2018 Formulary PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

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1 Magellan Rx Medicare Basic (PDP) 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE S WE COVER IN THIS PLAN Formulary File 18273, Version 8 This formulary was updated on 09/08/2017. For more recent information or other questions, please contact Magellan Rx Medicare Customer Service at or, for TTY users, 711, 24 hours a day, 7 days a week, 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. When this drug list (formulary) refers to "we," "us", or "our," it means Magellan Rx Medicare. When it refers to "plan" or "our plan," it means Magellan Rx Medicare Basic (PDP). This document includes a list of the drugs (formulary) for our plan which is current as of January 1, For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year _CLFMCM_2018 Accepted

2 What is the Magellan Rx Medicare Basic (PDP) Formulary? A formulary is a list of covered drugs selected by Magellan Rx Medicare Basic (PDP) 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. Magellan Rx Medicare Basic (PDP) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Magellan Rx Medicare Basic (PDP) 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 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) 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 January 1, To get updated information about the drugs covered by Magellan Rx Medicare Basic (PDP), please contact us. Our contact information appears on the front and back cover pages. If we have a mid-year non-maintenance formulary change (such as adding prior authorization requirements, quantity limits and/or step therapy restrictions on a drug, removing drugs from our formulary, or moving a drug to a higher cost-sharing tier), we will notify you by mail. We will also update our formulary with the information. The updated formulary will be available on our website or by calling Customer Service. Our contact information appears on the front and back cover pages of this document. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, CARDIOVASCULAR AGENTS. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. I

3 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 111. 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? Magellan Rx Medicare Basic (PDP) 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: Magellan Rx Medicare Basic (PDP) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Magellan Rx Medicare Basic (PDP) before you fill your prescriptions. If you don t get approval, Magellan Rx Medicare Basic (PDP) may not cover the drug. Quantity Limits: For certain drugs, Magellan Rx Medicare Basic (PDP) limits the amount of the drug that Magellan Rx Medicare Basic (PDP) will cover. For example, Magellan Rx Medicare Basic (PDP) provides 60 per prescription for PRADAXA. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Magellan Rx Medicare Basic (PDP) 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, Magellan Rx Medicare Basic (PDP) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Magellan Rx Medicare Basic (PDP) will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Magellan Rx Medicare Basic (PDP) 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 Magellan Rx Medicare Basic (PDP) formulary? on page III for information about how to request an exception. II

4 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Magellan Rx Medicare Basic (PDP) does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Magellan Rx Medicare Basic (PDP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Magellan Rx Medicare Basic (PDP). You can ask Magellan Rx Medicare Basic (PDP) 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 Magellan Rx Medicare Basic (PDP) Formulary? You can ask Magellan Rx Medicare Basic (PDP) 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, Magellan Rx Medicare Basic (PDP) 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, Magellan Rx Medicare Basic (PDP) will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. III

5 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 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 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Magellan Rx Management, a properly licensed affiliate of Magellan Health, Inc. (Magellan) implements and maintains an appropriate medication transition process consistent with Centers for Medicare and Medicaid Services (CMS) requirement for members whose current prescribed Part D drugs are not on Magellan s formulary. Magellan Rx Management (Magellan) implements and maintains an appropriate transition process in compliance with CMS rules and guidance. Transition supplies are available to members whose current drug therapy may not be covered by the plan, or that are on the formulary but subject to prior authorization (PA), step therapy (ST), or quantity limit (QL) edits based on Magellan s utilization management program. Transition supplies will allow members sufficient time to work with their medical provider to switch to a therapeutically appropriate formulary alternative or to request a coverage determination should the medication be medically necessary. For more information For more detailed information about your Magellan Rx Medicare Basic (PDP) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Magellan Rx Medicare Basic (PDP), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), 24 hours a day/7 days a week. TTY users should call Or, visit IV

6 Magellan Rx Medicare Basic (PDP) s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Magellan Rx Medicare Basic (PDP). If you have trouble finding your drug in the list, turn to the Index that begins on page 111. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANOXIN) and generic drugs are listed in lower-case italics (e.g., digoxin). The information in the column tells you if Magellan Rx Medicare Basic (PDP) has any special requirements for coverage of your drug. V

7 LEGEND NAME 1 Preferred Generic 2 Generic 3 Preferred Brand 4 Non-Preferred Drug 5 Specialty Tier SYMBOL NAME DESCRIPTION QL Quantity Limit There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. PA ST Prior Authorization Step Therapy You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. MO Mail Order This prescription may also be available via mail. 1

8 NAME Analgesics Nonsteroidal Anti-inflammatory Drugs diclofenac potassium 50 mg tab 4 MO diclofenac sodium (25 mg tab dr, 50 mg tab 4 MO dr, 75 mg tab dr) diclofenac sodium er 100 mg tab er 24h 4 MO diflunisal 500 mg tab 2 MO etodolac (200 mg cap, 300 mg cap, 400 mg 2 MO tab, 500 mg tab) flurbiprofen (50 mg tab, 100 mg tab) 2 MO ibuprofen 100 mg/5ml suspension 2 MO ibuprofen (400 mg tab, 600 mg tab, 800 mg 1 MO tab) indomethacin (25 mg cap, 50 mg cap) 4 MO ketoprofen (50 mg cap, 75 mg cap) 2 MO ketorolac tromethamine (15 mg/ml solution, 4 MO 30 mg/ml solution, 60 mg/2ml solution) ketorolac tromethamine 10 mg tab 4 QL (20 PER 30 OVER TIME), MO meclofenamate sodium (50 mg cap, 100 mg cap) 4 MO mefenamic acid 250 mg cap 4 MO meloxicam (7.5 mg tab, 15 mg tab) 1 MO nabumetone (500 mg tab, 750 mg tab) 2 MO naproxen 125 mg/5ml suspension 2 MO naproxen (250 mg tab, 375 mg tab, 500 mg tab) naproxen dr (dr 375 mg tab dr, dr 500 mg tab dr) 1 MO 2 MO naproxen sodium (275 mg tab, 550 mg tab) 2 MO 2

9 NAME oxaprozin 600 mg tab 2 MO piroxicam (10 mg cap, 20 mg cap) 2 MO sulindac (150 mg tab, 200 mg tab) 2 MO tolmetin sodium 400 mg cap 2 MO tolmetin sodium 600 mg tab 4 MO Opioid Analgesics, Long-acting EMBEDA ( MG CAP ER, 50-2 MG CAP ER) 3 QL (60 PER 30 DAYS), MO (MAIL EMBEDA MG CAP ER 5 QL (90 PER 30 DAYS), MO (MAIL EMBEDA MG CAP ER 3 QL (120 PER 30 DAYS), MO EMBEDA MG CAP ER 3 QL (180 PER 30 DAYS), MO EMBEDA MG CAP ER 5 QL (120 PER 30 DAYS), MO fentanyl (12 mcg/hr patch 72hr, 25 mcg/hr patch 72hr, 37.5 mcg/hr patch 72hr, 50 mcg/hr patch 72hr, 62.5 mcg/hr patch 72hr) fentanyl (75 mcg/hr patch 72hr, 100 mcg/hr patch 72hr) 4 QL (15 PER 30 DAYS), MO (MAIL 4 QL (30 PER 30 DAYS), MO (MAIL fentanyl 87.5 mcg/hr patch 72hr 5 QL (15 PER 30 DAYS), MO (MAIL methadone hcl (5 mg/5ml solution, 10 mg/5ml solution) 4 QL (1800 PER 30 DAYS), MO methadone hcl 10 mg/ml solution 4 MO methadone hcl (5 mg tab, 10 mg tab) 4 QL (360 PER 30 DAYS), MO morphine sulfate er (er 10 mg cap er 24h, er 20 mg cap er 24h, er 30 mg cap er 24h, er 50 mg cap er 24h, er 60 mg cap er 24h, er 80 mg cap er 24h) 4 QL (120 PER 30 DAYS), MO morphine sulfate er 100 mg cap er 24h 5 QL (180 PER 30 DAYS), MO 3

10 NAME morphine sulfate er (er 15 mg tab er, er 30 mg tab er, er 60 mg tab er) 2 QL (120 PER 30 DAYS), MO morphine sulfate er 100 mg tab er 2 QL (180 PER 30 DAYS), MO morphine sulfate er 200 mg tab er 4 QL (180 PER 30 DAYS), MO NUCYNTA ER (ER 50 MG TAB ER 12H, ER 100 MG TAB ER 12H, ER 150 MG TAB ER 12H, ER 200 MG TAB ER 12H, ER 250 MG TAB ER 12H) oxymorphone hcl er (er 5 mg tab er 12h, er 7.5 mg tab er 12h, er 10 mg tab er 12h, er 15 mg tab er 12h, er 20 mg tab er 12h, er 30 mg tab er 12h, er 40 mg tab er 12h) Opioid Analgesics, Short-acting acetaminophen-codeine mg/5ml solution 3 QL (60 PER 30 DAYS), MO (MAIL 4 QL (120 PER 30 DAYS), MO 1 QL (4500 PER 30 DAYS), MO acetaminophen-codeine mg tab 2 QL (390 PER 30 DAYS), MO acetaminophen-codeine mg tab 2 QL (180 PER 30 DAYS), MO acetaminophen-codeine # mg tab 2 QL (390 PER 30 DAYS), MO acetaminophen-codeine # mg tab 2 QL (360 PER 30 DAYS), MO acetaminophen-codeine # mg tab 2 QL (180 PER 30 DAYS), MO butorphanol tartrate (1 mg/ml solution, 2 mg/ml solution) 4 MO butorphanol tartrate 10 mg/ml solution 2 QL (5 PER DAY), MO (MAIL codeine sulfate (15 mg tab, 30 mg tab, 60 mg tab) duramorph (0.5 mg/ml solution, 1 mg/ml solution) endocet (5-325 mg tab, mg tab, mg tab) 2 QL (180 PER 30 DAYS), MO 2 MO 2 QL (360 PER 30 DAYS), MO 4

11 NAME MAGELLAN PDP (List of Covered Drugs) fentanyl citrate (200 mcg loz handle, 400 mcg loz handle) fentanyl citrate (600 mcg loz handle, 800 mcg loz handle, 1200 mcg loz handle, 1600 mcg loz handle) hydrocodone-acetaminophen ( mg/5ml solution, mg/10ml solution, mg/15ml solution) hydrocodone-acetaminophen ( mg tab, mg tab, mg tab, mg tab) 4 PA, QL (120 PER 30 DAYS), MO 5 PA, QL (120 PER 30 DAYS), MO 2 QL (5550 PER 30 DAYS), MO 2 QL (360 PER 30 DAYS), MO hydromorphone hcl 1 mg/ml liquid 2 QL (4800 PER 30 DAYS), MO hydromorphone hcl 2 mg/ml solution 2 MO hydromorphone hcl (2 mg tab, 4 mg tab, 8 mg tab) hydromorphone hcl pf (10 mg/ml solution, 50 mg/5ml solution, 500 mg/50ml solution) 2 QL (360 PER 30 DAYS), MO 4 MO lorcet mg tab 2 QL (360 PER 30 DAYS), MO lorcet hd mg tab 2 QL (360 PER 30 DAYS), MO lorcet plus mg tab 2 QL (360 PER 30 DAYS), MO lortab (5-325 mg tab, mg tab, mg tab) 2 QL (360 PER 30 DAYS), MO morphine sulfate 10 mg/5ml solution 2 QL (3600 PER 30 DAYS), MO morphine sulfate 20 mg/5ml solution 2 QL (2700 PER 30 DAYS), MO morphine sulfate (15 mg tab, 30 mg tab) 2 QL (360 PER 30 DAYS), MO morphine sulfate (concentrate) 100 mg/5ml solution 2 QL (540 PER 30 DAYS), MO 5

12 NAME morphine sulfate (pf) ((pf) 2 mg/ml solution, (pf) 4 mg/ml solution, (pf) 8 mg/ml solution, (pf) 10 mg/ml solution, (pf) 15 mg/ml solution) 2 MO nalbuphine hcl (10 mg/ml solution, 20 mg/ml solution) 4 PA - Part B vs D Determination, MO oxycodone hcl 100 mg/5ml conc 4 QL (360 PER 30 DAYS), MO oxycodone hcl 5 mg/5ml solution 2 QL (7200 PER 30 DAYS), MO oxycodone hcl (5 mg tab, 5 mg cap, 10 mg tab, 15 mg tab, 20 mg tab, 30 mg tab) oxycodone-acetaminophen mg/5ml solution oxycodone-acetaminophen ( mg tab, mg tab, mg tab, mg tab) 2 QL (480 PER 30 DAYS), MO 2 QL (1860 PER 30 DAYS), MO 2 QL (360 PER 30 DAYS), MO oxycodone-aspirin mg tab 2 QL (360 PER 30 DAYS), MO oxycodone-ibuprofen mg tab 2 QL (120 PER 30 DAYS), MO tramadol hcl 50 mg tab 1 QL (240 PER 30 DAYS), MO tramadol-acetaminophen mg tab 2 QL (240 PER 30 DAYS), MO vicodin mg tab 2 QL (390 PER 30 DAYS), MO vicodin es mg tab 2 QL (390 PER 30 DAYS), MO vicodin hp mg tab 2 QL (390 PER 30 DAYS), MO Anesthetics Local Anesthetics lidocaine 5 % patch 4 PA, MO lidocaine hcl (2 % gel, 2 % solution, 4 % solution) 2 MO 6

13 NAME lidocaine hcl (pf) 0.5 % solution 2 MO lidocaine viscous 2 % solution 1 MO lidocaine-prilocaine cream % 2 QL (30 PER 30 DAYS), MO (MAIL Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium 333 mg tab dr 2 MO disulfiram (250 mg tab, 500 mg tab) 2 MO VIVITROL 380 MG RECON SUSP 5 PA, MO Opioid Dependence Treatments buprenorphine hcl (2 mg sl tab, 8 mg sl tab) 2 QL (90 PER 30 DAYS), MO (MAIL buprenorphine hcl-naloxone hcl mg sl tab 2 QL (360 PER 30 DAYS), MO buprenorphine hcl-naloxone hcl 8-2 mg sl tab 2 QL (90 PER 30 DAYS), MO (MAIL naltrexone hcl 50 mg tab 2 MO SUBOXONE 12-3 MG FILM 4 QL (60 PER 30 DAYS), MO (MAIL SUBOXONE MG FILM 4 QL (360 PER 30 DAYS), MO SUBOXONE 4-1 MG FILM 4 QL (180 PER 30 DAYS), MO SUBOXONE 8-2 MG FILM 4 QL (90 PER 30 DAYS), MO (MAIL Opioid Reversal Agents naloxone hcl (0.4 mg/ml solution, 2 mg/2ml soln prsyr, 4 mg/10ml solution) 2 MO NARCAN 4 MG/0.1ML LIQUID 4 MO 7

14 NAME Smoking Cessation Agents bupropion hcl er (smoking det) tab er 12h 150 mg 2 QL (60 PER 30 OVER TIME), MO CHANTIX (0.5 MG TAB, 1 MG TAB) 4 QL (504 PER 365 OVER TIME), MO CHANTIX CONTINUING MONTH PAK 1 MG TAB CHANTIX STARTING MONTH PAK 0.5 MG X 11 & 1 MG X 42 TAB 4 QL (504 PER 365 OVER TIME), MO 4 QL (504 PER 365 OVER TIME), MO NICOTROL NS 10 MG/ML SOLUTION 3 QL (360 PER 365 OVER TIME), MO Antibacterials Aminoglycosides amikacin sulfate 500 mg/2ml solution 2 MO gentak 0.3 % ointment 2 MO gentamicin in saline ( mg/ml-% solution, mg/ml-% solution, mg/ml-% solution, mg/ml-% solution) 2 MO gentamicin sulfate (0.1 % ointment, 0.1 % cream, 0.3 % ointment, 10 mg/ml solution, 40 mg/ml solution) 2 MO gentamicin sulfate 0.3 % solution 1 MO neomycin sulfate 500 mg tab 2 MO neomycin-polymyxin b gu solution 2 MO paromomycin sulfate 250 mg cap 2 MO streptomycin sulfate 1 gm recon soln 4 MO tobramycin 0.3 % solution 1 MO tobramycin sulfate (1.2 gm/30ml solution, 2 gm/50ml solution, 10 mg/ml solution, 80 mg/2ml solution) 2 MO TOBREX 0.3 % OINTMENT 4 MO 8

15 NAME Antibacterials, Other baciim unit recon soln 2 MO bacitra-neomycin-polymyxin-hc 1 % ointment 2 MO bacitracin (500 unit/gm ointment, unit recon soln) 2 MO BACTROBAN NASAL 2 % OINTMENT 4 MO chloramphenicol sod succinate 1 gm recon soln clindamycin hcl (75 mg cap, 150 mg cap, 300 mg cap) clindamycin palmitate hcl 75 mg/5ml recon soln 4 MO 2 MO 2 MO clindamycin phosphate 1 % foam 4 MO clindamycin phosphate (1 % swab, 1 % lotion, 1 % gel, 1 % solution, 2 % cream, 300 mg/2ml solution, 600 mg/4ml solution, 900 mg/6ml solution) clindamycin phosphate in d5w (600 mg/50ml solution, 900 mg/50ml solution) clindamycin phosphate in d5w 300 mg/50ml solution 2 MO 4 MO 2 MO colistimethate sodium 150 mg recon soln 4 MO daptomycin 500 mg recon soln 5 MO linezolid 100 mg/5ml recon susp 5 QL (1800 PER 28 DAYS), MO linezolid 600 mg/300ml solution 4 MO linezolid 600 mg tab 5 QL (56 PER 28 DAYS), MO (MAIL methenamine hippurate tab 1 gm 4 MO metronidazole 1 % gel 4 MO metronidazole (0.75 % gel, 0.75 % cream, 0.75 % lotion, 250 mg tab, 375 mg cap, 500 mg tab) 2 MO 9

16 NAME metronidazole in nacl ( mg/ml-% solution, mg/100ml-% solution) 2 MO mupirocin 2 % ointment 2 MO neomycin-polymyxin-hc suspension 2 MO nitrofurantoin 25 mg/5ml suspension 4 QL (7200 PER 365 OVER TIME), MO nitrofurantoin macrocrystal 100 mg cap 4 QL (360 PER 365 OVER TIME), MO nitrofurantoin macrocrystal 25 mg cap 4 QL (1440 PER 365 OVER TIME), MO nitrofurantoin macrocrystal 50 mg cap 4 QL (720 PER 365 OVER TIME), MO nitrofurantoin monohyd macro 100 mg cap 4 QL (180 PER 365 OVER TIME), MO polymyxin b sulfate unit recon soln 2 MO silver sulfadiazine 1 % cream 2 MO ssd 1 % cream 2 MO SYNERCID MG RECON SOLN 5 MO trimethoprim 100 mg tab 2 MO TYGACIL 50 MG RECON SOLN 5 MO vancomycin hcl (125 mg cap, 250 mg cap) 4 MO vancomycin hcl (10 gm recon soln, 500 mg recon soln, 750 mg recon soln, 1000 mg recon soln, 5000 mg recon soln) 2 MO vandazole 0.75 % gel 2 MO XIFAXAN (200 MG TAB, 550 MG TAB) 5 PA, MO Beta-lactam, Cephalosporins cefaclor (250 mg cap, 500 mg cap) 4 MO cefaclor er 500 mg tab er 12h 4 MO cefadroxil (1 gm tab, 250 mg/5ml recon susp, 500 mg/5ml recon susp, 500 mg cap) 2 MO 10

17 NAME MAGELLAN PDP (List of Covered Drugs) cefazolin sodium (1 gm recon soln, 10 gm recon soln, 20 gm recon soln, 500 mg recon soln) cefdinir (125 mg/5ml recon susp, 250 mg/5ml recon susp, 300 mg cap) cefepime hcl (1 gm recon soln, 2 gm recon soln) cefixime (100 mg/5ml recon susp, 200 mg/5ml recon susp) cefotaxime sodium (1 gm recon soln, 2 gm recon soln, 500 mg recon soln) cefotetan disodium (1 gm recon soln, 2 gm recon soln) cefoxitin sodium (1 gm recon soln, 2 gm recon soln, 10 gm recon soln) cefpodoxime proxetil (50 mg/5ml recon susp, 100 mg tab, 200 mg tab) 2 MO 2 MO 2 MO 4 MO 2 MO 2 MO 2 MO 2 MO cefpodoxime proxetil 100 mg/5ml recon susp 4 MO cefprozil (125 mg/5ml recon susp, 250 mg/5ml recon susp, 250 mg tab, 500 mg tab) ceftazidime (1 gm recon soln, 2 gm recon soln, 6 gm recon soln) ceftriaxone sodium (1 gm recon soln, 2 gm recon soln, 10 gm recon soln, 250 mg recon soln, 500 mg recon soln) 2 MO 2 MO 2 MO cefuroxime axetil (250 mg tab, 500 mg tab) 2 MO cefuroxime sodium (1.5 gm recon soln, 7.5 gm recon soln, 750 mg recon soln) cephalexin (125 mg/5ml recon susp, 250 mg/5ml recon susp, 250 mg cap, 250 mg tab, 500 mg tab, 500 mg cap, 750 mg cap) SUPRAX (100 MG CHEW TAB, 200 MG CHEW TAB, 400 MG CAP) 2 MO 2 MO 3 MO SUPRAX 500 MG/5ML RECON SUSP 5 MO tazicef (1 gm recon soln, 2 gm recon soln, 6 gm recon soln) 2 MO 11

18 NAME TEFLARO (400 MG RECON SOLN, 600 MG RECON SOLN) 5 MO Beta-lactam, Other AZACTAM IN DEXTROSE (1 GM SOLUTION, 2 GM SOLUTION) 4 MO aztreonam 1 gm recon soln 4 MO imipenem-cilastatin (250 mg recon soln, 500 mg recon soln) 4 MO INVANZ 1 GM RECON SOLN 4 MO meropenem (1 gm recon soln, 500 mg recon soln) Beta-lactam, Penicillins amoxicillin (125 mg chew tab, 125 mg/5ml recon susp, 200 mg/5ml recon susp, 250 mg/5ml recon susp, 250 mg chew tab, 250 mg cap, 400 mg/5ml recon susp, 500 mg tab, 500 mg cap, 875 mg tab) amoxicillin-pot clavulanate ( mg/5ml recon susp, mg chew tab, mg/5ml recon susp, mg tab, mg/5ml recon susp, mg chew tab, mg tab, mg/5ml recon susp, mg tab) amoxicillin-pot clavulanate er mg tab er 12h 2 MO 1 MO 2 MO 2 MO ampicillin (250 mg cap, 500 mg cap) 1 MO ampicillin (125 mg/5ml recon susp, 250 mg/5ml recon susp) ampicillin sodium (1 gm recon soln, 2 gm recon soln, 10 gm recon soln) ampicillin sodium (125 mg recon soln, 250 mg recon soln, 500 mg recon soln) ampicillin-sulbactam sodium (1.5 (1-0.5) gm recon soln, 3 (2-1) gm recon soln, 15 (10-5) gm recon soln) 2 MO 2 MO 4 MO 2 MO 12

