Moda Health Plan, Inc. 018 Comprehensive Formulary (complete list of covered drugs) Please read: this document contains information about the drugs we cover in this plan 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. For more recent information or other questions, please contact Moda Health Plan, Inc. Customer Service at 1-888-786-7509, or, for TTY users, 711, from 7 a.m. to 8 p.m. Pacific Time, seven days a week or visit www.modahealth.com/medicare. H81-006 H8506-001 Y0115_CF_COMM18A Accepted
Next year, you can get plan documents delivered to you online Online documents give you easy access to all your Medicare information. The Centers for Medicare and Medicaid Services (CMS) require that we send you important plan documents every year. These documents contain information specific to your Moda Health plan: > > Combined Annual Notice of Changes (ANOC) and Evidence of Coverage (EOC) > > Comprehensive formulary (if applicable) That s a lot of paper to clutter your home. Luckily, all of these documents are available electronically through your mymoda account. To receive an email from Moda Health when new materials are available, simply log in to your mymoda account by visiting www.modahealth.com. The mymoda log in is on the right side of your screen. You can also create an account on this page. Once logged in, select the Account tab. Next, click on Change account settings. From here, you can update your email and make your electronic delivery preference. Once you request electronic delivery, you will no longer receive these documents in the mail. Questions? Call us at 877-99-906. www.modahealth.com Cut down on more paper sign up for ebill today! Now you can pay your premium online with ebill. Using ebill, you can view invoices online and set up your preferred payment methods (debit card, checking or savings) and set a recurring payment using our AutoPay feature. To access ebill, log in to mymoda and click on the ebill tab. 59876 (7/17) MDCR-14 Health plans in Oregon and Alaska provided by Moda Health Plan, Inc. Dental plans in Oregon provided by Oregon Dental Service, dba Delta Dental Plan of Oregon. Dental plans in Alaska provided by Delta Dental of Alaska.
Moda Health nondiscrimination notice Moda, Inc. complies with applicable federal civil rights laws. We do not discriminate on the basis of race, color, national origin, age, disability or sex. Moda provides free, timely aids and services to people with disabilities to help them communicate with us effectively. These accommodations include sign language interpreters and written information in other formats. If your primary language is not English, Moda also provides free, timely interpretation services and/or materials written in other languages. If you need any of the services listed above, contact: Medicare Customer Service, 877-99-906 (TDD/TTY 711) If you believe that Moda has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a written grievance by mailing or faxing it to: Moda, Inc. Attention: Appeal Unit 601 SW Second Ave. Portland, OR 9704 Fax: 50-41-400 If you need assistance filing a grievance, please call Customer Service. You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights at ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone to: U.S. Department of Health and Human Services 00 Independence Ave. SW, Room 509F HHH Building, Washington, DC 001 800-68-1019, 800-57-7697 (TDD). Office for Civil Rights complaint forms are available at hhs.gov/ocr/office/file/index.html. Moda s efforts to assure nondiscrimination are coordinated by: Tom Bikales, VP Legal Affairs 601 SW Second Ave. Portland, OR 9704 855--9111 compliance@modahealth.com Health plans in Oregon and Alaska provided by Moda Health Plan, Inc. Dental plans in Oregon provided by Oregon Dental Service, dba Delta Dental Plan of Oregon. Dental plans in Alaska provided by Delta Dental of Alaska. 15019019 (8/16)
