Aurora Special Needs Plan HMO SNP Formulary. (List of Covered Drugs)

Aurora Special Needs Plan HMO SNP 07 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 7044, Version 8 This formulary was updated on /30/07. For more recent information or other questions, please contact Aurora Special Needs Plan Customer Service, at -855-88-9 or, for TTY users, -800-947-359, 4 hours-a-day, 7 days-a-week, or visit www.icarehealthplan.org. 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 Independent Care Health Plan. When it refers to plan or our plan, it means Aurora Special Needs Plan. This document includes a list of the drugs (formulary) for our plan which is current as of January, 07. 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, 08, and from time to time during the year. The formulary may change at any time. You will receive notice when necessary. The icare Aurora Special Needs Plan is a Coordinated Care plan with a Medicare Advantage contract and a contract with the Wisconsin Medicaid program. Enrollment in the icare Aurora Special Needs Plan depends on contract renewal. If you have special needs, this document may be available for free in other formats or languages. Please call Customer Service at -855-88-9 (TTY: -800-947-359) for more information. H37_IC5 Accepted

What is the Aurora Special Needs Plan Formulary? A formulary is a list of covered drugs selected by Aurora Special Needs 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. Aurora Special Needs Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aurora Special Needs 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 07 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 07 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, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, 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 December, 07. To get updated information about the drugs covered by the Aurora Special Needs Plan, please contact us. Our contact information appears on the front and back cover pages. In the event of any mid-year non-maintenance formulary changes, Aurora Special Needs Plan will mail you an errata sheet to update your printed formulary. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 4. 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 4. 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. 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? Aurora Special Needs 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: Aurora Special Needs Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Aurora Special Needs Plan before you fill your prescriptions. If you don t get approval, Aurora Special Needs Plan may not cover the drug. Quantity Limits: For certain drugs, Aurora Special Needs Plan limits the amount of the drug that Aurora Special Needs Plan will cover. For example, Aurora Special Needs Plan provides 60 capsules per prescription for Aggrenox. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Aurora Special Needs Plan 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, Aurora Special Needs Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Aurora Special Needs Plan 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 4. 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 Aurora Special Needs 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 Aurora Special Needs Plan formulary? on page 4 for information about how to request an exception. 3

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. For more information, 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 learn that Aurora Special Needs 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 Aurora Special Needs 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 Aurora Special Needs Plan. You can ask Aurora Special Needs 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 Aurora Special Needs Plan s Formulary? You can ask Aurora Special Needs 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 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 waive coverage restrictions or limits on your drug. For example, for certain drugs, Aurora Special Needs 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, Aurora Special Needs Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, 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 4 hours after we get a supporting statement from your doctor or other prescriber. 4

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). 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 3-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. As a current member in our plan, we will also cover an emergency supply of medication if you experience a level of care change. This may include unplanned changes in treatment settings such as being discharged from a hospital to return home. For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, you must utilize the exceptions and appeals process. However, we will cover up to a temporary 30-day supply, while an exception request is being processed. For more information For more detailed information about your Aurora Special Needs Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Aurora Special Needs 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 -800- MEDICARE (-800-633-47) 4 hours a day/7 days a week. TTY users should call -877-486-048. Or, visit http://www.medicare.gov. Aurora Special Needs Plan s Formulary The formulary that begins on the page 4 provides coverage information about the drugs covered by the Aurora Special Needs Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page I. 5

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ABILIFY) and generic drugs are listed in lower-case italics (e.g., diltazem). The information in the Requirements/Limits column tells you if Aurora Special Needs Plan has any special requirements for coverage of your drug. 6

Co-pay Tiers This drug formulary includes three tiers described below. The co-payment you pay depends on the tier (or coverage level) assigned to your prescription drugs. Tier = Generic drug co-pay Tier = Brand drug co-pay Tier 3 = Brand drug co-pay or generic drug co-pay as applicable (Specialty Tier) For co-pay amounts, please refer to your Summary of Benefits. 7

The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA BvD PA-HRM PA NSO QL ST Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction You (or your physician) are required to get prior authorization from Aurora Special Needs Plan before you fill your prescription for this drug. Without prior approval, Aurora Special Needs Plan may not cover this drug. 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 Aurora Special Needs Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Aurora Special Needs Plan may not cover this drug. 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 Aurora Special Needs Plan before you fill your prescription for this drug. Without prior approval, Aurora Special Needs Plan may not cover this drug. If you are a new member or if you have not taken this drug previously, you (or your physician) are required to get prior authorization from Aurora Special Needs Plan before you fill your prescription for this drug. Without prior approval, Aurora Special Needs Plan may not cover this drug. Aurora Special Needs Plan limits the amount of this drug that is covered per prescription, or within a specific time frame. Before Aurora Special Needs Plan 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. 8

