Anthem Connect Plus (H) 019 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on March 1, 019. For more recent information or other questions, please contact Anthem Connect Plus (H) Customer Service, at 1-800-99-79 or, for TTY users, 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 1, and Monday to Friday (except holi from April 1 through September 0, or visit https://shop.anthem.com/medicare/ca. H0_09 Y011_19_070_I_C_1 08/0/018 CM_MAPD_19_v10_190_1
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 Anthem Blue Cross. When it refers to plan or our plan, it means Anthem Connect Plus (H). This document includes a list of the drugs (formulary) for our plan which is current as of April 1, 019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 00, and from time to time during the year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Effective Date April 1, 019 CM_MAPD_19_v10_190_1
What is the Anthem Connect Plus (H) formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary (drug list) change? Generally, if you are taking a drug on our 019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Anthem Connect Plus (H) s Formulary? s removed from the market. 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. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 0 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 0-day supply of the drug. The enclosed formulary is current as of April 1, 019. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (nonmaintenance change) is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated formulary. Effective Date April 1, 019 CM_MAPD_19_v10_190_1
How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular, Hypertension/ Lipids. If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 8. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 0 tablets per prescription for donepezil. This may be in addition to a standard one-month or three-month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our 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 our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Anthem Connect Plus (H)'s formulary? on page for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Anthem Connect Plus (H)'s formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make: You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level, and you would not be Effective Date April 1, 019 CM_MAPD_19_v10_190_1
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 approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 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 0-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a maximum 0 day supply of medication. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term-care facility and, you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug while you pursue a formulary exception. During the time when you are getting a temporary supply of a drug, you should talk to your prescriber or prescribing physician to decide what to do when your supply runs out. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you while you pursue a formulary exception. Please refer to the Evidence of Coverage for more information about exceptions. For more information For more detailed information about our plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800--7), hours a day/ 7 days a week. TTY users should call 1-877-8-08. Or, visit http://www.medicare.gov. Our plan s formulary The formulary on page 8 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 8. Effective Date April 1, 019 CM_MAPD_19_v10_190_1
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., SPIRIVA) and generic drugs are listed in lowercase italics (e.g., atenolol). The information in the column tells you if our plan has any special requirements for coverage of your drug. QLL Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. B/D PAR Part B vs. Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at 1-800-99-79, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 1, and Monday to Friday (except holi from April 1 through September 0 TTY/TDD users should call 711. Mail Orders: Prescription drugs available through mail order. Allow up to 1 days from the date the prescription is ordered to process and mail. For first time users of the home delivery pharmacy have at least a 0-day supply of medication on hand when a request is placed with home delivery pharmacy. HI - Home Infusion: This prescription drug may be covered under our medical benefit. For more information, call Customer Service at 1-800-99-79, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 1, and Monday to Friday (except holi from April 1 through September 0. TTY users should call 711. Effective Date April 1, 019 CM_MAPD_19_v10_190_1