ATENCIÓN: Si habla español, hay disponibles servicios de ayuda con el idioma sin costo alguno para usted. Llame al 1-877-605-9 (TTY: 711). 注意 : 如果您說中文, 可得到免費語言幫助服務 請致電 1-877-605-9( 聾啞人專用 :711) CHÚ Ý: Nếu bạn nói tiếng Việt, có dịch vụ hổ trợ ngôn ngữ miễn phí cho bạn. Gọi 1-877-605-9 (TTY:711) 주의 : 한국어로무료언어지원서비스를이용하시려면다음연락처로연락해주시기바랍니다. 전화 1-877-605-9 (TTY: 711) PAUNAWA: Kung nagsasalita ka ng Tagalog, ang a serbisyong tulong sa wika, ay walang bayad, at magagamit mo. Tumawag sa numerong 1-877-605-9 (TTY: 711) ВНИМАНИЕ! Если Вы говорите по-русски, воспользуйтесь бесплатной языковой поддержкой. Позвоните по тел. 1-877-605-9 (текстовый телефон: 711). تنبيه: إذا كنت تتحدث العربية فهناك خدمات مساعدة لغوية متاحة لك مجان ا. اتصل برقم 1-877-605-9 )الهاتف النصي: 711( ATANSYON: Si ou pale Kreyòl Ayisyen, nou ofri sèvis gratis pou ede w nan lang ou pale a. Rele nan 1-877-605-9 (moun ki itilize sistèm TTY rele : 711) ATTENTION : si vous êtes locuteurs francophones, le service d assistance linguistique gratuit est disponible. Appelez au 1-877-605-9 (TTY : 711) UWAGA: Dla osób mówiących po polsku dostępna jest bezpłatna pomoc językowa. Zadzwoń: 1-877-605-9 (obsługa TTY: 711) ATENÇÃO: Caso fale português, estão disponíveis serviços gratuitos de ajuda linguística. Telefone para 1-877-605-9 (TERMINAL: 711) ATTENZIONE: Se parla italiano, sono disponibili per lei servizi gratuiti di assistenza linguistica. Chiamare il numero 1-877-605-9 (TTY: 711) 注意 : 日本語をご希望の方には 日本語サービスを無料で提供しております 1-877-605-9(TTY テレタイプライターをご利用の方は 711) までお電話ください Achtung: Falls Sie Deutsch sprechen, stehen Ihnen kostenlos Sprachassistenzdienste zur Verfügung. Rufen sie 1-877-605-9 (TTY: 711) توجه: در صورتی که به فارسی صحبت می کنید خدمات ترجمه به صورت رایگان برای شما موجود است. با 711( 1-877-605-9 )TTY: تماس بگیرید. УВАГА! Якщо ви говорите українською, для вас доступні безкоштовні консультації рідною мовою. Зателефонуйте 1-877-605-9 (TTY: 711) ATENȚIE: Dacă vorbiți limba română, vă punem la dispoziție serviciul de asistență lingvistică în mod gratuit. Sunați la 1-877-605-9 (TTY 711) THOV CEEB TOOM: Yog hais tias koj hais lus Hmoob, muaj cov kev pab cuam txhais lus, pub dawb rau koj. Hu rau 1-877-605-9 (TTY: 711) โปรดทราบ: หากค ณพ ดภาษาไทย ค ณ สามารถใช บร การช วยเหล อด านภาษาได ฟร โทร 1-877-605-9 (TTY: 711) ត រ វចងច ប អ នកន យ យភ ស ខ ម រ ហ យត រ វ ក រស វ កម មជ ន យផ ន កភ ស ដ យឥតគ តថ ល គ ម នផ ដល ជ នល កអ នក ស មទ រស ព ទទ ក ន ល ខ 1-877-605-9 (TTY: 711) HUBACHIISA: Yoo afaan Kshtik kan dubbattan ta e tajaajiloonni gargaarsaa isiniif jira 1-877-605-9(TTY:711) tiin bilbilaa.
Moda Health PPORX (PPO) Moda Health HMO 018 Comprehensive Formulary (List of Covered Drugs) Formulary ID 00018016, Version 8 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on September 1, 017. For more recent information or other questions, please contact Moda Health at 1-888-786-7509 or, for TTY users, 711, from 7 a.m. to 8 p.m., Pacific Time, seven days a week from October 1 through February 14 (After February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi, or visit www.modahealth.com/medicare. 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 Moda Health Plan, Inc. When it refers to plan or our plan, it means Moda Health PPORX (PPO) or Moda Health HMO. This document includes a list of the drugs (formulary) for our plan which is current as of September 1, 017. 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, 019, and from time to time during the year. The formulary may change at any time. You will receive notice when necessary. Moda Health Plan, Inc. is a PPO and HMO with Medicare contracts. Enrollment in Moda Health PPORX or Moda Health HMO depends on contract renewal. 018 Formulary ID 00018016, Version 8 Y0115_CF_COMM18A Accepted i
What is the Moda Health Formulary? A formulary is a list of covered drugs selected by Moda Health 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. Moda Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Moda Health 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 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 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, 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 Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of September 1, 017. To get updated information about the drugs covered by Moda Health, please contact us. Our contact information appears on the front and back cover pages. Moda Health posts the future formulary change files on our website, www.modahealth.com/medicare by the first of each month. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. 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. ii