ABBREVIATION DESCRIPTION EXPLANATION LA NM Limited Access Drug Non-Mail Order Drug This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at -800-777-4376, 8:00 am to 8:00 pm, 7 days a week. TTY/TDD users should call -800-947-359. You may be able to receive greater than a -month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. 9

STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION DESCRIPTION adh. patch adhesive patch aer br act aerosol, breath activated aer pow aerosol, powder aer pow ba aerosol powder, breath activated aer refill aerosol refill aer w/adap aerosol with adapter ampul ampule blkbaginj bulk bag injection cap dr mp capsule, delayed release multiphasic cap ds pk capsule, dose pack cap er h capsule, hour extended release cap er 4h capsule, 4 hour extended release cap er deg capsule, extended release degradable cap er pel capsule, extended release pellets cap mphase capsule, multiphasic cap.sa 4h capsule, 4 hour sustained action cap.sr h capsule, hour sustained release cap.sr 4h capsule, 4 hour sustained release cap4h pct capsule, 4 hour controlled-onset pellets cap4h pel capsule, 4 hour sustained release pellets cap sprink capsule, sprinkle cap sr pel capsule sustained release pellets cap w/dev capsule with device capsule dr capsule, delayed release capsule er capsule, extended release capsule sa capsule, sustained action cmb cappad combination: capsule, pad cmb ont fm combination: ointment, foam cmb ont lt combination: ointment, lotion cmb tabpad combination: tablet, pad combo. pkg combination package cpmp hr capsule, hour multiphasic cpmp 4hr capsule, 4 hour multiphasic cpmp 30-70 capsule, multiphasic, 30%-70% cpmp 50-50 capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) 0

ABBREVIATION cream(ml) cream/appl cream, er (g) cream pack dehp fr bg dis needle disk w/dev disp syrin drops susp drps hpvis emul adhes emul packt emulsn(g) foam/appl. froz.piggy g gel/pf app gel (gm) gel (ml) gel md pmp gel w/appl gel w/pump gran pack hfa aer ad infus. btl insuln pen ip soln irrig soln iv soln. jel jelly/app jel/pf app kit cl&crm kt crm le kt lotn ce kt oint le lotion, er lozenge hd DESCRIPTION cream (milliliters) cream with applicator cream, extended release (grams) cream, package di(-ethylhexyl)phthalate free bag disposable needle disk with inhalation device disposable syringe drops, suspension drops, hyperviscous emulsion adhesive emulsion packet emulsion (grams) foam with applicator frozen piggyback gram gel with prefilled applicator gel (grams) gel (milliliters) gel in metered dose pump gel with applicator gel with pump granule pack hfa aerosol adapter infusion bottle insulin pen intraperitoneal solution irrigating solution intravenous solution jelly jelly with applicator jelly with pre-filled applicator kit: cleanser and cream kit: cream, lotion emollient kit: lotion, cream emollient kit: ointment, lotion emollient lotion, extended release lozenge handle

ABBREVIATION m.ht patch ma buc tab mcg med. pad med. swab med. tape ml muc er h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td4 patch td7 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag DESCRIPTION medicated heated patch mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram milliliter mucoadhesive system, hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 4 hour transdermal patch, 7 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal

ABBREVIATION suppos. sus er 4h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er h tab er 4h tab er prt tab er seq tab disper tab ds pk tab er 4 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr h tab.sr 4h tabergr4hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp hr tbmp 4hr u vag ring DESCRIPTION suppository suspension, 4 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, hour extended release tablet, 4 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 4 hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, hour sustained release tablet, 4 hour sustained release tablet, 4 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack tablet, rapid disintegrating dose pack tablet, 3-month dose pack tablet, hour multiphasic tablet, 4 hour multiphasic unit vaginal ring 3