Cost-sharing for a one-month supply of a covered Part D prescription drug during the Initial Coverage Stage: Cost-Sharing 1: Preferred Generic Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (1-day supply) Cost-Sharing : Generic Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (1-day supply) Cost-Sharing : Preferred Brand Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (1-day supply) Cost-Sharing : Nonpreferred s Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (1-day supply) Cost-Sharing : Specialty * Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (1-day supply) Cost-Sharing : Select Care s Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (1-day supply) Please refer to our Evidence of Coverage for more information on cost sharing. The amount you pay will depend if you qualify for low-income subsidy (LIS), also known as Medicare's "Extra Help" program. Network Pharmacy with preferred cost-sharing A network pharmacy that offers covered drugs to members of our plan that may have lower cost-sharing levels than other network pharmacies with standard cost-sharing. * A long-term supply is not available for drugs in the : Specialty ** Mail-Order Pharmacy Mail-order service allows you to order a 90-day supply of drugs or 0-day supply for drugs. The drugs available through our plan s mail-order service are marked as mail-order drugs in our drug list. % % % % % % Effective Date April 1, 019 7 CM_MAPD_19_v10_190_1
Covered Medications by Therapeutic Category Legend Generic drugs are shown in lowercase italic (e.g., atenolol). Brand-name drugs are shown in capital letters (e.g., SPIRIVA). QLL Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. B/D PAR Part B vs. Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at 1-800-99-79, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 1, and Monday to Friday (except holi from April 1 through September 0. TTY/TDD users should call 711. Mail Orders: Prescription drugs available through mail order. Allow up to 1 days from the date the prescription is ordered to process and mail. For first time users of the home delivery pharmacy have at least a 0-day supply of medication on hand when a request is placed with home delivery pharmacy. HI - Home Infusion: This prescription drug may be covered under our medical benefit. For more information, call Customer Service at 1-800-99-79, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through March 1, and Monday to Friday (except holi from April 1 through September 0. TTY users should call 711. Anti - Infectives abacavir oral solution abacavir oral tablet abacavir-lamivudine abacavir-lamivudinezidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 00 / ml acyclovir oral tablet acyclovir sodium 0 /ml intravenous solution adefovir ALBENDAZOLE ALBENZA ; QLL (90 per 0 0 ; QLL (0 per 0 0 B/D PAR; ; HI B/D PAR; ; HI PAR; ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amantadine hcl oral capsule amantadine hcl oral tablet AMBISOME amikacin injection solution 1,000 / ml amikacin injection solution 00 / ml amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet, chewable 1, 0 amoxicillin-pot clavulanate amphotericin b ; QLL (180 per 0 ; QLL ( per 0 B/D PAR; ; HI B/D PAR; CM_MAPD_19_v10_190_1 8 Effective Date April 1, 019
ampicillin oral capsule 00 ampicillin sodium injection recon soln 1 gram, 10 gram, 1 ampicillin sodium injection recon soln gram, 0, 00 ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1. gram, gram ampicillin-sulbactam injection recon soln 1 gram ampicillin-sulbactam intravenous recon soln 1. gram ampicillin-sulbactam intravenous recon soln gram APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 10, 00 atazanavir oral capsule 00 atovaquone atovaquone-proguanil oral tablet 0-100 ATRIPLA AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) azithromycin intravenous azithromycin oral aztreonam injection recon soln 1 gram baciim bacitracin intramuscular BARACLUDE ORAL SOLUTION ; HI ; HI HI ; QLL (10 per 0 QLL (80 per 0 0 ; QLL (0 per 0 PAR; ; QLL (0 per 0 ; HI ; HI PAR; BICILLIN C-R INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML(00K/00K) BIKTARVY BILTRICIDE CAPASTAT CASPOFUNGIN INTRAVENOUS RECON SOLN 0 MG CASPOFUNGIN INTRAVENOUS RECON SOLN 70 MG CAYSTON cefaclor oral capsule cefaclor oral suspension for reconstitution 1 / ml, 0 / ml cefaclor oral suspension for reconstitution 7 / ml cefaclor oral tablet extended release 1 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 0 / ml, 00 / ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/0 ml cefazolin injection recon soln 1 gram, 00 cefazolin injection recon soln 10 gram cefazolin injection recon soln 100 gram, 0 gram, 00 g cefazolin intravenous cefdinir cefepime in dextrose,iso-osm intravenous piggyback 1 gram/0 ml cefepime in dextrose,iso-osm intravenous piggyback gram/100 ml ; QLL (0 per 0 B/D PAR B/D PAR PAR; ; LA ; HI HI CM_MAPD_19_v10_190_1 9 Effective Date April 1, 019