What are generic drugs? Moda Health 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: Moda Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Moda Health before you fill your prescriptions. If you don t get approval, Moda Health may not cover the drug. Quantity Limits: For certain drugs, Moda Health limits the amount of the drug that Moda Health will cover. For example, Moda Health provides 0 tablets in 0 days per prescription for olanzapine. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Moda Health requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Moda Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Moda Health will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. 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 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 Moda Health 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 Moda Health formulary? on page iv 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 Moda Health does not cover your drug, you have two options: iii
You can ask Customer Service for a list of similar drugs that are covered by Moda Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Moda Health. You can ask Moda Health 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 Moda Health Formulary? You can ask Moda Health to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Moda Health 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, Moda Health 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 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 1-day supply (unless you have a prescription written for fewer when you go to a iv
network pharmacy. After your first 1-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 up to a 9-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 1-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you have a level of care change (such as going into or coming out of a skilled nursing facility or long term care home) we will cover a temporary 1-day transition supply (unless you have a prescription written for fewer. 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 1-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. For more information For more detailed information about your Moda Health prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Moda Health, 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 (1-800-6-47) 4 hours a day/7 days a week. TTY users should call 1-877-486-048. Or, visit http://www.medicare.gov. Moda Health Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Moda Health. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LYRICA) and generic drugs are listed in lower-case italics (e.g., valsartan). The information in the Requirements/Limits column tells you if Moda Health has any special requirements for coverage of your drug. v
Utilization Management Restrictions Abbreviation Description Explanation AGE (Max 64 Years) LA NDS PA Age Restricted Drug Limited Access Drug Non-Extended Days Supply Prior Authorization Restriction If you are 64 years or younger, the requirement for a prior authorization for this high risk medication (PA-HRM) does not apply to you. Please refer to the definition for PA-HRM below. For more information call Customer Service at 1-888-786-7509 from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users call 711. This prescription may be available only at certain pharmacies. For more information call Customer Service at 1-888-786-7509 from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users call 711. This prescription is limited to a 1-day supply. For more information call Customer Service at 1-888-786-7509 from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users call 711. You (or your physician) are required to get prior authorization from Moda Health before you fill your prescription for this drug. Without prior approval, Moda Health may not cover the drug. To request a coverage determination, please call Customer Service at 1-888-786-7509 from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users call 711. vi
Utilization Management Restrictions Abbreviation Description Explanation PA BvD PA-HRM Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from Moda Health to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Moda Health may not cover the drug. To request a coverage determination, please call Customer Service at 1-888-786-7509 from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users call 711. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 years or older are required to get prior authorization from Moda Health before you fill your prescription for this drug. Without prior approval, Moda Health may not cover the drug. To request a coverage determination, please call Customer Service at 1-888-786-7509 from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users call 711. vii