Table of Contents Analgesics... 6 Anesthetics... Anti-Addiction/Substance Abuse Treatment Agents... Antianxiety Agents... 3 Antibacterials... 4 Anticancer Agents... 3 Anticholinergic Agents... 4 Anticonvulsants... 4 Antidementia Agents... 45 Antidepressants... 45 Antidiabetic Agents... 48 Antifungals... 5 Antigout Agents... 53 Antihistamines... 53 Anti-Infectives (Skin And Mucous Membrane)... 53 Antimigraine Agents... 54 Antimycobacterials... 54 Antinausea Agents... 55 Antiparasite Agents... 56 Antiparkinsonian Agents... 57 Antipsychotic Agents... 58 Antivirals (Systemic)... 6 Blood Products/Modifiers/Volume Expanders... 67 Caloric Agents... 70 Cardiovascular Agents... 73 Central Nervous System Agents... 85 Contraceptives... 88 4

Dental And Oral Agents... 94 Dermatological Agents... 94 Devices... 99 Enzyme Replacement/Modifiers... 00 Eye, Ear, Nose, Throat Agents... 0 Gastrointestinal Agents... 05 Genitourinary Agents... 08 Heavy Metal Antagonists... 09 Hormonal Agents, Stimulant/Replacement/Modifying... 0 Immunological Agents... 5 Inflammatory Bowel Disease Agents... 3 Irrigating Solutions... 3 Metabolic Bone Disease Agents... 4 Miscellaneous Therapeutic Agents... 5 Ophthalmic Agents... 7 Replacement Preparations... 8 Respiratory Tract Agents... 3 Skeletal Muscle Relaxants... 35 Sleep Disorder Agents... 36 Vasodilating Agents... 37 Vitamins And Minerals... 38 5

Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 0- QL (700 per 30 days) /5 ml, 360-36 /5 ml (5 ml) acetaminophen-codeine oral tablet 300-5 QL (360 per 30 days) acetaminophen-codeine oral tablet 300-30 (Tylenol-Codeine #3) QL (360 per 30 days) acetaminophen-codeine oral tablet 300-60 (Tylenol-Codeine #4) QL (80 per 30 days) ALLZITAL ORAL TABLET 5-35 MG PA-HRM; QL (360 per 30 days); AGE (Max 64 ascomp with codeine oral capsule 30-50- 35-40 BELBUCA BUCCAL FILM 50 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml buprenorphine transdermal patch weekly 0 mcg/hour, 5 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule 30-50-35-40 butalbital-acetaminop-caf-cod oral capsule 50-300-40-30, 50-35-40-30 butalbital-acetaminophen oral tablet 50-35 butalbital-acetaminophen-caff oral capsule 50-35-40 butalbital-acetaminophen-caff oral tablet 50-35-40 (Buprenex) Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) QL (60 per 30 days) (Butrans) QL (4 per 8 days) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) (Marten-Tab) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) (Capacet) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) (Esgic) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) 6

butalbital-aspirin-caffeine oral capsule 50-35-40 butalbital-aspirin-caffeine oral tablet 50-35-40 (Fiorinal) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) QL (4 per 8 days) BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HOUR capacet oral capsule 50-35-40 PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) codeine sulfate oral tablet 5, 30, QL (80 per 30 days) 60 endocet oral tablet 0-35 QL (40 per 30 days) endocet oral tablet.5-35, 5-35 QL (360 per 30 days) endocet oral tablet 7.5-35 QL (300 per 30 days) endodan oral tablet 4.8355-35 QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, (Actiq) 3 PA; NM; NDS; QL (0 per 30 days) 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 (Duragesic) QL (0 per 30 days) mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 7 hour 37.5 QL (0 per 30 days) mcg/hour fentanyl transdermal patch 7 hour 6.5 mcg/hour, 87.5 mcg/hour ; QL (0 per 30 days) hydrocodone-acetaminophen oral solution QL (700 per 30 days).5-67 /5 ml, 5-63 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) QL (700 per 30 days) 7.5-35 /5 ml hydrocodone-acetaminophen oral tablet (Vicodin HP) QL (390 per 30 days) 0-300 hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (360 per 30 days) 0-35 hydrocodone-acetaminophen oral tablet (Verdrocet) QL (360 per 30 days).5-35 hydrocodone-acetaminophen oral tablet 5- (Vicodin) QL (390 per 30 days) 300 hydrocodone-acetaminophen oral tablet 5- (Lorcet (hydrocodone)) QL (360 per 30 days) 35 hydrocodone-acetaminophen oral tablet 7.5-300 (Vicodin ES) QL (390 per 30 days) 7

hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (360 per 30 days) 7.5-35 hydrocodone-ibuprofen oral tablet 0-00 (Ibudone) QL (50 per 30 days), 5-00 hydrocodone-ibuprofen oral tablet 7.5-00 QL (50 per 30 days) hydromorphone (pf) injection solution 0 (/ml) (5 ml) hydromorphone (pf) injection solution 0 /ml hydromorphone 0 /ml vial p/f,sdv,latex-f 0 /ml hydromorphone injection solution /ml, 4 /ml hydromorphone injection syringe /ml, (Dilaudid) 4 /ml hydromorphone oral liquid /ml (Dilaudid) QL (00 per 30 days) hydromorphone oral tablet, 4, 8 (Dilaudid) QL (80 per 30 days) HYSINGLA ER ORAL TABLET,ORAL QL (30 per 30 days) ONLY,EXT.REL.4 HR 00 MG, 0 MG, 0 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 300 3 PA; NM; NDS; QL (30 per 30 days) MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-35 QL (360 per 30 days) lorcet hd oral tablet 0-35 QL (360 per 30 days) lorcet plus oral tablet 7.5-35 QL (360 per 30 days) margesic oral capsule 50-35-40 PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) methadone injection solution 0 /ml methadone oral solution 0 /5 ml, 5 QL (800 per 30 days) /5 ml methadone oral tablet 0 (Dolophine) QL (360 per 30 days) methadone oral tablet 5 (Dolophine) QL (80 per 30 days) methadose oral tablet,soluble 40 QL (90 per 30 days) morphine 0 /ml carpuject outer, p/f, l/f, suv 0 /ml morphine /ml carpuject outer, l/f, p/f, sdv /ml 8

morphine 4 /ml syringe p/f, latexfree,suv 4 /ml morphine 8 /ml syringe 8 /ml morphine concentrate oral solution 00 QL (80 per 30 days) /5 ml (0 /ml) morphine intramuscular pen injector 0 /0.7 ml morphine intravenous cartridge 5 /ml morphine intravenous syringe 0 /ml, /ml, 4 /ml, 8 /ml morphine oral solution 0 /5 ml QL (700 per 30 days) morphine oral solution 0 /5 ml (4 QL (300 per 30 days) /ml) MORPHINE ORAL TABLET 5 MG QL (80 per 30 days) MORPHINE ORAL TABLET 30 MG QL (0 per 30 days) morphine oral tablet extended release 00 (MS Contin) QL (60 per 30 days), 00, 60 morphine oral tablet extended release 5 (MS Contin) QL (80 per 30 days) morphine oral tablet extended release 30 (MS Contin) QL (0 per 30 days) NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE HR 00 MG, 50 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 00 MG, 50 QL (8 per 30 days) MG, 75 MG oxycodone oral concentrate 0 /ml QL (0 per 30 days) oxycodone oral solution 5 /5 ml QL (300 per 30 days) oxycodone oral tablet 0 QL (80 per 30 days) oxycodone oral tablet 5, 30 (Roxicodone) QL (0 per 30 days) oxycodone oral tablet 0 QL (0 per 30 days) oxycodone oral tablet 5 (Roxicodone) QL (80 per 30 days) oxycodone oral tablet,oral only,ext.rel. (OxyContin) QL (60 per 30 days) hr 0, 5, 0, 30, 40, 60 oxycodone oral tablet,oral only,ext.rel. hr 80 (OxyContin) ; QL (0 per 30 days) oxycodone-acetaminophen oral solution 5- QL (800 per 30 days) 35 /5 ml oxycodone-acetaminophen oral tablet 0-35 (Endocet) QL (40 per 30 days) 9