19 NAME AUGMENTIN MG/5ML RECON SUSP BICILLIN C-R UNIT/2ML SUSPENSION BICILLIN C-R 900/ UNIT/2ML SUSPENSION BICILLIN L-A ( UNIT/ML SUSPENSION, UNIT/2ML SUSPENSION, UNIT/4ML SUSPENSION) dicloxacillin sodium (250 mg cap, 500 mg cap) 5 MO 4 MO 4 MO 4 MO 2 MO nafcillin sodium 1 gm recon soln 4 MO nafcillin sodium 10 gm recon soln 5 MO oxacillin sodium (1 gm recon soln, 10 gm recon soln) penicillin g pot in dextrose (20000 unit/ml solution, unit/ml solution, unit/ml solution) penicillin g potassium ( recon soln, recon soln) 5 MO 4 MO 4 MO penicillin g sodium unit recon soln 5 MO penicillin v potassium (125 mg/5ml recon soln, 250 mg/5ml recon soln) penicillin v potassium (250 mg tab, 500 mg tab) piperacillin sod-tazobactam so (d-tazobactam 2.25 (2-0.25) gm recon ln, d-tazobactam ( ) gm recon ln, d-tazobactam 4.5 (4-0.5) gm recon ln, d-tazobactam 40.5 (36-4.5) gm recon ln) 1 MO 2 MO 4 MO Macrolides AZASITE 1 % SOLUTION 4 MO azithromycin (1 gm packet, 100 mg/5ml recon susp, 200 mg/5ml recon susp, 250 mg tab, 500 mg recon soln, 500 mg tab, 600 mg tab) 2 MO 13

20 NAME clarithromycin (125 mg/5ml recon susp, 250 mg tab, 250 mg/5ml recon susp, 500 mg tab) 2 MO clarithromycin er 500 mg tab er 24h 2 MO DIFICID 200 MG TAB 5 MO ery 2 % pad 2 MO ERY-TAB (250 MG TAB DR, 333 MG TAB DR, 500 MG TAB DR) ERYTHROCIN LACTOBIONATE 500 MG RECON SOLN 4 MO 4 MO ERYTHROCIN STEARATE 250 MG TAB 4 MO erythromycin (2 % solution, 2 % gel, 5 mg/gm ointment) erythromycin base (250 mg tab, 250 mg cp dr part, 500 mg tab) erythromycin ethylsuccinate (200 mg/5ml recon susp, 400 mg tab) 2 MO 4 MO 4 MO Quinolones BESIVANCE 0.6 % SUSPENSION 4 MO ciprofloxacin (200 mg/20ml solution, 250 mg/5ml (5%) recon susp, 400 mg/40ml solution, 500 mg/5ml (10%) recon susp) ciprofloxacin hcl (0.3 % solution, 250 mg tab, 500 mg tab, 750 mg tab) 2 MO 1 MO ciprofloxacin hcl 100 mg tab 4 MO ciprofloxacin in d5w (200 mg/100ml solution, 400 mg/200ml solution) ciprofloxacin-ciproflox hcl er (er 500 mg tab er 24h, er 1000 mg tab er 24h) 2 MO 2 MO gatifloxacin 0.5 % solution 2 MO levofloxacin (0.5 % solution, 250 mg tab, 500 mg tab, 750 mg tab) 2 MO levofloxacin 25 mg/ml oral solution 4 MO levofloxacin 25 mg/ml solution inj 4 MO 14

21 NAME levofloxacin in d5w ( 250 mg/50ml solution, 500 mg/100ml solution, 750 mg/150ml solution) 2 MO moxifloxacin hcl 400 mg/250ml solution 4 MO moxifloxacin hcl 400 mg tab 2 MO ofloxacin (300 mg tab, 400 mg tab) 2 MO ofloxacin 0.3 % ophthalmic solution 2 MO ofloxacin 0.3 % otic solution 2 MO VIGAMOX 0.5 % SOLUTION 4 MO Sulfonamides sulfacetamide sodium (10 % solution, 10 % ointment) 2 MO sulfadiazine 500 mg tab 4 MO sulfamethoxazole-trimethoprim mg/5ml solution sulfamethoxazole-trimethoprim mg/5ml suspension sulfamethoxazole-trimethoprim ( mg tab, mg tab) 4 MO 2 MO 1 MO Tetracyclines demeclocycline hcl (150 mg tab, 300 mg tab) 2 MO doxy mg recon soln 2 MO doxycycline hyclate (20 mg tab, 50 mg cap, 100 mg tab, 100 mg cap) 2 MO doxycycline monohydrate 75 mg cap 4 MO doxycycline monohydrate (25 mg/5ml recon susp, 50 mg tab, 50 mg cap, 75 mg tab, 100 mg tab, 100 mg cap, 150 mg tab) minocycline hcl (50 mg cap, 75 mg cap, 100 mg cap) 2 MO 2 MO morgidox 50 mg cap 2 MO tetracycline hcl (250 mg cap, 500 mg cap) 4 MO 15

22 NAME Anticonvulsants Anticonvulsants, Other APTIOM (200 MG TAB, 400 MG TAB, 600 MG TAB, 800 MG TAB) 5 MO BRIVIACT 50 MG/5ML SOLUTION 4 MO BRIVIACT (10 MG TAB, 10 MG/ML SOLUTION, 25 MG TAB, 50 MG TAB, 75 MG TAB, 100 MG TAB) FYCOMPA (0.5 MG/ML SUSPENSION, 2 MG TAB, 8 MG TAB) FYCOMPA (4 MG TAB, 6 MG TAB, 10 MG TAB, 12 MG TAB) 5 MO 4 MO 5 MO levetiracetam 500 mg/5ml solution 4 MO levetiracetam (100 mg/ml solution, 250 mg tab, 500 mg tab, 750 mg tab, 1000 mg tab) levetiracetam er (er 500 mg tab er 24h, er 750 mg tab er 24h) levetiracetam in nacl (500 mg/100ml solution, 1000 mg/100ml solution, 1500 mg/100ml solution) POTIGA (50 MG TAB, 200 MG TAB, 300 MG TAB, 400 MG TAB) 2 MO 2 MO 4 MO 5 MO roweepra 500 mg tab 2 MO SPRITAM (250 MG TAB, 500 MG TAB, 750 MG TAB, 1000 MG TAB) 4 MO Calcium Channel Modifying Agents CELONTIN 300 MG CAP 4 MO ethosuximide (250 mg/5ml solution, 250 mg cap) LYRICA (25 MG CAP, 50 MG CAP, 75 MG CAP, 100 MG CAP, 150 MG CAP, 200 MG CAP, 225 MG CAP) 2 MO 3 QL (90 PER 30 DAYS), MO (MAIL LYRICA 300 MG CAP 3 QL (60 PER 30 DAYS), MO (MAIL 16

23 NAME LYRICA 20 MG/ML SOLUTION 3 QL (900 PER 30 DAYS), MO zonisamide (25 mg cap, 50 mg cap, 100 mg cap) 2 MO Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam (0.5 mg tab, 1 mg tab, 2 mg tab) 1 MO clonazepam (0.125 mg tab disp, 0.25 mg tab disp, 0.5 mg tab disp, 1 mg tab disp) 2 QL (90 PER 30 DAYS), MO (MAIL clonazepam 2 mg tab disp 2 QL (300 PER 30 DAYS), MO DIASTAT ACUDIAL (10 MG GEL, 20 MG GEL) 4 MO DIASTAT PEDIATRIC 2.5 MG GEL 4 MO diazepam (2.5 mg gel, 10 mg gel, 20 mg gel) 4 MO divalproex sodium (125 mg tab dr, 250 mg tab dr, 500 mg tab dr) 2 MO divalproex sodium 125 mg dr sprinkle cap 2 MO divalproex sodium er (er 250 mg tab er 24h, er 500 mg tab er 24h) gabapentin (100 mg cap, 300 mg cap, 400 mg cap) gabapentin (250 mg/5ml solution, 300 mg/6ml solution, 600 mg tab, 800 mg tab) 2 MO 1 MO 2 MO GABITRIL (12 MG TAB, 16 MG TAB) 4 MO ONFI (2.5 MG/ML SUSPENSION, 10 MG TAB, 20 MG TAB) phenobarbital (15 mg tab, 16.2 mg tab, 20 mg/5ml elixir, 20 mg/5ml solution, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab, 100 mg tab) 5 PA - FOR NEW STARTS ONLY, MO 4 MO primidone (50 mg tab, 250 mg tab) 2 MO SABRIL (500 MG TAB, 500 MG PACKET) 5 PA - FOR NEW STARTS ONLY, MO tiagabine hcl (2 mg tab, 4 mg tab) 4 MO 17

24 NAME valproate sodium (100 mg/ml solution, 500 mg/5ml solution) 4 MO valproate sodium 250 mg/5ml solution 2 MO valproic acid (250 mg cap, 250 mg/5ml solution) 2 MO Glutamate Reducing Agents felbamate 600 mg/5ml suspension 5 MO felbamate (400 mg tab, 600 mg tab) 4 MO lamotrigine (5 mg chew tab, 25 mg chew tab) 2 MO lamotrigine (25 mg tab, 100 mg tab, 150 mg tab, 200 mg tab) topiramate (15 mg cap sprink, 25 mg cap sprink) topiramate (25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) Sodium Channel Agents BANZEL (40 MG/ML SUSPENSION, 200 MG TAB, 400 MG TAB) carbamazepine (100 mg chew tab, 100 mg/5ml suspension, 200 mg tab) carbamazepine er (er 100 mg tab er 12h, er 100 mg cap er 12h, er 200 mg tab er 12h, er 200 mg cap er 12h, er 300 mg cap er 12h) 1 MO 2 MO 1 MO 5 PA - FOR NEW STARTS ONLY, MO 2 MO 2 MO carbamazepine er 400 mg tab er 12h 4 MO DILANTIN 30 MG CAP 4 MO epitol 200 mg tab 2 MO fosphenytoin sodium 100 mg pe/2ml solution 2 MO oxcarbazepine 300 mg/5ml suspension 4 MO oxcarbazepine (150 mg tab, 300 mg tab, 600 mg tab) 2 MO PEGANONE 250 MG TAB 4 MO phenytoin (50 mg chew tab, 125 mg/5ml suspension) 2 MO 18

25 NAME phenytoin infatabs 50 mg chew tab 2 MO phenytoin sodium extended (100 mg cap, 200 mg cap, 300 mg cap) VIMPAT (10 MG/ML SOLUTION, 50 MG TAB, 100 MG TAB, 150 MG TAB, 200 MG/20ML SOLUTION, 200 MG TAB) 2 MO 4 MO Antidementia Agents Antidementia Agents, Other ergoloid mesylates 1 mg tab 4 MO Cholinesterase Inhibitors donepezil hcl (5 mg tab, 5 mg tab disp, 10 mg tab disp, 10 mg tab) 1 MO galantamine hydrobromide 4 mg/ml solution 4 MO galantamine hydrobromide (4 mg tab, 8 mg tab, 12 mg tab) galantamine hydrobromide er (er 8 mg cap er 24h, er 16 mg cap er 24h, er 24 mg cap er 24h) rivastigmine (4.6 mg/24hr patch 24hr, 9.5 mg/24hr patch 24hr, 13.3 mg/24hr patch 24hr) rivastigmine tartrate (1.5 mg cap, 3 mg cap, 4.5 mg cap, 6 mg cap) 2 MO 2 MO 4 MO 2 MO N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (2 mg/ml solution, 5 (28)-10 (21) mg tab) 4 MO memantine hcl (5 mg tab, 10 mg tab) 2 MO NAMENDA XR (7 MG CAP ER 24H, 14 MG CAP ER 24H, 21 MG CAP ER 24H, 28 MG CAP ER 24H) NAMENDA XR TITRATION PACK 7 & 14 & 21 &28 MG CAP ER 24H 3 QL (30 PER 30 DAYS), MO (MAIL 3 QL (56 PER 365 OVER TIME), MO 19

26 NAME Antidepressants Antidepressants, Other bupropion hcl (75 mg tab, 100 mg tab) 2 MO bupropion hcl er (sr) (er (sr) 100 mg tab er 12h, er (sr) 150 mg tab er 12h, er (sr) 200 mg tab er 12h) 2 QL (90 PER 30 DAYS), MO (MAIL bupropion hcl er (xl) 150 mg tab er 24h 2 QL (90 PER 30 DAYS), MO (MAIL bupropion hcl er (xl) 300 mg tab er 24h 2 QL (30 PER 30 DAYS), MO (MAIL mirtazapine (7.5 mg tab, 15 mg tab, 15 mg tab disp, 30 mg tab disp, 30 mg tab, 45 mg tab disp, 45 mg tab) Monoamine Oxidase Inhibitors EMSAM (6 MG/24HR PATCH 24HR, 9 MG/24HR PATCH 24HR, 12 MG/24HR PATCH 24HR) 2 MO 5 ST, QL (30 PER 30 DAYS), MO MARPLAN 10 MG TAB 4 MO phenelzine sulfate 15 mg tab 2 MO tranylcypromine sulfate 10 mg tab 4 MO SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide 10 mg/5ml solution 2 MO citalopram hydrobromide (10 mg tab, 20 mg tab, 40 mg tab) desvenlafaxine succinate er (er 25 mg tab er 24h, er 50 mg tab er 24h, er 100 mg tab er 24h) duloxetine hcl (20 mg cp dr part, 60 mg cp dr part) 1 MO 4 QL (30 PER 30 DAYS), MO (MAIL 2 QL (60 PER 30 DAYS), MO (MAIL duloxetine hcl 30 mg cp dr part 2 QL (90 PER 30 DAYS), MO (MAIL 20

27 NAME MAGELLAN PDP (List of Covered Drugs) duloxetine hcl 40 mg cp dr part 4 QL (90 PER 30 DAYS), MO (MAIL escitalopram oxalate 5 mg/5ml solution 2 MO escitalopram oxalate (5 mg tab, 10 mg tab, 20 mg tab) FETZIMA (20 MG CAP ER 24H, 40 MG CAP ER 24H, 80 MG CAP ER 24H, 120 MG CAP ER 24H) FETZIMA TITRATION 20 & 40 MG CP24 THPK fluoxetine hcl (10 mg cap, 20 mg cap, 40 mg cap) 1 MO 4 ST, QL (30 PER 30 DAYS), MO 4 ST, QL (56 PER 365 OVER TIME), MO 1 MO fluoxetine hcl 90 mg cap dr 2 QL (4 PER 28 DAYS), MO (MAIL fluoxetine hcl (10 mg tab, 20 mg/5ml solution, 20 mg tab, 60 mg tab) fluvoxamine maleate (25 mg tab, 50 mg tab, 100 mg tab) maprotiline hcl (25 mg tab, 50 mg tab, 75 mg tab) nefazodone hcl (50 mg tab, 100 mg tab, 150 mg tab, 200 mg tab, 250 mg tab) paroxetine hcl (10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab) paroxetine hcl er (er 12.5 mg tab er 24h, er 25 mg tab er 24h, er 37.5 mg tab er 24h) 2 MO 2 MO 2 MO 4 MO 1 MO 2 MO PAXIL 10 MG/5ML SUSPENSION 4 MO sertraline hcl 20 mg/ml conc 2 MO sertraline hcl (25 mg tab, 50 mg tab, 100 mg tab) trazodone hcl (50 mg tab, 100 mg tab, 150 mg tab, 300 mg tab) TRINTELLIX (5 MG TAB, 10 MG TAB, 20 MG TAB) venlafaxine hcl (25 mg tab, 37.5 mg tab, 50 mg tab, 75 mg tab, 100 mg tab) 1 MO 2 MO 4 QL (30 PER 30 DAYS), MO (MAIL 2 MO 21

28 NAME venlafaxine hcl er (er 37.5 mg cap er 24h, er 37.5 mg tab er 24h, er 75 mg cap er 24h, er 75 mg tab er 24h, er 150 mg tab er 24h, er 150 mg cap er 24h, er 225 mg tab er 24h) 2 MO VIIBRYD (10 MG TAB, 20 MG TAB, 40 MG TAB) 4 QL (30 PER 30 DAYS), MO (MAIL VIIBRYD STARTER PACK 10 & 20 MG KIT 4 QL (60 PER 365 OVER TIME), MO Tricyclics amitriptyline hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 mg tab, 100 mg tab, 150 mg tab) amoxapine (25 mg tab, 50 mg tab, 100 mg tab, 150 mg tab) chlordiazepoxide-amitriptyline ( mg tab, mg tab) clomipramine hcl (25 mg cap, 50 mg cap, 75 mg cap) desipramine hcl (10 mg tab, 25 mg tab, 50 mg tab, 75 mg tab, 100 mg tab, 150 mg tab) doxepin hcl (10 mg/ml conc, 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap, 100 mg cap, 150 mg cap) imipramine hcl (10 mg tab, 25 mg tab, 50 mg tab) nortriptyline hcl (10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap) 4 MO 2 MO 4 MO 4 MO 2 MO 4 MO 4 MO 1 MO nortriptyline hcl 10 mg/5ml solution 2 MO perphenazine-amitriptyline (2-10 mg tab, 2-25 mg tab, 4-50 mg tab, 4-10 mg tab, 4-25 mg tab) 4 MO protriptyline hcl (5 mg tab, 10 mg tab) 2 MO trimipramine maleate (25 mg cap, 50 mg cap, 100 mg cap) 4 MO 22

29 NAME Antiemetics Antiemetics, Other compro 25 mg suppos 2 MO meclizine hcl (12.5 mg tab, 25 mg tab) 2 MO phenadoz 12.5 mg suppos 4 MO phenergan (12.5 mg suppos, 25 mg suppos, 50 mg suppos) 4 MO prochlorperazine 25 mg suppos 2 MO prochlorperazine edisylate 5 mg/ml solution 4 MO prochlorperazine maleate (5 mg tab, 10 mg tab) promethazine hcl (6.25 mg/5ml syrup, 6.25 mg/5ml solution, 12.5 mg tab, 12.5 mg suppos, 25 mg tab, 25 mg/ml solution, 25 mg suppos, 50 mg suppos, 50 mg tab, 50 mg/ml solution) 1 MO 4 MO promethegan (25 mg suppos, 50 mg suppos) 4 MO TRANSDERM-SCOP (1.5 MG) 1 MG/3DAYS PATCH 72HR 4 MO Emetogenic Therapy Adjuncts ALOXI 0.25 MG/5ML SOLUTION 4 MO aprepitant 125 mg cap 2 PA - Part B vs D Determination, QL (2 PER 30 OVER TIME), MO aprepitant 40 mg cap 2 PA - Part B vs D Determination, QL (1 PER 30 OVER TIME), MO aprepitant 80 & 125 mg cap 2 PA - Part B vs D Determination, QL (6 PER 30 OVER TIME), MO aprepitant 80 mg cap 2 PA - Part B vs D Determination, QL (8 PER 30 OVER TIME), MO 23

30 NAME MAGELLAN PDP (List of Covered Drugs) dronabinol (2.5 mg cap, 5 mg cap, 10 mg cap) 4 PA, QL (60 PER 30 OVER TIME), MO EMEND 125 MG RECON SUSP 4 PA - Part B vs D Determination, QL (6 PER 30 OVER TIME), MO granisetron hcl (0.1 mg/ml solution, 1 mg/ml solution, 4 mg/4ml solution) 2 MO granisetron hcl 1 mg tab 2 PA - Part B vs D Determination, QL (30 PER 30 OVER TIME), MO ondansetron (4 mg tab disp, 8 mg tab disp) 1 PA - Part B vs D Determination, MO ondansetron hcl (4 mg/2ml solution, 40 mg/20ml solution) 2 QL (240 PER 30 DAYS), MO ondansetron hcl 4 mg/5ml solution 2 PA - Part B vs D Determination, QL (450 PER 30 DAYS), MO ondansetron hcl (4 mg tab, 8 mg tab) 2 PA - Part B vs D Determination, MO ondansetron hcl 24 mg tab 2 PA - Part B vs D Determination, QL (14 PER 28 OVER TIME), MO Antifungals ABELCET 5 MG/ML SUSPENSION 5 PA - Part B vs D Determination, MO AMBISOME 50 MG RECON SUSP 5 PA - Part B vs D Determination, MO amphotericin b 50 mg recon soln 4 PA - Part B vs D Determination, MO CANCIDAS (50 MG RECON SOLN, 70 MG RECON SOLN) 5 MO ciclopirox (0.77 % gel, 1 % shampoo) 2 MO ciclopirox olamine (0.77 % suspension, 0.77 % cream) 2 MO ciclopirox solution 8 % 2 PA, MO 24

31 NAME MAGELLAN PDP (List of Covered Drugs) clotrimazole 1 % cream 1 MO clotrimazole (1 % solution, 10 mg lozenge, 10 mg troche) 2 MO econazole nitrate 1 % cream 4 MO fluconazole (10 mg/ml recon susp, 40 mg/ml recon susp, 50 mg tab, 100 mg tab, 150 mg tab, 200 mg tab) fluconazole in sodium chloride ( mg/100ml-% solution, mg/200ml-% solution) 2 MO 2 MO flucytosine (250 mg cap, 500 mg cap) 5 MO griseofulvin microsize 125 mg/5ml suspension 2 MO griseofulvin microsize 500 mg tab 4 MO griseofulvin ultramicrosize (125 mg tab, 250 mg tab) 4 MO itraconazole 100 mg cap 4 PA, MO ketoconazole (2 % shampoo, 2 % cream, 200 mg tab) 2 MO MICONAZOLE MG SUPPOS 2 MO NATACYN 5 % SUSPENSION 4 MO NOXAFIL (40 MG/ML SUSPENSION, 100 MG TAB DR) 5 MO nyamyc unit/gm powder 2 MO nyata unit/gm powder 2 MO nystatin ( unit/gm ointment, unit/ml suspension, unit/gm cream, unit/gm powder, unit tab) nystatin-triamcinolone ( unit/gm-% ointment, unit/gm-% cream) 2 MO 2 MO nystop unit/gm powder 2 MO oxiconazole nitrate 1 % cream 4 MO SPORANOX 10 MG/ML SOLUTION 5 PA, MO 25

32 NAME terbinafine hcl 250 mg tab 1 QL (84 PER 180 OVER TIME), MO terconazole (0.4 % cream, 0.8 % cream, 80 mg suppos) voriconazole (40 mg/ml recon susp, 200 mg recon soln) 2 MO 5 MO voriconazole (50 mg tab, 200 mg tab) 4 MO zazole 0.8 % cream 2 MO Antigout Agents allopurinol (100 mg tab, 300 mg tab) 2 MO colchicine (0.6 mg tab, 0.6 mg cap) 3 MO colchicine-probenecid mg tab 2 MO probenecid 500 mg tab 2 MO ULORIC (40 MG TAB, 80 MG TAB) 3 ST, MO Antimigraine Agents Ergot Alkaloids dihydroergotamine mesylate 1 mg/ml solution 5 MO dihydroergotamine mesylate 4 mg/ml solution 5 QL (8 PER 30 OVER TIME), MO ergotamine-caffeine mg tab 2 MO MIGERGOT MG SUPPOS 5 MO Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl (1 mg tab, 2.5 mg tab) 2 QL (9 PER 30 OVER TIME), MO rizatriptan benzoate (5 mg tab, 5 mg tab disp, 10 mg tab disp, 10 mg tab) sumatriptan (5 mg/act solution, 20 mg/act solution) 2 QL (18 PER 30 OVER TIME), MO 4 QL (12 PER 30 OVER TIME), MO sumatriptan succinate 4 mg/0.5ml soln a-inj 4 QL (8 PER 30 OVER TIME), MO 26