Utilization Management Restrictions Abbreviation Description Explanation PA NSO PA NSO-HRM Prior Authorization Restriction for New Starts Only Prior Authorization Restriction for New Starts Only and High Risk Medications If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from Moda Health before you fill your prescription for this drug. Without prior approval, Moda Health may not cover the drug. To request a coverage determination, please call Customer Service at 1-888-786-7509 from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users call 711. If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from Moda Health before you fill your prescription for this drug. Additionally, this drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 years or older are required to get prior authorization from Moda Health before you fill your prescription for this drug. Without prior approval, Moda Health may not cover the drug. To request a coverage determination, please call Customer Service at 1-888-786-7509 from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users call 711. viii
Utilization Management Restrictions Abbreviation Description Explanation QL Quantity Limit Restriction Moda Health limits the amount of this drug that is covered per prescription, or within a specific time frame. Without prior approval, Moda Health may not cover the drug. To request a coverage determination, please call Customer Service at 1-888-786-7509 from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users call 711. ST Step Therapy Restriction Before Moda Health will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. To request a coverage determination, please call Customer Service at 1-888-786-7509 from 7 a.m. to 8 p.m., Pacific time, seven days a week, from October 1st to February 14 (after February 15, your call will be handled by our automated phone system Saturdays, Sundays and holi. TTY users call 711. ix
Moda Health PPORX (PPO) Deductible $10.00 Drug Tier up to a 1-day supply up to a 9-day supply Tier 1 $.00 copay $6.00 copay Tier $0.00 copay $60.00 copay Tier $45.00 copay $15.00 copay Tier 4 $100.00 copay $00.00 copay Tier 5 0% coinsurance drugs on this tier are limited to a 1-day supply Moda Health HMO Deductible $10.00 Drug Tier up to a 1-day supply up to a 9-day supply Tier 1 $4.00 copay $1.00 copay Tier $10.00 copay $0.00 copay Tier $45.00 copay $15.00 copay Tier 4 $95.00 copay $85.00 copay Tier 5 0% coinsurance drugs on this tier are limited to a 1-day supply x
Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml acetaminophen-codeine oral tablet 00-15 acetaminophen-codeine oral tablet 00-0 acetaminophen-codeine oral tablet 00-60 ascomp with codeine oral capsule 0-50- 5-40 BELBUCA BUCCAL FILM 150 MCG, 00 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0. /ml buprenorphine hcl injection syringe 0. /ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule 0-50-5-40 butalbital-acetaminop-caf-cod oral capsule 50-00-40-0, 50-5-40-0 butalbital-acetaminophen oral tablet 50-5 butalbital-acetaminophen-caff oral capsule 50-5-40 butalbital-acetaminophen-caff oral tablet 50-5-40 butalbital-aspirin-caffeine oral capsule 50-5-40 BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HOUR QL (700 per 0 QL (60 per 0 (Tylenol-Codeine #) QL (60 per 0 (Tylenol-Codeine #4) QL (180 per 0 (Buprenex) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) QL (60 per 0 (Butrans) QL (4 per 8 1 PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) (Marten-Tab) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) (Zebutal) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) (Esgic) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) (Fiorinal) PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) QL (4 per 8