oxycodone-acetaminophen oral tablet.5- (Endocet) QL (360 per 30 days) 35, 5-35 oxycodone-acetaminophen oral tablet 7.5- (Endocet) QL (300 per 30 days) 35 oxycodone-aspirin oral tablet 4.8355-35 QL (360 per 30 days) OXYCONTIN ORAL TABLET,ORAL QL (60 per 30 days) ONLY,EXT.REL. HR 0 MG, 5 MG, 0 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (0 per 30 days) ONLY,EXT.REL. HR 80 MG oxymorphone oral tablet 0 (Opana) QL (0 per 30 days) oxymorphone oral tablet 5 (Opana) QL (80 per 30 days) oxymorphone oral tablet extended release QL (60 per 30 days) hr 0, 5, 0, 30, 40, 5, 7.5 reprexain oral tablet 0-00,.5-00 QL (50 per 30 days), 5-00 tencon oral tablet 50-35 PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) tramadol oral tablet 50 (Ultram) QL (40 per 30 days) tramadol-acetaminophen oral tablet 37.5- (Ultracet) QL (40 per 30 days) 35 vicodin es oral tablet 7.5-300 QL (390 per 30 days) vicodin hp oral tablet 0-300 QL (390 per 30 days) vicodin oral tablet 5-300 QL (390 per 30 days) XTAMPZA ER ORAL QL (60 per 30 days) CAPSULE,SPRINKLE,ER HR TMPRR 3.5 MG, 8 MG, 9 MG XTAMPZA ER ORAL QL (0 per 30 days) CAPSULE,SPRINKLE,ER HR TMPRR 7 MG XTAMPZA ER ORAL QL (40 per 30 days) CAPSULE,SPRINKLE,ER HR TMPRR 36 MG xylon 0 oral tablet 0-00 QL (50 per 30 days) zebutal oral capsule 50-35-40 PA-HRM; QL (80 per 30 days); AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents 0

CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (00 MG/ML), 800 MG/8 ML (00 MG/ML) celecoxib oral capsule 00, 00, (Celebrex) QL (60 per 30 days) 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 00 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, 300 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 FLECTOR TRANSDERMAL PATCH PA HOUR.3 % flurbiprofen oral tablet 00, 50 ibuprofen oral suspension 00 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 5 QL (40 per 30 days) indomethacin oral capsule 50 QL (0 per 30 days) indomethacin oral capsule, extended QL (60 per 30 days) release 75 indomethacin sodium intravenous recon soln ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets 4 hr 00 ketorolac oral tablet 0 QL (0 per 30 days) mefenamic acid oral capsule 50 (Ponstel) meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5, 7.5 (Mobic)

nabumetone oral tablet 500, 750 naproxen oral suspension 5 /5 ml (Naprosyn) naproxen oral tablet 50, 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375, 500 naproxen sodium oral tablet 75 naproxen sodium oral tablet 550 (Anaprox DS) piroxicam oral capsule 0, 0 (Feldene) sulindac oral tablet 50, 00 tolmetin oral capsule 400 tolmetin oral tablet 00, 600 VOLTAREN TOPICAL GEL % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 0 /ml (Xylocaine-MPF) ( %), 5 /ml (.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl injection solution 0 /ml (Xylocaine) ( %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl injection syringe 0 /ml ( %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine hcl(pf) in 0.9% nacl injection syringe 00 /0 ml ( %) lidocaine topical adhesive (Lidoderm) PA patch,medicated 5 % lidocaine topical ointment 5 % PA NSO; QL (90 per 30 days) 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) 333 BUNAVAIL BUCCAL FILM.-0.3 MG QL (30 per 30 days) BUNAVAIL BUCCAL FILM 4.-0.7 QL (60 per 30 days) MG, 6.3- MG buprenorphine hcl sublingual tablet, PA; QL (90 per 30 days) 8 buprenorphine-naloxone sublingual tablet QL (90 per 30 days) -0.5, 8- buproban oral tablet extended release hr 50 bupropion hcl (smoking deter) oral tablet extended release hr 50 (Zyban) CHANTIX CONTINUING MONTH QL (68 per 84 days) BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, QL (68 per 84 days) MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) QL (53 per 8 days) disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL (4 per 30 days) AEROSOL MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION QL (008 per 90 days) CARTRIDGE 0 MG SUBOXONE SUBLINGUAL FILM -3 QL (60 per 30 days) MG, 8- MG SUBOXONE SUBLINGUAL FILM -0.5 QL (30 per 30 days) MG, 4- MG ZUBSOLV SUBLINGUAL TABLET 0.7-0.8 MG,.4-0.36 MG,.4-.9 MG,.9- QL (30 per 30 days) 0.7 MG, 5.7-.4 MG ZUBSOLV SUBLINGUAL TABLET 8.6-. MG Antianxiety Agents Benzodiazepines QL (60 per 30 days) 3