33 NAME sumatriptan succinate (6 mg/0.5ml soln prsyr, 6 mg/0.5ml soln a-inj, 6 mg/0.5ml solution) sumatriptan succinate (25 mg tab, 50 mg tab, 100 mg tab) sumatriptan succinate refill (4 mg/0.5ml soln cart, 6 mg/0.5ml soln cart) 4 QL (5 PER 30 OVER TIME), MO 2 QL (9 PER 30 OVER TIME), MO 4 QL (5 PER 30 OVER TIME), MO zolmitriptan (2.5 mg tab, 5 mg tab) 2 QL (12 PER 30 OVER TIME), MO Antimyasthenic Agents Parasympathomimetics guanidine hcl 125 mg tab 4 MO pyridostigmine bromide 60 mg tab 2 MO Antimycobacterials Antimycobacterials, Other dapsone (25 mg tab, 100 mg tab) 2 MO rifabutin 150 mg cap 4 MO Antituberculars CAPASTAT SULFATE 1 GM RECON SOLN 4 MO ethambutol hcl (100 mg tab, 400 mg tab) 2 MO isoniazid (50 mg/5ml syrup, 100 mg/ml 4 MO solution) isoniazid (100 mg tab, 300 mg tab) 1 MO PASER 4 GM PACKET 4 MO PRIFTIN 150 MG TAB 4 MO pyrazinamide 500 mg tab 2 MO rifampin (150 mg cap, 300 mg cap) 2 MO rifampin 600 mg recon soln 4 MO RIFATER MG TAB 4 MO 27

34 NAME SIRTURO 100 MG TAB 5 MO TRECATOR 250 MG TAB 4 MO Antineoplastics Alkylating Agents BICNU 100 MG RECON SOLN 5 MO busulfan 6 mg/ml solution 5 PA - Part B vs D Determination, MO carboplatin (50 mg/5ml solution, 150 mg/15ml solution, 450 mg/45ml solution, 600 mg/60ml solution) cisplatin (50 mg/50ml solution, 100 mg/100ml solution) 2 MO 2 MO cyclophosphamide (25 mg cap, 50 mg cap) 4 PA - Part B vs D Determination, MO dacarbazine 200 mg recon soln 2 MO GLEOSTINE 5 MG CAP 4 MO HEXALEN 50 MG CAP 5 MO ifosfamide (1 gm recon soln, 1 gm/20ml solution, 3 gm/60ml solution, 3 gm recon soln) 4 MO LEUKERAN 2 MG TAB 5 MO MATULANE 50 MG CAP 5 MO melphalan hcl 50 mg recon soln 5 MO MUSTARGEN 10 MG RECON SOLN 5 MO oxaliplatin (50 mg/10ml solution, 100 mg/20ml solution) 4 PA - Part B vs D Determination, MO thiotepa 15 mg recon soln 5 MO TREANDA (25 MG RECON SOLN, 100 MG RECON SOLN) 5 MO VALCHLOR % GEL 5 PA - FOR NEW STARTS ONLY, MO 28

35 NAME YONDELIS 1 MG RECON SOLN 5 MO ZANOSAR 1 GM RECON SOLN 5 MO Antiandrogens bicalutamide 50 mg tab 2 MO flutamide 125 mg cap 2 MO nilutamide 150 mg tab 5 MO XTANDI 40 MG CAP 5 PA - FOR NEW STARTS ONLY, MO ZYTIGA 250 MG TAB 5 PA - FOR NEW STARTS ONLY, MO Antiangiogenic Agents POMALYST (1 MG CAP, 2 MG CAP, 3 MG CAP, 4 MG CAP) REVLIMID (2.5 MG CAP, 5 MG CAP, 10 MG CAP, 15 MG CAP, 20 MG CAP, 25 MG CAP) THALOMID (50 MG CAP, 100 MG CAP, 150 MG CAP, 200 MG CAP) 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO Antiestrogens/Modifiers EMCYT 140 MG CAP 5 MO FARESTON 60 MG TAB 5 MO FASLODEX 250 MG/5ML SOLUTION 5 MO SOLTAMOX 10 MG/5ML SOLUTION 4 MO tamoxifen citrate (10 mg tab, 20 mg tab) 2 MO Antimetabolites adrucil (2.5 gm/50ml solution, 5 gm/100ml solution, 500 mg/10ml solution) ALIMTA (100 MG RECON SOLN, 500 MG RECON SOLN) 2 PA - Part B vs D Determination, MO 5 PA - FOR NEW STARTS ONLY, MO ARRANON 5 MG/ML SOLUTION 5 MO cladribine 10 mg/10ml solution 5 PA - Part B vs D Determination, MO 29

36 NAME clofarabine 1 mg/ml solution 5 MO CLOLAR 1 MG/ML SOLUTION 5 MO cytarabine 20 mg/ml solution 2 PA - Part B vs D Determination, MO cytarabine (pf) ((pf) 20 mg/ml solution, (pf) 100 mg/ml solution) DROXIA (200 MG CAP, 300 MG CAP, 400 MG CAP) fluorouracil (1 gm/20ml solution, 2.5 gm/50ml solution, 5 gm/100ml solution, 500 mg/10ml solution) FOLOTYN (20 MG/ML SOLUTION, 40 MG/2ML SOLUTION) gemcitabine hcl (1 gm recon soln, 2 gm recon soln, 200 mg recon soln) 2 PA - Part B vs D Determination, MO 4 MO 2 PA - Part B vs D Determination, MO 5 PA - FOR NEW STARTS ONLY, MO 4 MO hydroxyurea 500 mg cap 2 MO LONSURF MG TAB 5 PA - FOR NEW STARTS ONLY, QL (100 PER 28 DAYS), MO LONSURF MG TAB 5 PA - FOR NEW STARTS ONLY, QL (80 PER 28 DAYS), MO (MAIL mercaptopurine 50 mg tab 2 MO NIPENT 10 MG RECON SOLN 5 MO PURIXAN 2000 MG/100ML SUSPENSION 5 MO TABLOID 40 MG TAB 4 MO Antineoplastics, Other ABRAXANE 100 MG RECON SUSP 5 MO adriamycin 2 mg/ml solution 2 PA - Part B vs D Determination, MO azacitidine 100 mg recon susp 5 MO BELEODAQ 500 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY, MO 30

37 NAME MAGELLAN PDP (List of Covered Drugs) bleomycin sulfate 30 unit recon soln 2 PA - Part B vs D Determination, MO COTELLIC 20 MG TAB 5 PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS), MO (MAIL daunorubicin hcl 5 mg/ml injectable 4 MO decitabine 50 mg recon soln 5 PA - FOR NEW STARTS ONLY, MO dexrazoxane (250 mg recon soln, 500 mg recon soln) docetaxel (20 mg/ml conc, 20 mg/2ml solution, 80 mg/4ml conc, 80 mg/8ml solution, 140 mg/7ml conc, 160 mg/8ml conc, 160 mg/16ml solution, 200 mg/20ml solution, 200 mg/10ml conc) 5 MO 5 MO doxorubicin hcl 2 mg/ml solution 2 PA - Part B vs D Determination, MO doxorubicin hcl liposomal 2 mg/ml injectable 5 PA - Part B vs D Determination, MO epirubicin hcl (50 mg/25ml solution, 200 mg/100ml solution) 2 MO ERWINAZE UNIT RECON SOLN 5 MO FARYDAK (10 MG CAP, 15 MG CAP, 20 MG CAP) fludarabine phosphate (50 mg recon soln, 50 mg/2ml solution) 5 PA - FOR NEW STARTS ONLY, QL (6 PER 21 OVER TIME), MO 4 MO HALAVEN 1 MG/2ML SOLUTION 5 PA - FOR NEW STARTS ONLY, MO IBRANCE (75 MG CAP, 100 MG CAP, 125 MG CAP) idarubicin hcl (5 mg/5ml solution, 10 mg/10ml solution, 20 mg/20ml solution) irinotecan hcl (40 mg/2ml solution, 100 mg/5ml solution) 5 PA - FOR NEW STARTS ONLY, MO 5 MO 2 PA - Part B vs D Determination, MO ISTODAX 10 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY, MO 31

38 NAME MAGELLAN PDP (List of Covered Drugs) ISTODAX (OVERFILL) 10 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY, MO JEVTANA 60 MG/1.5ML SOLUTION 5 PA - FOR NEW STARTS ONLY, MO KISQALI FEMARA 200 DOSE 200 & 2.5 MG TAB THPK KISQALI FEMARA 400 DOSE MG TAB THPK KISQALI FEMARA 600 DOSE 200 & 2.5 MG TAB THPK leucovorin calcium (100 mg recon soln, 350 mg recon soln) leucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25 mg tab) levoleucovorin calcium (50 mg recon soln, 175 mg recon soln, 175 mg/17.5ml solution) levoleucovorin calcium pf 250 mg/25ml solution 5 PA - FOR NEW STARTS ONLY, QL (91 PER 28 DAYS), MO (MAIL 5 PA - FOR NEW STARTS ONLY, QL (91 PER 28 DAYS), MO (MAIL 5 PA - FOR NEW STARTS ONLY, QL (91 PER 28 DAYS), MO (MAIL 4 MO 2 MO 5 MO 5 MO LYNPARZA 50 MG CAP 5 PA - FOR NEW STARTS ONLY, MO mitomycin (5 mg recon soln, 20 mg recon soln, 40 mg recon soln) mitoxantrone hcl (20 mg/10ml conc, 25 mg/12.5ml conc, 30 mg/15ml conc) NINLARO (2.3 MG CAP, 3 MG CAP, 4 MG CAP) paclitaxel (30 mg/5ml conc, 100 mg/16.7ml conc, 150 mg/25ml conc, 300 mg/50ml conc) 5 MO 2 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 2 MO PROLEUKIN UNIT RECON SOLN 5 MO RUBRACA (200 MG TAB, 300 MG TAB) 5 PA - FOR NEW STARTS ONLY, QL (120 PER 30 DAYS), MO RYDAPT 25 MG CAP 5 PA - FOR NEW STARTS ONLY, QL (240 PER 30 DAYS), MO 32

39 NAME SYLATRON (200 MCG KIT, 300 MCG KIT, 600 MCG KIT) 5 PA - FOR NEW STARTS ONLY, MO SYNRIBO 3.5 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY, MO TRISENOX 10 MG/10ML SOLUTION 4 MO VELCADE 3.5 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY, MO vinblastine sulfate 1 mg/ml solution 2 PA - Part B vs D Determination, MO vincasar pfs 1 mg/ml solution 2 PA - Part B vs D Determination, MO vincristine sulfate 1 mg/ml solution 2 PA - Part B vs D Determination, MO vinorelbine tartrate (10 mg/ml solution, 50 mg/5ml solution) ZALTRAP (100 MG/4ML SOLUTION, 200 MG/8ML SOLUTION) 2 MO 5 PA - FOR NEW STARTS ONLY, MO ZEJULA 100 MG CAP 5 PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS), MO (MAIL ZOLINZA 100 MG CAP 5 PA - FOR NEW STARTS ONLY, MO Aromatase Inhibitors, 3rd Generation anastrozole 1 mg tab 1 MO exemestane 25 mg tab 4 MO letrozole 2.5 mg tab 1 MO Enzyme Inhibitors etoposide (1 gm/50ml solution, 100 mg/5ml solution, 500 mg/25ml solution) KYPROLIS (30 MG RECON SOLN, 60 MG RECON SOLN) toposar (1 gm/50ml solution, 100 mg/5ml solution, 500 mg/25ml solution) 2 MO 5 PA - FOR NEW STARTS ONLY, MO 2 MO 33

40 NAME topotecan hcl 4 mg recon soln 5 MO ZYDELIG (100 MG TAB, 150 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO Molecular Target Inhibitors AFINITOR (2.5 MG TAB, 5 MG TAB, 7.5 MG TAB, 10 MG TAB) AFINITOR DISPERZ (2 MG TAB SOL, 3 MG TAB SOL, 5 MG TAB SOL) 5 PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (MAIL 5 PA - FOR NEW STARTS ONLY, MO ALECENSA 150 MG CAP 5 PA - FOR NEW STARTS ONLY, QL (240 PER 30 DAYS), MO ALUNBRIG 30 MG TAB 5 PA - FOR NEW STARTS ONLY, QL (180 PER 30 DAYS), MO BOSULIF (100 MG TAB, 500 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO CABOMETYX (20 MG TAB, 40 MG TAB, 60 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO CAPRELSA 100 MG TAB 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (MAIL CAPRELSA 300 MG TAB 5 PA - FOR NEW STARTS ONLY, MO COMETRIQ (100 MG DAILY DOSE) 1 X 80 & 1 X 20 MG KIT COMETRIQ (140 MG DAILY DOSE) 1 X 80 & 3 X 20 MG KIT COMETRIQ (60 MG DAILY DOSE) 20 MG KIT 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO ERIVEDGE 150 MG CAP 5 PA - FOR NEW STARTS ONLY, MO GILOTRIF (20 MG TAB, 30 MG TAB, 40 MG TAB) 5 PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (MAIL ICLUSIG 15 MG TAB 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (MAIL 34

41 NAME MAGELLAN PDP (List of Covered Drugs) ICLUSIG 45 MG TAB 5 PA - FOR NEW STARTS ONLY, MO imatinib mesylate (100 mg tab, 400 mg tab) 5 PA - FOR NEW STARTS ONLY, MO IMBRUVICA 140 MG CAP 5 PA - FOR NEW STARTS ONLY, MO INLYTA (1 MG TAB, 5 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO IRESSA 250 MG TAB 5 PA - FOR NEW STARTS ONLY, MO JAKAFI (5 MG TAB, 10 MG TAB, 15 MG TAB, 20 MG TAB, 25 MG TAB) 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (MAIL KISQALI 200 DOSE 200 MG TAB 5 PA - FOR NEW STARTS ONLY, MO KISQALI 400 DOSE 200 MG TAB 5 PA - FOR NEW STARTS ONLY, MO KISQALI 600 DOSE 200 MG TAB 5 PA - FOR NEW STARTS ONLY, MO LENVIMA 10 MG DAILY DOSE 10 MG CAP THPK LENVIMA 14 MG DAILY DOSE 10 & 4 MG CAP THPK LENVIMA 18 MG DAILY DOSE 10 & 4 (2) MG CAP THPK LENVIMA 20 MG DAILY DOSE 10 (2) MG CAP THPK LENVIMA 24 MG DAILY DOSE 10 (2) & 4 MG CAP THPK LENVIMA 8 MG DAILY DOSE 4 (2) MG CAP THPK 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO MEKINIST (0.5 MG TAB, 2 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO NEXAVAR 200 MG TAB 5 PA - FOR NEW STARTS ONLY, MO 35

42 NAME MAGELLAN PDP (List of Covered Drugs) ODOMZO 200 MG CAP 5 PA - FOR NEW STARTS ONLY, MO SPRYCEL (20 MG TAB, 50 MG TAB, 70 MG TAB, 80 MG TAB, 100 MG TAB, 140 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO STIVARGA 40 MG TAB 5 PA - FOR NEW STARTS ONLY, MO SUTENT (12.5 MG CAP, 25 MG CAP, 37.5 MG CAP, 50 MG CAP) 5 PA - FOR NEW STARTS ONLY, MO TAFINLAR (50 MG CAP, 75 MG CAP) 5 PA - FOR NEW STARTS ONLY, MO TAGRISSO (40 MG TAB, 80 MG TAB) 5 PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (MAIL TARCEVA (100 MG TAB, 150 MG TAB) 5 PA - FOR NEW STARTS ONLY, QL (30 PER 30 DAYS), MO (MAIL TARCEVA 25 MG TAB 5 PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS), MO (MAIL TASIGNA (150 MG CAP, 200 MG CAP) 5 PA - FOR NEW STARTS ONLY, MO TORISEL 25 MG/ML SOLUTION 5 MO TYKERB 250 MG TAB 5 PA - FOR NEW STARTS ONLY, MO VENCLEXTA (10 MG TAB, 50 MG TAB) 4 PA - FOR NEW STARTS ONLY, MO VENCLEXTA 100 MG TAB 5 PA - FOR NEW STARTS ONLY, MO VENCLEXTA STARTING PACK 10 & 50 & 100 MG TAB THPK 5 PA - FOR NEW STARTS ONLY, MO VOTRIENT 200 MG TAB 5 PA - FOR NEW STARTS ONLY, MO XALKORI (200 MG CAP, 250 MG CAP) 5 PA - FOR NEW STARTS ONLY, MO ZELBORAF 240 MG TAB 5 PA - FOR NEW STARTS ONLY, MO 36

43 NAME ZYKADIA 150 MG CAP 5 PA - FOR NEW STARTS ONLY, MO Monoclonal Antibody/Antibody-Drug Conjugate AVASTIN (100 MG/4ML SOLUTION, 400 MG/16ML SOLUTION) 5 PA - Part B vs D Determination, MO BAVENCIO 200 MG/10ML SOLUTION 5 PA - FOR NEW STARTS ONLY, MO CYRAMZA (100 MG/10ML SOLUTION, 500 MG/50ML SOLUTION) DARZALEX (100 MG/5ML SOLUTION, 400 MG/20ML SOLUTION) EMPLICITI (300 MG RECON SOLN, 400 MG RECON SOLN) ERBITUX (100 MG/50ML SOLUTION, 200 MG/100ML SOLUTION) HERCEPTIN (150 MG RECON SOLN, 440 MG RECON SOLN) IMFINZI (120 MG/2.4ML SOLUTION, 500 MG/10ML SOLUTION) KADCYLA (100 MG RECON SOLN, 160 MG RECON SOLN) KEYTRUDA (50 MG RECON SOLN, 100 MG/4ML SOLUTION) LARTRUVO (190 MG/19ML SOLUTION, 500 MG/50ML SOLUTION) OPDIVO (40 MG/4ML SOLUTION, 100 MG/10ML SOLUTION) 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA - FOR NEW STARTS ONLY, MO PERJETA 420 MG/14ML SOLUTION 5 PA - FOR NEW STARTS ONLY, MO RITUXAN (100 MG/10ML SOLUTION, 500 MG/50ML SOLUTION) 5 PA - FOR NEW STARTS ONLY, MO TECENTRIQ 1200 MG/20ML SOLUTION 5 PA - FOR NEW STARTS ONLY, MO VECTIBIX (100 MG/5ML SOLUTION, 400 MG/20ML SOLUTION) 5 PA - Part B vs D Determination, MO 37

44 NAME YERVOY (50 MG/10ML SOLUTION, 200 MG/40ML SOLUTION) 5 PA - FOR NEW STARTS ONLY, MO Retinoids bexarotene 75 mg cap 5 PA - FOR NEW STARTS ONLY, MO PANRETIN 0.1 % GEL 5 MO TARGRETIN 1 % GEL 5 PA - FOR NEW STARTS ONLY, MO tretinoin 10 mg cap 5 MO Treatment Adjuncts ELITEK (1.5 MG RECON SOLN, 7.5 MG RECON SOLN) 4 MO mesna 100 mg/ml solution 2 MO MESNEX 400 MG TAB 5 MO Antiparasitics Anthelmintics ALBENZA 200 MG TAB 5 MO BILTRICIDE 600 MG TAB 3 MO ivermectin 3 mg tab 2 MO Antiprotozoals atovaquone 750 mg/5ml suspension 5 MO atovaquone-proguanil hcl ( mg tab, 2 MO mg tab) chloroquine phosphate (250 mg tab, 500 mg 2 MO tab) COARTEM MG TAB 4 MO hydroxychloroquine sulfate 200 mg tab 2 MO mefloquine hcl 250 mg tab 2 MO NEBUPENT 300 MG RECON SOLN 4 PA - Part B vs D Determination, MO 38

45 NAME PENTAM 300 MG RECON SOLN 4 MO primaquine phosphate 26.3 mg tab 2 MO quinine sulfate 324 mg cap 2 PA, MO tinidazole (250 mg tab, 500 mg tab) 2 MO Pediculicides/Scabicides lindane 1 % shampoo 4 MO malathion 0.5 % lotion 4 MO permethrin 5 % cream 2 MO Antiparkinson Agents Anticholinergics benztropine mesylate 1 mg/ml solution 2 MO benztropine mesylate (0.5 mg tab, 1 mg tab, 2 mg tab) 4 MO trihexyphenidyl hcl (2 mg tab, 5 mg tab) 2 MO Antiparkinson Agents, Other entacapone 200 mg tab 4 MO tolcapone 100 mg tab 5 MO Dopamine Agonists APOKYN 30 MG/3ML SOLN CART 5 PA, QL (60 PER 30 DAYS), MO bromocriptine mesylate (2.5 mg tab, 5 mg cap) NEUPRO (1 MG/24HR PATCH 24HR, 2 MG/24HR PATCH 24HR, 3 MG/24HR PATCH 24HR, 4 MG/24HR PATCH 24HR, 6 MG/24HR PATCH 24HR, 8 MG/24HR PATCH 24HR) pramipexole dihydrochloride (0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab) 4 MO 4 ST, MO 2 MO 39

46 NAME ropinirole hcl (0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab, 5 mg tab) 1 MO Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa 25 mg tab 5 MO carbidopa-levodopa ( mg tab disp, mg tab, mg tab, mg tab disp, mg tab disp, mg tab) carbidopa-levodopa er (er mg tab er, er mg tab er) 2 MO 2 MO Monoamine Oxidase B (MAO-B) Inhibitors rasagiline mesylate (0.5 mg tab, 1 mg tab) 2 MO selegiline hcl (5 mg cap, 5 mg tab) 2 MO Antipsychotics 1st Generation/Typical chlorpromazine hcl 50 mg/2ml solution 2 MO chlorpromazine hcl (10 mg tab, 25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) 4 MO fluphenazine decanoate 25 mg/ml solution 2 MO fluphenazine hcl (2.5 mg/5ml elixir, 2.5 mg/ml solution, 5 mg/ml conc) fluphenazine hcl (1 mg tab, 2.5 mg tab, 5 mg tab, 10 mg tab) haloperidol (0.5 mg tab, 1 mg tab, 2 mg tab, 5 mg tab, 10 mg tab, 20 mg tab) haloperidol decanoate (50 mg/ml solution, 100 mg/ml solution) 2 MO 4 MO 2 MO 2 MO haloperidol lactate 2 mg/ml conc 1 MO haloperidol lactate 5 mg/ml solution 2 MO loxapine succinate (5 mg cap, 10 mg cap, 25 mg cap, 50 mg cap) molindone hcl (5 mg tab, 10 mg tab, 25 mg tab) 2 MO 4 MO 40

47 NAME perphenazine (2 mg tab, 4 mg tab, 8 mg tab, 16 mg tab) 2 MO pimozide (1 mg tab, 2 mg tab) 4 MO thioridazine hcl (10 mg tab, 25 mg tab, 50 mg tab, 100 mg tab) thiothixene (1 mg cap, 2 mg cap, 5 mg cap, 10 mg cap) trifluoperazine hcl (1 mg tab, 2 mg tab, 5 mg tab, 10 mg tab) 4 MO 2 MO 2 MO 2nd Generation/Atypical ABILIFY MAINTENA (300 MG RECON SUSP, 400 MG RECON SUSP) aripiprazole (10 mg tab, 15 mg tab, 20 mg tab, 30 mg tab) 5 MO 4 QL (30 PER 30 DAYS), MO (MAIL aripiprazole (2 mg tab, 5 mg tab) 4 QL (60 PER 30 DAYS), MO (MAIL aripiprazole (10 mg tab disp, 15 mg tab disp) 5 QL (60 PER 30 DAYS), MO (MAIL ARISTADA (441 MG/1.6ML PRSYR, 662 MG/2.4ML PRSYR, 882 MG/3.2ML PRSYR, 1064 MG/3.9ML PRSYR) 5 MO FANAPT (1 MG TAB, 2 MG TAB, 4 MG TAB) 4 ST, QL (60 PER 30 DAYS), MO FANAPT (6 MG TAB, 8 MG TAB, 10 MG TAB, 12 MG TAB) FANAPT TITRATION PACK 1 & 2 & 4 & 6 MG TAB 5 ST, QL (60 PER 30 DAYS), MO 4 ST, QL (8 PER 180 OVER TIME), MO GEODON 20 MG RECON SOLN 4 QL (60 PER 30 DAYS), MO (MAIL INVEGA SUSTENNA (78 MG/0.5ML SUSPENSION, 117 MG/0.75ML SUSPENSION, 156 MG/ML SUSPENSION, 234 MG/1.5ML SUSPENSION) INVEGA SUSTENNA 39 MG/0.25ML SUSPENSION 5 MO 4 MO 41