capacet oral capsule 50-5-40 PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) codeine sulfate oral tablet 15, 0, QL (180 per 0 60 endocet oral tablet 10-5 QL (40 per 0 endocet oral tablet.5-5, 5-5 QL (60 per 0 endocet oral tablet 7.5-5 QL (00 per 0 fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, (Actiq) 5 PA; NDS; QL (10 per 0 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 (Duragesic) QL (10 per 0 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution QL (700 per 0.5-167 /5 ml, 5-16 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) QL (700 per 0 7.5-5 /15 ml hydrocodone-acetaminophen oral tablet (Norco) QL (60 per 0 10-5, 5-5, 7.5-5 hydrocodone-acetaminophen oral tablet (Verdrocet) QL (60 per 0.5-5 hydrocodone-ibuprofen oral tablet 7.5-00 QL (150 per 0 hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone injection solution /ml, 4 /ml hydromorphone injection syringe /ml, (Dilaudid) 4 /ml hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 per 0 hydromorphone oral tablet, 4, 8 (Dilaudid) QL (180 per 0 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.4 HR 100 MG, 10 MG, 0 MG, 0 MG, 40 MG, 60 MG, 80 MG QL (0 per 0 LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 400 MCG/SPRAY 5 PA; NDS; QL (0 per 0 lorcet (hydrocodone) oral tablet 5-5 QL (60 per 0 lorcet hd oral tablet 10-5 QL (60 per 0 lorcet plus oral tablet 7.5-5 QL (60 per 0
methadone injection solution 10 /ml methadone oral solution 10 /5 ml, 5 QL (1800 per 0 /5 ml methadone oral tablet 10 (Dolophine) QL (60 per 0 methadone oral tablet 5 (Dolophine) QL (180 per 0 methadose oral tablet,soluble 40 QL (90 per 0 morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine 4 /ml carpuject outer,l/f,p/f, sdv 4 /ml morphine 8 /ml syringe 8 /ml morphine concentrate oral solution 100 QL (180 per 0 /5 ml (0 /ml) morphine intravenous syringe 10 /ml, /ml, 4 /ml, 8 /ml morphine oral solution 10 /5 ml QL (700 per 0 morphine oral solution 0 /5 ml (4 QL (00 per 0 /ml) MORPHINE ORAL TABLET 15 MG 4 QL (180 per 0 MORPHINE ORAL TABLET 0 MG 4 QL (10 per 0 morphine oral tablet extended release 100 (MS Contin) QL (60 per 0, 00, 60 morphine oral tablet extended release 15 (MS Contin) QL (90 per 0, 0 morphine sulfate 10 /ml vial 10 /ml NUCYNTA ER ORAL TABLET QL (60 per 0 EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 QL (181 per 0 MG, 75 MG oxycodone oral concentrate 0 /ml QL (10 per 0 oxycodone oral solution 5 /5 ml QL (100 per 0 oxycodone oral tablet 10 QL (180 per 0 oxycodone oral tablet 15, 0 (Roxicodone) QL (10 per 0 oxycodone oral tablet 0 QL (10 per 0 oxycodone oral tablet 5 (Roxicodone) QL (180 per 0 oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 per 0 hr 10, 15, 0, 0, 40, 60 oxycodone oral tablet,oral only,ext.rel.1 hr 80 (OxyContin) 5 NDS; QL (10 per 0
oxycodone-acetaminophen oral solution 5- QL (1800 per 0 5 /5 ml oxycodone-acetaminophen oral tablet 10- (Endocet) QL (40 per 0 5 oxycodone-acetaminophen oral tablet.5- (Percocet) QL (60 per 0 5, 5-5 oxycodone-acetaminophen oral tablet 7.5- (Endocet) QL (00 per 0 5 oxycodone-aspirin oral tablet 4.855-5 QL (60 per 0 OXYCONTIN ORAL TABLET,ORAL QL (60 per 0 ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (10 per 0 ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10 (Opana) QL (10 per 0 oxymorphone oral tablet 5 (Opana) QL (180 per 0 oxymorphone oral tablet extended release QL (60 per 0 1 hr 10, 15, 0, 0, 40, 5, 7.5 reprexain oral tablet.5-00 QL (150 per 0 tencon oral tablet 50-5 PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) tramadol oral tablet 50 (Ultram) 1 QL (40 per 0 tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (40 per 0 5 XTAMPZA ER ORAL QL (60 per 0 CAPSULE,SPRINKLE,ER 1HR TMPRR 1.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (10 per 0 CAPSULE,SPRINKLE,ER 1HR TMPRR 7 MG XTAMPZA ER ORAL QL (40 per 0 CAPSULE,SPRINKLE,ER 1HR TMPRR 6 MG zebutal oral capsule 50-5-40 PA-HRM; QL (180 per 0 ; AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML) 4 4
celecoxib oral capsule 100, 00, (Celebrex) QL (60 per 0 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic 50-00 mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic 75-00 mcg diflunisal oral tablet 500 etodolac oral capsule 00, 00 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5 ml (Children's Advil) ibuprofen oral tablet 400, 600, 800 1 indomethacin oral capsule 5 1 PA-HRM; QL (40 per 0 ; AGE (Max 64 Years) indomethacin oral capsule 50 1 PA-HRM; QL (10 per 0 ; AGE (Max 64 Years) indomethacin oral capsule, extended PA-HRM; QL (60 per 0 release 75 ; AGE (Max 64 Years) indomethacin sodium intravenous recon soln 1 ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets 4 hr 00 ketorolac oral tablet 10 PA-HRM; QL (0 per 0 ; AGE (Max 64 Years) mefenamic acid oral capsule 50 (Ponstel) meloxicam oral suspension 7.5 /5 ml 5