cefepime injection cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram, gram cefoxitin intravenous recon soln 10 gram cefpodoxime cefprozil ceftazidime in dw ceftazidime injection recon soln 1 gram, gram ceftazidime injection recon soln gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, gram, 0, 00 ceftriaxone injection recon soln 10 gram ceftriaxone injection recon soln 100 gram ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 70 cefuroxime sodium intravenous recon soln 1. gram cefuroxime sodium intravenous recon soln 7. gram cephalexin oral capsule 0, 00 cephalexin oral suspension for reconstitution chloramphenicol sod succinate chloroquine phosphate CIMDUO ciprofloxacin hcl oral tablet 0, 00, 70 ciprofloxacin tablet extended release hr mphase clarithromycin clindamycin hcl capsule ; HI ; HI HI ; HI HI ; HI HI ; HI ; HI HI ; QLL (0 per 0 clindamycin phosphate injection clindamycin phosphate intravenous solution 00 / ml, 900 / ml clindamycin phosphate intravenous solution 00 / ml clotrimazole mucous membrane COARTEM colistin (colistimethate na) COMPLERA CRIXIVAN ORAL CAPSULE 00 MG CRIXIVAN ORAL CAPSULE 00 MG dapsone oral DAPTOMYCIN INTRAVENOUS RECON SOLN 0 MG DAPTOMYCIN INTRAVENOUS RECON SOLN 00 MG DARAPRIM DELSTRIGO demeclocycline DESCOVY dicloxacillin didanosine oral capsule, delayed release(dr/ec) 00 didanosine oral capsule, delayed release(dr/ec) 0, 00 doxy-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100, 0 ; HI ; HI ; QLL (0 per 0 0 ; QLL (180 per 0 ; QLL (0 per 0 ; QLL (0 per 0 0 ; QLL (0 per 0 CM_MAPD_19_v10_190_1 10 Effective Date April 1, 019
doxycycline monohydrate oral capsule 100, 0, 7 EDURANT efavirenz oral capsule 00 efavirenz oral capsule 0 efavirenz oral tablet EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPCLUSA EPIVIR HBV ORAL SOLUTION ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG ertapenem ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/ EC) 0 MG, 00 MG ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/ EC) MG ERYTHROCIN (AS STEARATE) ORAL TABLET 0 MG ERYTHROCIN INTRAVENOUS RECON SOLN 00 MG erythromycin ethylsuccinate oral tablet erythromycin oral tablet 0 ERYTHROMYCIN ORAL TABLET 00 MG ethambutol EVOTAZ ; QLL (0 per 0 ; QLL (10 per 0 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 PAR; PAR; ; QLL (0 per 0 PAR; ; HI ; QLL (0 per 0 famciclovir oral tablet 1, 0 famciclovir oral tablet 00 fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) intravenous piggyback 100 /0 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 /100 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 /00 ml flucytosine fosamprenavir FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium intravenous recon soln gentamicin injection solution 0 / ml gentamicin injection solution 0 /ml gentamicin sulfate (ped) (pf) GENVOYA griseofulvin microsize oral suspension griseofulvin ultramicrosize HARVONI hydroxychloroquine imipenem-cilastatin INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 00 MG INTELENCE ORAL TABLET MG INVANZ INJECTION 0 ; QLL (1 per 7 ; HI HI ; QLL (10 per 0 0 B/D PAR; ; HI ; QLL (0 per 0 PAR; ; QLL (8 per 8 ; HI ; QLL (10 per 0 0 ; QLL (80 per 0 ; HI CM_MAPD_19_v10_190_1 11 Effective Date April 1, 019
INVIRASE ORAL TABLET ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE MG isoniazid oral itraconazole oral capsule ivermectin JULUCA KALETRA ORAL TABLET 100- MG KALETRA ORAL TABLET 00-0 MG ketoconazole oral lamivudine oral solution lamivudine oral tablet 100 lamivudine oral tablet 10 lamivudine oral tablet 00 lamivudine-zidovudine levofloxacin intravenous levofloxacin oral LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET linezolid in dextrose % linezolid oral suspension for reconstitution linezolid oral tablet ; QLL (10 per 0 0 ; QLL (180 per 0 ; QLL (10 per 0 ; QLL (180 per 0 ; QLL (70 per 0 PAR; ; QLL (0 per 0 ; QLL (00 per 0 ; QLL (10 per 0 ; QLL (90 per 0 0 ; QLL (0 per 0 0 ; QLL (1800 per 0 ; QLL (10 per 0 HI PAR; ; QLL (1800 per 0 PAR; ; QLL ( per 8 linezolid-0.9% sodium chloride lopinavir-ritonavir mefloquine meropenem intravenous recon soln 1 gram meropenem intravenous recon soln 00 meropenem-0.9% sodium chloride intravenous piggyback 00 /0 ml methenamine hippurate methenamine mandelate oral tablet 1 gram metro i.v. metronidazole in nacl (iso-os) metronidazole oral minocycline oral capsule minocycline oral tablet moderiba NUROL morgidox nafcillin in dextrose iso-osm intravenous piggyback 1 gram/0 ml nafcillin in dextrose iso-osm intravenous piggyback gram/100 ml nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram nafcillin injection recon soln gram nafcillin intravenous NEBUPENT neomycin nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release hr 100 ; QLL (80 per 0 ; HI ; HI ; HI ; HI B/D PAR; QLL (100 per 0 0 CM_MAPD_19_v10_190_1 1 Effective Date April 1, 019
