2017 Formulary for Groups

Transcription

1 Confidence comes with every card. BCN Advantage SM HMO-POS 07 Formulary for Groups List of covered drugs PLEASE READ: DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on /0/07. For more recent information or other questions, please contact BCN Advantage Customer Service at or, for TTY users, 7, 8 a.m. to 8 p.m. Monday through Friday, with weekend hours Oct. through Feb., or visit 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. Updated: /07 Formulary 79, Version BCN Advantage is an HMO POS plan with a Medicare contract. Enrollment in BCN Advantage depends on contract renewal. bcbsm.com/medicare

2 When this drug list (formulary) refers to we, us, or our, it means Blue Care Network. When it refers to plan or our plan, it means BCN Advantage. This document includes a list of the drugs (formulary) for our plan which is current as of /0/07. 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.

3 ) Multi-language Interpreter Services Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 7). Arabic: ملحوظة : إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 7). Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 7) Syriac: ܢܘܗܪܐ : ܡܓܢܡܥܕܪܝܢܢܘܡܓܢܡܫܡܫܝܢܢܐܢܡܠܠܝܬܘܢ ܣ ܘܪܝ ܝ ܐ ܥܒܕܛܝܒܐ ܡܠܠܥܡܢܥܠܡܢܝ ܢܐ: ) TTY: Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 7). Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 7). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 7) 번으로전화해주십시오. Bengali: ম ন র খ বন: য দ আপন র ভ ষ ব ল হয়, ভ ষ সহ য়ত প র ষব, আপ ন বন ম লয প ত প রন কল করন (TTY: 7) Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 7). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 7). DF 606 AUG 6 H88_C_BCNAMultilangInsrt CMS Accepted a

4 Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 7). Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 7) まで お電話にてご連絡ください Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 7). Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY: Telefon za osobe sa oštećenim govorom ili sluhom: 7). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 7). b

5 Discrimination is Against the Law Blue Cross Blue Shield of Michigan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross Blue Shield of Michigan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Blue Cross Blue Shield of Michigan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact the Office of Civil Rights Coordinator. If you believe that Blue Cross Blue Shield of Michigan 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 grievance with: Office of Civil Rights Coordinator 600 E. Lafayette Blvd. MC 0 Detroit, MI , TTY: 7 Fax: civilrights@bcbsm.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Office of Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 00 Independence Avenue, SW Room 09F, HHH Building Washington, D.C , (TDD) Complaint forms are available at c

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7 What is the BCN Advantage Formulary? A formulary is a list of covered drugs selected by BCN Advantage 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. BCN Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BCN Advantage 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 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 up to a 60 day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of /0/07. To get updated information about the drugs covered by BCN Advantage, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid year non maintenance formulary change, we will send out an errata sheet to notify you of this change. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. 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. Then look under the category name on 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 Index. 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? BCN Advantage 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. i

8 How much will I pay for BCN Advantage covered drugs? The amount you pay depends on the drug coverage your group has selected, the drug that has been prescribed for you and where you have your prescription filled. A drug rider, which is a part of your contract with Blue Care Network, describes the deductible, copayment or coinsurance you pay when you fill a prescription. A copayment is a set dollar amount. Coinsurance is a percentage of the cost of the drug that the member pays. The term tier as used below refers to categories in our drug formulary, not to the copayment and coinsurance amounts described in your group s prescription drug rider. The examples below show how the tier categories of our drug formulary relate to your group s prescription drug rider. Example of two tier Pharmacy benefit BCN Formulary (as defined in Prescription Rider) : Formulary Preferred Copay 07 BCN Advantage Formulary : Preferred Generics : Generics : Preferred Brands : Formulary Options Copay : Non preferred s Example of a three tier Pharmacy benefit : Specialty BCN Formulary (as defined in Prescription Rider) : Formulary Preferred Copay : Formulary Options Copay : Non Formulary Copay 07 BCN Advantage Formulary : Preferred Generics : Generics : Preferred Brands : Non preferred s : Specialty Example of a five tier Pharmacy benefit BCN Formulary (as defined in Prescription Rider) : Formulary Preferred Copay : Formulary Options Copay : Non Formulary : Specialty Formulary : Specialty Non Formulary 07 BCN Advantage Formulary : Preferred Generics : Generics : Preferred Brands : Non preferred s : Specialty ii