alprazolam oral tablet 0.5, 0.5, (Xanax) QL (0 per 30 days) alprazolam oral tablet (Xanax) QL (50 per 30 days) chlordiazepoxide hcl oral capsule 0, QL (0 per 30 days) 5, 5 clonazepam oral tablet 0.5, (Klonopin) QL (90 per 30 days) clonazepam oral tablet (Klonopin) QL (300 per 30 days) clonazepam oral tablet,disintegrating QL (90 per 30 days) 0.5, 0.5, 0.5, clonazepam oral tablet,disintegrating QL (300 per 30 days) clorazepate dipotassium oral tablet 5, 3.75 QL (80 per 30 days) clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (80 per 30 days) DIASTAT ACUDIAL RECTAL KIT.5-5-7.5-0 MG, 5-7.5-0 MG DIASTAT RECTAL KIT.5 MG diazepam injection solution 5 /ml QL (0 per 8 days) diazepam intensol oral concentrate 5 QL (00 per 30 days) /ml diazepam oral solution 5 /5 ml ( /ml) QL (00 per 30 days) diazepam oral tablet 0,, 5 (Valium) QL (0 per 30 days) diazepam rectal kit.5-5-7.5-0, 5- (Diastat AcuDial) 7.5-0 diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml (Ativan) QL ( per 30 days) lorazepam oral tablet 0.5, (Ativan) QL (90 per 30 days) lorazepam oral tablet (Ativan) QL (50 per 30 days) ONFI ORAL SUSPENSION.5 MG/ML 3 PA NSO; NM; NDS; QL (480 per 30 days) ONFI ORAL TABLET 0 MG, 0 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION 3 PA BvD; NM; NDS FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 00 /50 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin injection solution 40 /ml 4

gentamicin ped 0 / ml vial latex-free, sdv 0 / ml gentamicin sulfate (pf) intravenous solution 00 /0 ml neomycin oral tablet 500 streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE ; QL (4 per 8 days) 8 MG tobramycin in 0.5 % nacl inhalation (Tobi) 3 PA BvD; NM; NDS solution for nebulization 300 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 0 /ml, 40 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln (BACiiM) 50,000 unit chloramphenicol sod succinate intravenous recon soln gram clindamycin 75 /5 ml soln 75 /5 ml (Cleocin Pediatric) clindamycin hcl oral capsule 50, 300, 75 (Cleocin HCl) clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) clindamycin phosphate injection solution 50 /ml clindamycin phosphate intravenous solution 600 /4 ml colistin (colistimethate na) injection recon soln 50 daptomycin intravenous recon soln 500 linezolid intravenous parenteral solution 600 /300 ml linezolid oral suspension for reconstitution 00 /5 ml (Cleocin in 5 % dextrose) (Cleocin) (Cleocin) (Coly-Mycin M Parenteral) (Cubicin) (Zyvox) (Zyvox) 5

linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /00 ml metronidazole oral capsule 375 (Flagyl) metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 00, 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 (0 per 30 days); AGE (Max 64 Years) nitrofurantoin monohyd/m-cryst oral capsule 00 (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 30 days); AGE (Max 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 vancomycin hcl g/00 ml bag gram/00 ml vancomycin intravenous recon soln,000, 0 gram, 750 vancomycin intravenous recon soln 500 vancomycin oral capsule 5, 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG 3 PA; NM; NDS; QL (9 per 30 days) XIFAXAN ORAL TABLET 550 MG 3 PA; NM; NDS Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 5 /5 ml, 50 /5 ml, 375 /5 ml 6

cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, gram/50 ml cefazolin injection recon soln gram, 0 gram, 500 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 400 (Spectracef) CEFEPIME GM INJECTION GRAM/50 ML CEFEPIME INJECTION RECON SOLN (Maxipime) GRAM, GRAM CEFEPIME-DEXTROSE GM/50 ML GRAM/50 ML cefotaxime injection recon soln gram, 500 cefotaxime injection recon soln 0 gram, (Claforan) gram cefoxitin gm piggyback bag gram/50 ml cefoxitin intravenous recon soln gram, 0 gram cefoxitin intravenous recon soln gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram, 6 (Fortaz) gram ceftibuten oral capsule 400 (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 80 /5 ml ceftriaxone gm piggyback l/g, single use gram/50 ml 7