nevirapine oral tablet extended release hr 00 nitrofurantoin macrocrystal oral capsule 100, 0 nitrofurantoin monohyd/mcryst NORVIR ORAL POWDER IN PACKET NORVIR ORAL SOLUTION NORVIR ORAL TABLET NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet ODEFSEY ofloxacin oral tablet 00 ofloxacin oral tablet 00 oseltamivir oxacillin injection recon soln 1 gram oxacillin injection recon soln 10 gram paromomycin paser PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/0 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK MILLION UNIT/0 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK MILLION UNIT/0 ML ; QLL (0 per 0 PAR; PAR; 0 ; QLL (80 per 0 0 PAR; ; QLL (0 per 0 HI HI ; HI penicillin g potassium injection recon soln 0 million unit penicillin g potassium injection recon soln million unit penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 00, 000 unit/ml penicillin g sodium penicillin v potassium PENTAM pfizerpen-g PIFELTRO piperacillin-tazobactam intravenous recon soln 1. gram piperacillin-tazobactam intravenous recon soln. gram piperacillin-tazobactam intravenous recon soln.7 gram,. gram, 0. gram praziquantel PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 10 MG PREZISTA ORAL TABLET 00 MG, 800 MG PREZISTA ORAL TABLET 7 MG PRIFTIN primaquine pyrazinamide quinine sulfate RELENZA DISKHALER ; HI ; HI ; QLL (0 per 0 ; HI ; QLL (0 per 0 ; QLL (00 per 0 ; QLL (180 per 0 0 ; QLL (00 per 0 PAR; 180 CM_MAPD_19_v10_190_1 1 Effective Date April 1, 019
RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 ribavirin oral capsule ribavirin oral tablet 00 rifabutin rifampin intravenous rifampin oral RIFATER rimantadine ritonavir SELZENTRY ORAL SOLUTION SELZENTRY ORAL TABLET 10 MG, 00 MG SELZENTRY ORAL TABLET MG SELZENTRY ORAL TABLET 7 MG SIRTURO stavudine oral capsule 1, 0 stavudine oral capsule 0, 0 STREPTOMYCIN STRIBILD sulfadiazine sulfamethoxazoletrimethoprim SYMFI SYMFI LO SYMTUZA ; QLL (180 per 0 0 ; QLL (0 per 0 ; HI 0 ; QLL (180 per 0 ; QLL (10 per 0 ; QLL (10 per 0 0 PAR; ; LA ; QLL (10 per 0 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 SYNAGIS SYNERCID tazicef injection recon soln 1 gram tazicef injection recon soln gram, gram TAZICEF INTRAVENOUS TECHNIVIE TEFLARO tenofovir disoproxil fumarate terbinafine hcl oral tetracycline TIGECYCLINE TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET MG, 0 MG tobramycin in 0.% nacl for nebulization tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ TROGARZO TRUVADA TYBOST valacyclovir oral tablet 1 gram valacyclovir oral tablet 00 valganciclovir oral recon soln valganciclovir oral tablet vancomycin in 0.9 % sodium chl intravenous piggyback PAR; ; LA PAR; ; QLL ( per 8 ; QLL (0 per 0 0 0 B/D PAR; ; QLL (80 per 8 ; HI ; QLL (0 per 0 ; QLL (10. per 8 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 0 CM_MAPD_19_v10_190_1 1 Effective Date April 1, 019
vancomycin in dextrose % intravenous piggyback 1 gram/00 ml vancomycin in dextrose % intravenous piggyback 00 /100 ml, 70 /10 ml vancomycin injection vancomycin intravenous recon soln 1,000, 10 gram, 00 VANCOMYCIN INTRAVENOUS RECON SOLN 1. GRAM, 1. GRAM, 0 MG vancomycin intravenous recon soln gram vancomycin intravenous recon soln 70 vancomycin oral capsule 1 vancomycin oral capsule 0 VEMLIDY VIDEX GRAM PEDIATRIC VIDEX GRAM PEDIATRIC VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 1 MG VIRACEPT ORAL TABLET 0 MG VIRACEPT ORAL TABLET MG VIRAMUNE ORAL SUSPENSION VIREAD ORAL POWDER VIREAD ORAL TABLET 10 MG VIREAD ORAL TABLET 00 MG, 0 MG voriconazole intravenous B/D PAR ; HI B/D PAR; PAR; ; QLL (0 per 10 PAR; ; QLL (80 per 10 PAR; ; QLL (0 per 0 ; QLL (100 per 0 ; QLL (100 per 0 ; QLL (90 per 0 ; QLL (00 per 0 ; QLL (10 per 0 ; QLL (100 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 voriconazole oral suspension for reconstitution voriconazole oral tablet 00 voriconazole oral tablet 0 VOSEVI XIFAXAN ORAL TABLET 0 MG XOFLUZA ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK. GRAM/ 0 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK.7 GRAM/0 ML,. GRAM/100 ML PAR; PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (8 per 8 ; QLL (90 per 0 ; QLL (180 per 0 ; QLL (190 per 0 0 Antineoplastic / Immunosuppressant s ABRAXANE PAR; adriamycin intravenous solution B/D PAR adrucil intravenous solution. gram/0 ml B/D PAR adrucil intravenous solution 00 /10 ml B/D PAR; AFINITOR PAR; AFINITOR DISPERZ PAR; ALECENSA PAR; ; LA; QLL (0 per 0 ALIMTA ALIQOPA PAR; PAR; ; LA CM_MAPD_19_v10_190_1 1 Effective Date April 1, 019