9 Description of our Formulary s s Includes : Preferred Generic s This is the lowest cost-sharing tier. : Generic s These are still generic drugs but not the lowest cost-sharing tier. : Preferred Brand s This is the lowest cost non-generic tier. : Non-Preferred s These are brand and generic drugs not in a preferred tier. : Specialty s This is the highest cost-sharing tier. Group Enhanced List (Excluded Part D s): These drugs may be covered under your group s BCN Advantage drug benefit and are not normally covered in a Medicare Prescription Plan. These enhanced drugs are represented as EX in your formulary. Your copayment for these drugs is based on the employer s drug benefit and the drug s tier. The amount you pay when you fill a prescription for an enhanced drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs. Only the generic dosage form for drugs on the Enhanced List are covered, unless indicated. Formulary exceptions for the brand products are not allowed. For more information on the Enhanced s, please review your group drug rider. iii

10 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: BCN Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from BCN Advantage before you fill your prescriptions. If you don t get approval, BCN Advantage may not cover the drug. Quantity Limits: For certain drugs, BCN Advantage limits the amount of the drug that BCN Advantage will cover. For example, BCN Advantage provides thirty one per prescription for Onglyza. This may be in addition to a standard one month or three month supply. : In some cases, BCN Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, BCN Advantage may not cover B unless you try A first. If A does not work for you, BCN Advantage will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask BCN Advantage 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 BCN Advantage s formulary? on this page for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that BCN Advantage does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by BCN Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BCN Advantage. You can ask BCN Advantage 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 BCN Advantage Formulary? You can ask BCN Advantage 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, BCN Advantage 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, BCN Advantage 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 iv

11 supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 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 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 day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. Other times when we will cover a temporary day transition supply (or less, if you have a prescription for fewer includes: When you enter a long term care facility from hospitals or other settings When you leave a long term care facility and return to a home When you are discharged from a hospital to a home When you leave a skilled nursing facility covered under Medicare Part A (where all pharmacy charges are covered) and must revert to coverage under the BCN Advantage drug list When you cancel hospice care to revert to standard Medicare Parts A and B benefits When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized BCN Advantage will send you a letter within three business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options. Note: Our transition policy applies only to those drugs that are Part D drugs and that are bought at a network pharmacy. The transition policy can t be used to buy a non Part D drug or a drug out of network, unless you qualify for out of network access. In addition to any exclusions or limitations described in the BCN Advantage 07 Formulary for Groups, or in the Evidence of Coverage, the following items and services aren t covered under Original Medicare or by our plan: Replacement prescriptions resulting from loss, theft or mishandling Reimbursement for prescriptions that are not approved by the FDA Reimbursement for prescriptions that are not purchased in the United States or its territories Covered prescription drugs beyond 90 day supply limit, including early refill requests Prescriptions written by prescribers who are subject to the plan s Prescriber Block Policy Out of state prescription refills are available to you when you spend time outside of Michigan; for example, if you travel to Florida in the winter months. Please call our Customer Service number located on the front and back covers of this booklet if you need help locating an out of state participating pharmacy. v

12 For more information For more detailed information about your BCN Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about BCN Advantage, 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 ( ) hours a day/7 days a week. TTY users call Or, visit BCN Advantage Formulary The formulary provides coverage information about the drugs covered by BCN Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page Index. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., Suprax ) and generic drugs are listed in lower case italics (e.g., sumatriptan). The information in the column tells you if BCN Advantage has any special requirements for coverage of your drug. All drugs on our Formulary are available for mail order: Our plan s mail order service requires you to order at least a day supply of the drug and no more than a 90 day supply. specialty drugs are limited to day supply via mail order. List of Abbreviations QL: Quantity Limit. For certain drugs, BCN Advantage limits the amount of the drug that we will cover. ST:. In some cases, BCN Advantage requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. PA: Prior Authorization. BCN Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don t get approval, we may not cover the drug. B/D: This drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. HI: Home Infusion. This prescription drug is covered under our medical benefit. For more information, call Customer Service at the numbers listed on the cover of this document. LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Customer Service. EX: This prescription drug is not normally covered in a Medicare Prescription Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. BRAND NAME DRUGS ARE CAPITALIZED. Generic drugs are lower case italics. vi

13 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET SUSPENSION AMBISOME SUSPENSION FOR RECONSTITUTIO N amphotericin b injection recon soln CANCIDAS CASPOFUNGIN clotrimazole mucous membrane troche ERAXIS(WATER DILUENT) FLUCONAZOLE IN NACL (ISO- OSM) PIGGYBACK 00 MG/0 ML fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 00 mg/00 ml B/D PA B/D PA B/D PA HI Name fluconazole oral suspension for reconstitution fluconazole oral flucytosine oral griseofulvin microsize oral suspension griseofulvin microsize oral griseofulvin ultramicrosize oral itraconazole oral ketoconazole oral NOXAFIL NOXAFIL ORAL SUSPENSION NOXAFIL ORAL,DELAYE D RELEASE (DR/EC) nystatin oral suspension nystatin oral SPORANOX ORAL : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - QL (9 per