48 NAME MAGELLAN PDP (List of Covered Drugs) INVEGA TRINZA (273 MG/0.875ML SUSPENSION, 410 MG/1.315ML SUSPENSION, 546 MG/1.75ML SUSPENSION, 819 MG/2.625ML SUSPENSION) LATUDA (20 MG TAB, 40 MG TAB, 60 MG TAB, 120 MG TAB) 5 MO 5 QL (30 PER 30 DAYS), MO (MAIL LATUDA 80 MG TAB 5 QL (60 PER 30 DAYS), MO (MAIL NUPLAZID 17 MG TAB 5 PA - FOR NEW STARTS ONLY, QL (60 PER 30 DAYS), MO (MAIL olanzapine 10 mg recon soln 2 MO olanzapine (2.5 mg tab, 5 mg tab disp, 5 mg tab, 7.5 mg tab, 10 mg tab disp, 10 mg tab, 15 mg tab, 15 mg tab disp, 20 mg tab, 20 mg tab disp) paliperidone er (er 1.5 mg tab er 24h, er 3 mg tab er 24h) 2 QL (30 PER 30 DAYS), MO (MAIL 2 QL (30 PER 30 DAYS), MO (MAIL paliperidone er 6 mg tab er 24h 2 QL (60 PER 30 DAYS), MO (MAIL paliperidone er 9 mg tab er 24h 5 QL (30 PER 30 DAYS), MO (MAIL quetiapine fumarate (25 mg tab, 50 mg tab, 100 mg tab, 200 mg tab) 2 QL (90 PER 30 DAYS), MO (MAIL quetiapine fumarate (300 mg tab, 400 mg tab) 2 QL (60 PER 30 DAYS), MO (MAIL quetiapine fumarate er (er 50 mg tab er 24h, er 150 mg tab er 24h, er 300 mg tab er 24h, er 400 mg tab er 24h) 4 QL (60 PER 30 DAYS), MO (MAIL quetiapine fumarate er 200 mg tab er 24h 4 QL (90 PER 30 DAYS), MO (MAIL REXULTI (0.25 MG TAB, 0.5 MG TAB, 1 MG TAB, 2 MG TAB, 3 MG TAB, 4 MG TAB) RISPERDAL CONSTA (12.5 MG RECON SUSP, 25 MG RECON SUSP) RISPERDAL CONSTA (37.5 MG RECON SUSP, 50 MG RECON SUSP) 5 QL (30 PER 30 DAYS), MO (MAIL 4 MO 5 MO 42

49 NAME risperidone 1 mg/ml solution 2 QL (240 PER 30 DAYS), MO risperidone (0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab) risperidone (0.25 mg tab disp, 0.5 mg tab disp, 1 mg tab disp, 2 mg tab disp, 3 mg tab disp, 4 mg tab disp) 1 QL (60 PER 30 DAYS), MO (MAIL 2 QL (60 PER 30 DAYS), MO (MAIL SAPHRIS (2.5 MG SL TAB, 5 MG SL TAB) 4 ST, QL (60 PER 30 DAYS), MO SAPHRIS 10 MG SL TAB 5 ST, QL (60 PER 30 DAYS), MO VRAYLAR (1.5 MG CAP, 3 MG CAP, 4.5 MG CAP, 6 MG CAP) 5 ST, QL (30 PER 30 DAYS), MO VRAYLAR 1.5 & 3 MG CAP THPK 4 ST, QL (14 PER 365 OVER TIME), MO ziprasidone hcl (20 mg cap, 40 mg cap, 60 mg cap, 80 mg cap) ZYPREXA RELPREVV 210 MG RECON SUSP 2 QL (60 PER 30 DAYS), MO (MAIL 4 MO Treatment-Resistant clozapine (25 mg tab, 100 mg tab) 2 QL (270 PER 30 DAYS), MO clozapine 200 mg tab 2 QL (120 PER 30 DAYS), MO clozapine 50 mg tab 2 QL (180 PER 30 DAYS), MO clozapine (25 mg tab disp, 100 mg tab disp) 4 QL (270 PER 30 DAYS), MO clozapine 12.5 mg tab disp 4 QL (90 PER 30 DAYS), MO (MAIL clozapine 150 mg tab disp 4 QL (180 PER 30 DAYS), MO clozapine 200 mg tab disp 5 QL (120 PER 30 DAYS), MO VERSACLOZ 50 MG/ML SUSPENSION 5 QL (540 PER 30 DAYS), MO 43

50 NAME Antispasticity Agents baclofen (10 mg tab, 20 mg tab) 2 MO dantrolene sodium (25 mg cap, 50 mg cap, 100 mg cap) 2 MO tizanidine hcl (2 mg tab, 4 mg tab) 2 MO Antivirals Anti-HIV Agents, Integrase Inhibitors (INSTI) GENVOYA MG TAB 5 QL (30 PER 30 DAYS), MO (MAIL ISENTRESS 25 MG CHEW TAB 3 MO ISENTRESS (100 MG CHEW TAB, 100 MG PACKET, 400 MG TAB) 5 MO STRIBILD MG TAB 5 QL (30 PER 30 DAYS), MO (MAIL TIVICAY (25 MG TAB, 50 MG TAB) 5 MO TIVICAY 10 MG TAB 4 MO TRIUMEQ MG TAB 5 QL (30 PER 30 DAYS), MO (MAIL Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) ATRIPLA MG TAB 5 QL (30 PER 30 DAYS), MO (MAIL COMPLERA MG TAB 5 QL (30 PER 30 DAYS), MO (MAIL EDURANT 25 MG TAB 5 MO INTELENCE (100 MG TAB, 200 MG TAB) 5 MO INTELENCE 25 MG TAB 4 MO nevirapine 50 mg/5ml suspension 4 MO nevirapine 200 mg tab 2 MO nevirapine er (er 100 mg tab er 24h, er 400 mg tab er 24h) 4 MO 44

51 NAME ODEFSEY MG TAB 5 QL (30 PER 30 DAYS), MO (MAIL RESCRIPTOR (100 MG TAB, 200 MG TAB) 4 MO SUSTIVA 50 MG CAP 4 MO SUSTIVA (200 MG CAP, 600 MG TAB) 5 MO Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir sulfate 300 mg tab 4 MO abacavir sulfate-lamivudine mg tab 5 QL (30 PER 30 DAYS), MO (MAIL abacavir-lamivudine-zidovudine mg tab 5 QL (60 PER 30 DAYS), MO (MAIL DESCOVY MG TAB 5 QL (30 PER 30 DAYS), MO (MAIL didanosine (125 mg cap dr, 200 mg cap dr, 250 mg cap dr, 400 mg cap dr) EMTRIVA (10 MG/ML SOLUTION, 200 MG CAP) 2 MO 4 MO lamivudine 10 mg/ml solution 2 MO lamivudine (150 mg tab, 300 mg tab) 4 MO lamivudine-zidovudine mg tab 4 QL (60 PER 30 DAYS), MO (MAIL RETROVIR 10 MG/ML SOLUTION 4 MO stavudine (15 mg cap, 20 mg cap, 30 mg cap, 40 mg cap) TRUVADA ( MG TAB, MG TAB, MG TAB, MG TAB) VIDEX (2 GM RECON SOLN, 4 GM RECON SOLN) VIREAD (40 MG/GM POWDER, 150 MG TAB, 200 MG TAB, 250 MG TAB, 300 MG TAB) 2 MO 5 QL (30 PER 30 DAYS), MO (MAIL 4 MO 5 MO ZERIT 1 MG/ML RECON SOLN 4 MO 45

52 NAME ZIAGEN 20 MG/ML SOLUTION 4 MO zidovudine (50 mg/5ml syrup, 100 mg cap, 300 mg tab) 2 MO Anti-HIV Agents, Other FUZEON 90 MG RECON SOLN 5 QL (60 PER 30 DAYS), MO (MAIL SELZENTRY (150 MG TAB, 300 MG TAB) 5 MO SELZENTRY (25 MG TAB, 75 MG TAB) 4 MO TYBOST 150 MG TAB 3 MO Anti-HIV Agents, Protease Inhibitors APTIVUS (100 MG/ML SOLUTION, 250 MG CAP) 5 MO CRIXIVAN (200 MG CAP, 400 MG CAP) 3 MO EVOTAZ MG TAB 5 QL (30 PER 30 DAYS), MO (MAIL INVIRASE (200 MG CAP, 500 MG TAB) 5 MO KALETRA MG TAB 4 MO KALETRA MG TAB 5 MO LEXIVA 50 MG/ML SUSPENSION 4 MO LEXIVA 700 MG TAB 5 MO lopinavir-ritonavir mg/5ml solution 2 MO NORVIR (80 MG/ML SOLUTION, 100 MG CAP, 100 MG TAB) 4 MO PREZCOBIX MG TAB 5 QL (30 PER 30 DAYS), MO (MAIL PREZISTA (100 MG/ML SUSPENSION, 600 MG TAB, 800 MG TAB) 5 MO PREZISTA (75 MG TAB, 150 MG TAB) 4 MO REYATAZ (50 MG PACKET, 150 MG CAP, 200 MG CAP, 300 MG CAP) 5 MO VIRACEPT (250 MG TAB, 625 MG TAB) 5 MO 46

53 NAME Anti-cytomegalovirus (CMV) Agents cidofovir 75 mg/ml solution 5 MO ganciclovir sodium 500 mg recon soln 2 PA - Part B vs D Determination, MO valganciclovir hcl (50 mg/ml recon soln, 450 mg tab) 5 MO ZIRGAN 0.15 % GEL 4 MO Anti-hepatitis B (HBV) Agents adefovir dipivoxil 10 mg tab 5 MO BARACLUDE 0.05 MG/ML SOLUTION 4 QL (600 PER 30 DAYS), MO entecavir (0.5 mg tab, 1 mg tab) 5 QL (30 PER 30 DAYS), MO (MAIL EPIVIR HBV 5 MG/ML SOLUTION 4 MO INTRON A ( UNIT/ML SOLUTION, UNIT/ML SOLUTION, UNIT RECON SOLN, UNIT RECON SOLN, UNIT RECON SOLN) 5 PA - FOR NEW STARTS ONLY, MO lamivudine 100 mg tab 4 MO Anti-hepatitis C (HCV) Agents, Direct Acting Agents EPCLUSA MG TAB 5 PA, QL (84 PER 365 OVER TIME), MO HARVONI MG TAB 5 PA, QL (168 PER 365 OVER TIME), MO Anti-hepatitis C (HCV) Agents, Other moderiba 200 mg tab 4 MO PEGASYS (180 MCG/0.5ML SOLUTION, 180 MCG/ML SOLUTION) PEGASYS PROCLICK (135 MCG/0.5ML SOLUTION, 180 MCG/0.5ML SOLUTION) 5 PA, MO 5 PA, MO RIBASPHERE (200 MG CAP, 400 MG TAB) 4 MO 47

54 NAME ribasphere 200 mg tab 2 MO RIBASPHERE 600 MG TAB 5 MO ribavirin 200 mg cap 4 MO ribavirin 200 mg tab 2 MO Anti-influenza Agents amantadine hcl (50 mg/5ml syrup, 100 mg tab, 100 mg cap) 2 MO oseltamivir phosphate 30 mg cap 2 QL (112 PER 365 OVER TIME), MO oseltamivir phosphate 45 mg cap 2 QL (60 PER 365 OVER TIME), MO oseltamivir phosphate 75 mg cap 2 QL (110 PER 365 OVER TIME), MO RELENZA DISKHALER 5 MG/BLISTER AER POW BA 4 QL (240 PER 365 OVER TIME), MO rimantadine hcl 100 mg tab 2 MO TAMIFLU 6 MG/ML RECON SUSP 4 QL (720 PER 365 OVER TIME), MO Antiherpetic Agents acyclovir 200 mg cap 1 MO acyclovir 200 mg/5ml suspension 4 MO acyclovir (400 mg tab, 800 mg tab) 2 MO acyclovir sodium 50 mg/ml solution 4 PA - Part B vs D Determination, MO famciclovir (125 mg tab, 250 mg tab, 500 mg tab) 2 MO trifluridine 1 % solution 2 MO valacyclovir hcl (1 gm tab, 500 mg tab) 2 QL (120 PER 30 DAYS), MO 48

55 NAME Anxiolytics Anxiolytics, Other buspirone hcl (5 mg tab, 7.5 mg tab, 10 mg tab, 15 mg tab, 30 mg tab) hydroxyzine pamoate (25 mg cap, 50 mg cap, 100 mg cap) 2 MO 4 MO Benzodiazepines alprazolam (0.25 mg tab, 0.5 mg tab, 1 mg tab) 1 QL (120 PER 30 DAYS), MO alprazolam 2 mg tab 1 QL (150 PER 30 DAYS), MO alprazolam er (er 0.5 mg tab er 24h, er 1 mg tab er 24h) 2 QL (30 PER 30 DAYS), MO (MAIL alprazolam er 2 mg tab er 24h 2 QL (150 PER 30 DAYS), MO alprazolam er 3 mg tab er 24h 2 QL (90 PER 30 DAYS), MO (MAIL alprazolam xr (0.5 mg tab er 24h, 1 mg tab er 24h) 2 QL (30 PER 30 DAYS), MO (MAIL alprazolam xr 2 mg tab er 24h 2 QL (150 PER 30 DAYS), MO alprazolam xr 3 mg tab er 24h 2 QL (90 PER 30 DAYS), MO (MAIL chlordiazepoxide hcl 10 mg cap 1 QL (900 PER 30 DAYS), MO chlordiazepoxide hcl 25 mg cap 1 QL (360 PER 30 DAYS), MO chlordiazepoxide hcl 5 mg cap 1 QL (120 PER 30 DAYS), MO clorazepate dipotassium 15 mg tab 2 QL (180 PER 30 DAYS), MO clorazepate dipotassium 3.75 mg tab 2 QL (720 PER 30 DAYS), MO 49

56 NAME clorazepate dipotassium 7.5 mg tab 2 QL (360 PER 30 DAYS), MO diazepam (1 mg/ml solution, 5 mg/ml conc) 2 MO diazepam (2 mg tab, 5 mg tab, 10 mg tab) 1 MO diazepam intensol 5 mg/ml conc 2 MO estazolam (1 mg tab, 2 mg tab) 2 QL (30 PER 30 DAYS), MO (MAIL lorazepam 2 mg/ml conc 2 MO lorazepam (0.5 mg tab, 1 mg tab) 1 QL (90 PER 30 DAYS), MO (MAIL lorazepam 2 mg tab 1 QL (150 PER 30 DAYS), MO lorazepam intensol 2 mg/ml conc 2 MO temazepam (7.5 mg cap, 15 mg cap, 22.5 mg cap, 30 mg cap) 2 QL (30 PER 30 DAYS), MO (MAIL Bipolar Agents Mood Stabilizers EQUETRO (100 MG CAP ER 12H, 200 MG 4 MO CAP ER 12H, 300 MG CAP ER 12H) lithium 8 meq/5ml solution 2 MO lithium carbonate (150 mg cap, 300 mg cap, 1 MO 600 mg cap) lithium carbonate 300 mg tab 2 MO lithium carbonate er (er 300 mg tab er, er 450 mg tab er) 2 MO Blood Glucose Regulators Antidiabetic Agents acarbose (25 mg tab, 50 mg tab, 100 mg tab) 2 MO glimepiride 1 mg tab 1 QL (240 PER 30 DAYS), MO 50

57 NAME MAGELLAN PDP (List of Covered Drugs) glimepiride 2 mg tab 1 QL (120 PER 30 DAYS), MO glimepiride 4 mg tab 1 QL (60 PER 30 DAYS), MO (MAIL glipizide 10 mg tab 1 QL (120 PER 30 DAYS), MO glipizide 5 mg tab 1 QL (240 PER 30 DAYS), MO glipizide er 10 mg tab er 24h 1 QL (60 PER 30 DAYS), MO (MAIL glipizide er 2.5 mg tab er 24h 1 QL (240 PER 30 DAYS), MO glipizide er 5 mg tab er 24h 1 QL (120 PER 30 DAYS), MO glipizide xl 10 mg tab er 24h 1 QL (60 PER 30 DAYS), MO (MAIL glipizide xl 2.5 mg tab er 24h 1 QL (240 PER 30 DAYS), MO glipizide xl 5 mg tab er 24h 1 QL (120 PER 30 DAYS), MO glipizide-metformin hcl ( mg tab, 5 2 QL (120 PER 30 DAYS), MO 500 mg tab) glipizide-metformin hcl mg tab 2 QL (240 PER 30 DAYS), MO glyburide 1.25 mg tab 2 QL (480 PER 30 DAYS), MO glyburide 2.5 mg tab 2 QL (240 PER 30 DAYS), MO glyburide 5 mg tab 2 QL (120 PER 30 DAYS), MO glyburide micronized 1.5 mg tab 2 QL (240 PER 30 DAYS), MO glyburide micronized 3 mg tab 2 QL (120 PER 30 DAYS), MO glyburide micronized 6 mg tab 2 QL (60 PER 30 DAYS), MO (MAIL 51

58 NAME MAGELLAN PDP (List of Covered Drugs) glyburide-metformin ( mg tab, mg tab) 2 QL (120 PER 30 DAYS), MO glyburide-metformin mg tab 2 QL (240 PER 30 DAYS), MO INVOKAMET ( MG TAB, MG TAB, MG TAB) 3 ST, QL (60 PER 30 DAYS), MO INVOKAMET MG TAB 3 ST, QL (120 PER 30 DAYS), MO INVOKAMET XR ( MG TAB ER 24H, MG TAB ER 24H, MG TAB ER 24H, MG TAB ER 24H) 3 ST, QL (60 PER 30 DAYS), MO INVOKANA 100 MG TAB 3 ST, QL (90 PER 30 DAYS), MO INVOKANA 300 MG TAB 3 ST, QL (30 PER 30 DAYS), MO JANUMET ( MG TAB, MG TAB) JANUMET XR ( MG TAB ER 24H, MG TAB ER 24H) 3 ST, QL (60 PER 30 DAYS), MO 3 ST, QL (60 PER 30 DAYS), MO JANUMET XR MG TAB ER 24H 3 ST, QL (30 PER 30 DAYS), MO JANUVIA (25 MG TAB, 50 MG TAB, 100 MG TAB) 3 ST, MO JARDIANCE 10 MG TAB 3 ST, QL (60 PER 30 DAYS), MO JARDIANCE 25 MG TAB 3 ST, QL (30 PER 30 DAYS), MO JENTADUETO ( MG TAB, MG TAB, MG TAB) JENTADUETO XR MG TAB ER 24H 3 ST, QL (60 PER 30 DAYS), MO 3 ST, QL (60 PER 30 DAYS), MO JENTADUETO XR MG TAB ER 24H 3 ST, QL (30 PER 30 DAYS), MO metformin hcl 1000 mg tab 1 QL (60 PER 30 DAYS), MO (MAIL 52

59 NAME MAGELLAN PDP (List of Covered Drugs) metformin hcl 500 mg tab 1 QL (150 PER 30 DAYS), MO metformin hcl 850 mg tab 1 QL (90 PER 30 DAYS), MO (MAIL metformin hcl er 500 mg tab er 24h 1 QL (120 PER 30 DAYS), MO metformin hcl er 750 mg tab er 24h 1 QL (60 PER 30 DAYS), MO (MAIL nateglinide (60 mg tab, 120 mg tab) 2 MO pioglitazone hcl 15 mg tab 1 QL (60 PER 30 DAYS), MO (MAIL pioglitazone hcl 30 mg tab 1 QL (45 PER 30 DAYS), MO (MAIL pioglitazone hcl 45 mg tab 1 QL (30 PER 30 DAYS), MO (MAIL repaglinide (0.5 mg tab, 1 mg tab, 2 mg tab) 2 MO SYMLINPEN MCG/2.7ML SOLN PEN SYMLINPEN MCG/1.5ML SOLN PEN SYNJARDY ( MG TAB, MG TAB) SYNJARDY (5-500 MG TAB, MG TAB) 5 PA, MO 5 PA, MO 3 ST, QL (60 PER 30 DAYS), MO 3 ST, QL (120 PER 30 DAYS), MO tolazamide 250 mg tab 1 QL (240 PER 30 DAYS), MO tolazamide 500 mg tab 1 QL (120 PER 30 DAYS), MO tolbutamide 500 mg tab 2 QL (180 PER 30 DAYS), MO TRADJENTA 5 MG TAB 3 ST, MO TRULICITY (0.75 MG/0.5ML SOLN PEN, 1.5 MG/0.5ML SOLN PEN) 3 ST, QL (2 PER 28 DAYS), MO VICTOZA 18 MG/3ML SOLN PEN 3 ST, QL (9 PER 30 DAYS), MO 53

60 NAME Glycemic Agents GLUCAGEN HYPOKIT 1 MG RECON SOLN 4 MO GLUCAGON EMERGENCY 1 MG KIT 3 MO PROGLYCEM 50 MG/ML SUSPENSION 5 MO Insulins HUMALOG (100 UNIT/ML SOLUTION, 100 UNIT/ML SOLN CART) HUMALOG KWIKPEN (100 UNIT/ML SOLN PEN, 200 UNIT/ML SOLN PEN) HUMALOG MIX 50/50 (50-50) 100 UNIT/ML SUSPENSION HUMALOG MIX 50/50 KWIKPEN (50-50) 100 UNIT/ML SUSP PEN HUMALOG MIX 75/25 (75-25) 100 UNIT/ML SUSPENSION HUMALOG MIX 75/25 KWIKPEN (75-25) 100 UNIT/ML SUSP PEN HUMULIN 70/30 (70-30) 100 UNIT/ML SUSPENSION HUMULIN 70/30 KWIKPEN (70-30) 100 UNIT/ML SUSP PEN HUMULIN 70/30 PEN (70-30) 100 UNIT/ML SUSP PEN 3 MO 3 MO 3 MO 3 MO 3 MO 3 MO 3 MO 3 MO 3 MO HUMULIN N 100 UNIT/ML SUSPENSION 3 MO HUMULIN N KWIKPEN 100 UNIT/ML SUSP PEN 3 MO HUMULIN N PEN 100 UNIT/ML SUSP PEN 3 MO HUMULIN R 100 UNIT/ML SOLUTION 3 MO HUMULIN R U-500 (CONCENTRATED) 500 UNIT/ML SOLUTION HUMULIN R U-500 KWIKPEN 500 UNIT/ML SOLN PEN 5 MO 5 MO LANTUS 100 UNIT/ML SOLUTION 3 MO 54