ALUNBRIG ORAL TABLET 180 MG ALUNBRIG ORAL TABLET 0 MG ALUNBRIG ORAL TABLET 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK anastrozole ARRANON ARSENIC TRIOXIDE ARZERRA ASTAGRAF XL AVASTIN azacitidine azasan azathioprine oral tablet azathioprine sodium solution for injection BAVENCIO BELEODAQ BENDEKA BESPONSA bexarotene bicalutamide BICNU bleomycin BLINCYTO INTRAVENOUS KIT BORTEZOMIB BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 00 MG, 00 MG BRAFTOVI ORAL CAPSULE 0 MG BRAFTOVI ORAL CAPSULE 7 MG BUSULFEX PAR; ; QLL (0 per 0 PAR; ; QLL (180 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 180 ; QLL (0 per 0 B/D PAR PAR; B/D PAR; PAR; ; LA PAR; B/D PAR; B/D PAR; B/D PAR PAR; ; LA PAR; B/D PAR; B/D PAR; PAR; ; QLL (00 per 0 ; QLL (0 per 0 B/D PAR; B/D PAR; PAR; PAR; PAR; ; QLL (10 per 0 PAR; ; QLL (0 per 0 PAR; ; LA; QLL (10 per 0 PAR; ; LA; QLL (180 per 0 B/D PAR CABOMETYX CALQUENCE CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 00 MG carboplatin intravenous solution carmustine CELLCEPT INTRAVENOUS cisplatin cladribine clofarabine CLOLAR COMETRIQ ORAL CAPSULE 100 MG/ DAY(80 MG X1-0 MG X1) COMETRIQ ORAL CAPSULE 10 MG/ DAY(80 MG X1-0 MG X) COMETRIQ ORAL CAPSULE 0 MG/DAY (0 MG X /DAY) COPIKTRA COSMEGEN COTELLIC CYCLOPHOSPHAMIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified oral capsule cyclosporine modified oral solution cyclosporine oral capsule PAR; ; LA; QLL (0 per 0 PAR; ; LA PAR; ; LA; QLL (90 per 0 PAR; ; LA; QLL (0 per 0 B/D PAR; B/D PAR; B/D PAR; B/D PAR; B/D PAR; B/D PAR B/D PAR PAR; ; LA; QLL ( per 8 PAR; ; LA; QLL (11 per 8 PAR; ; LA; QLL (8 per 8 PAR; ; LA; QLL (0 per 0 B/D PAR; PAR; ; LA; QLL (90 per 0 B/D PAR; B/D PAR B/D PAR; B/D PAR; B/D PAR; CM_MAPD_19_v10_190_1 1 Effective Date April 1, 019
CYRAMZA cytarabine (pf) injection solution 100 / ml (0 / ml), gram/0 ml (100 / ml) cytarabine (pf) injection solution 0 /ml cytarabine injection solution 0/ml dacarbazine dactinomycin DARZALEX daunorubicin intravenous solution DAURIS ORAL TABLET 100 MG DAURIS ORAL TABLET MG decitabine dexrazoxane hcl intravenous recon soln 0 dexrazoxane hcl intravenous recon soln 00 docetaxel intravenous solution 10 /1 ml (10 /ml), 0 / ml (10 /ml) docetaxel intravenous solution 10 /8 ml (0 /ml), 0 /ml (1 ml), 80 / ml (0 /ml), 80 /8 ml (10 /ml) DOCETAXEL INTRAVENOUS SOLUTION 0 MG/ML doxorubicin intravenous recon soln 10 doxorubicin intravenous recon soln 0 doxorubicin intravenous solution doxorubicin, peg-liposomal DROXIA ELITEK EMCYT EMPLICITI PAR; ; LA B/D PAR; B/D PAR B/D PAR; B/D PAR; B/D PAR PAR; ; LA B/D PAR PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 B/D PAR; B/D PAR B/D PAR; B/D PAR B/D PAR; B/D PAR B/D PAR B/D PAR; B/D PAR; PAR; PAR; PAR; epirubicin intravenous solution ERBITUX ERIVEDGE ERLEADA ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 1 MG, 0 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN GAZYVA gemcitabine intravenous recon soln 1 gram, 00 gemcitabine intravenous recon soln gram B/D PAR; PAR; PAR; ; LA; QLL (0 per 0 PAR; PAR; B/D PAR; B/D PAR; B/D PAR; 0 ; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 PAR; PAR; ; QLL ( per PAR; ; QLL (1 per 8 B/D PAR; B/D PAR B/D PAR; B/D PAR; PAR; B/D PAR; B/D PAR CM_MAPD_19_v10_190_1 17 Effective Date April 1, 019
gemcitabine intravenous solution 1 gram/. ml (8 /ml), 00 /. ml (8 /ml) GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML gemcitabine intravenous solution gram/. ml (8 /ml) gengraf oral capsule 100, gengraf oral solution GILOTRIF GLEOSTINE HALAVEN HERCEPTIN INTRAVENOUS RECON SOLN 10 MG HERCEPTIN INTRAVENOUS RECON SOLN 0 MG hydroxyurea IBRANCE ICLUSIG ORAL TABLET 1 MG ICLUSIG ORAL TABLET MG idarubicin IDHIFA ORAL TABLET 100 MG IDHIFA ORAL TABLET 0 MG ifosfamide intravenous recon soln ifosfamide intravenous solution 1 gram/0 ml B/D PAR; B/D PAR B/D PAR B/D PAR; B/D PAR; PAR; ; LA; QLL (0 per 0 PAR; PAR; B/D PAR; B/D PAR; ; LA PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 B/D PAR PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 B/D PAR; B/D PAR; ifosfamide intravenous solution gram/0 ml imatinib oral tablet 100 imatinib oral tablet 00 IMBRUVICA ORAL CAPSULE 10 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET 10 MG IMBRUVICA ORAL TABLET 80 MG, 0 MG, 0 MG IMFINZI INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET MG IRESSA irinotecan intravenous solution 100 / ml, 0 / ml irinotecan intravenous solution 00 / ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 10 MG JAKAFI ORAL TABLET 1 MG JAKAFI ORAL TABLET 0 MG JAKAFI ORAL TABLET MG JAKAFI ORAL TABLET MG B/D PAR PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; LA; QLL (90 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (90 per 0 PAR; ; QLL (0 per 0 PAR; PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (10 per 0 ; LA B/D PAR; B/D PAR PAR; PAR; PAR; ; LA; QLL (10 per 0 PAR; ; LA; QLL (100 per 0 PAR; ; LA; QLL (7 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (00 per 0 CM_MAPD_19_v10_190_1 18 Effective Date April 1, 019