14 Name terbinafine hcl oral voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral ANTIVIRALS abacavir oral abacavir oral abacavir-lamivudine oral abacavirlamivudinezidovudine oral acyclovir oral acyclovir oral suspension 00 mg/ ml acyclovir oral acyclovir sodium intravenous recon soln 00 mg acyclovir sodium intravenous adefovir oral amantadine hcl oral B/D PA Name amantadine hcl oral amantadine hcl oral APTIVUS ORAL CAPSULE APTIVUS ORAL ATRIPLA ORAL BARACLUDE ORAL cidofovir intravenous COMPLERA ORAL CRIXIVAN ORAL CAPSULE 00 MG, 00 MG DAKLINZA ORAL DESCOVY ORAL didanosine oral,delayed release(dr/ec) EDURANT ORAL EMTRIVA ORAL CAPSULE EMTRIVA ORAL entecavir oral PA : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST -

15 Name Name EPCLUSA ORAL PA ISENTRESS HD ORAL EPIVIR HBV ORAL EPZICOM ORAL EVOTAZ ORAL famciclovir oral fosamprenavir oral foscarnet intravenous FUZEON ganciclovir sodium intravenous recon soln GENVOYA ORAL HARVONI ORAL INTELENCE ORAL 00 MG, 00 MG INTELENCE ORAL MG INVIRASE ORAL CAPSULE INVIRASE ORAL B/D PA PA ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL ISENTRESS ORAL,CHEWAB LE 00 MG ISENTRESS ORAL,CHEWAB LE MG KALETRA ORAL KALETRA ORAL 00- MG KALETRA ORAL 00-0 MG lamivudine oral lamivudine oral lamivudinezidovudine oral LEXIVA ORAL SUSPENSION LEXIVA ORAL lopinavir-ritonavir oral : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST -

16 Name MAVYRET ORAL moderiba dose pack oral s,dose pack 00 mg (7)- 00 mg (7), 600 mg (7)- 00 mg (7) moderiba dose pack oral s,dose pack 00 mg (7)- 00 mg (7), 600 mg (7)- 600 mg (7) moderiba oral nevirapine oral suspension nevirapine oral nevirapine oral extended release hr NORVIR ORAL CAPSULE NORVIR ORAL NORVIR ORAL ODEFSEY ORAL OLYSIO ORAL CAPSULE oseltamivir oral 0 mg oseltamivir oral mg, 7 mg PA PA QL (6 per 80 QL (8 per 80 Name PREZCOBIX ORAL PREZISTA ORAL SUSPENSION PREZISTA ORAL 0 MG, 7 MG PREZISTA ORAL 600 MG, 800 MG REBETOL ORAL RELENZA DISKHALER INHALATION BLISTER WITH DEVICE RESCRIPTOR ORAL RESCRIPTOR ORAL, DISPERSIBLE RETROVIR REYATAZ ORAL CAPSULE 0 MG, 00 MG, 00 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - QL (80 per

17 Name Name ribasphere oral 00 mg, 00 mg ribasphere oral 600 mg ribasphere ribapak oral s,dose pack SUSTIVA ORAL SYNAGIS R 0 MG/0. ML TAMIFLU ORAL CAPSULE 0 MG QL (6 per 80 ribavirin inhalation recon soln ribavirin oral ribavirin oral 00 mg rimantadine oral SELZENTRY ORAL SELZENTRY ORAL 0 MG, 00 MG, 7 MG SELZENTRY ORAL MG SOVALDI ORAL stavudine oral STRIBILD ORAL SUSTIVA ORAL CAPSULE B/D PA PA TAMIFLU ORAL CAPSULE MG, 7 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTIO N TECHNIVIE ORAL TIVICAY ORAL 0 MG TIVICAY ORAL MG, 0 MG TRIUMEQ ORAL TRUVADA ORAL TYBOST ORAL valacyclovir oral valganciclovir oral recon soln valganciclovir oral QL (8 per 80 QL (60 per 80 PA : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST -

18 Name VIDEX GRAM PEDIATRIC ORAL VIDEX GRAM PEDIATRIC ORAL VIEKIRA PAK ORAL S,DOSE PACK VIEKIRA XR ORAL, IR - ER, BIPHASIC HR VIRACEPT ORAL VIRAZOLE INHALATION VIREAD ORAL POWDER VIREAD ORAL ZEPATIER ORAL ZERIT ORAL ZIAGEN ORAL zidovudine oral zidovudine oral syrup zidovudine oral PA PA B/D PA PA Name CEPHALOSPORINS CEDAX ORAL CAPSULE cefaclor oral cefaclor oral suspension for reconstitution mg/ ml, 0 mg/ ml, 7 mg/ ml cefaclor oral extended release hr cefadroxil oral cefadroxil oral suspension for reconstitution 0 mg/ ml, 00 mg/ ml cefadroxil oral cefazolin in dextrose (iso-os) intravenous piggyback gram/0 ml cefazolin injection recon soln cefazolin intravenous recon soln cefdinir oral cefdinir oral suspension for reconstitution : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 6

19 Name Name CEFEPIME IN DEXTROSE % PIGGYBACK GRAM/0 ML CEFEPIME IN DEXTROSE % PIGGYBACK GRAM/0 ML cefepime in dextrose,iso-osm intravenous piggyback cefepime injection recon soln gram cefprozil oral suspension for reconstitution cefprozil oral CEFTAZIDIME IN DW PIGGYBACK ceftazidime injection recon soln ceftibuten oral ceftibuten oral suspension for reconstitution cefixime oral suspension for reconstitution ceftriaxone injection recon soln 0 gram, 0 mg, 00 mg cefotaxime injection recon soln CEFOTETAN IN DEXTROSE, ISO- OSM PIGGYBACK CEFTRIAXONE INJECTION 00 GRAM ceftriaxone intravenous recon soln HI cefoxitin in dextrose, iso-osm intravenous piggyback cefoxitin intravenous recon soln cefuroxime axetil oral cefuroxime sodium injection recon soln 70 mg cefpodoxime oral suspension for reconstitution cefuroxime sodium intravenous recon soln cefpodoxime oral cephalexin oral : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 7

20 Name cephalexin oral suspension for reconstitution cephalexin oral MAXIPIME GRAM SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 00 MG/ ML SUPRAX ORAL,CHEWAB LE TAZICEF INJECTION TAZICEF TEFLARO ZERBAXA ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln HI Name azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral clarithromycin oral suspension for reconstitution clarithromycin oral clarithromycin oral extended release hr DIFICID ORAL e.e.s. 00 oral ery-tab oral,delayed release (dr/ec) 0 mg, mg ERY-TAB ORAL,DELAYE D RELEASE (DR/EC) 00 MG erythrocin (as stearate) oral 0 mg ERYTHROCIN 00 MG HI : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 8

21 Name Name erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral erythromycin oral,delayed release(dr/ec) erythromycin oral PCE ORAL, PARTICLES/CRYS TALS ZMAX ORAL SUSPENSION,EXT ENDED REL RECON MISCELLANEOUS ANTIINFECTIVES ALBENZA ORAL ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL amikacin injection,000 mg/ ml, 00 mg/ ml atovaquone oral suspension atovaquoneproguanil oral AZACTAM IN DEXTROSE (ISO- OSM) PIGGYBACK GRAM/0 ML AZACTAM IN DEXTROSE (ISO- OSM) PIGGYBACK GRAM/0 ML AZACTAM INJECTION GRAM aztreonam injection recon soln baciim intramuscular recon soln bacitracin intramuscular recon soln BETHKIS INHALATION FOR NEBULIZATION BILTRICIDE ORAL CAPASTAT INJECTION HI B/D PA : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 9

22 Name CAYSTON INHALATION FOR NEBULIZATION chloramphenicol sod succinate intravenous recon soln chloroquine phosphate oral clindamycin hcl oral clindamycin in % dextrose intravenous piggyback clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln clindamycin phosphate injection clindamycin phosphate intravenous 00 mg/ ml, 900 mg/6 ml clindamycin phosphate intravenous 600 mg/ ml COARTEM ORAL PA; QL (8 per 8 HI HI Name colistin (colistimethate na) injection recon soln CUBICIN CUBICIN RF CYCLOSERINE ORAL CAPSULE DALVANCE dapsone oral daptomycin intravenous recon soln DARAPRIM ORAL ethambutol oral gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/0 ml, 80 mg/00 ml GENTAMICIN IN NACL (ISO-OSM) PIGGYBACK 00 MG/0 ML B/D PA B/D PA B/D PA HI : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 0