61 NAME LANTUS SOLOSTAR 100 UNIT/ML SOLN PEN TOUJEO SOLOSTAR 300 UNIT/ML SOLN PEN 3 MO 3 MO Blood Products/Modifiers/Volume Expanders Anticoagulants ELIQUIS 2.5 MG TAB 3 QL (60 PER 30 DAYS), MO (MAIL ELIQUIS 5 MG TAB 3 QL (90 PER 30 DAYS), MO (MAIL enoxaparin sodium (100 mg/ml solution, 150 mg/ml solution) enoxaparin sodium (80 mg/0.8ml solution, 120 mg/0.8ml solution) 4 QL (35 PER 90 OVER TIME), MO 4 QL (28 PER 90 OVER TIME), MO enoxaparin sodium 30 mg/0.3ml solution 4 QL (10.5 PER 90 OVER TIME), MO enoxaparin sodium 300 mg/3ml solution 4 QL (105 PER 90 OVER TIME), MO enoxaparin sodium 40 mg/0.4ml solution 4 QL (14 PER 90 OVER TIME), MO enoxaparin sodium 60 mg/0.6ml solution 4 QL (21 PER 90 OVER TIME), MO fondaparinux sodium 10 mg/0.8ml solution 5 QL (28 PER 90 OVER TIME), MO fondaparinux sodium 2.5 mg/0.5ml solution 4 QL (17.5 PER 90 OVER TIME), MO fondaparinux sodium 5 mg/0.4ml solution 5 QL (14 PER 90 OVER TIME), MO fondaparinux sodium 7.5 mg/0.6ml solution 5 QL (21 PER 90 OVER TIME), MO heparin (porcine) in d5w 40-5 unit/ml-% solution 2 MO heparin (porcine) in nacl ((porcine) MO unit/ml-% solution, (porcine) unit/ml % solution) 55

62 NAME heparin sodium (porcine) ((porcine) 1000 unit/ml solution, (porcine) 5000 unit/ml solution, (porcine) unit/ml solution, (porcine) unit/ml solution) jantoven (1 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab, 10 mg tab) 2 MO 1 MO PRADAXA (75 MG CAP, 110 MG CAP, 150 MG CAP) warfarin sodium (1 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab, 7.5 mg tab, 10 mg tab) 4 QL (60 PER 30 DAYS), MO (MAIL 1 MO XARELTO (10 MG TAB, 20 MG TAB) 3 QL (30 PER 30 DAYS), MO (MAIL XARELTO 15 MG TAB 3 QL (60 PER 30 DAYS), MO (MAIL XARELTO STARTER PACK 15 & 20 MG TAB THPK 3 QL (102 PER 365 OVER TIME), MO Blood Formation Modifiers anagrelide hcl (0.5 mg cap, 1 mg cap) 2 MO ARANESP (ALBUMIN FREE) (FREE) 10 MCG/0.4ML SOLN PRSYR, FREE) 25 MCG/ML SOLUTION, FREE) 25 MCG/0.42ML SOLN PRSYR, FREE) 40 MCG/0.4ML SOLN PRSYR, FREE) 40 MCG/ML SOLUTION, FREE) 60 MCG/0.3ML SOLN PRSYR) ARANESP (ALBUMIN FREE) (FREE) 60 MCG/ML SOLUTION, FREE) 100 MCG/0.5ML SOLN PRSYR, FREE) 100 MCG/ML SOLUTION, FREE) 150 MCG/0.3ML SOLN PRSYR, FREE) 200 MCG/ML SOLUTION, FREE) 200 MCG/0.4ML SOLN PRSYR, FREE) 300 MCG/ML SOLUTION, FREE) 300 MCG/0.6ML SOLN PRSYR, FREE) 500 MCG/ML SOLN PRSYR) 4 PA, MO 5 PA, MO LEUKINE 250 MCG RECON SOLN 5 PA, MO 56

63 NAME MOZOBIL 24 MG/1.2ML SOLUTION 5 PA, QL (38.4 PER 365 OVER TIME), MO NEULASTA 6 MG/0.6ML SOLN PRSYR 5 PA, MO NEULASTA ONPRO 6 MG/0.6ML PREF SY KT NEUPOGEN (300 MCG/0.5ML SOLN PRSYR, 300 MCG/ML SOLUTION, 480 MCG/0.8ML SOLN PRSYR, 480 MCG/1.6ML SOLUTION) PROCRIT (2000 UNIT/ML SOLUTION, 3000 UNIT/ML SOLUTION, 4000 UNIT/ML SOLUTION, UNIT/ML SOLUTION) PROCRIT (20000 UNIT/ML SOLUTION, UNIT/ML SOLUTION) PROMACTA (12.5 MG TAB, 25 MG TAB, 50 MG TAB, 75 MG TAB) 5 PA, MO 5 MO 4 PA, MO 5 PA, MO 5 PA, MO Hemostasis Agents tranexamic acid 1000 mg/10ml solution 2 MO tranexamic acid 650 mg tab 4 MO Platelet Modifying Agents aspirin-dipyridamole er mg cap er 12h 4 MO BRILINTA (60 MG TAB, 90 MG TAB) 4 MO cilostazol (50 mg tab, 100 mg tab) 2 MO clopidogrel bisulfate 300 mg tab 4 MO clopidogrel bisulfate 75 mg tab 1 MO Cardiovascular Agents Alpha-adrenergic Agonists clonidine hcl (0.1 mg/24hr patch wk, 0.2 mg/24hr patch wk) 2 MO clonidine hcl 0.3 mg/24hr patch wk 4 MO clonidine hcl (0.1 mg tab, 0.2 mg tab, 0.3 mg tab) 1 MO 57

64 NAME guanfacine hcl (1 mg tab, 2 mg tab) 4 MO methyldopa (250 mg tab, 500 mg tab) 4 MO methyldopa-hydrochlorothiazide ( mg tab, mg tab) midodrine hcl (2.5 mg tab, 5 mg tab, 10 mg tab) 4 MO 2 MO Alpha-adrenergic Blocking Agents phenoxybenzamine hcl 10 mg cap 5 MO prazosin hcl (1 mg cap, 2 mg cap, 5 mg cap) 2 MO Angiotensin II Receptor Antagonists candesartan cilexetil (4 mg tab, 8 mg tab, 16 mg tab, 32 mg tab) candesartan cilexetil-hctz ( mg tab, mg tab, mg tab) 2 MO 2 MO eprosartan mesylate 600 mg tab 2 MO irbesartan (75 mg tab, 150 mg tab, 300 mg tab) irbesartan-hydrochlorothiazide ( mg tab, mg tab) losartan potassium (25 mg tab, 50 mg tab, 100 mg tab) losartan potassium-hctz ( mg tab, mg tab, mg tab) 1 MO 1 MO 1 MO 1 MO olmesartan medoxomil (5 mg tab, 40 mg tab) 2 MO telmisartan (20 mg tab, 40 mg tab, 80 mg tab) 2 MO telmisartan-hctz ( mg tab, mg tab, mg tab) valsartan (40 mg tab, 80 mg tab, 160 mg tab, 320 mg tab) valsartan-hydrochlorothiazide ( mg tab, mg tab, mg tab, mg tab, mg tab) 2 MO 2 MO 1 MO 58

65 NAME Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl (5 mg tab, 10 mg tab, 20 mg tab, 40 mg tab) 1 MO benazepril-hydrochlorothiazide ( mg tab, mg tab, mg tab, mg tab) captopril (12.5 mg tab, 25 mg tab, 50 mg tab, 100 mg tab) captopril-hydrochlorothiazide (25-25 mg tab, mg tab, mg tab, mg tab) enalapril maleate (2.5 mg tab, 5 mg tab, 10 mg tab, 20 mg tab) enalapril-hydrochlorothiazide ( mg tab, mg tab) fosinopril sodium (10 mg tab, 20 mg tab, 40 mg tab) 2 MO 2 MO 2 MO 1 MO 1 MO 1 MO fosinopril sodium-hctz ( mg tab, 20 2 MO 12.5 mg tab) lisinopril (2.5 mg tab, 5 mg tab, 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab) lisinopril-hydrochlorothiazide ( mg tab, mg tab, mg tab) 1 MO 1 MO moexipril hcl (7.5 mg tab, 15 mg tab) 2 MO moexipril-hydrochlorothiazide ( mg tab, mg tab, mg tab) perindopril erbumine (2 mg tab, 4 mg tab, 8 mg tab) quinapril hcl (5 mg tab, 10 mg tab, 20 mg tab, 40 mg tab) quinapril-hydrochlorothiazide ( mg tab, mg tab, mg tab) ramipril (1.25 mg cap, 2.5 mg cap, 5 mg cap, 10 mg cap) 1 MO 1 MO 1 MO 1 MO 1 MO trandolapril (1 mg tab, 2 mg tab, 4 mg tab) 1 MO 59

66 NAME trandolapril-verapamil hcl er (er mg tab er, er mg tab er, er mg tab er, er mg tab er) 2 MO Antiarrhythmics amiodarone hcl (100 mg tab, 150 mg/3ml solution, 400 mg tab, 450 mg/9ml solution) 2 MO amiodarone hcl 200 mg tab 1 MO disopyramide phosphate (100 mg cap, 150 mg cap) dofetilide (125 mcg cap, 250 mcg cap, 500 mcg cap) flecainide acetate (50 mg tab, 100 mg tab, 150 mg tab) mexiletine hcl (150 mg cap, 200 mg cap, 250 mg cap) NORPACE CR (100 MG CAP ER 12H, 150 MG CAP ER 12H) procainamide hcl (100 mg/ml solution, 500 mg/ml solution) propafenone hcl (150 mg tab, 225 mg tab, 300 mg tab) propafenone hcl er (er 225 mg cap er 12h, er 325 mg cap er 12h, er 425 mg cap er 12h) 4 MO 4 MO 2 MO 2 MO 4 MO 2 MO 2 MO 4 MO quinidine gluconate 80 mg/ml solution 2 MO quinidine gluconate er 324 mg tab er 4 MO quinidine sulfate (200 mg tab, 300 mg tab) 2 MO sorine (80 mg tab, 120 mg tab, 160 mg tab, 240 mg tab) sotalol hcl (80 mg tab, 120 mg tab, 160 mg tab, 240 mg tab) sotalol hcl (af) ((af) 80 mg tab, (af) 120 mg tab, (af) 160 mg tab) 2 MO 2 MO 2 MO 60

67 NAME Beta-adrenergic Blocking Agents acebutolol hcl (200 mg cap, 400 mg cap) 2 MO atenolol (25 mg tab, 50 mg tab, 100 mg tab) 1 MO atenolol-chlorthalidone (50-25 mg tab, mg tab) 2 MO betaxolol hcl (10 mg tab, 20 mg tab) 2 MO bisoprolol fumarate (5 mg tab, 10 mg tab) 2 MO bisoprolol-hydrochlorothiazide ( mg tab, mg tab, mg tab) BYSTOLIC (2.5 MG TAB, 5 MG TAB, 10 MG TAB, 20 MG TAB) carvedilol (3.125 mg tab, 6.25 mg tab, 12.5 mg tab, 25 mg tab) labetalol hcl (100 mg tab, 200 mg tab, 300 mg tab) metoprolol succinate er (er 25 mg tab er 24h, er 50 mg tab er 24h, er 100 mg tab er 24h, er 200 mg tab er 24h) metoprolol tartrate (25 mg tab, 50 mg tab, 100 mg tab) 1 MO 3 MO 1 MO 2 MO 2 MO 1 MO nadolol (20 mg tab, 40 mg tab, 80 mg tab) 2 MO pindolol (5 mg tab, 10 mg tab) 2 MO propranolol hcl (1 mg/ml solution, 10 mg tab, 20 mg/5ml solution, 20 mg tab, 40 mg/5ml solution, 40 mg tab, 60 mg tab, 80 mg tab) propranolol hcl er (er 60 mg cap er 24h, er 80 mg cap er 24h, er 120 mg cap er 24h, er 160 mg cap er 24h) propranolol-hctz (40-25 mg tab, mg tab) timolol maleate (5 mg tab, 10 mg tab, 20 mg tab) 2 MO 2 MO 2 MO 2 MO 61

68 NAME Calcium Channel Blocking Agents afeditab cr (30 mg tab er 24h, 60 mg tab er 24h) amlodipine besy-benazepril hcl ( mg cap, 5-40 mg cap, 5-20 mg cap, 5-10 mg cap, mg cap, mg cap) amlodipine besylate (2.5 mg tab, 5 mg tab, 10 mg tab) amlodipine besylate-valsartan (5-320 mg tab, mg tab, mg tab, mg tab) amlodipine-atorvastatin ( mg tab, 5-80 mg tab, 5-40 mg tab, 5-20 mg tab, 5-10 mg tab, mg tab, mg tab, mg tab, mg tab) cartia xt (120 mg cap er 24h, 180 mg cap er 24h, 240 mg cap er 24h, 300 mg cap er 24h) dilt-xr (120 mg cap er 24h, 180 mg cap er 24h, 240 mg cap er 24h) diltiazem cd (120 mg cap er 24h, 180 mg cap er 24h, 240 mg cap er 24h, 300 mg cap er 24h) diltiazem hcl (25 mg/5ml solution, 30 mg tab, 50 mg/10ml solution, 60 mg tab, 90 mg tab, 100 mg recon soln, 120 mg tab, 125 mg/25ml solution) diltiazem hcl er (er 60 mg cap er 12h, er 90 mg cap er 12h, er 120 mg cap er 24h, er 120 mg cap er 12h, er 180 mg cap er 24h, er 240 mg cap er 24h) diltiazem hcl er beads (er beads 120 mg cap er 24h, er beads 180 mg cap er 24h, er beads 240 mg cap er 24h, er beads 300 mg cap er 24h, er beads 360 mg cap er 24h, er beads 420 mg cap er 24h) 2 MO 1 MO 1 MO 1 MO 2 MO 2 MO 2 MO 2 MO 2 MO 2 MO 2 MO 62

69 NAME diltiazem hcl er coated beads (er beads 120 mg cap er 24h, er beads 180 mg cap er 24h, er beads 180 mg tab er 24h, er beads 240 mg cap er 24h, er beads 240 mg tab er 24h, er beads 300 mg cap er 24h, er beads 300 mg tab er 24h, er beads 360 mg tab er 24h, er beads 360 mg cap er 24h) felodipine er (er 2.5 mg tab er 24h, er 5 mg tab er 24h, er 10 mg tab er 24h) matzim la (180 mg tab er 24h, 240 mg tab er 24h, 300 mg tab er 24h, 360 mg tab er 24h, 420 mg tab er 24h) nicardipine hcl (2.5 mg/ml solution, 20 mg cap, 30 mg cap) nifedipine er (er 30 mg tab er 24h, er 60 mg tab er 24h, er 90 mg tab er 24h) nifedipine er osmotic release (er 30 mg tab er 24h, er 60 mg tab er 24h, er 90 mg tab er 24h) 2 MO 2 MO 2 MO 4 MO 2 MO 2 MO nimodipine 30 mg cap 5 MO taztia xt (120 mg cap er 24h, 180 mg cap er 24h, 240 mg cap er 24h, 300 mg cap er 24h, 360 mg cap er 24h) 2 MO verapamil hcl 2.5 mg/ml solution 2 MO verapamil hcl (40 mg tab, 80 mg tab, 120 mg tab) verapamil hcl er (er 100 mg cap er 24h, er 120 mg tab er, er 120 mg cap er 24h, er 180 mg cap er 24h, er 180 mg tab er, er 200 mg cap er 24h, er 240 mg tab er, er 240 mg cap er 24h, er 300 mg cap er 24h, er 360 mg cap er 24h) 1 MO 2 MO Cardiovascular Agents, Other CORLANOR (5 MG TAB, 7.5 MG TAB) 4 PA, QL (60 PER 30 DAYS), MO DEMSER 250 MG CAP 5 MO digitek 125 mcg tab 2 QL (30 PER 30 DAYS), MO (MAIL 63

70 NAME digitek 250 mcg tab 4 MO digox 125 mcg tab 2 QL (30 PER 30 DAYS), MO (MAIL digox 250 mcg tab 4 MO digoxin 0.05 mg/ml solution 2 MO digoxin (0.25 mg/ml solution, 250 mcg tab) 4 MO digoxin 125 mcg tab 2 QL (30 PER 30 DAYS), MO (MAIL ENTRESTO (24-26 MG TAB, MG TAB, MG TAB) 4 PA, QL (60 PER 30 DAYS), MO LANOXIN MCG TAB 4 QL (30 PER 30 DAYS), MO (MAIL LANOXIN 62.5 MCG TAB 4 QL (60 PER 30 DAYS), MO (MAIL NORTHERA (100 MG CAP, 200 MG CAP, 300 MG CAP) 5 PA, MO pentoxifylline er 400 mg tab er 4 MO PRALUENT (75 MG/ML SOLN PRSYR, 75 MG/ML SOLN PEN, 150 MG/ML SOLN PEN) RANEXA (500 MG TAB ER 12H, 1000 MG TAB ER 12H) 5 PA, QL (2 PER 28 DAYS), MO 3 MO REPATHA 140 MG/ML SOLN PRSYR 5 PA, QL (3 PER 28 DAYS), MO REPATHA PUSHTRONEX SYSTEM 420 MG/3.5ML SOLN CART REPATHA SURECLICK 140 MG/ML SOLN A-INJ 5 PA, QL (3.5 PER 28 DAYS), MO 5 PA, QL (3 PER 28 DAYS), MO Diuretics, Carbonic Anhydrase Inhibitors acetazolamide sodium 500 mg recon soln 5 MO methazolamide 25 mg tab 2 MO methazolamide 50 mg tab 4 MO 64

71 NAME Diuretics, Loop bumetanide (0.25 mg/ml solution, 0.5 mg tab, 1 mg tab, 2 mg tab) furosemide (8 mg/ml solution, 10 mg/ml solution) 2 MO 2 MO furosemide (20 mg tab, 40 mg tab, 80 mg tab) 1 MO torsemide (5 mg tab, 10 mg tab, 20 mg tab, 100 mg tab) 1 MO Diuretics, Potassium-sparing amiloride hcl 5 mg tab 2 MO amiloride-hydrochlorothiazide 5-50 mg tab 2 MO eplerenone (25 mg tab, 50 mg tab) 2 MO spironolactone (25 mg tab, 50 mg tab, 100 mg tab) 1 MO spironolactone-hctz mg tab 2 MO triamterene-hctz ( mg cap, mg cap) triamterene-hctz ( mg tab, mg tab) 2 MO 1 MO Diuretics, Thiazide chlorothiazide (250 mg tab, 500 mg tab) 2 MO chlorothiazide sodium 500 mg recon soln 4 MO chlorthalidone (25 mg tab, 50 mg tab) 2 MO hydrochlorothiazide (12.5 mg tab, 12.5 mg cap, 25 mg tab, 50 mg tab) 1 MO indapamide (1.25 mg tab, 2.5 mg tab) 2 MO methyclothiazide 5 mg tab 2 MO metolazone (2.5 mg tab, 5 mg tab, 10 mg tab) 2 MO Dyslipidemics, Fibric Acid Derivatives fenofibrate (48 mg tab, 54 mg tab, 120 mg tab, 145 mg tab, 160 mg tab) 2 MO 65

72 NAME fenofibrate micronized (67 mg cap, 134 mg cap, 200 mg cap) 2 MO gemfibrozil 600 mg tab 1 MO Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin calcium (10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab) 1 MO fluvastatin sodium (20 mg cap, 40 mg cap) 2 MO fluvastatin sodium er 80 mg tab er 24h 4 MO lovastatin (10 mg tab, 20 mg tab, 40 mg tab) 1 MO pravastatin sodium (10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab) rosuvastatin calcium (5 mg tab, 10 mg tab, 20 mg tab, 40 mg tab) simvastatin (5 mg tab, 10 mg tab, 20 mg tab, 40 mg tab) 1 MO 1 MO 1 MO simvastatin 80 mg tab 1 PA, MO Dyslipidemics, Other cholestyramine (4 gm packet, 4 gm/dose powder) cholestyramine light (4 gm packet, 4 gm/dose powder) colestipol hcl (1 gm tab, 5 gm granules, 5 gm packet) 4 MO 4 MO 2 MO ezetimibe 10 mg tab 2 MO ezetimibe-simvastatin (10-10 mg tab, mg tab, mg tab) 2 MO ezetimibe-simvastatin mg tab 2 PA, MO niacin er (antihyperlipidemic) (er (antihyperlipidemic) 500 mg tab er, er (antihyperlipidemic) 1000 mg tab er) 2 MO niacin er (antihyperlipidemic) 750 mg tab er 4 MO NIACOR 500 MG TAB 2 MO 66

73 NAME omega-3-acid ethyl esters 1 gm cap 4 MO prevalite (4 gm packet, 4 gm/dose powder) 4 MO Vasodilators, Direct-acting Arterial hydralazine hcl (10 mg tab, 25 mg tab, 50 mg tab, 100 mg tab) 2 MO minoxidil (2.5 mg tab, 10 mg tab) 4 MO Vasodilators, Direct-acting Arterial/Venous isosorbide dinitrate (5 mg tab, 10 mg tab, 20 mg tab, 30 mg tab) 2 MO isosorbide dinitrate er 40 mg tab er 2 MO isosorbide mononitrate (10 mg tab, 20 mg tab) isosorbide mononitrate er (er 30 mg tab er 24h, er 60 mg tab er 24h, er 120 mg tab er 24h) minitran (0.1 mg/hr patch 24hr, 0.2 mg/hr patch 24hr, 0.4 mg/hr patch 24hr, 0.6 mg/hr patch 24hr) 1 MO 2 MO 2 MO NITRO-BID 2 % OINTMENT 4 MO nitroglycerin (0.1 mg/hr patch 24hr, 0.2 mg/hr patch 24hr, 0.3 mg sl tab, 0.4 mg/hr patch 24hr, 0.4 mg sl tab, 0.6 mg sl tab, 0.6 mg/hr patch 24hr) NITROSTAT (0.3 MG SL TAB, 0.4 MG SL TAB, 0.6 MG SL TAB) Central Nervous System Agents 2 MO 3 MO Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine-dextroamphet er (er 5 mg cap er 24h, er 10 mg cap er 24h, er 15 mg cap er 24h, er 20 mg cap er 24h, er 25 mg cap er 24h, er 30 mg cap er 24h) amphetamine-dextroamphetamine (5 mg tab, 7.5 mg tab, 10 mg tab, 12.5 mg tab, 15 mg tab, 20 mg tab, 30 mg tab) 2 PA, QL (30 PER 30 DAYS), MO 2 QL (90 PER 30 DAYS), MO (MAIL 67