ceftriaxone gm piggyback l/f, single use gram/50 ml ceftriaxone injection recon soln 0 gram, 50, 500 ceftriaxone intravenous recon soln gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln (Zinacef) 750 cefuroxime sodium intravenous recon soln (Zinacef).5 gram, 7.5 gram cefuroxime-dextrose (iso-osm) intravenous piggyback 750 /50 ml cephalexin oral capsule 50, 500, (Keflex) 750 cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 MEFOXIN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET,CHEWABLE 00 MG, 00 MG tazicef injection recon soln gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 (3 pack) azithromycin oral tablet 50, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 8

clarithromycin oral tablet extended release 4 hr 500 DIFICID ORAL TABLET 00 MG ; QL (0 per 0 days) e.e.s. 400 oral tablet 400 e.e.s. granules oral suspension for reconstitution 00 /5 ml ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG, 500 MG erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml 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 gram, gram (Azactam) CAYSTON INHALATION SOLUTION 3 NM; LA; NDS FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50 9

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 50-5 amoxicillin-pot clavulanate oral tablet (Augmentin) 500-5, 875-5 amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release hr,000-6.5 amoxicillin-pot clavulanate oral tablet,chewable 00-8.5, 400-57 ampicillin oral capsule 50, 500 ampicillin oral suspension for reconstitution 5 /5 ml, 50 /5 ml ampicillin sodium injection recon soln gram, 0 gram, 5, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn).5 gram, 5 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML(600K/600K),,00,000 UNIT/ ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial 0's, latex-free gram nafcillin injection recon soln gram, 0 gram nafcillin intravenous recon soln gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, gram/50 ml 30

oxacillin injection recon soln 0 gram, gram oxacillin intravenous recon soln gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 5 million unit penicillin g procaine intramuscular syringe. million unit/ ml, 600,000 unit/ml penicillin gk 0 million unit 0 million unit (Pfizerpen-G) penicillin v potassium oral recon soln 5 /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, 3.375 gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 00, 750 ciprofloxacin hcl oral tablet 50, 500 (Cipro) ciprofloxacin in 5 % dextrose intravenous piggyback 00 /00 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 /00 ml, 750 /50 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50, 500, 750 (Levaquin) 3

moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 300, 400 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) 400-80 sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) 800-60 sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) (dr/ec) 500 sulfatrim oral suspension 00-40 /5 ml Tetracyclines doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon (Doxy-00) soln 00 doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 0 doxycycline monohydrate oral capsule 00 (Mondoxyne NL), 50, 75 doxycycline monohydrate oral capsule 50 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 00 (Avidoxy) doxycycline monohydrate oral tablet 50, 50, 75 minocycline oral capsule 00, 50, (Minocin) 75 minocycline oral tablet 00, 50, 75 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents 3

ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous solution /ml, 0 /0 ml adrucil,500 /50 ml vial outer, latexfree.5 gram/50 ml 3 PA NSO; NM; NDS; QL (4 per days) PA BvD PA BvD adrucil intravenous solution 500 /0 ml PA BvD AFINITOR DISPERZ ORAL TABLET 3 PA NSO; NM; NDS; QL FOR SUSPENSION MG, 3 MG, 5 MG ( per 8 days) AFINITOR ORAL TABLET 0 MG 3 PA NSO; NM; NDS; QL (56 per 8 days) AFINITOR ORAL TABLET.5 MG, 5 3 PA NSO; NM; NDS; QL MG, 7.5 MG (8 per 8 days) ALECENSA ORAL CAPSULE 50 MG 3 PA NSO; NM; NDS; QL (40 per 30 days) ALIMTA INTRAVENOUS RECON SOLN 00 MG, 500 MG ALIQOPA INTRAVENOUS RECON 3 PA NSO; NM; NDS; QL SOLN 60 MG (3 per 8 days) ALUNBRIG ORAL TABLET 30 MG 3 PA NSO; NM; NDS; QL (80 per 30 days) anastrozole oral tablet (Arimidex) AVASTIN INTRAVENOUS SOLUTION 3 PA NSO; NM; NDS 5 MG/ML, 5 MG/ML (6 ML) azacitidine injection recon soln 00 (Vidaza) BAVENCIO INTRAVENOUS 3 PA NSO; NM; NDS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON 3 PA NSO; NM; NDS SOLN 500 MG BENDEKA INTRAVENOUS 3 PA NSO; NM; NDS SOLUTION 5 MG/ML BESPONSA INTRAVENOUS RECON 3 PA NSO; NM; NDS SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 3 PA NSO; NM; NDS; QL (40 per 30 days) bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 5 unit (Bleo 5K) PA BvD bleomycin injection recon soln 30 unit PA BvD BLINCYTO INTRAVENOUS KIT 35 3 PA NSO; NM; NDS; QL MCG (40 per 365 days) 33