meloxicam oral tablet 15, 7.5 (Mobic) 1 nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, 75 1 naproxen oral tablet 500 (Naprosyn) 1 naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75, 500 piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet 150, 00 Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 10 /ml (Xylocaine-MPF) (1 %), 15 /ml (1.5 %), 0 /ml ( %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine (pf) injection solution 5 /ml (Xylocaine-MPF) (0.5 %) lidocaine hcl % vial inner,ltx-fr,p/f,sdv (Xylocaine-MPF) 0 /ml ( %) lidocaine hcl injection solution 10 /ml (Xylocaine) (1 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive (Lidoderm) PA; QL (90 per 0 patch,medicated 5 % lidocaine topical ointment 5 % PA; QL (90 per 0 lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) BUNAVAIL BUCCAL FILM.1-0. MG QL (0 per 0 BUNAVAIL BUCCAL FILM 4.-0.7 MG, 6.-1 MG QL (60 per 0 6
buprenorphine hcl sublingual tablet, PA; QL (90 per 0 8 buprenorphine-naloxone sublingual tablet -0.5, 8- QL (90 per 0 bupropion hcl (smoking deter) oral tablet extended release 1 hr 150 (Zyban) CHANTIX CONTINUING MONTH QL (168 per 84 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 QL (168 per 84 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (4) QL (5 per 8 disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, 1 /ml naltrexone oral tablet 50 (Revia) NARCAN NASAL SPRAY,NON- QL (4 per 0 AEROSOL MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION 4 QL (1008 per 90 CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM 1- QL (60 per 0 MG, 8- MG SUBOXONE SUBLINGUAL FILM -0.5 QL (0 per 0 MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET 0.7- QL (0 per 0 0.18 MG, 1.4-0.6 MG, 11.4-.9 MG,.9-0.71 MG, 5.7-1.4 MG ZUBSOLV SUBLINGUAL TABLET 8.6-.1 MG QL (60 per 0 Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 (Xanax) 1 QL (10 per 0 alprazolam oral tablet (Xanax) 1 QL (150 per 0 buspirone oral tablet 10, 15, 0, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 1 QL (10 per 0 5, 5 clonazepam oral tablet 0.5, 1 (Klonopin) 1 QL (90 per 0 clonazepam oral tablet (Klonopin) 1 QL (00 per 0 7
clonazepam oral tablet,disintegrating QL (90 per 0 0.15, 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 per 0 clorazepate dipotassium oral tablet 15, QL (180 per 0.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (180 per 0 DIASTAT ACUDIAL RECTAL KIT 4 1.5-15-17.5-0 MG, 5-7.5-10 MG DIASTAT RECTAL KIT.5 MG 4 diazepam injection solution 5 /ml QL (10 per 8 diazepam intensol oral concentrate 5 QL (100 per 0 /ml diazepam oral solution 5 /5 ml (1 /ml) QL (100 per 0 diazepam oral tablet 10,, 5 (Valium) 1 QL (10 per 0 diazepam rectal kit 1.5-15-17.5-0, 5- (Diastat AcuDial) 7.5-10 diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml, 4 (Ativan) QL ( per 0 /ml lorazepam injection syringe /ml QL ( per 0 lorazepam oral tablet 0.5, 1 (Ativan) 1 QL (90 per 0 lorazepam oral tablet (Ativan) 1 QL (150 per 0 ONFI ORAL SUSPENSION.5 MG/ML 5 PA NSO; NDS; QL (480 per 0 ONFI ORAL TABLET 10 MG, 0 MG 5 PA NSO; NDS; QL (60 per 0 temazepam oral capsule 15, 0 (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 ; AGE (Max 64 Years) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION 5 PA BvD; NDS FOR NEBULIZATION 00 MG/4 ML gentamicin 10 /ml vial sdv 60 /6 ml 8
gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 10 /100 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 40 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml neomycin oral tablet 500 1 streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 00 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 40 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram 5 NDS; QL (4 per 8 (Tobi) 5 PA BvD; NDS (BACiiM) clindamycin 75 /5 ml soln 75 /5 ml (Cleocin Pediatric) clindamycin hcl oral capsule 150, 00 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous (Cleocin in 5 % piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml dextrose) clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 150 /ml clindamycin phosphate intravenous (Cleocin) solution 600 /4 ml colistin (colistimethate na) injection recon soln 150 (Coly-Mycin M Parenteral) 9
daptomycin intravenous recon soln 500 (Cubicin) 5 NDS linezolid intravenous parenteral solution 600 /00 ml (Zyvox) 5 NDS linezolid oral suspension for reconstitution (Zyvox) 5 NDS 100 /5 ml linezolid oral tablet 600 (Zyvox) 5 NDS methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /100 ml metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 100, 5, 50 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 0 ; AGE (Max 64 Years) nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 0 ; AGE (Max 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON 5 NDS SOLN 500 MG trimethoprim oral tablet 100 1 vancomycin in dextrose 5 % intravenous piggyback 1 gram/00 ml, 500 /100 ml, 750 /150 ml vancomycin intravenous recon soln 1,000, 10 gram, 5 gram, 500, 750 vancomycin oral capsule 15, 50 (Vancocin) 5 NDS XIFAXAN ORAL TABLET 00 MG 5 PA; NDS; QL (9 per 0 XIFAXAN ORAL TABLET 550 MG 5 PA; NDS 10
Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback gram/100 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefazolin intravenous recon soln 1 gram cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 400 (Spectracef) CEFEPIME 1 GM INJECTION 1 4 GRAM/50 ML CEFEPIME INJECTION RECON SOLN (Maxipime) 4 1 GRAM, GRAM CEFEPIME-DEXTROSE GM/50 ML 4 GRAM/50 ML cefotaxime injection recon soln 1 gram, 10 (Claforan) gram, gram cefotaxime injection recon soln 500 cefoxitin gm piggyback bag gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) ceftibuten oral capsule 400 (Cedax) 11
ceftibuten oral suspension for (Cedax) reconstitution 180 /5 ml ceftriaxone 1 gm piggyback l/g, single use 1 gram/50 ml ceftriaxone gm piggyback l/f, single use gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 50, 500 ceftriaxone intravenous recon soln 1 gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln (Zinacef) 750 cefuroxime sodium intravenous recon soln (Zinacef) 1.5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex) 1 cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 MEFOXIN IN DEXTROSE (ISO-OSM) 4 INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG 4 SUPRAX ORAL TABLET,CHEWABLE 4 100 MG, 00 MG tazicef injection recon soln 1 gram, gram, 6 gram TEFLARO INTRAVENOUS RECON 4 SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 ( pack) azithromycin oral tablet 50, 600 (Zithromax) azithromycin oral tablet 500 (Zithromax TRI-PAK) clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 1
clarithromycin oral tablet extended release 4 hr 500 DIFICID ORAL TABLET 00 MG 5 ST; NDS; QL (0 per 10 e.e.s. 400 oral tablet 400 4 e.e.s. granules oral suspension for 4 reconstitution 00 /5 ml ERYPED 00 ORAL SUSPENSION FOR 4 RECONSTITUTION 00 MG/5 ML ERYPED 400 ORAL SUSPENSION FOR 4 RECONSTITUTION 400 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL TABLET,DELAYED 4 RELEASE (DR/EC) MG erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG 4 erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 LA; NDS imipenem-cilastatin intravenous recon (Primaxin IV) soln 50, 500 INVANZ INJECTION RECON SOLN 1 4 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, 500 1 amoxicillin oral suspension for 1 reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 1 amoxicillin oral tablet,chewable 15, 50 1 1
amoxicillin-pot clavulanate oral suspension for reconstitution 00-8.5 /5 ml, 400-57 /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution 50-6.5 /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution 600-4.9 /5 ml amoxicillin-pot clavulanate oral tablet 50-15 amoxicillin-pot clavulanate oral tablet (Augmentin) 500-15, 875-15 amoxicillin-pot clavulanate oral tablet,chewable 00-8.5, 400-57 ampicillin oral capsule 50, 500 1 ampicillin oral suspension for 1 reconstitution 15 /5 ml, 50 /5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram BICILLIN C-R INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) BICILLIN L-A INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram 5 NDS nafcillin intravenous recon soln gram 5 NDS oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, gram/50 ml oxacillin injection recon soln 10 gram, gram 14
oxacillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 5 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin gk 0 million unit 0 million unit (Pfizerpen-G) penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous recon (Zosyn) soln.5 gram,.75 gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 100, 750 1 ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50, 500, (Levaquin) 750 moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 00, 400 15
Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution 400-80 /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 00-40 /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) 1 400-80 sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) 1 800-160 sulfatrim oral suspension 00-40 /5 ml Tetracyclines doxy-100 intravenous recon soln 100 doxycycline hyclate oral capsule 100 (Vibramycin) doxycycline hyclate oral capsule 50 (Morgidox) doxycycline hyclate oral tablet 100, 0 doxycycline monohydrate oral capsule 100 (Monodox) doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral capsule 50 (Mondoxyne NL), 75 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 150, 50, 75 minocycline oral capsule 100, 50, (Minocin) 75 minocycline oral tablet 100, 50, 75 tigecycline intravenous recon soln 50 (Tygacil) 5 NDS Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 /5 ml, 0 /10 ml 5 NDS PA BvD 16
adrucil intravenous solution.5 gram/50 PA BvD ml, 500 /10 ml AFINITOR DISPERZ ORAL TABLET 5 PA NSO; NDS; QL (11 FOR SUSPENSION MG, MG, 5 MG per 8 AFINITOR ORAL TABLET 10 MG 5 PA NSO; NDS; QL (56 per 8 AFINITOR ORAL TABLET.5 MG, 5 5 PA NSO; NDS; QL (8 MG, 7.5 MG per 8 ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (40 per 0 ALIMTA INTRAVENOUS RECON 5 NDS SOLN 100 MG, 500 MG ALUNBRIG ORAL TABLET 0 MG 5 PA NSO; NDS; QL (180 per 0 anastrozole oral tablet 1 (Arimidex) 1 AVASTIN INTRAVENOUS SOLUTION 5 PA NSO; NDS 5 MG/ML, 5 MG/ML (16 ML) azacitidine injection recon soln 100 (Vidaza) 5 NDS BAVENCIO INTRAVENOUS 5 PA NSO; NDS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON 5 PA NSO; NDS SOLN 500 MG BENDEKA INTRAVENOUS 5 PA NSO; NDS SOLUTION 5 MG/ML bexarotene oral capsule 75 (Targretin) 5 PA NSO; NDS; QL (40 per 0 bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 15 unit (Bleo 15K) PA BvD bleomycin injection recon soln 0 unit PA BvD BLINCYTO INTRAVENOUS KIT 5 5 PA NSO; NDS; QL (140 MCG per 65 BOSULIF ORAL TABLET 100 MG 5 PA NSO; NDS; QL (10 per 0 BOSULIF ORAL TABLET 500 MG 5 PA NSO; NDS; QL (0 per 0 CABOMETYX ORAL TABLET 0 MG, 5 PA NSO; NDS; QL (0 60 MG per 0 CABOMETYX ORAL TABLET 40 MG 5 PA NSO; NDS; QL (60 per 0 CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (60 per 0 CAPRELSA ORAL TABLET 00 MG 5 PA NSO; NDS; QL (0 per 0 17
clofarabine intravenous solution 0 /0 (Clolar) 5 NDS ml COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1), 140 5 PA NSO; NDS; QL (11 per 8 MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) COTELLIC ORAL TABLET 0 MG 5 PA NSO; LA; NDS; QL (6 per 8 cyclophosphamide intravenous recon soln 5 PA BvD; NDS 1 gram, gram, 500 CYCLOPHOSPHAMIDE ORAL 4 PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 5 PA NSO; NDS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS 5 PA NSO; LA; NDS SOLUTION 0 MG/ML decitabine intravenous recon soln 50 (Dacogen) 5 NDS doxorubicin intravenous solution 10 /5 (Adriamycin) PA BvD ml, /ml, 0 /10 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) 5 PA BvD; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 400 MG ELIGARD ( MONTH) 4 SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) 4 SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) 4 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 4 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG 5 NDS EMPLICITI INTRAVENOUS RECON 5 PA NSO; NDS SOLN 00 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (0 per 0 ETOPOPHOS INTRAVENOUS RECON 4 SOLN 100 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG 5 NDS 18
FARYDAK ORAL CAPSULE 10 MG, 15 5 PA NSO; NDS MG, 0 MG FASLODEX INTRAMUSCULAR 5 NDS SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil 5,000 /100 ml latex-free 5 (Adrucil) PA BvD gram/100 ml fluorouracil intravenous solution 1 PA BvD gram/0 ml fluorouracil intravenous solution.5 (Adrucil) PA BvD gram/50 ml, 500 /10 ml flutamide oral capsule 15 GAZYVA INTRAVENOUS SOLUTION 5 PA NSO; NDS 1,000 MG/40 ML GILOTRIF ORAL TABLET 0 MG, 0 5 PA NSO; NDS; QL (0 MG, 40 MG per 0 GLEOSTINE ORAL CAPSULE 10 MG, 4 100 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON 5 PA NSO; NDS SOLN 150 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG 5 NDS hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 5 PA NSO; NDS; QL (1 15 MG, 75 MG per 8 ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NDS; QL (60 per 0 ICLUSIG ORAL TABLET 45 MG 5 PA NSO; NDS; QL (0 per 0 ifosfamide intravenous recon soln 1 gram, (Ifex) PA BvD gram ifosfamide intravenous solution 1 gram/0 PA BvD ml, gram/60 ml ifosfamide-mesna intravenous kit 1-1 5 PA BvD; NDS gram,,000-1,000 imatinib oral tablet 100 (Gleevec) 5 PA NSO; NDS; QL (90 per 0 imatinib oral tablet 400 (Gleevec) 5 PA NSO; NDS; QL (60 per 0 IMBRUVICA ORAL CAPSULE 140 MG 5 PA NSO; NDS IMFINZI INTRAVENOUS SOLUTION 5 PA NSO; NDS 50 MG/ML, 50 MG/ML (10 ML) IMLYGIC INJECTION SUSPENSION 5 PA NSO; NDS; QL (4 10EXP6 (1 MILLION) PFU/ML per 65 19