74 NAME dextroamphetamine sulfate 10 mg tab 2 PA, QL (180 PER 30 DAYS), MO dextroamphetamine sulfate 5 mg tab 2 PA, QL (90 PER 30 DAYS), MO dextroamphetamine sulfate er 10 mg cap er 24h dextroamphetamine sulfate er 15 mg cap er 24h dextroamphetamine sulfate er 5 mg cap er 24h 2 PA, QL (180 PER 30 DAYS), MO 4 PA, QL (120 PER 30 DAYS), MO 2 PA, QL (60 PER 30 DAYS), MO Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines atomoxetine hcl (18 mg cap, 25 mg cap, 40 mg cap, 60 mg cap, 80 mg cap, 100 mg cap) 2 QL (30 PER 30 DAYS), MO (MAIL atomoxetine hcl 10 mg cap 2 QL (60 PER 30 DAYS), MO (MAIL dexmethylphenidate hcl (2.5 mg tab, 5 mg tab, 10 mg tab) dexmethylphenidate hcl er (er 5 mg cap er 24h, er 10 mg cap er 24h, er 15 mg cap er 24h, er 20 mg cap er 24h, er 25 mg cap er 24h, er 30 mg cap er 24h, er 35 mg cap er 24h, er 40 mg cap er 24h) guanfacine hcl er (er 1 mg tab er 24h, er 2 mg tab er 24h, er 3 mg tab er 24h, er 4 mg tab er 24h) 2 PA, QL (60 PER 30 DAYS), MO 4 PA, QL (30 PER 30 DAYS), MO 4 MO metadate er 20 mg tab er 4 PA, QL (90 PER 30 DAYS), MO methylphenidate hcl 10 mg chew tab 2 PA, QL (180 PER 30 DAYS), MO methylphenidate hcl (5 mg/5ml solution, 10 mg/5ml solution) methylphenidate hcl (2.5 mg chew tab, 5 mg tab, 5 mg chew tab, 10 mg tab, 20 mg tab) 4 PA, MO 2 PA, QL (90 PER 30 DAYS), MO methylphenidate hcl er 10 mg tab er 4 PA, QL (180 PER 30 DAYS), MO methylphenidate hcl er 20 mg tab er 4 PA, QL (90 PER 30 DAYS), MO 68

75 NAME methylphenidate hcl er (er 18 mg tab er 24h, er 27 mg tab er 24h, er 54 mg tab er 24h) 4 PA, QL (30 PER 30 DAYS), MO methylphenidate hcl er 36 mg tab er 24h 4 PA, QL (60 PER 30 DAYS), MO methylphenidate hcl er (cd) (er (cd) 10 mg cap er, er (cd) 20 mg cap er, er (cd) 30 mg cap er, er (cd) 40 mg cap er, er (cd) 50 mg cap er, er (cd) 60 mg cap er) methylphenidate hcl er (la) (er (la) 20 mg cap er 24h, er (la) 40 mg cap er 24h) 4 PA, QL (30 PER 30 DAYS), MO 4 PA, QL (30 PER 30 DAYS), MO methylphenidate hcl er (la) 30 mg cap er 24h 4 PA, QL (30 PER 30 DAYS), MO methylphenidate hcl er (la) 60 mg cap er 24h 2 PA, QL (30 PER 30 DAYS), MO Central Nervous System, Other butalbital-acetaminophen mg tab 4 MO butalbital-acetaminophen mg tab 4 QL (360 PER 30 DAYS), MO butalbital-aspirin-caffeine mg cap 4 MO INGREZZA 40 MG CAP 5 PA, MO NUEDEXTA MG CAP 4 MO riluzole 50 mg tab 2 PA, MO TENCON MG TAB 4 QL (360 PER 30 DAYS), MO tetrabenazine (12.5 mg tab, 25 mg tab) 5 PA, MO Multiple Sclerosis Agents AMPYRA 10 MG TAB ER 12H 5 PA, QL (60 PER 30 DAYS), MO AUBAGIO (7 MG TAB, 14 MG TAB) 5 PA, QL (30 PER 30 DAYS), MO AVONEX 30 MCG KIT 5 PA, QL (4 PER 28 DAYS), MO AVONEX PEN 30 MCG/0.5ML AUT-IJ KIT 5 PA, QL (4 PER 28 DAYS), MO 69

76 NAME MAGELLAN PDP (List of Covered Drugs) AVONEX PREFILLED 30 MCG/0.5ML PREF SY KT 5 PA, QL (4 PER 28 DAYS), MO COPAXONE 40 MG/ML SOLN PRSYR 5 PA, QL (12 PER 28 DAYS), MO EXTAVIA 0.3 MG KIT 5 PA, QL (15 PER 30 DAYS), MO GILENYA 0.5 MG CAP 5 PA, QL (30 PER 30 DAYS), MO glatopa 20 mg/ml soln prsyr 5 PA, QL (30 PER 30 DAYS), MO PLEGRIDY (125 MCG/0.5ML SOLN PEN, 125 MCG/0.5ML SOLN PRSYR) PLEGRIDY STARTER PACK 63 & 94 MCG/0.5ML SOLN PEN TECFIDERA (120 MG CAP DR, 240 MG CAP DR) 5 PA, QL (1 PER 28 DAYS), MO 5 PA, QL (2 PER 365 OVER TIME), MO 5 PA, QL (60 PER 30 DAYS), MO TECFIDERA 120 & 240 MG MISC 5 PA, QL (120 PER 365 OVER TIME), MO TYSABRI 300 MG/15ML CONC 5 PA, MO Dental and Oral Agents chlorhexidine gluconate 0.12 % solution 1 MO periogard 0.12 % solution 1 MO pilocarpine hcl (5 mg tab, 7.5 mg tab) 2 MO triamcinolone acetonide 0.1 % paste 2 MO Dermatological Agents acitretin (10 mg cap, 25 mg cap) 4 MO acitretin 17.5 mg cap 5 MO adapalene (0.1 % cream, 0.1 % gel, 0.3 % gel) 2 MO ammonium lactate (12 % lotion, 12 % cream) 2 MO benzoyl peroxide-erythromycin 5-3 % gel 4 MO 70

77 NAME MAGELLAN PDP (List of Covered Drugs) calcipotriene (0.005 % cream, % ointment) 4 MO calcipotriene % solution 2 MO claravis (10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap) clindamycin phos-benzoyl perox (1-5 % gel, % gel) 4 PA, MO 4 MO clindamycin-tretinoin % gel 4 MO clotrimazole-betamethasone ( % lotion, % cream) 2 MO COSENTYX 150 MG/ML SOLN PRSYR 5 PA, MO COSENTYX 300 DOSE 150 MG/ML SOLN PRSYR COSENTYX SENSOREADY 300 DOSE 150 MG/ML SOLN A-INJ COSENTYX SENSOREADY PEN 150 MG/ML SOLN A-INJ 5 PA, MO 5 PA, MO 5 PA, MO diclofenac sodium 1 % gel 4 QL (1000 PER 30 DAYS), MO diclofenac sodium 1.5 % solution 4 PA, MO fluorouracil 0.5 % cream 5 MO fluorouracil (2 % solution, 5 % solution, 5 % cream) 2 MO imiquimod 5 % cream 2 MO MIRVASO 0.33 % GEL 4 PA, MO myorisan (10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap) 4 PA, MO podofilox 0.5 % solution 2 MO SANTYL 250 UNIT/GM OINTMENT 4 MO selenium sulfide 2.5 % lotion 2 MO tacrolimus (0.03 % ointment, 0.1 % ointment) 4 MO tazarotene 0.1 % cream 2 MO 71

78 NAME tretinoin (0.01 % gel, % gel, % cream, 0.05 % gel, 0.05 % cream, 0.1 % cream) 4 PA, MO tretinoin microsphere (0.04 % gel, 0.1 % gel) 4 PA, MO zenatane (10 mg cap, 20 mg cap, 30 mg cap, 40 mg cap) 4 PA, MO Electrolytes/Minerals/Metals/Vitamins Electrolyte/Mineral Replacement aminosyn ii/electrolytes 8.5 % solution 2 PA - Part B vs D Determination, MO AMINOSYN/ELECTROLYTES 7 % SOLUTION 4 PA - Part B vs D Determination, MO aminosyn/electrolytes 8.5 % solution 2 PA - Part B vs D Determination, MO CARBAGLU 200 MG TAB 5 MO dextrose (5 % solution, 10 % solution, 50 % solution, 70 % solution) 2 MO dextrose in lactated ringers 5 % solution 2 MO dextrose-nacl ( % solution, % solution, % solution, % solution, % solution, % solution, % solution, % solution, % solution) 2 MO IONOSOL-B IN D5W SOLUTION 4 MO IONOSOL-MB IN D5W 5 % SOLUTION 4 MO ISOLYTE-P IN D5W 5 % SOLUTION 4 MO ISOLYTE-S SOLUTION 4 MO ISOLYTE-S PH 7.4 SOLUTION 4 MO 72

79 NAME MAGELLAN PDP (List of Covered Drugs) kcl in dextrose-nacl ( meq/l-%-% 2 MO solution, meq/l-%-% solution, meq/l-%-% solution, meq/l-% % solution, meq/l-%-% solution, meq/l-%-% solution, meq/l-% % solution, meq/l-%-% solution, meq/l-%-% solution) kcl-lactated ringers-d5w 20 meq/l solution 2 MO klor-con 8 meq tab er 2 MO klor-con meq tab er 2 MO klor-con m10 10 meq tab er 2 MO KLOR-CON M15 15 MEQ TAB ER 2 MO klor-con m20 20 meq tab er 2 MO klor-con sprinkle (8 cap er, 10 cap er) 2 MO lactated ringers (solution, solution) 2 MO magnesium sulfate 50 % solution 2 MO magnesium sulfate 50 % syringe 2 MO NORMOSOL-M IN D5W 5 % SOLUTION 4 MO NORMOSOL-R SOLUTION 4 MO NORMOSOL-R IN D5W 5 % SOLUTION 4 MO NORMOSOL-R PH 7.4 SOLUTION 4 MO PLASMA-LYTE 148 SOLUTION 4 MO PLASMA-LYTE A SOLUTION 4 MO potassium chloride (0.4 meq/ml solution, 2 meq/ml solution, 10 meq/50ml solution, 10 meq/100ml solution, 20 meq/100ml solution, 20 meq/50ml solution, 40 meq/100ml solution) potassium chloride crys er (crys er 10 tab er, crys er 20 tab er) potassium chloride er (er 8 tab er, er 8 cap er, er 10 tab er, er 10 cap er, er 20 tab er) potassium chloride in dextrose (20-5 meq/l-% solution, 40-5 meq/l-% solution) 2 MO 2 MO 2 MO 2 MO 73

80 NAME potassium chloride in nacl ( meq/l-% solution, meq/l-% solution, meq/l-% solution) potassium chloride solution 20 meq/15ml (10%) potassium chloride solution 40 meq/15ml (20%) potassium citrate er (er 5 (540 mg) tab er, er 10 (1080 mg) tab er) 2 MO 2 MO 2 MO 2 MO PROCALAMINE 3 % SOLUTION 4 PA - Part B vs D Determination, MO ringers solution 2 MO sodium chloride (0.45 % solution, 0.9 % solution, 2.5 meq/ml solution, 3 % solution, 5 % solution) sodium fluoride 2.2 mg (fluoride ion 1 mg) oral tablet 2 MO 2 MO sodium lactate 5 meq/ml solution 2 MO Electrolyte/Mineral/Metal Modifiers DEPEN TITRATABS 250 MG TAB 5 MO EXJADE (125 MG TAB SOL, 250 MG TAB SOL, 500 MG TAB SOL) FERRIPROX (100 MG/ML SOLUTION, 500 MG TAB) JADENU (90 MG TAB, 180 MG TAB, 360 MG TAB) JADENU SPRINKLE (90 MG PACKET, 180 MG PACKET, 360 MG PACKET) 5 PA, MO 5 PA, MO 5 PA, MO 5 PA, MO kionex powder 2 MO sodium polystyrene sulfonate (15 gm/60ml suspension, 30 gm/120ml suspension, 50 gm/200ml suspension) 2 MO sps 15 gm/60ml suspension 2 MO SYPRINE 250 MG CAP 5 PA, MO 74

81 NAME Phosphate Binders calcium acetate (phos binder) (binder) 667 mg tab, binder) 667 mg cap) FOSRENOL (500 MG CHEW TAB, 750 MG PACKET, 750 MG CHEW TAB, 1000 MG PACKET, 1000 MG CHEW TAB) 2 MO 5 MO RENAGEL 400 MG TAB 3 MO RENAGEL 800 MG TAB 5 MO RENVELA (0.8 GM PACKET, 2.4 GM PACKET, 800 MG TAB) sevelamer carbonate (0.8 gm packet, 2.4 gm packet) 5 MO 5 MO VELPHORO 500 MG CHEW TAB 5 MO Vitamins PRENATAL VITAMIN WITH MINERALS AND FOLIC ACID GREATER THAN 0.8 MG ORAL TABLET 2 MO Gastrointestinal Agents Antispasmodics, Gastrointestinal dicyclomine hcl (10 mg/ml solution, 10 mg/5ml solution) 2 MO dicyclomine hcl (10 mg cap, 20 mg tab) 1 MO glycopyrrolate (1 mg tab, 2 mg tab) 2 MO methscopolamine bromide (2.5 mg tab, 5 mg tab) 4 MO Gastrointestinal Agents, Other CHENODAL 250 MG TAB 5 MO CHOLBAM (50 MG CAP, 250 MG CAP) 5 PA, MO cromolyn sodium 100 mg/5ml conc 4 MO diphenoxylate-atropine mg tab 4 MO 75

82 NAME loperamide hcl 2 mg cap 2 MO metoclopramide hcl (5 mg/ml solution, 5 mg/5ml solution, 10 mg/10ml solution) 2 MO metoclopramide hcl (5 mg tab, 10 mg tab) 1 MO RELISTOR 12 MG/0.6ML SOLUTION 5 PA, QL (18 PER 30 DAYS), MO RELISTOR 8 MG/0.4ML SOLUTION 5 PA, QL (12 PER 30 DAYS), MO ursodiol (250 mg tab, 500 mg tab) 2 MO Histamine2 (H2) Receptor Antagonists cimetidine (200 mg tab, 300 mg tab, 400 mg tab, 800 mg tab) 2 MO cimetidine hcl 300 mg/5ml solution 2 MO famotidine (20 mg/2ml solution, 40 mg/5ml recon susp, 40 mg/4ml solution, 200 mg/20ml solution) 2 MO famotidine (20 mg tab, 40 mg tab) 1 MO nizatidine (150 mg cap, 300 mg cap) 1 MO nizatidine 15 mg/ml solution 4 MO ranitidine hcl (50 mg/2ml solution, 150 mg cap, 300 mg cap) ranitidine hcl (15 mg/ml syrup, 75 mg/5ml syrup, 150 mg tab, 150 mg/10ml syrup, 300 mg tab) 2 MO 1 MO Irritable Bowel Syndrome Agents alosetron hcl (0.5 mg tab, 1 mg tab) 5 PA, MO AMITIZA (8 MCG CAP, 24 MCG CAP) 3 QL (60 PER 30 DAYS), MO (MAIL LINZESS (72 MCG CAP, 145 MCG CAP, 290 MCG CAP) 3 QL (30 PER 30 DAYS), MO (MAIL Laxatives constulose 10 gm/15ml solution 2 MO 76

83 NAME enulose 10 gm/15ml solution 2 MO gavilyte-c 240 gm recon soln 2 MO gavilyte-g 236 gm recon soln 2 MO gavilyte-h mg-gm kit 4 MO gavilyte-n with flavor pack 420 gm recon soln 2 MO generlac 10 gm/15ml solution 2 MO lactulose (10 gm/15ml solution, 20 gm/30ml solution) 2 MO MOVIPREP 100 GM RECON SOLN 3 MO peg 3350-kcl-na bicarb-nacl 420 gm recon soln 2 MO peg-3350/electrolytes 236 gm recon soln 2 MO polyethylene glycol 3350 (3350powder, 3350packet, g/dosepowder) SUPREP BOWEL PREP KIT GM/180ML SOLUTION 2 MO 3 MO trilyte 420 gm recon soln 2 MO Protectants misoprostol (100 mcg tab, 200 mcg tab) 2 MO sucralfate 1 gm tab 2 MO Proton Pump Inhibitors DEXILANT CAP DR 30 MG 4 MO DEXILANT CAP DR 60 MG 4 MO esomeprazole magnesium (20 mg cap dr, 40 mg cap dr) esomeprazole sodium (20 mg recon soln, 40 mg recon soln) omeprazole (10 mg cap dr, 20 mg cap dr, 40 mg cap dr) 4 QL (60 PER 30 DAYS), MO (MAIL 4 MO 2 QL (60 PER 30 DAYS), MO (MAIL pantoprazole sodium 40 mg recon soln 2 MO pantoprazole sodium (20 mg tab dr, 40 mg tab dr) 1 QL (60 PER 30 DAYS), MO (MAIL 77

84 NAME Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ADAGEN 250 UNIT/ML SOLUTION 5 PA, MO ALDURAZYME 2.9 MG/5ML SOLUTION 5 PA, MO CERDELGA 84 MG CAP 5 PA, MO CEREZYME 400 UNIT RECON SOLN 5 PA, MO CREON ( CP DR PART, 6000 CP DR PART, CP DR PART, CP DR PART) 3 MO CREON UNIT CP DR PART 5 MO CYSTAGON (50 MG CAP, 150 MG CAP) 4 MO ELAPRASE 6 MG/3ML SOLUTION 5 PA, MO FABRAZYME (5 MG RECON SOLN, 35 MG RECON SOLN) KUVAN (100 MG TAB SOL, 100 MG PACKET, 500 MG PACKET) 5 PA, MO 5 PA, MO LUMIZYME 50 MG RECON SOLN 5 PA, MO NAGLAZYME 1 MG/ML SOLUTION 5 PA, MO ORFADIN (2 MG CAP, 4 MG/ML SUSPENSION, 5 MG CAP, 10 MG CAP) 5 MO RAVICTI 1.1 GM/ML LIQUID 5 PA, MO sodium phenylbutyrate 3 gm/tsp powder 5 MO VPRIV 400 UNIT RECON SOLN 5 PA, MO ZAVESCA 100 MG CAP 5 PA, MO ZENPEP ( CP DR PART, 5000 CP DR PART, CP DR PART, CP DR PART, CP DR PART, CP DR PART) 3 MO ZENPEP UNIT CP DR PART 5 MO 78

85 NAME Genitourinary Agents Antispasmodics, Urinary darifenacin hydrobromide er (er 7.5 mg tab er 4 MO 24h, er 15 mg tab er 24h) flavoxate hcl 100 mg tab 2 MO MYRBETRIQ (25 MG TAB ER 24H, 50 MG 3 MO TAB ER 24H) oxybutynin chloride 5 mg/5ml syrup 1 MO oxybutynin chloride 5 mg tab 2 MO oxybutynin chloride er (er 5 mg tab er 24h, er 2 MO 10 mg tab er 24h, er 15 mg tab er 24h) tolterodine tartrate (1 mg tab, 2 mg tab) 2 MO tolterodine tartrate 2 mg cap er 24h 2 MO tolterodine tartrate 4 mg cap er 24h 2 MO trospium chloride 20 mg tab 2 MO trospium chloride er 60 mg cap er 24h 2 MO VESICARE (5 MG TAB, 10 MG TAB) 3 MO Benign Prostatic Hypertrophy Agents alfuzosin hcl er 10 mg tab er 24h 2 MO doxazosin mesylate (1 mg tab, 2 mg tab, 4 2 MO mg tab, 8 mg tab) dutasteride 0.5 mg cap 4 MO finasteride 5 mg tab 1 MO tamsulosin hcl 0.4 mg cap 2 MO terazosin hcl (1 mg cap, 2 mg cap, 5 mg cap, 10 mg cap) 1 MO Genitourinary Agents, Other bethanechol chloride (5 mg tab, 10 mg tab, 25 mg tab, 50 mg tab) 2 MO 79

86 NAME MAGELLAN PDP (List of Covered Drugs) ELMIRON 100 MG CAP 4 MO Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) ala-cort 2.5 % cream 1 MO alclometasone dipropionate (0.05 % cream, 2 MO 0.05 % ointment) amcinonide (0.1 % cream, 0.1 % lotion, 0.1 % ointment) betamethasone dipropionate (0.05 % lotion, 0.05 % ointment, 0.05 % cream) betamethasone dipropionate aug (0.05 % cream, 0.05 % ointment, 0.05 % lotion, 0.05 % gel) 4 MO 2 MO 2 MO betamethasone valerate 0.12 % foam 4 MO betamethasone valerate (0.1 % cream, 0.1 % ointment, 0.1 % lotion) clobetasol propionate (0.05 % solution, 0.05 % lotion, 0.05 % shampoo, 0.05 % ointment, 0.05 % gel, 0.05 % foam, 0.05 % cream, 0.05 % liquid) 2 MO 4 MO clobetasol propionate e 0.05 % cream 4 MO clobetasol propionate emulsion 0.05 % foam 4 MO colocort 100 mg/60ml enema 2 MO cormax scalp application 0.05 % solution 4 MO cortisone acetate 25 mg tab 2 MO desonide 0.05 % lotion 4 MO desonide (0.05 % ointment, 0.05 % cream) 2 MO desoximetasone (0.05 % ointment, 0.05 % cream, 0.05 % gel, 0.25 % ointment, 0.25 % cream) 4 MO dexamethasone 0.5 mg/5ml elixir 2 MO dexamethasone (0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab) 1 MO 80

87 NAME MAGELLAN PDP (List of Covered Drugs) DEXAMETHASONE INTENSOL 1 MG/ML CONC dexamethasone sod phosphate pf 10 mg/ml solution dexamethasone sodium phosphate (4 mg/ml solution, 10 mg/ml solution, 20 mg/5ml solution, 100 mg/10ml solution, 120 mg/30ml solution) diflorasone diacetate (0.05 % cream, 0.05 % ointment) 2 MO 1 MO 1 MO 4 MO fludrocortisone acetate 0.1 mg tab 2 MO fluocinolone acetonide (0.01 % cream, 0.01 % solution, % ointment, % cream) 2 MO fluocinonide 0.1 % cream 5 MO fluocinonide (0.05 % cream, 0.05 % solution, 0.05 % ointment, 0.05 % gel) 2 MO fluocinonide emulsified base 0.05 % cream 2 MO flurandrenolide 0.05 % ointment 4 MO fluticasone propionate (0.005 % ointment, 0.05 % cream) 2 MO fluticasone propionate 0.05 % lotion 4 MO halobetasol propionate (0.05 % ointment, 0.05 % cream) 2 MO hydrocortisone (2.5 % ointment, 2.5 % cream) 1 MO hydrocortisone (2.5 % lotion, 5 mg tab, 10 mg tab, 20 mg tab, 100 mg/60ml enema) 2 MO hydrocortisone butyr lipo base 0.1 % cream 2 MO hydrocortisone butyrate (0.1 % cream, 0.1 % ointment, 0.1 % solution) hydrocortisone valerate (0.2 % ointment, 0.2 % cream) 2 MO 2 MO lokara 0.05 % lotion 4 MO methylprednisolone (4 mg tab thpk, 4 mg tab, 8 mg tab, 16 mg tab, 32 mg tab) 2 MO 81

88 NAME MAGELLAN PDP (List of Covered Drugs) methylprednisolone acetate (40 mg/ml suspension, 80 mg/ml suspension) methylprednisolone sodium succ (40 mg recon soln, 125 mg recon soln) mometasone furoate (0.1 % ointment, 0.1 % cream) 2 MO 2 MO 1 MO mometasone furoate 0.1 % solution 2 MO prednicarbate (0.1 % ointment, 0.1 % cream) 2 MO prednisolone (15 mg/5ml syrup, 15 mg/5ml solution) prednisolone sodium phosphate (6.7 (5 base) mg/5ml solution, 10 mg/5ml solution, 15 mg/5ml solution, 20 mg/5ml solution, 25 mg/5ml solution) prednisone (5 mg/5ml solution, 5 mg (21) tab thpk, 5 mg (48) tab thpk, 10 mg (48) tab thpk, 10 mg (21) tab thpk) prednisone (1 mg tab, 2.5 mg tab, 5 mg tab, 10 mg tab, 20 mg tab, 50 mg tab) 2 MO 2 MO 2 MO 1 MO PREDNISONE INTENSOL 5 MG/ML CONC 2 MO procto-med hc 2.5 % cream 2 MO procto-pak 1 % cream 2 MO proctosol hc 2.5 % cream 2 MO proctozone-hc 2.5 % cream 2 MO triamcinolone acetonide mg/gm aero soln triamcinolone acetonide (0.025 % cream, 0.1 % cream, 0.5 % cream) triamcinolone acetonide (0.025 % ointment, % lotion, 0.1 % lotion, 0.1 % ointment, 0.5 % ointment) 4 MO 1 MO 2 MO triderm 0.1 % cream 1 MO 82

