1 per 84 4 QL (1 per QL (1 per EMCYT 3 Material ID: Y0039_2016_PharmacyHandbook 42

43 Name ERIVEDGE 5 PA NSO; QL (30 per 30 ETOPOPHOS 4 etoposide intravenous (Etoposide) exemestane (Aromasin) FARESTON 5 FARYDAK 5 PA NSO FASLODEX 5 floxuridine (Floxuridine) 2 PA BvD; GC fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml (Fluorouracil) 2 PA BvD; GC flutamide (Flutamide) GAZYVA 5 PA NSO gemcitabine intravenous recon soln 1 gram (Gemzar) 5 GILOTRIF 5 PA NSO; QL (30 per 30 GLEEVEC ORAL TABLET 100 MG 5 PA NSO; QL (90 per 30 GLEEVEC ORAL TABLET 400 MG 5 PA NSO; QL (60 per 30 HERCEPTIN 5 PA NSO HEXALEN 5 Material ID: Y0039_2016_PharmacyHandbook 43

44 Name hydroxyurea (Hydrea) IBRANCE 5 PA NSO; QL (21 per 28 ICLUSIG ORAL TABLET 15 MG 5 PA NSO; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG 5 PA NSO; QL (30 per 30 ifosfamide intravenous recon soln 1 gram ifosfamide intravenous solution 1 gram/20 ml (Ifex) 2 PA BvD; GC (Ifex) 2 PA BvD; GC ifosfamide-mesna (Ifosfamide/Mesna) 5 PA BvD IMBRUVICA 5 PA NSO INLYTA ORAL TABLET 1 MG 5 PA NSO; QL (180 per 30 INLYTA ORAL TABLET 5 MG 5 PA NSO; QL (60 per 30 irinotecan intravenous solution 100 mg/5 ml (Camptosar) IXEMPRA 5 JAKAFI 5 PA NSO; QL (60 per 30 KEYTRUDA 5 PA NSO KYPROLIS 5 PA NSO; QL (6 per 28 Material ID: Y0039_2016_PharmacyHandbook 44

45 Name LENVIMA 5 PA NSO letrozole (Femara) LEUKERAN 4 leuprolide (Leuprolide Acetate) lipodox (Doxil) 5 PA BvD lomustine (Gleostine) LUPRON DEPOT 5 LUPRON DEPOT (3 MONTH) 5 QL (1 per 84 LUPRON DEPOT (4 MONTH) 5 QL (1 per 84 LUPRON DEPOT (6 MONTH) 5 QL (1 per 168 LYNPARZA 5 PA NSO; QL (480 per 30 LYSODREN 3 MARQIBO 5 PA NSO; QL (4 per 28 MATULANE 5 megestrol oral tablet (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; QL (90 per 30 MEKINIST ORAL TABLET 2 MG 5 PA NSO; QL (30 per 30 melphalan hcl (Alkeran) 5 Material ID: Y0039_2016_PharmacyHandbook 45

46 Name mercaptopurine (Mercaptopurine) methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral (Methotrexate Sodium/PF) (Methotrexate Sodium) (Methotrexate Sodium) (Methotrexate Sodium) 2 PA BvD; GC 2 PA BvD; GC 2 PA BvD; GC 2 PA BvD; ST; GC mitoxantrone (Mitoxantrone HCl) NEXAVAR 5 PA NSO; QL (120 per 30 NILANDRON 3 ONCASPAR 5 PA NSO onxol (Paclitaxel) OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 mg/20 ml (Eloxatin) 5 5 PA NSO paclitaxel (Paclitaxel) PERJETA 5 PA NSO POMALYST 5 PA NSO; QL (21 per 28 PROLEUKIN 5 Material ID: Y0039_2016_PharmacyHandbook 46

47 Name PURIXAN 5 REVLIMID 5 PA NSO; LA RITUXAN 5 PA NSO SOLTAMOX 4 SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 20 MG 5 PA NSO; QL (60 per 30 STIVARGA 5 PA NSO; QL (84 per 28 SUTENT 5 PA NSO; QL (30 per 30 SYLVANT 5 PA NSO SYNRIBO 5 PA NSO; QL (28 per 28 TABLOID 3 TAFINLAR 5 PA NSO; QL (120 per 30 tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 25 MG 5 PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 150 MG 5 PA NSO; QL (90 per 30 TARGRETIN ORAL 5 PA NSO; QL (420 per 30 Material ID: Y0039_2016_PharmacyHandbook 47

48 Name TARGRETIN TOPICAL 5 PA NSO; QL (60 per 28 TASIGNA 5 PA NSO; QL (112 per 28 TEMODAR INTRAVENOUS 5 PA NSO; (vial only) teniposide (Teniposide) 5 toposar (Etoposide) topotecan intravenous recon soln (Hycamtin) 5 TORISEL 5 PA BvD; QL (4 per 28 TREANDA 5 TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML 5 QL (1 per QL (1 per 84 5 QL (1 per tretinoin (chemotherapy) (Tretinoin) 5 (capsule: 10mg) TREXALL 4 PA BvD; ST TYKERB 5 VALSTAR 5 Material ID: Y0039_2016_PharmacyHandbook 48

49 Name VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML) 5 PA NSO VELCADE 5 PA NSO vinblastine intravenous solution (Vinblastine Sulfate) 2 PA BvD; GC vincasar pfs (Vincristine Sulfate) 2 PA BvD; GC vincristine (Vincristine Sulfate) 2 PA BvD; GC vinorelbine intravenous solution 50 mg/5 ml (Navelbine) VOTRIENT 5 PA NSO; QL (120 per 30 XALKORI 5 PA NSO; QL (60 per 30 XTANDI 5 PA NSO; QL (120 per 30 YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML) 5 PA NSO 5 PA NSO ZELBORAF 5 PA NSO; QL (240 per 30 ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG 4 QL (1 per 84 4 QL (1 per 28 Material ID: Y0039_2016_PharmacyHandbook 49

50 Name ZOLINZA 5 ZYDELIG 5 PA NSO; QL (60 per 30 ZYKADIA 5 PA NSO; QL (140 per 28 ZYTIGA 5 PA NSO; QL (120 per 30 6BAnticholinergic Agents 62BAntimuscarinics/Antispasmodics atropine 0.1 mg/ml syringe luer-jet syr (Atropine Sulfate) atropine injection solution (Atropine Sulfate) atropine injection syringe 0.05 mg/ml, 0.1 mg/ml (Atropine Sulfate) propantheline (Propantheline Bromide) 7BAnticonvulsants 63BAnticonvulsants APTIOM 4 BANZEL 4 carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml (Carbatrol) (Tegretol) Material ID: Y0039_2016_PharmacyHandbook 50

51 Name carbamazepine oral tablet (Tegretol) carbamazepine oral tablet extended release 12 hr (Tegretol XR) carbamazepine oral tablet,chewable (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG 3 DILANTIN divalproex oral capsule, sprinkle (Depakote Sprinkle) divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) (Depakote ER) (Depakote) epitol (Tegretol) ethosuximide (Zarontin) felbamate (Felbatol) fosphenytoin (Cerebyx) FYCOMPA 4 gabapentin oral capsule (Neurontin) gabapentin oral solution 250 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG 3 Material ID: Y0039_2016_PharmacyHandbook 51