23 Name gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/0 ml, 90 mg/00 ml gentamicin injection 0 mg/ml gentamicin sulfate (pf) intravenous 00 mg/0 ml hydroxychloroquine oral imipenem-cilastatin intravenous recon soln INVANZ INJECTION INVANZ isoniazid injection isoniazid oral isoniazid oral ivermectin oral linezolid intravenous parenteral linezolid oral suspension for reconstitution linezolid oral HI Name linezolid-0.9% sodium chloride intravenous parenteral mefloquine oral meropenem intravenous recon soln gram meropenem intravenous recon soln 00 mg MEROPENEM- 0.9% SODIUM CHLORIDE PIGGYBACK GRAM/0 ML MEROPENEM- 0.9% SODIUM CHLORIDE PIGGYBACK 00 MG/0 ML metronidazole in nacl (iso-os) intravenous piggyback metronidazole oral metronidazole oral NEBUPENT INHALATION neomycin oral : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - HI B/D PA

24 Name paromomycin oral PASER ORAL GRANULES DR FOR SUSP IN PACKET PENTAM INJECTION polymyxin b sulfate injection recon soln PRIFTIN ORAL PRIMAQUINE ORAL pyrazinamide oral quinine sulfate oral rifabutin oral rifampin intravenous recon soln rifampin oral RIFATER ORAL RIMSO-0 INTRAVESICAL SIRTURO ORAL SIVEXTRO ORAL PA Name STREPTOMYCIN R SYNERCID tinidazole oral TOBI PODHALER INHALATION CAPSULE TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in 0. % nacl inhalation for nebulization tobramycin sulfate injection recon soln tobramycin sulfate injection TRECATOR ORAL TYGACIL XIFAXAN ORAL 00 MG XIFAXAN ORAL 0 MG B/D PA QL (9 per QL (80 per : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST -

25 Name ZYVOX PARENTERAL PENICILLINS amoxicillin oral amoxicillin oral suspension for reconstitution amoxicillin oral amoxicillin oral,chewable mg, 0 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral amoxicillin-pot clavulanate oral extended release hr amoxicillin-pot clavulanate oral,chewable ampicillin oral ampicillin sodium injection recon soln gram, mg, gram, 0 mg, 00 mg Name ampicillin sodium intravenous recon soln ampicillin-sulbactam injection recon soln. gram ampicillin-sulbactam injection recon soln gram, gram BICILLIN C-R R SYRINGE BICILLIN L-A R SYRINGE dicloxacillin oral nafcillin in dextrose iso-osm intravenous piggyback nafcillin injection recon soln nafcillin intravenous recon soln oxacillin in dextrose(iso-osm) intravenous piggyback oxacillin injection recon soln oxacillin intravenous recon soln gram : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - HI HI

26 Name Name PENICILLIN G POT IN DEXTROSE PIGGYBACK MILLION UNIT/0 ML PENICILLIN G POT IN DEXTROSE PIGGYBACK MILLION UNIT/0 ML, MILLION UNIT/0 ML penicillin g potassium injection recon soln HI piperacillintazobactam intravenous recon soln. gram,.7 gram, 0. gram piperacillintazobactam intravenous recon soln. gram ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK. GRAM/0 ML,.7 GRAM/0 ML HI HI penicillin g procaine intramuscular syringe. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium injection recon soln ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK. GRAM/00 ML QUINOLONES ciprofloxacin (mixture) oral, er multiphase hr QL ( per penicillin v potassium oral recon soln penicillin v potassium oral pfizerpen-g injection recon soln 0 million unit ciprofloxacin hcl oral ciprofloxacin in % dextrose intravenous piggyback 00 mg/00 ml ciprofloxacin lactate intravenous HI : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST -

27 Name ciprofloxacin oral suspension,microcap sule recon levofloxacin in dw intravenous piggyback 00 mg/00 ml levofloxacin intravenous levofloxacin oral levofloxacin oral moxifloxacin oral ofloxacin oral 00 mg, 00 mg HI SULFA'S / RELATED AGENTS sulfadiazine oral sulfamethoxazoletrimethoprim intravenous sulfamethoxazoletrimethoprim oral suspension sulfamethoxazoletrimethoprim oral sulfatrim oral suspension TETRACYCLINES demeclocycline oral Name doxy-00 intravenous recon soln doxycycline hyclate oral doxycycline hyclate oral doxycycline hyclate oral,delayed release (dr/ec) doxycycline monohydrate oral 00 mg, 0 mg, 0 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral minocycline oral minocycline oral minocycline oral extended release hr mondoxyne nl oral morgidox oral tetracycline oral URINARY TRACT AGENTS : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST -

28 Name methenamine hippurate oral methenamine mandelate oral nitrofurantoin macrocrystal oral nitrofurantoin monohyd/m-cryst oral nitrofurantoin oral suspension PRIMSOL ORAL trimethoprim oral VANCOMYCIN VANCOMYCIN IN 0.9% SODIUM CL PIGGYBACK VANCOMYCIN IN DEXTROSE % PIGGYBACK vancomycin intravenous recon soln,000 mg, 0 gram, gram vancomycin intravenous recon soln 00 mg HI Name VANCOMYCIN 70 MG vancomycin oral VIBATIV 70 MG ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline intravenous recon soln dexrazoxane hcl intravenous recon soln 0 mg ELITEK FUSILEV KEPIVANCE leucovorin calcium injection recon soln leucovorin calcium oral : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 6

29 Name levoleucovorin intravenous recon soln 0 mg levoleucovorin intravenous mesna intravenous MESNEX ORAL XGEVA PA ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE SUSPENSION FOR RECONSTITUTIO N adriamycin intravenous adrucil intravenous AFINITOR DISPERZ ORAL FOR SUSPENSION AFINITOR ORAL ALECENSA ORAL CAPSULE ALIMTA B/D PA PA PA PA Name ALUNBRIG ORAL anastrozole oral ARRANON ARZERRA,000 MG/0 ML ARZERRA 00 MG/ ML ASTAGRAF XL ORAL CAPSULE,EXTEN DED RELEASE HR 0. MG, MG ASTAGRAF XL ORAL CAPSULE,EXTEN DED RELEASE HR MG AVASTIN azacitidine injection recon soln AZASAN ORAL azathioprine oral PA B/D PA B/D PA B/D PA B/D PA : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 7

30 Name Name azathioprine sodium injection recon soln B/D PA CABOMETYX ORAL PA BAVENCIO BELEODAQ BENDEKA bexarotene oral bicalutamide oral BICNU bleo k injection recon soln bleomycin injection recon soln unit bleomycin injection recon soln 0 unit BLINCYTO KIT BOSULIF ORAL PA PA PA PA B/D PA B/D PA PA CAPRELSA ORAL carboplatin intravenous CELLCEPT cisplatin intravenous cladribine intravenous CLOFARABINE CLOLAR COMETRIQ ORAL CAPSULE COTELLIC ORAL cyclophosphamide intravenous recon soln CYCLOPHOSPHA MIDE ORAL CAPSULE B/D PA B/D PA PA PA; LA B/D PA busulfan intravenous cyclosporine intravenous B/D PA BUSULFEX cyclosporine modified oral B/D PA : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 8

31 Name cyclosporine modified oral cyclosporine oral CYRAMZA cytarabine (pf) injection 00 mg/ ml (0 mg/ml) cytarabine (pf) injection gram/0 ml (00 mg/ml), 0 mg/ml cytarabine injection dacarbazine intravenous recon soln DARZALEX daunorubicin intravenous decitabine intravenous recon soln B/D PA B/D PA PA B/D PA B/D PA PA; LA Name docetaxel intravenous 60 mg/6 ml (0 mg/ml), 60 mg/8 ml (0 mg/ml), 0 mg/ ml (0 mg/ml), 0 mg/ml ( ml), 80 mg/ ml (0 mg/ml), 80 mg/8 ml (0 mg/ml) DOCETAXEL 0 MG/ML doxorubicin intravenous recon soln doxorubicin intravenous doxorubicin, pegliposomal intravenous suspension DROXIA ORAL CAPSULE ELLENCE EMCYT ORAL CAPSULE EMPLICITI ENVARSUS XR ORAL EXTENDED RELEASE HR : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - PA B/D PA 9

32 Name epirubicin intravenous ERBITUX 00 MG/0 ML ERBITUX 00 MG/00 ML ERIVEDGE ORAL CAPSULE ERWINAZE INJECTION ETOPOPHOS etoposide intravenous EVOMELA exemestane oral FARESTON ORAL FARYDAK ORAL CAPSULE FASLODEX R SYRINGE floxuridine injection recon soln PA PA PA; QL (6 per Name fludarabine intravenous recon soln fludarabine intravenous fluorouracil intravenous gram/0 ml fluorouracil intravenous. gram/0 ml, gram/00 ml, 00 mg/0 ml flutamide oral GAZYVA gemcitabine intravenous recon soln gemcitabine intravenous : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 0 B/D PA B/D PA gengraf oral B/D PA gengraf oral B/D PA GILOTRIF ORAL GLEOSTINE ORAL CAPSULE HALAVEN HERCEPTIN PA