89 NAME Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) desmopressin ace spray refrig 0.01 % solution 2 MO desmopressin acetate 4 mcg/ml solution 4 MO desmopressin acetate (0.1 mg tab, 0.2 mg tab) 2 MO desmopressin acetate spray 0.01 % solution 2 MO GENOTROPIN (5 MG RECON SOLN, 12 MG RECON SOLN) GENOTROPIN MINIQUICK (0.4 MG RECON SOLN, 0.6 MG RECON SOLN, 0.8 MG RECON SOLN, 1 MG RECON SOLN, 1.2 MG RECON SOLN, 1.4 MG RECON SOLN, 1.6 MG RECON SOLN, 1.8 MG RECON SOLN, 2 MG RECON SOLN) GENOTROPIN MINIQUICK 0.2 MG RECON SOLN 5 PA, MO 5 PA, MO 4 PA, MO INCRELEX 40 MG/4ML SOLUTION 5 PA, MO Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) KORLYM 300 MG TAB 5 PA, QL (120 PER 30 DAYS), MO Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids ANADROL MG TAB 5 PA, MO oxandrolone 10 mg tab 4 PA, QL (60 PER 30 DAYS), MO oxandrolone 2.5 mg tab 4 PA, QL (240 PER 30 DAYS), MO Androgens ANDRODERM (2 MG/24HR PATCH 24HR, 4 MG/24HR PATCH 24HR) 3 PA, MO 83

90 NAME ANDROGEL (20.25 MG/1.25GM (1.62%) GEL, 40.5 MG/2.5GM (1.62%) GEL) ANDROGEL PUMP MG/ACT (1.62%) GEL 3 PA, MO 3 PA, MO danazol (50 mg cap, 100 mg cap) 2 MO danazol 200 mg cap 4 MO testosterone cypionate (100 mg/ml solution, 200 mg/ml solution) 2 PA, MO testosterone enanthate 200 mg/ml solution 2 PA, MO Estrogens alyacen 1/ mg-mcg tab 2 MO amethia &0.01 mg tab 2 QL (91 PER 91 DAYS), MO (MAIL amethia lo & 0.01 mg tab 2 QL (91 PER 91 DAYS), MO (MAIL apri mg-mcg tab 2 MO aranelle 0.5/1/ mg-mcg tab 2 MO ashlyna &0.01 mg tab 2 QL (91 PER 91 DAYS), MO (MAIL aubra mg-mcg tab 2 MO aviane mg-mcg tab 2 MO balziva mg-mcg tab 2 MO bekyree /0.01 mg (21/5) tab 2 MO blisovi 24 fe 1-20 mg-mcg(24) tab 2 MO blisovi fe 1.5/ mg-mcg tab 2 MO blisovi fe 1/ mg-mcg tab 2 MO briellyn mg-mcg tab 2 MO camrese lo & 0.01 mg tab 2 QL (91 PER 91 DAYS), MO (MAIL caziant 0.1/0.125/ mg tab 2 MO cryselle mg-mcg tab 2 MO 84

91 NAME MAGELLAN PDP (List of Covered Drugs) cyclafem 1/ mg-mcg tab 2 MO cyclafem 7/7/7 0.5/0.75/1-35 mg-mcg tab 2 MO delyla mg-mcg tab 2 MO desogestrel-ethinyl estradiol /0.01 mg (21/5) tab drospiren-eth estrad-levomefol mg tab drospirenone-ethinyl estradiol ( mg tab, mg tab) 2 MO 2 MO 2 MO emoquette mg-mcg tab 2 MO enpresse tab 2 MO ESTRACE 0.1 MG/GM CREAM 4 MO estradiol (0.025 mg/24hr patch wk, mg/24hr patch tw, mg/24hr patch wk, mg/24hr patch tw, 0.05 mg/24hr patch tw, 0.05 mg/24hr patch wk, 0.06 mg/24hr patch wk, mg/24hr patch wk, mg/24hr patch tw, 0.1 mg/24hr patch tw, 0.1 mg/24hr patch wk, 0.5 mg tab, 1 mg tab, 2 mg tab) 4 MO estradiol valerate (20 mg/ml oil, 40 mg/ml oil) 2 MO estradiol-norethindrone acet ( mg tab, mg tab) 4 MO ESTRING 2 MG RING 4 QL (1 PER 90 OVER TIME), MO estropipate (0.75 mg tab, 1.5 mg tab, 3 mg tab) 4 MO ethynodiol diac-eth estradiol 1-50 mg-mcg tab 2 MO falmina mg-mcg tab 2 MO femynor mg-mcg tab 2 MO fyavolv ( tab, 1-5 tab) 4 MO gianvi mg tab 2 MO gildagia mg-mcg tab 2 MO 85

92 NAME MAGELLAN PDP (List of Covered Drugs) introvale mg tab 2 QL (91 PER 91 DAYS), MO (MAIL jinteli 1-5 mg-mcg tab 4 MO juleber mg-mcg tab 2 MO junel 1.5/ mg-mcg tab 2 MO junel 1/ mg-mcg tab 2 MO junel fe 1.5/ mg-mcg tab 2 MO junel fe 1/ mg-mcg tab 2 MO junel fe mg-mcg(24) tab 2 MO kaitlib fe mg-mcg chew tab 2 MO kariva /0.01 mg (21/5) tab 2 MO kelnor 1/ mg-mcg tab 2 MO kimidess /0.01 mg (21/5) tab 2 MO larin 1.5/ mg-mcg tab 2 MO larin 1/ mg-mcg tab 2 MO larin fe 1.5/ mg-mcg tab 2 MO larin fe 1/ mg-mcg tab 2 MO larissia mg-mcg tab 2 MO layolis fe mg-mcg chew tab 2 MO leena 0.5/1/ mg-mcg tab 2 MO lessina mg-mcg tab 2 MO levonest tab 2 MO levonorg-eth estrad triphasic tab 2 MO levonorgest-eth estrad 91-day ( mg tab, &0.01 mg tab) levonorgestrel-ethinyl estrad ( mg-mcg tab, mcg tab) 2 QL (91 PER 91 DAYS), MO (MAIL 2 MO levora 0.15/30 (28) mg-mcg tab 2 MO lomedia 24 fe 1-20 mg-mcg(24) tab 2 MO 86

93 NAME MAGELLAN PDP (List of Covered Drugs) loryna mg tab 2 MO low-ogestrel mg-mcg tab 2 MO lutera mg-mcg tab 2 MO marlissa mg-mcg tab 2 MO microgestin 1.5/ mg-mcg tab 2 MO microgestin 1/ mg-mcg tab 2 MO microgestin fe 1.5/ mg-mcg tab 2 MO microgestin fe 1/ mg-mcg tab 2 MO mimvey mg tab 4 MO mimvey lo mg tab 4 MO mononessa mg-mcg tab 2 MO necon 0.5/35 (28) mg-mcg tab 2 MO NECON 1/50 (28) 1-50 MG-MCG TAB 2 MO NECON 10/11 (28) 35 MCG TAB 2 MO necon 7/7/7 0.5/0.75/1-35 mg-mcg tab 2 MO nikki mg tab 2 MO norethin ace-eth estrad-fe 1-20 mg-mcg(24) tab norethin-eth estradiol-fe ( chew tab, chew tab) norethindrone acet-ethinyl est 1-20 mg-mcg tab norethindrone-eth estradiol ( tab, 1-5 tab) norgestim-eth estrad triphasic (0.18/0.215/0.25 mg-35 mcg tab, 0.18/0.215/0.25 mg-25 mcg tab) 2 MO 2 MO 2 MO 4 MO 2 MO nortrel 0.5/35 (28) mg-mcg tab 2 MO nortrel 1/35 (21) 1-35 mg-mcg tab 2 MO nortrel 1/35 (28) 1-35 mg-mcg tab 2 MO nortrel 7/7/7 0.5/0.75/1-35 mg-mcg tab 2 MO 87

94 NAME MAGELLAN PDP (List of Covered Drugs) NUVARING MG/24HR RING 4 MO ocella mg tab 2 MO OGESTREL MG-MCG TAB 2 MO orsythia mg-mcg tab 2 MO pimtrea /0.01 mg (21/5) tab 2 MO pirmella 1/ mg-mcg tab 2 MO portia mg-mcg tab 2 MO PREMARIN MG/GM CREAM 3 MO PREMARIN (0.3 MG TAB, 0.45 MG TAB, MG TAB, 0.9 MG TAB, 1.25 MG TAB) 4 MO PREMPHASE MG TAB 4 MO PREMPRO ( MG TAB, MG TAB, MG TAB, MG TAB) 4 MO previfem mg-mcg tab 2 MO quasense mg tab 2 QL (91 PER 91 DAYS), MO (MAIL reclipsen mg-mcg tab 2 MO setlakin mg tab 2 QL (91 PER 91 DAYS), MO (MAIL sprintec mg-mcg tab 2 MO sronyx mg-mcg tab 2 MO tarina fe 1/ mg-mcg tab 2 MO tri-legest fe 1-20/1-30/1-35 mg-mcg tab 2 MO tri-lo-estarylla 0.18/0.215/0.25 mg-25 mcg tab 2 MO tri-lo-sprintec 0.18/0.215/0.25 mg-25 mcg tab 2 MO tri-previfem 0.18/0.215/0.25 mg-35 mcg tab 2 MO tri-sprintec 0.18/0.215/0.25 mg-35 mcg tab 2 MO trinessa (28) 0.18/0.215/0.25 mg-35 mcg tab 2 MO trivora (28) ((28) tab, (28) tab) 2 MO velivet 0.1/0.125/ mg tab 2 MO 88

95 NAME vestura mg tab 2 MO vienva mg-mcg tab 2 MO vyfemla mg-mcg tab 2 MO wymzya fe mg-mcg chew tab 2 MO XULANE MCG/24HR PATCH WK 4 MO zarah mg tab 2 MO zenchent mg-mcg tab 2 MO zenchent fe mg-mcg chew tab 2 MO zovia 1/35e (28) 1-35 mg-mcg tab 2 MO zovia 1/50e (28) 1-50 mg-mcg tab 2 MO Progestins camila 0.35 mg tab 2 MO CRINONE (4 % GEL, 8 % GEL) 4 PA, MO deblitane 0.35 mg tab 2 MO DEPO-PROVERA 400 MG/ML SUSPENSION 4 QL (10 PER 28 DAYS), MO (MAIL errin 0.35 mg tab 2 MO hydroxyprogesterone caproate 1.25 gm/5ml solution 5 PA - FOR NEW STARTS ONLY, MO jolivette 0.35 mg tab 2 MO lyza 0.35 mg tab 2 MO MAKENA 250 MG/ML OIL 5 PA, MO medroxyprogesterone acetate 150 mg/ml suspension medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10 mg tab) megestrol acetate (20 mg tab, 40 mg tab, 40 mg/ml suspension, 400 mg/10ml suspension, 625 mg/5ml suspension) 2 QL (1 PER 90 OVER TIME), MO 1 MO 4 MO nora-be 0.35 mg tab 2 MO 89

96 NAME norethindrone 0.35 mg tab 2 MO norethindrone acetate 5 mg tab 2 MO norlyroc 0.35 mg tab 2 MO progesterone micronized (100 mg cap, 200 mg cap) 2 MO sharobel 0.35 mg tab 2 MO Selective Estrogen Receptor Modifying Agents raloxifene hcl 60 mg tab 2 MO Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothyroxine sodium (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab) levoxyl (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab) 2 MO 2 MO liothyronine sodium 10 mcg/ml solution 4 MO liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg tab) unithroid (25 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab, 100 mcg tab, 112 mcg tab, 125 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 300 mcg tab) 2 MO 2 MO Hormonal Agents, Suppressant (Adrenal) LYSODREN 500 MG TAB 5 MO Hormonal Agents, Suppressant (Pituitary) cabergoline 0.5 mg tab 2 MO FIRMAGON 120 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY, QL (4 PER 365 OVER TIME), MO 90

97 NAME MAGELLAN PDP (List of Covered Drugs) FIRMAGON 80 MG RECON SOLN 4 PA - FOR NEW STARTS ONLY, QL (1 PER 28 OVER TIME), MO leuprolide acetate 1 mg/0.2ml kit 5 PA - FOR NEW STARTS ONLY, MO LUPRON DEPOT (11.25 MG KIT, 22.5 MG KIT) 5 PA - FOR NEW STARTS ONLY, QL (1 PER 84 OVER TIME), MO LUPRON DEPOT (3.75 MG KIT, 7.5 MG KIT) 5 PA - FOR NEW STARTS ONLY, QL (1 PER 28 OVER TIME), MO LUPRON DEPOT 30 MG KIT 5 PA - FOR NEW STARTS ONLY, QL (1 PER 112 OVER TIME), MO LUPRON DEPOT (6-MONTH) 45 MG KIT 5 PA - FOR NEW STARTS ONLY, QL (1 PER 168 OVER TIME), MO LUPRON DEPOT-PED (11.25 MG KIT, 15 MG KIT) octreotide acetate (50 mcg/ml solution, 100 mcg/ml solution, 200 mcg/ml solution, 500 mcg/ml solution, 1000 mcg/ml solution) SANDOSTATIN LAR DEPOT (10 MG KIT, 20 MG KIT, 30 MG KIT) SIGNIFOR (0.3 MG/ML SOLUTION, 0.6 MG/ML SOLUTION, 0.9 MG/ML SOLUTION) 5 PA, QL (1 PER 28 OVER TIME), MO 4 PA, MO 5 PA, MO 5 PA, QL (60 PER 30 DAYS), MO SIGNIFOR LAR (20 MG, 40 MG, 60 MG) 5 PA, QL (1 PER 28 DAYS), MO SOMATULINE DEPOT (60 MG/0.2ML SOLUTION, 90 MG/0.3ML SOLUTION) SOMATULINE DEPOT 120 MG/0.5ML SOLUTION SOMAVERT (10 MG RECON SOLN, 15 MG RECON SOLN, 20 MG RECON SOLN, 25 MG RECON SOLN, 30 MG RECON SOLN) TRELSTAR MIXJECT MG RECON SUSP 5 PA, MO 5 PA - FOR NEW STARTS ONLY, MO 5 PA, MO 5 PA - FOR NEW STARTS ONLY, QL (1 PER 84 OVER TIME), MO 91

98 NAME TRELSTAR MIXJECT 22.5 MG RECON SUSP TRELSTAR MIXJECT 3.75 MG RECON SUSP 5 PA - FOR NEW STARTS ONLY, QL (1 PER 168 OVER TIME), MO 5 PA - FOR NEW STARTS ONLY, QL (1 PER 28 OVER TIME), MO Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole (5 mg tab, 10 mg tab) 1 MO propylthiouracil 50 mg tab 2 MO Immunological Agents Angioedema Agents BERINERT 500 UNIT KIT 5 PA, MO CINRYZE 500 UNIT RECON SOLN 5 PA, MO FIRAZYR 30 MG/3ML SOLUTION 5 PA, MO Immune Suppressants azathioprine 50 mg tab 2 PA - Part B vs D Determination, MO azathioprine sodium 100 mg recon soln 2 PA - Part B vs D Determination, MO BENLYSTA (120 MG RECON SOLN, 400 MG RECON SOLN) 5 PA, MO cyclosporine (25 mg cap, 100 mg cap) 4 PA - Part B vs D Determination, MO cyclosporine 50 mg/ml solution 2 PA - Part B vs D Determination, MO cyclosporine modified (25 mg cap, 50 mg cap, 100 mg cap, 100 mg/ml solution) ENBREL (25 MG/0.5ML SOLN PRSYR, 25 MG RECON SOLN, 50 MG/ML SOLN PRSYR) 2 PA - Part B vs D Determination, MO 5 PA, MO 92

99 NAME MAGELLAN PDP (List of Covered Drugs) ENBREL SURECLICK 50 MG/ML SOLN A INJ gengraf (25 mg cap, 50 mg cap, 100 mg/ml solution, 100 mg cap) HUMIRA (10 MG/0.2ML PREF SY KT, 20 MG/0.4ML PREF SY KT, 40 MG/0.8ML PREF SY KT) HUMIRA PEDIATRIC CROHNS START 40 MG/0.8ML PREF SY KT 5 PA, MO 2 PA - Part B vs D Determination, MO 5 PA, MO 5 PA, MO HUMIRA PEN 40 MG/0.8ML PEN KIT 5 PA, MO HUMIRA PEN-CROHNS STARTER 40 MG/0.8ML PEN KIT HUMIRA PEN-PSORIASIS STARTER 40 MG/0.8ML PEN KIT 5 PA, MO 5 PA, MO INFLECTRA 100 MG RECON SOLN 5 PA, MO methotrexate 2.5 mg tab 2 MO methotrexate sodium (1 gm recon soln, 50 mg/2ml solution, 250 mg/10ml solution) methotrexate sodium (pf) ((pf) 1 gm/40ml solution, (pf) 50 mg/2ml solution, (pf) 100 mg/4ml solution, (pf) 200 mg/8ml solution, (pf) 250 mg/10ml solution) 2 MO 2 MO mycophenolate mofetil 200 mg/ml recon susp 5 PA - Part B vs D Determination, MO mycophenolate mofetil (250 mg cap, 500 mg tab) 2 PA - Part B vs D Determination, MO mycophenolate mofetil hcl 500 mg recon soln 2 PA - Part B vs D Determination, MO mycophenolate sodium (180 mg tab dr, 360 mg tab dr) 4 PA - Part B vs D Determination, MO NULOJIX 250 MG RECON SOLN 5 PA - FOR NEW STARTS ONLY, MO ORENCIA (50 MG/0.4ML SOLN PRSYR, 87.5 MG/0.7ML SOLN PRSYR, 125 MG/ML SOLN PRSYR, 250 MG RECON SOLN) 5 PA, MO 93

100 NAME MAGELLAN PDP (List of Covered Drugs) ORENCIA CLICKJECT 125 MG/ML SOLN A INJ 5 PA, QL (4 PER 28 DAYS), MO PROGRAF 5 MG/ML SOLUTION 4 PA - Part B vs D Determination, MO RAPAMUNE 1 MG/ML SOLUTION 5 PA - Part B vs D Determination, MO RASUVO 10 MG/0.2ML SOLN A-INJ 4 PA, QL (0.8 PER 28 DAYS), MO RASUVO 12.5 MG/0.25ML SOLN A-INJ 4 PA, QL (1 PER 28 DAYS), MO RASUVO 15 MG/0.3ML SOLN A-INJ 4 PA, QL (1.2 PER 28 DAYS), MO RASUVO 17.5 MG/0.35ML SOLN A-INJ 4 PA, QL (1.4 PER 28 DAYS), MO RASUVO 20 MG/0.4ML SOLN A-INJ 4 PA, QL (1.6 PER 28 DAYS), MO RASUVO 22.5 MG/0.45ML SOLN A-INJ 4 PA, QL (1.8 PER 28 DAYS), MO RASUVO 25 MG/0.5ML SOLN A-INJ 4 PA, QL (2 PER 28 DAYS), MO RASUVO 27.5 MG/0.55ML SOLN A-INJ 4 PA, QL (2.2 PER 28 DAYS), MO RASUVO 30 MG/0.6ML SOLN A-INJ 4 PA, QL (2.4 PER 28 DAYS), MO RASUVO 7.5 MG/0.15ML SOLN A-INJ 4 PA, QL (0.6 PER 28 DAYS), MO REMICADE 100 MG RECON SOLN 5 PA, MO SANDIMMUNE 100 MG/ML SOLUTION 4 PA - Part B vs D Determination, MO sirolimus (0.5 mg tab, 1 mg tab) 4 PA - Part B vs D Determination, MO sirolimus 2 mg tab 5 PA - Part B vs D Determination, MO tacrolimus (0.5 mg cap, 1 mg cap, 5 mg cap) 2 PA - Part B vs D Determination, MO 94

101 NAME ZORTRESS (0.25 MG TAB, 0.5 MG TAB, 0.75 MG TAB) 5 PA - FOR NEW STARTS ONLY, MO Immunizing Agents, Passive ATGAM 50 MG/ML INJECTABLE 5 PA - Part B vs D Determination, MO BIVIGAM (5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION) CARIMUNE NF (6 GM RECON SOLN, 12 GM RECON SOLN) FLEBOGAMMA DIF (0.5 GM/10ML SOLUTION, 2.5 GM/50ML SOLUTION, 5 GM/100ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 10 GM/200ML SOLUTION, 20 GM/200ML SOLUTION, 20 GM/400ML SOLUTION) GAMASTAN S/D (S/D 15%-18% INJECTABLE, S/D INJECTABLE) GAMMAGARD (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 20 GM/200ML SOLUTION, 30 GM/300ML SOLUTION) GAMMAGARD S/D LESS IGA (S/D 5 GM RECON SOLN, S/D 10 GM RECON SOLN) GAMMAKED (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 20 GM/200ML SOLUTION) GAMMAPLEX (5 GM/100ML SOLUTION, 10 GM/200ML SOLUTION, 20 GM/400ML SOLUTION) GAMUNEX-C (1 GM/10ML SOLUTION, 2.5 GM/25ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 20 GM/200ML SOLUTION, 40 GM/400ML SOLUTION) 5 PA, MO 5 PA, MO 5 PA, MO 4 PA, MO 5 PA, MO 5 PA, MO 5 PA, MO 5 PA, MO 5 PA, MO 95

102 NAME OCTAGAM (1 GM/20ML SOLUTION, 2 GM/20ML SOLUTION, 2.5 GM/50ML SOLUTION, 5 GM/50ML SOLUTION, 5 GM/100ML SOLUTION, 10 GM/200ML SOLUTION, 10 GM/100ML SOLUTION, 20 GM/200ML SOLUTION, 25 GM/500ML SOLUTION) PRIVIGEN (5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 20 GM/200ML SOLUTION, 40 GM/400ML SOLUTION) 5 PA, MO 5 PA, MO SYNAGIS 50 MG/0.5ML SOLUTION 5 PA, MO Immunomodulators ACTIMMUNE UNIT/0.5ML SOLUTION 5 PA - FOR NEW STARTS ONLY, MO ARCALYST 220 MG RECON SOLN 5 PA, MO ILARIS 180 MG RECON SOLN 5 PA, MO leflunomide (10 mg tab, 20 mg tab) 2 MO OTEZLA 30 MG TAB 5 PA, MO SYLVANT (100 MG RECON SOLN, 400 MG RECON SOLN) 5 PA, MO XELJANZ 5 MG TAB 5 PA, MO XELJANZ XR 11 MG TAB ER 24H 5 PA, MO Vaccines ACTHIB 10 MCG/0.5 RECON SOLN 3 MO ADACEL LF-MCG/0.5 SUSPENSION 3 MO bcg vaccine 50 mg injectable 3 MO BEXSERO SUSP PRSYR 3 MO BOOSTRIX SUSPENSION 3 MO DAPTACEL SUSPENSION 3 MO diphtheria-tetanus toxoids dt 25-5 lfu/0.5ml suspension ENGERIX-B (10 MCG/0.5ML SUSPENSION, 20 MCG/ML SUSPENSION) 2 MO 3 PA - Part B vs D Determination, MO 96