JEVTANA KADCYLA INTRAVENOUS RECON SOLN 100 MG KADCYLA INTRAVENOUS RECON SOLN 10 MG KEPIVANCE KEYTRUDA INTRAVENOUS SOLUTION KHAPZORY KISQALI FEMARA CO- PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-. MG KISQALI FEMARA CO- PACK ORAL TABLET 00 MG/DAY(00 MG X )-. MG KISQALI FEMARA CO- PACK ORAL TABLET 00 MG/DAY(00 MG X )-. MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1) KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) KYPROLIS INTRAVENOUS RECON SOLN 10 MG KYPROLIS INTRAVENOUS RECON SOLN 0 MG, 0 MG LARTRUVO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1) LENVIMA ORAL CAPSULE 1 MG/DAY ( MG X ) PAR; PAR; ; LA PAR; PAR; PAR PAR; ; QLL (9 per 8 PAR; ; QLL (70 per 8 PAR; ; QLL (91 per 8 PAR; ; QLL (1 per 1 PAR; ; QLL ( per 1 PAR; ; QLL ( per 1 PAR; PAR; ; LA PAR; ; LA PAR; ; LA; QLL (0 per 0 PAR; ; QLL (90 per 0 LENVIMA ORAL CAPSULE 1 MG/DAY(10 MG X 1- MG X 1), 0 MG/DAY (10 MG X ), 8 MG/DAY ( MG X ) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1- MG X), MG/DAY(10 MG X - MG X 1) LENVIMA ORAL CAPSULE MG letrozole leucovorin calcium injection recon soln 100, 00, 0, 0 leucovorin calcium injection recon soln 00 leucovorin calcium oral LEUKERAN leuprolide subcutaneous kit levoleucovorin calcium intravenous recon soln 0 levoleucovorin calcium intravenous solution LIBTAYO LONSURF LORBRENA ORAL TABLET 100 MG LORBRENA ORAL TABLET MG LUXITI LUPRON DEPOT LUPRON DEPOT ( NTH) LUPRON DEPOT-PED ( NTH) INTRAMUSCULAR SYRINGE KIT 11. MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7. MG (PED) LYNPARZA ORAL TABLET PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (90 per 0 PAR; ; QLL (0 per 0 ; QLL (0 per 0 B/D PAR; B/D PAR PAR; PAR PAR PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (90 per 0 PAR; PAR; ; QLL (1 per 8 PAR; ; QLL (1 per 8 PAR; ; QLL (1 per 8 PAR; ; QLL (1 per 8 PAR; ; QLL (10 per 0 CM_MAPD_19_v10_190_1 19 Effective Date April 1, 019
LYSODREN MARQIBO MATULANE megestrol oral suspension 00 /10 ml (10 ml), 800 / 0 ml (0 ml) megestrol oral suspension 00 /10 ml (0 /ml) megestrol oral tablet MEKINIST ORAL TABLET 0. MG MEKINIST ORAL TABLET MG MEKTOVI melphalan hcl intravenous solution mercaptopurine mesna MESNEX ORAL methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral mitomycin intravenous recon soln 0, mitomycin intravenous recon soln 0 mitoxantrone mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium MYLOTARG NERLYNX ; LA PAR PAR; PAR; PAR; ; QLL (90 per 0 PAR; ; QLL (0 per 0 PAR; ; LA; QLL (180 per 0 B/D PAR PAR; PAR; B/D PAR; B/D PAR; B/D PAR; B/D PAR; B/D PAR; B/D PAR; B/D PAR; PAR; ; LA PAR; ; LA; QLL (180 per 0 NEXAVAR nilutamide NINLARO NIPENT NULOJIX octreotide acetate injection solution 1,000 mcg/ml, 00 mcg/ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 0 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 0 mcg/ml (1 ml) octreotide acetate injection syringe 00 mcg/ml (1 ml) ODOMZO OPDIVO oxaliplatin intravenous recon soln 100 oxaliplatin intravenous recon soln 0 oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE 1 MG POMALYST ORAL CAPSULE MG POMALYST ORAL CAPSULE MG, MG PORTRAZZA POTELIGEO PROGRAF INTRAVENOUS PAR; ; LA; QLL (10 per 0 ; QLL (0 per 0 PAR; ; QLL ( per 8 B/D PAR; PAR; PAR; PAR; PAR; PAR; PAR; ; LA; QLL (0 per 0 PAR; B/D PAR; B/D PAR B/D PAR; B/D PAR; PAR; ; LA PAR; ; LA; QLL (10 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 B/D PAR; B/D PAR; CM_MAPD_19_v10_190_1 0 Effective Date April 1, 019
PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 10 MG REVLIMID ORAL CAPSULE 1 MG,. MG, 0 MG, MG REVLIMID ORAL CAPSULE MG RITUXAN RITUXAN HYCELA ROMIDEPSIN RUBRACA ORAL TABLET 00 MG RUBRACA ORAL TABLET 0 MG, 00 MG RYDAPT SANDIMMUNE ORAL SOLUTION SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus oral solution sirolimus oral tablet SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE 1. MG SUTENT ORAL CAPSULE MG, 7. MG, 0 MG PAR; ; LA B/D PAR; PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (10 per 0 B/D PAR; ; LA B/D PAR; PAR PAR; ; LA; QLL (180 per 0 PAR; ; LA; QLL (10 per 0 PAR; ; QLL (0 per 0 B/D PAR; PAR; ; LA B/D PAR B/D PAR; B/D PAR; B/D PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; LA; QLL (10 per 0 PAR; ; QLL (90 per 0 PAR; ; QLL (0 per 0 SYNRIBO TABLOID tacrolimus oral TAFINLAR TAGRISSO ORAL TABLET 0 MG TAGRISSO