33 Name HEXALEN ORAL CAPSULE hydroxyurea oral IBRANCE ORAL CAPSULE ICLUSIG ORAL idarubicin intravenous IDHIFA ORAL ifosfamide intravenous recon soln ifosfamide intravenous imatinib oral IMBRUVICA ORAL CAPSULE IMFINZI INLYTA ORAL IRESSA ORAL irinotecan intravenous IXEMPRA JAKAFI ORAL PA PA PA PA PA PA PA Name JEVTANA KADCYLA KEYTRUDA KEYTRUDA KISQALI FEMARA CO-PACK ORAL KISQALI ORAL KYPROLIS LARTRUVO LENVIMA ORAL CAPSULE letrozole oral LEUKERAN ORAL leuprolide subcutaneous kit LONSURF ORAL : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - B/D PA PA PA PA PA PA PA

34 Name LUPRON DEPOT ( MONTH) R SYRINGE KIT LUPRON DEPOT ( MONTH) R SYRINGE KIT LUPRON DEPOT (6 MONTH) R SYRINGE KIT LUPRON DEPOT R SYRINGE KIT LUPRON DEPOT- PED ( MONTH) R SYRINGE KIT LUPRON DEPOT- PED R KIT LYNPARZA ORAL CAPSULE LYNPARZA ORAL LYSODREN ORAL MATULANE ORAL CAPSULE megestrol oral suspension 00 mg/0 ml (0 ml), 00 mg/0 ml (0 mg/ml), 6 mg/ ml PA PA Name megestrol oral MEKINIST ORAL melphalan hcl intravenous recon soln melphalan oral mercaptopurine oral methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection methotrexate sodium injection methotrexate sodium oral mitomycin intravenous recon soln 0 mg, mg mitomycin intravenous recon soln 0 mg mitoxantrone intravenous concentrate MUSTARGEN INJECTION PA B/D PA B/D PA : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST -

35 Name mycophenolate mofetil hcl intravenous recon soln mycophenolate mofetil oral mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral mycophenolate sodium oral,delayed release (dr/ec) 80 mg MYCOPHENOLAT E SODIUM ORAL,DELAYE D RELEASE (DR/EC) 60 MG NAVELBINE 0 MG/ML NERLYNX ORAL NEXAVAR ORAL NILANDRON ORAL nilutamide oral NINLARO ORAL CAPSULE B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA PA PA PA Name NIPENT NULOJIX octreotide acetate injection,000 mcg/ml, 00 mcg/ml octreotide acetate injection 00 mcg/ml, 00 mcg/ml, 0 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 0 mcg/ml ( ml) octreotide acetate injection syringe 00 mcg/ml ( ml) ODOMZO ORAL CAPSULE ONCASPAR INJECTION OPDIVO oxaliplatin intravenous recon soln oxaliplatin intravenous 00 mg/0 ml : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - B/D PA PA; LA

36 Name oxaliplatin intravenous 0 mg/0 ml ( mg/ml) paclitaxel intravenous concentrate PERJETA POMALYST ORAL CAPSULE PORTRAZZA PROGRAF PURIXAN ORAL SUSPENSION RAPAMUNE ORAL REVLIMID ORAL CAPSULE RITUXAN HYCELA RITUXAN CONCENTRATE RUBRACA ORAL RYDAPT ORAL CAPSULE PA; QL ( per B/D PA B/D PA PA; LA PA PA Name SANDOSTATIN LAR DEPOT R SUSPENSION,EXT ENDED REL RECON SIGNIFOR LAR R SUSPENSION FOR RECONSTITUTIO N SIGNIFOR SIMULECT sirolimus oral B/D PA SOLTAMOX ORAL SOMATULINE DEPOT SYRINGE SPRYCEL ORAL STIVARGA ORAL SUPPRELIN LA IMPLANT KIT SUTENT ORAL CAPSULE PA PA : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST -

37 Name SYLVANT SYNRIBO TABLOID ORAL tacrolimus oral 0. mg, mg tacrolimus oral mg TAFINLAR ORAL CAPSULE TAGRISSO ORAL tamoxifen oral TARCEVA ORAL TARGRETIN TOPICAL GEL TASIGNA ORAL CAPSULE TECENTRIQ TEMODAR THALOMID ORAL CAPSULE thiotepa injection recon soln PA PA B/D PA B/D PA PA PA; LA PA PA PA PA PA Name toposar intravenous topotecan intravenous recon soln topotecan intravenous TORISEL TREANDA TRELSTAR R SUSPENSION FOR RECONSTITUTIO N TRELSTAR R SYRINGE tretinoin (chemotherapy) oral TREXALL ORAL TRISENOX TYKERB ORAL VALSTAR INTRAVESICAL PA B/D PA : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST -

38 Name VECTIBIX VELCADE INJECTION VENCLEXTA ORAL 0 MG, 0 MG VENCLEXTA ORAL 00 MG VENCLEXTA STARTING PACK ORAL S,DOSE PACK vinblastine intravenous vincasar pfs intravenous vincristine intravenous vinorelbine intravenous VOTRIENT ORAL VYXEOS XALKORI ORAL CAPSULE XATMEP ORAL PA PA PA PA B/D PA B/D PA B/D PA PA PA; QL (6 per B/D PA Name XTANDI ORAL CAPSULE YERVOY YONDELIS ZALTRAP ZANOSAR ZEJULA ORAL CAPSULE ZELBORAF ORAL ZOLADEX IMPLANT 0.8 MG ZOLADEX IMPLANT.6 MG ZOLINZA ORAL CAPSULE ZORTRESS ORAL 0. MG ZORTRESS ORAL 0. MG, 0.7 MG ZYDELIG ORAL ZYKADIA ORAL CAPSULE PA PA PA : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 6 PA PA; QL (8 per PA B/D PA B/D PA PA PA

39 Name ZYTIGA ORAL PA AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL BANZEL ORAL SUSPENSION BANZEL ORAL BRIVIACT BRIVIACT ORAL BRIVIACT ORAL carbamazepine oral, er multiphase hr carbamazepine oral suspension 00 mg/ ml carbamazepine oral carbamazepine oral extended release hr carbamazepine oral,chewable CELONTIN ORAL CAPSULE 00 MG PA PA; QL (800 per PA; QL (80 per Name CEREBYX INJECTION 00 MG PE/0 ML clonazepam oral clonazepam oral,disintegrating DIASTAT ACUDIAL RECTAL KIT DIASTAT RECTAL KIT diazepam rectal kit DILANTIN 0 MG ORAL CAPSULE divalproex oral, delayed rel sprinkle divalproex oral extended release hr divalproex oral,delayed release (dr/ec) epitol oral ethosuximide oral ethosuximide oral felbamate oral suspension felbamate oral : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 7

40 Name fosphenytoin injection FYCOMPA ORAL SUSPENSION FYCOMPA ORAL gabapentin oral gabapentin oral gabapentin oral 600 mg, 800 mg GABITRIL ORAL MG, 6 MG LAMICTAL STARTER (BLUE) KIT ORAL S,DOSE PACK LAMICTAL STARTER (GREEN) KIT ORAL S,DOSE PACK LAMICTAL STARTER (ORANGE) KIT ORAL S,DOSE PACK lamotrigine oral Name lamotrigine oral disintegrating, dose pk lamotrigine oral extended release hr lamotrigine oral, chewable dispersible lamotrigine oral,disintegrating lamotrigine oral s,dose pack LEVETIRACETAM IN NACL (ISO-OS) PIGGYBACK levetiracetam intravenous levetiracetam oral levetiracetam oral levetiracetam oral extended release hr LYRICA ORAL CAPSULE LYRICA ORAL ONFI ORAL SUSPENSION ONFI ORAL 0 MG, 0 MG : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - 8 HI QL (0 per QL (80 per

41 Name oxcarbazepine oral suspension oxcarbazepine oral PEGANONE ORAL phenobarbital oral elixir phenobarbital oral phenobarbital sodium injection phenytoin oral suspension phenytoin oral,chewable phenytoin sodium extended oral phenytoin sodium intravenous phenytoin sodium intravenous syringe primidone oral roweepra oral SABRIL ORAL POWDER IN PACKET SABRIL ORAL Name SPRITAM ORAL FOR SUSPENSION tiagabine oral topiramate oral, sprinkle topiramate oral valproate sodium intravenous valproic acid (as sodium salt) oral valproic acid oral vigabatrin oral powder in packet VIMPAT VIMPAT ORAL VIMPAT ORAL zonisamide oral : -Preferred Generic -Generic -Preferred Brand -Non-Preferred s -Specialty s : B/D - Prior Authorization, Part B vs. Part D only HI - Home Infusion LA - Limited Availability EX Excluded PA - Prior Authorization QL - Quantity Limit ST - PA PA PA ANTIPARKINSONISM AGENTS APOKYN CARTRIDGE AZILECT ORAL benztropine injection 9