BOSULIF ORAL TABLET 00 MG 3 PA NSO; NM; NDS; QL (0 per 30 days) BOSULIF ORAL TABLET 500 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) CABOMETYX ORAL TABLET 0 MG, 60 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) CABOMETYX ORAL TABLET 40 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) CAPRELSA ORAL TABLET 00 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) CAPRELSA ORAL TABLET 300 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) clofarabine intravenous solution 0 /0 (Clolar) ml COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 MG/DAY(80 MG X-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) 3 PA NSO; NM; NDS; QL ( per 8 days) COTELLIC ORAL TABLET 0 MG 3 PA NSO; NM; LA; NDS; QL (63 per 8 days) cyclophosphamide intravenous recon soln 3 PA BvD; NM; NDS gram, gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 3 PA NSO; NM; NDS SOLUTION 0 MG/ML, 0 MG/ML (50 ML) DARZALEX INTRAVENOUS 3 PA NSO; NM; LA; NDS SOLUTION 0 MG/ML decitabine intravenous recon soln 50 (Dacogen) doxorubicin 00 /00 ml vial latex-free (Adriamycin) PA BvD /ml doxorubicin intravenous solution 50 (Adriamycin) PA BvD /5 ml doxorubicin, peg-liposomal intravenous (Doxil) 3 PA BvD; NM; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, 300 MG, 400 MG ELIGARD (3 MONTH) QL ( per 84 days) SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG QL ( per days) 34

ELIGARD (6 MONTH) QL ( per 68 days) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON 3 PA NSO; NM; NDS SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 3 PA NSO; NM; NDS MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil 5,000 /00 ml latex-free 5 (Adrucil) PA BvD gram/00 ml fluorouracil intravenous solution PA BvD gram/0 ml fluorouracil intravenous solution.5 (Adrucil) PA BvD gram/50 ml, 500 /0 ml flutamide oral capsule 5 GAZYVA INTRAVENOUS SOLUTION 3 PA NSO; NM; NDS,000 MG/40 ML GILOTRIF ORAL TABLET 0 MG, 30 MG, 40 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON 3 PA NSO; NM; NDS SOLN 50 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG 3 PA NSO; NM; NDS; QL ( per 8 days) ICLUSIG ORAL TABLET 5 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) ICLUSIG ORAL TABLET 45 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) 35

IDHIFA ORAL TABLET 00 MG, 50 MG 3 PA NSO; NM; NDS; QL (30 per 30 days) ifosfamide gm/0 ml vial sdv,p/f,latexfree PA BvD gram/0 ml ifosfamide intravenous recon soln gram (Ifex) PA BvD ifosfamide-mesna intravenous kit - 3 PA BvD; NM; NDS gram, 3,000-,000 imatinib oral tablet 00 (Gleevec) 3 PA NSO; NM; NDS; QL (90 per 30 days) imatinib oral tablet 400 (Gleevec) 3 PA NSO; NM; NDS; QL (60 per 30 days) IMBRUVICA ORAL CAPSULE 40 MG 3 PA NSO; NM; NDS IMFINZI INTRAVENOUS SOLUTION 3 PA NSO; NM; NDS 50 MG/ML, 50 MG/ML (0 ML) IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML 3 PA NSO; NM; NDS; QL (4 per 365 days) IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML 3 PA NSO; NM; NDS; QL (8 per 8 days) INLYTA ORAL TABLET MG 3 PA NSO; NM; NDS; QL (80 per 30 days) INLYTA ORAL TABLET 5 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) IRESSA ORAL TABLET 50 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) IXEMPRA INTRAVENOUS RECON SOLN 5 MG, 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG 3 PA NSO; NM; NDS; QL (60 per 30 days) KEYTRUDA INTRAVENOUS RECON 3 PA NSO; NM; NDS SOLN 50 MG KEYTRUDA INTRAVENOUS 3 PA NSO; NM; NDS SOLUTION 5 MG/ML KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG 3 PA NSO; NM; NDS; QL (49 per 8 days) KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X 3)-.5 MG 3 PA NSO; NM; NDS; QL (70 per 8 days) 3 PA NSO; NM; NDS; QL (9 per 8 days) 36