ORAL TABLET 80 MG TALZENNA ORAL CAPSULE 0. MG TALZENNA ORAL CAPSULE 1 MG tamoxifen TARCEVA ORAL TABLET 100 MG, 10 MG TARCEVA ORAL TABLET MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 10 MG, 00 MG TASIGNA ORAL CAPSULE 0 MG TECENTRIQ temsirolimus THALOMID ORAL CAPSULE 100 MG, 0 MG THALOMID ORAL CAPSULE 10 MG, 00 MG thiotepa TIBSOVO toposar topotecan intravenous recon soln topotecan intravenous solution PAR; B/D PAR; PAR; ; QLL (10 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; QLL (180 per 0 PAR; ; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (90 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (11 per 8 PAR; ; QLL ( per 8 PAR; ; LA; QLL (0 per 1 PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 B/D PAR; PAR; ; QLL (0 per 0 B/D PAR; B/D PAR B/D PAR; CM_MAPD_19_v10_190_1 1 Effective Date April 1, 019
toremifene TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11. MG TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION. MG TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.7 MG tretinoin (chemotherapy) trexall TRISENOX INTRAVENOUS SOLUTION MG/ML TYKERB UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 0 MG VENCLEXTA STARTING PACK ; QLL (0 per 0 PAR; B/D PAR; PAR; ; QLL (1 per 8 PAR; ; QLL (1 per 18 PAR; ; QLL (1 per 8 B/D PAR; PAR; ; LA; QLL (180 per 0 B/D PAR; PAR; PAR; PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (180 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (8 per VERZENIO vinblastine intravenous solution vincasar pfs intravenous solution 1 /ml vincasar pfs intravenous solution / ml vincristine vinorelbine VITRAKVI ORAL CAPSULE 100 MG VITRAKVI ORAL CAPSULE MG VITRAKVI ORAL SOLUTION VIZIMPRO ORAL TABLET 1 MG VIZIMPRO ORAL TABLET 0 MG, MG VOTRIENT VYXEOS XALKORI XATMEP XGEVA XOSPATA XTANDI YERVOY INTRAVENOUS SOLUTION 00 MG/0 ML ( MG/ML) PAR; ; LA; QLL (0 per 0 B/D PAR; B/D PAR B/D PAR; B/D PAR; B/D PAR; PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (180 per 0 PAR; ; LA; QLL (00 per 0 PAR; ; QLL (90 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (10 per 0 B/D PAR; PAR; ; LA; QLL (0 per 0 PAR; ; QLL (1.7 per 8 PAR; ; LA; QLL (90 per 0 PAR; ; LA; QLL (10 per 0 PAR; CM_MAPD_19_v10_190_1 Effective Date April 1, 019
YERVOY INTRAVENOUS SOLUTION 0 MG/10 ML ( MG/ML) PAR; ; LA yondelis B/D PAR; ; LA YONSA PAR; ; QLL (10 per 0 ZALTRAP PAR; ZANOSAR B/D PAR; ZEJULA PAR; ; LA; QLL (90 per 0 ZELBORAF PAR; ; LA; QLL (0 per 0 ZOLINZA PAR; ; QLL (10 per 0 ZORTRESS B/D PAR; ZYDELIG PAR; ; LA; QLL (0 per 0 ZYKADIA PAR; ; LA; QLL (90 per 0 ZYTIGA ORAL TABLET 0 MG PAR; ; LA; QLL (10 per 0 ZYTIGA ORAL TABLET 00 MG PAR; ; QLL (0 per 0 Autonomic / Cns s, Neurology / Psych ABILIFY MAINTENA ; QLL (1 per 8 ABSTRAL PAR; ; QLL (10 per 0 acetaminophen-codeine oral solution 10-1 / ml ( ml), 0 - /10 ml (10 ml), 00-0 / 1. ml QLL (900 per 0 acetaminophen-codeine oral solution 10-1 / ml ; QLL (900 per 0 acetaminophen-codeine oral ; QLL (180 per tablet ADASUVE 0 QLL (0 per 0 alprazolam oral tablet amitriptyline amoxapine AMPYRA AMRIX APOKYN APTIOM aripiprazole oral solution aripiprazole oral tablet 10 aripiprazole oral tablet 1 aripiprazole oral tablet aripiprazole oral tablet 0, 0 aripiprazole oral tablet aripiprazole oral tablet, disintegrating 10 aripiprazole oral tablet, disintegrating 1 ARISTADA INITIO ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 1,0 MG/.9 ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 1 MG/1. ML ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING MG/. ML ; QLL (10 per 0 PAR; PAR; PAR; ; LA; QLL (0 per 0 PAR; PAR; ; LA ; QLL (900 per 0 ; QLL (90 per 0 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (90 per 0 0 ; QLL (.8 per ; QLL (.9 per 0 ; QLL (1. per 0 ; QLL (. per 0 CM_MAPD_19_v10_190_1 Effective Date April 1, 019
ARISTADA INTRAMUSCULAR SUSPENSION, EXTENDED REL SYRING 88 MG/. ML atomoxetine oral capsule 10, 18,, 0 atomoxetine oral capsule 100, 0, 80 baclofen oral BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 00 MG BANZEL ORAL TABLET 00 MG benztropine oral BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 7 MG BRIVIACT ORAL TABLET MG BRIVIACT ORAL TABLET 0 MG bromocriptine buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet buprenorphine hcl sublingual tablet 8 buprenorphine-naloxone sublingual tablet -0. buprenorphine-naloxone sublingual tablet 8- bupropion hcl oral tablet 100 ; QLL (. per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (0 per 0 PAR; PAR PAR; ; QLL (00 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (10 per 0 ; QLL (90 per 0 QLL (90 per 0 ; QLL (0 per 0 0 0 ; QLL (90 per 0 ; QLL (1 per 0 bupropion hcl oral tablet 7 bupropion hcl oral tablet extended release hr 10 bupropion hcl oral tablet extended release hr 00 bupropion hcl oral tablet sustained-release 1 hr 100 bupropion hcl oral tablet sustained-release 1 hr 10, 00 buspirone butalbital-acetaminop-caf-cod oral capsule 0--0-0 butalbital-acetaminophen oral tablet 0- butalbital-acetaminophen-caff oral tablet 0--0 butorphanol tartrate injection solution 1 /ml butorphanol tartrate injection solution /ml butorphanol tartrate nasal carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 / ml carbamazepine oral suspension 00 /10 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr carbamazepine oral tablet, chewable carbidopa-levodopa celecoxib CELONTIN ORAL CAPSULE 00 MG chlorpromazine ; QLL (180 per 0 ; QLL (90 per 0 ; QLL (0 per 0 ; QLL (10 per 0 0 PAR; ; QLL (180 per 0 PAR; ; QLL (180 per 0 PAR; ; QLL (180 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL ( per 8 PAR; CM_MAPD_19_v10_190_1 Effective Date April 1, 019
citalopram oral solution citalopram oral tablet 10 citalopram oral tablet 0 citalopram oral tablet 0 clobazam oral suspension clobazam oral tablet 10 clobazam oral tablet 0 clomipramine clonazepam oral tablet 0. clonazepam oral tablet 1 clonazepam oral tablet clonazepam oral tablet, disintegrating 0.1 clonazepam oral tablet, disintegrating 0. clonazepam oral tablet, disintegrating 0. clonazepam oral tablet, disintegrating 1 clonazepam oral tablet, disintegrating clorazepate dipotassium clozapine oral tablet 100 clozapine oral tablet 00 clozapine oral tablet clozapine oral tablet 0 clozapine oral tablet, disintegrating 100 clozapine oral tablet, disintegrating 1. ; QLL (00 per 0 ; QLL (10 per 0 0 ; QLL (0 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (10 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (100 per 0 ; QLL (00 per 0 ; QLL (00 per 0 ; QLL (800 per 0 ; QLL (00 per 0 ; QLL (100 per 0 ; QLL (00 per 0 ; QLL (00 per 0 ; QLL (70 per 0 ; QLL (10 per 0 ; QLL (1080 per 0 ; QLL (0 per 0 QLL (70 per 0 QLL (10 per 0 clozapine oral tablet, disintegrating 10 clozapine oral tablet, disintegrating 00 clozapine oral tablet, disintegrating COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML dalfampridine dantrolene desipramine desvenlafaxine oral tablet extended release hr 100 DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 100 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG desvenlafaxine succinate oral tablet extended release hr 100 desvenlafaxine succinate oral tablet extended release hr desvenlafaxine succinate oral tablet extended release hr 0 dextroamphetamine oral tablet 10 dextroamphetamine oral tablet dextroamphetamineamphetamine oral tablet 10, 1., 1, 0,, 7. QLL (180 per 0 QLL (10 per 0 QLL (1080 per 0 PAR; ; QLL (1 per 8 PAR; ; QLL (0 per 0 PAR; ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (0 per 0 ; QLL (10 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (180 per 0 ; QLL (90 per 0 PAR; ; QLL (90 per 0 CM_MAPD_19_v10_190_1 Effective Date April 1, 019
dextroamphetamineamphetamine oral tablet 0 DIASTAT DIASTAT ACUDIAL RECTAL KIT 1.-1-17.-0 MG DIASTAT ACUDIAL RECTAL KIT -7.-10 MG diazepam injection solution diazepam injection syringe diazepam intensol diazepam oral concentrate diazepam oral solution / ml (1 /ml) diazepam oral solution / ml (1 /ml, ml) diazepam oral tablet 10 diazepam oral tablet diazepam oral tablet diazepam rectal kit 1.-1-17.-0 diazepam rectal kit., -7.-10 diclofenac potassium diclofenac sodium oral diclofenac sodium topical gel 1 % diflunisal dihydroergotamine nasal DILANTIN EXTENDED ORAL CAPSULE 100 MG DILANTIN INFATABS DILANTIN ORAL CAPSULE 0 MG divalproex donepezil oral tablet 10, PAR; ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (100 per 0 QLL (100 per 0 ; QLL (10 per 0 ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (1000 per 0 ; QLL (8 per 8 ; QLL (0 per 0 doxepin oral duloxetine oral capsule, delayed release(dr/ec) 0 duloxetine oral capsule, delayed release(dr/ec) 0 duloxetine oral capsule, delayed release(dr/ec) 0 duloxetine oral capsule, delayed release(dr/ec) 0 duramorph (pf) injection solution 0. /ml duramorph (pf) injection solution 1 /ml EMSAM endocet oral tablet 10-, -, 7.- entacapone EPIDIOLEX epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 00 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 1 HR 00 MG ergoloid ergomar escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 escitalopram oxalate oral tablet 0 escitalopram oxalate oral tablet eszopiclone ethosuximide PAR; ; QLL (180 per 0 ; QLL (10 per 0 ; QLL (90 per 0 0 ; QLL (180 per 0 QLL (180 per 0 PAR; ; QLL (0 per 0 ; QLL (180 per 0 PAR; ; LA ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (180 per 0 PAR; ; QLL (00 per 0 0 ; QLL (0 per 0 ; QLL (10 per 0 PAR; ; QLL (0 per 0 CM_MAPD_19_v10_190_1 Effective Date April 1, 019