103 NAME MAGELLAN PDP (List of Covered Drugs) ENGERIX-B 10 MCG/0.5ML SYRINGE 3 PA - Part B vs D Determination, MO GARDASIL 20-40/0.5 SUSP PRSYR 3 MO GARDASIL 20-40/0.5 SUSPENSION 3 MO GARDASIL 9 (9 SUSPENSION, 9 SUSP PRSYR) HAVRIX (720 U/0.5ML SUSPENSION, 1440 U/ML SUSPENSION) 3 MO 3 MO HIBERIX 10 MCG RECON SOLN 3 MO IMOVAX RABIES 2.5 UNIT/ML INJECTABLE 4 PA - Part B vs D Determination, MO INFANRIX SUSPENSION 3 MO IPOL INJECTABLE 3 MO IXIARO 6MCG/0.5ML SUSPENSION 3 MO KINRIX PREFILLED SYRINGE 3 MO KINRIX INJECTABLE SUSPENSION 3 MO M-M-R II 12500/0.5 INJECTABLE 3 MO MENACTRA 4MCG/0.5ML INJECTABLE 3 MO MENOMUNE INJECTABLE 3 MO MENVEO RECON SOLN 3 MO PEDIARIX SUSPENSION 4 MO PEDVAX HIB 7.5 MCG/0.5ML SUSPENSION 3 MO PROQUAD INJECTABLE 3 MO QUADRACEL SUSPENSION 3 MO RABAVERT 2.5 UNIT RECON SUSP 4 PA - Part B vs D Determination, MO RECOMBIVAX HB (5 MCG/0.5ML SUSPENSION, 10 MCG/ML SUSPENSION, 40 MCG/ML SUSPENSION) 3 PA - Part B vs D Determination, MO ROTARIX 10E6/ML RECON SUSP 3 MO ROTATEQ 2 ML SOLUTION 3 MO 97

104 NAME TENIVAC 5-2 LFU INJECTABLE 3 MO tetanus-diphtheria toxoids td 2-2 lf/0.5ml suspension 3 MO TRUMENBA SUSP PRSYR 3 MO TWINRIX ( SUSPENSION, SUSPENSION) 3 PA - Part B vs D Determination, MO TYPHIM VI 25 MCG/0.5ML SOLUTION 3 MO VAQTA (25 UNIT/0.5ML SUSPENSION, 50 UNIT/ML SUSPENSION) 3 MO VARIVAX 1350 PFU/0.5ML INJECTABLE 3 MO VARIZIG 125 UNIT/1.2ML SOLUTION 5 PA, MO YF-VAX 10E4.74 INJECTABLE 3 MO ZOSTAVAX UNT/0.65ML RECON SUSP Inflammatory Bowel Disease Agents 3 MO Aminosalicylates APRISO GM CAP ER 24H 3 MO balsalazide disodium 750 mg cap 2 MO CANASA 1000 MG SUPPOS 5 MO DIPENTUM 250 MG CAP 5 MO LIALDA 1.2 GM TAB DR 3 MO mesalamine 4 gm enema 4 MO mesalamine-cleanser 4 gm kit 4 MO Glucocorticoids budesonide 3 mg cp dr part 4 MO Sulfonamides sulfasalazine (500 mg tab dr, 500 mg tab) 2 MO 98

105 NAME Metabolic Bone Disease Agents alendronate sodium 70 mg/75ml solution 2 MO alendronate sodium (5 mg tab, 10 mg tab, 35 mg tab, 40 mg tab) 1 MO alendronate sodium 70 mg tab 1 QL (4 PER 28 DAYS), MO (MAIL calcitonin (salmon) 200 unit/act solution 2 QL (3.7 PER 30 DAYS), MO (MAIL calcitriol (0.25 mcg cap, 0.5 mcg cap) 1 MO calcitriol 1 mcg/ml solution 2 MO doxercalciferol (0.5 mcg cap, 1 mcg cap, 2.5 mcg cap) 4 MO etidronate disodium (200 mg tab, 400 mg tab) 2 MO FORTEO 600 MCG/2.4ML SOLUTION 5 PA, MO ibandronate sodium 150 mg tab 2 QL (1 PER 28 DAYS), MO (MAIL MIACALCIN 200 UNIT/ML SOLUTION 5 MO NATPARA (25 MCG CARTRIDGE, 50 MCG CARTRIDGE, 75 MCG CARTRIDGE, 100 MCG CARTRIDGE) pamidronate disodium (6 mg/ml solution, 30 mg/10ml solution, 90 mg/10ml solution) paricalcitol (1 mcg cap, 2 mcg cap, 2 mcg/ml solution, 4 mcg cap, 5 mcg/ml solution) 5 PA, QL (2 PER 28 DAYS), MO 2 MO 4 MO PROLIA 60 MG/ML SOLUTION 4 QL (2 PER 365 OVER TIME), MO SENSIPAR (30 MG TAB, 60 MG TAB, 90 MG TAB) 5 PA - Part B vs D Determination, MO XGEVA 120 MG/1.7ML SOLUTION 5 PA, MO zoledronic acid (4 mg/5ml conc, 5 mg/100ml solution) 4 MO 99

106 NAME Miscellaneous Therapeutic Agents AMINOSYN II (7 % SOLUTION, 10 % SOLUTION) 4 PA - Part B vs D Determination, MO AMINOSYN-HBC 7 % SOLUTION 4 PA - Part B vs D Determination, MO AMINOSYN-PF (7 % SOLUTION, 10 % SOLUTION) 4 PA - Part B vs D Determination, MO AMINOSYN-RF 5.2 % SOLUTION 4 PA - Part B vs D Determination, MO FREAMINE HBC 6.9 % SOLUTION 4 PA - Part B vs D Determination, MO GAUZE PADS & DRESSINGS - PADS 2 X 2 3 MO HEPATAMINE 8 % SOLUTION 4 PA - Part B vs D Determination, MO INSULIN PEN NEEDLE 3 QL (200 PER 30 DAYS), MO INSULIN SYRINGE (DISP) U ML 3 QL (200 PER 30 DAYS), MO INSULIN SYRINGE (DISP) U ML 3 QL (200 PER 30 DAYS), MO INSULIN SYRINGE (DISP) U-100 1/2 ML 3 QL (200 PER 30 DAYS), MO INTRALIPID (20 % EMULSION, 30 % EMULSION) ISOPROPYL ALCOHOL 0.7 ML/ML MEDICATED PAD 4 PA - Part B vs D Determination, MO 3 MO lactated ringers solution 2 MO levocarnitine (1 gm/10ml solution, 330 mg tab) 2 MO MYALEPT 11.3 MG RECON SOLN 5 PA, MO NEEDLES, INSULIN DISP., SAFETY 3 QL (200 PER 30 DAYS), MO NEPHRAMINE 5.4 % SOLUTION 4 PA - Part B vs D Determination, MO 100

107 NAME nutrilipid 20 % emulsion 4 PA - Part B vs D Determination, MO premasol (6 % solution, 10 % solution) 4 PA - Part B vs D Determination, MO PROSOL 20 % SOLUTION 4 PA - Part B vs D Determination, MO ringers irrigation solution 2 MO sodium chloride 0.9 % solution 2 MO sterile water for irrigation solution 2 MO SURE COMFORT ALCOHOL PREP 70 % PAD 3 MO TRAVASOL 10 % SOLUTION 4 PA - Part B vs D Determination, MO TROPHAMINE 10 % SOLUTION 4 PA - Part B vs D Determination, MO Ophthalmic Agents Ophthalmic Agents, Other atropine sulfate 1 % solution 2 MO bacitracin-polymyxin b unit/gm 2 MO ointment CYSTARAN 0.44 % SOLUTION 5 PA, QL (60 PER 28 OVER TIME), MO neomycin-bacitracin zn-polymyx ointment 2 MO neomycin-polymyxin-gramicidin MO.025 solution polymyxin b-trimethoprim unit/ml 1 MO % solution PROCYSBI (25 MG CAP DR, 75 MG CAP DR) 5 PA, MO proparacaine hcl 0.5 % solution 2 MO RESTASIS 0.05 % EMULSION 3 MO 101

108 NAME Ophthalmic Anti-allergy Agents azelastine hcl 0.05 % solution 2 MO cromolyn sodium 4 % solution 1 MO epinastine hcl 0.05 % solution 2 MO olopatadine hcl (0.1 % solution, 0.2 % solution) 2 MO PATADAY 0.2 % SOLUTION 3 MO PAZEO 0.7 % SOLUTION 3 MO Ophthalmic Anti-inflammatories ALREX 0.2 % SUSPENSION 4 MO BLEPHAMIDE % SUSPENSION 4 MO BLEPHAMIDE S.O.P % OINTMENT 4 MO bromfenac sodium 0.09 % solution 4 MO dexamethasone sodium phosphate 0.1 % solution 2 MO diclofenac sodium 0.1 % solution 1 MO DUREZOL 0.05 % EMULSION 4 MO flurbiprofen sodium 0.03 % solution 1 MO FML FORTE 0.25 % SUSPENSION 4 MO ILEVRO 0.3 % SUSPENSION 4 QL (6 PER 30 OVER TIME), MO ketorolac tromethamine (0.4 % solution, 0.5 % solution) 2 MO LOTEMAX 0.5 % OINTMENT 4 QL (14 PER 365 OVER TIME), MO LOTEMAX 0.5 % SUSPENSION 4 MO neomycin-polymyxin-dexameth ( MO 0.1 ointment, suspension) prednisolone acetate 1 % suspension 2 MO prednisolone sodium phosphate 1 % solution 2 MO 102

109 NAME sulfacetamide-prednisolone % solution 2 MO TOBRADEX % OINTMENT 4 MO TOBRADEX ST % SUSPENSION 4 MO tobramycin-dexamethasone % suspension 2 MO ZYLET % SUSPENSION 4 MO Ophthalmic Antiglaucoma Agents acetazolamide (125 mg tab, 250 mg tab) 2 MO acetazolamide er 500 mg cap er 12h 2 MO apraclonidine hcl 0.5 % solution 2 MO AZOPT 1 % SUSPENSION 4 MO betaxolol hcl 0.5 % solution 2 MO BETIMOL (0.25 % SOLUTION, 0.5 % SOLUTION) brimonidine tartrate (0.15 % solution, 0.2 % solution) 4 MO 2 MO carteolol hcl 1 % solution 1 MO dorzolamide hcl 2 % solution 2 MO dorzolamide hcl-timolol mal mg/ml solution 2 MO levobunolol hcl 0.5 % solution 2 MO metipranolol 0.3 % solution 2 MO PHOSPHOLINE IODIDE % RECON SOLN pilocarpine hcl (1 % solution, 2 % solution, 4 % solution) 4 MO 2 MO SIMBRINZA % SUSPENSION 4 MO timolol maleate (0.25 % gel f soln, 0.5 % gel f soln) timolol maleate (0.25 % solution, 0.5 % solution) 2 MO 1 MO 103

110 NAME Ophthalmic Prostaglandin and Prostamide Analogs bimatoprost 0.03 % solution 2 QL (5 PER 30 DAYS), MO (MAIL COMBIGAN % SOLUTION 3 MO latanoprost % solution 1 QL (2.5 PER 25 DAYS), MO (MAIL LUMIGAN 0.01 % SOLUTION 3 QL (2.5 PER 25 DAYS), MO (MAIL TRAVATAN Z % SOLUTION 3 QL (2.5 PER 25 DAYS), MO (MAIL Otic Agents acetic acid 2 % solution 2 MO CIPRODEX % SUSPENSION 4 MO fluocinolone acetonide 0.01 % oil 2 MO hydrocortisone-acetic acid 1-2 % solution 2 MO neomycin-polymyxin-hc (1 % solution, suspension, solution) 2 MO Respiratory Tract/Pulmonary Agents Anti-inflammatories, Inhaled Corticosteroids ASMANEX 120 METERED DOSES 220 MCG/INH AER POW BA ASMANEX 30 METERED DOSES ( MCG/INH AER POW BA, MCG/INH AER POW BA) ASMANEX 60 METERED DOSES 220 MCG/INH AER POW BA ASMANEX HFA (100 MCG/ACT AEROSOL, 200 MCG/ACT AEROSOL) BREO ELLIPTA ( MCG/INH AER POW BA, MCG/INH AER POW BA) budesonide (0.25 mg/2ml suspension, 0.5 mg/2ml suspension, 1 mg/2ml suspension) 4 QL (1 PER 30 DAYS), MO (MAIL 4 QL (1 PER 30 DAYS), MO (MAIL 4 QL (1 PER 30 DAYS), MO (MAIL 4 QL (26 PER 30 DAYS), MO (MAIL 3 QL (60 PER 30 DAYS), MO (MAIL 4 PA - Part B vs D Determination, QL (120 PER 30 DAYS), MO 104

111 NAME FLOVENT DISKUS (50 MCG/BLIST AER POW BA, 100 MCG/BLIST AER POW BA) FLOVENT DISKUS 250 MCG/BLIST AER POW BA FLOVENT HFA (110 MCG/ACT AEROSOL, 220 MCG/ACT AEROSOL) 3 QL (60 PER 30 DAYS), MO (MAIL 3 QL (240 PER 30 DAYS), MO 3 QL (24 PER 30 DAYS), MO (MAIL FLOVENT HFA 44 MCG/ACT AEROSOL 3 QL (21.2 PER 30 DAYS), MO flunisolide 25 mcg/act (0.025%) solution, nasal 2 QL (50 PER 30 DAYS), MO (MAIL fluticasone propionate nasal susp 50 mcg/act 1 MO NUCALA 100 MG RECON SOLN 5 PA, QL (1 PER 28 DAYS), MO QVAR 40 MCG/ACT AERO SOLN 3 QL (17.4 PER 30 DAYS), MO QVAR 80 MCG/ACT AERO SOLN 3 QL (26.1 PER 30 DAYS), MO triamcinolone acetonide 55 mcg/act aerosol 2 MO Antihistamines azelastine hcl (0.1 % solution, 0.15 % solution) cetirizine hcl (1 mg/ml solution, 1 mg/ml syrup, 5 mg/5ml syrup) 2 QL (60 PER 30 DAYS), MO (MAIL 2 MO cyproheptadine hcl 4 mg tab 4 MO desloratadine 5 mg tab 2 MO diphenhydramine hcl 50 mg/ml solution 2 MO hydroxyzine hcl (10 mg/5ml syrup, 10 mg tab, 10 mg/5ml solution, 25 mg tab, 25 mg/ml solution, 50 mg tab) 4 MO levocetirizine dihydrochloride 5 mg tab 2 MO olopatadine hcl 0.6 % solution 4 QL (30.5 PER 30 DAYS), MO 105

112 NAME Antileukotrienes montelukast sodium (4 mg chew tab, 5 mg chew tab, 10 mg tab) 1 MO montelukast sodium 4 mg packet 4 MO zafirlukast (10 mg tab, 20 mg tab) 2 MO Bronchodilators, Anticholinergic ATROVENT HFA 17 MCG/ACT AERO SOLN 4 QL (25.8 PER 30 DAYS), MO COMBIVENT RESPIMAT MCG/ACT AERO SOLN ipratropium bromide (0.03 % solution, 0.06 % solution) 3 QL (8 PER 30 DAYS), MO (MAIL 2 MO ipratropium bromide 0.02 % solution 2 PA - Part B vs D Determination, QL (312.5 PER 30 DAYS), MO ipratropium-albuterol (3) mg/3ml solution 2 PA - Part B vs D Determination, QL (540 PER 30 DAYS), MO SPIRIVA HANDIHALER 18 MCG CAP 3 QL (30 PER 30 DAYS), MO (MAIL SPIRIVA RESPIMAT (1.25 MCG/ACT AERO SOLN, 2.5 MCG/ACT AERO SOLN) Bronchodilators, Sympathomimetic albuterol sulfate (0.63 mg/3ml nebu soln, 1.25 mg/3ml nebu soln) albuterol sulfate (2.5 mg/3ml) 0.083% nebu soln 3 QL (4 PER 30 DAYS), MO (MAIL 2 PA - Part B vs D Determination, QL (375 PER 30 DAYS), MO 2 PA - Part B vs D Determination, QL (525 PER 30 DAYS), MO albuterol sulfate (5 mg/ml) 0.5% nebu soln 2 PA - Part B vs D Determination, QL (100 PER 30 DAYS), MO albuterol sulfate (2 mg tab, 2 mg/5ml syrup, 4 mg tab) 4 MO 106

113 NAME epinephrine 0.15 mg/0.15ml soln a-inj 4 MO epinephrine 0.3 mg/0.3ml soln a-inj (nda019430) epinephrine 0.3 mg/0.3ml soln a-inj (nda020800) 3 MO 4 MO EPIPEN 2-PAK 0.3 MG/0.3ML SOLN A-INJ 3 MO EPIPEN JR 2-PAK 0.15 MG/0.3ML SOLN A INJ 3 MO levalbuterol hcl 0.31 mg/3ml nebu soln 2 PA - Part B vs D Determination, QL (540 PER 30 DAYS), MO levalbuterol hcl 0.63 mg/3ml nebu soln 4 PA - Part B vs D Determination, QL (540 PER 30 DAYS), MO levalbuterol hcl 1.25 mg/0.5ml nebu soln 4 PA - Part B vs D Determination, QL (90 PER 30 DAYS), MO (MAIL levalbuterol hcl 1.25 mg/3ml nebu soln 4 PA - Part B vs D Determination, QL (270 PER 30 DAYS), MO metaproterenol sulfate (10 mg tab, 10 mg/5ml syrup, 20 mg tab) 4 MO PERFOROMIST 20 MCG/2ML NEBU SOLN 5 PA - Part B vs D Determination, QL (120 PER 30 DAYS), MO PROAIR HFA 108 (90 BASE) MCG/ACT AERO SOLN PROAIR RESPICLICK 108 (90 BASE) MCG/ACT AER POW BA SEREVENT DISKUS 50 MCG/DOSE AER POW BA 3 QL (17 PER 30 DAYS), MO (MAIL 3 QL (2 PER 30 DAYS), MO (MAIL 3 QL (60 PER 30 DAYS), MO (MAIL terbutaline sulfate 1 mg/ml solution 5 MO terbutaline sulfate (2.5 mg tab, 5 mg tab) 4 MO Cystic Fibrosis Agents BETHKIS 300 MG/4ML NEBU SOLN 5 PA - Part B vs D Determination, MO 107

114 NAME CAYSTON 75 MG RECON SOLN 5 PA, MO KALYDECO (50 MG PACKET, 75 MG PACKET, 150 MG TAB) 5 PA, MO ORKAMBI ( MG TAB, MG TAB) 5 PA, QL (112 PER 28 DAYS), MO PULMOZYME 1 MG/ML SOLUTION 5 PA, MO tobramycin 300 mg/5ml nebu soln 5 PA - Part B vs D Determination, MO Mast Cell Stabilizers cromolyn sodium 20 mg/2ml nebu soln 2 PA - Part B vs D Determination, MO Phosphodiesterase Inhibitors, Airways Disease aminophylline 25 mg/ml solution 2 MO DALIRESP 500 MCG TAB 4 PA, MO theophylline er (er 100 mg tab er 12h, er 200 mg tab er 12h, er 300 mg tab er 12h, er 400 mg tab er 24h, er 450 mg tab er 12h, er 600 mg tab er 24h) 2 MO Pulmonary Antihypertensives ADCIRCA 20 MG TAB 5 PA, QL (60 PER 30 DAYS), MO ADEMPAS (0.5 MG TAB, 1 MG TAB, 1.5 MG TAB, 2 MG TAB, 2.5 MG TAB) 5 PA, QL (90 PER 30 DAYS), MO LETAIRIS (5 MG TAB, 10 MG TAB) 5 PA, QL (30 PER 30 DAYS), MO OPSUMIT 10 MG TAB 5 PA, QL (30 PER 30 DAYS), MO ORENITRAM (0.25 MG TAB ER, 1 MG TAB ER, 2.5 MG TAB ER) 5 PA, MO ORENITRAM MG TAB ER 4 PA, MO REMODULIN (1 MG/ML SOLUTION, 2.5 MG/ML SOLUTION, 5 MG/ML SOLUTION, 10 MG/ML SOLUTION) 5 PA, MO 108

115 NAME REVATIO 10 MG/ML RECON SUSP 5 PA, MO sildenafil citrate 10 mg/12.5ml solution 5 PA, MO sildenafil citrate 20 mg tab 2 PA, QL (90 PER 30 DAYS), MO VENTAVIS (10 MCG/ML SOLUTION, 20 MCG/ML SOLUTION) 5 PA, QL (270 PER 30 DAYS), MO Respiratory Tract Agents, Other acetylcysteine (10 % solution, 20 % solution) 2 PA - Part B vs D Determination, MO ADVAIR DISKUS ( MCG/DOSE AER POW BA, MCG/DOSE AER POW BA, MCG/DOSE AER POW BA) ADVAIR HFA (45-21 MCG/ACT AEROSOL, MCG/ACT AEROSOL, MCG/ACT AEROSOL) ANORO ELLIPTA MCG/INH AER POW BA ARALAST NP (400 MG RECON SOLN, 500 MG RECON SOLN, 1000 MG RECON SOLN) 3 QL (60 PER 30 DAYS), MO (MAIL 3 QL (24 PER 30 DAYS), MO (MAIL 3 QL (60 PER 30 DAYS), MO (MAIL 5 PA, MO ESBRIET 267 MG CAP 5 PA, MO OFEV (100 MG CAP, 150 MG CAP) 5 PA, MO PROLASTIN-C 1000 MG RECON SOLN 5 PA, MO STIOLTO RESPIMAT MCG/ACT AERO SOLN 3 QL (4 PER 30 DAYS), MO (MAIL SYMBICORT MCG/ACT AEROSOL 3 QL (12 PER 30 DAYS), MO (MAIL SYMBICORT MCG/ACT AEROSOL 3 QL (13.8 PER 30 DAYS), MO XOLAIR 150 MG RECON SOLN 5 PA, MO ZEMAIRA 1000 MG RECON SOLN 5 PA, MO Skeletal Muscle Relaxants chlorzoxazone 500 mg tab 4 MO 109

116 NAME cyclobenzaprine hcl (5 mg tab, 10 mg tab) 4 MO Sleep Disorder Agents GABA Receptor Modulators zaleplon 10 mg cap 4 QL (60 PER 30 DAYS), MO (MAIL zaleplon 5 mg cap 4 QL (30 PER 30 DAYS), MO (MAIL zolpidem tartrate (5 mg tab, 10 mg tab) 4 QL (30 PER 30 DAYS), MO (MAIL Sleep Disorders, Other BELSOMRA (5 MG TAB, 10 MG TAB, 15 MG TAB, 20 MG TAB) 3 QL (30 PER 30 DAYS), MO (MAIL HETLIOZ 20 MG CAP 5 PA, QL (30 PER 30 DAYS), MO modafinil (100 mg tab, 200 mg tab) 4 PA, QL (30 PER 30 DAYS), MO XYREM 500 MG/ML SOLUTION 5 PA, QL (540 PER 30 DAYS), MO Uncategorized Unclassified olmesartan medoxomil 20 mg tab 2 MO olmesartan medoxomil-hctz ( mg tab, mg tab, mg tab) 2 MO 110

117 Alphabetical Listing A abacavir sulfate 45 abacavir sulfate-lamivudine 45 abacavir-lamivudine-zidovudine 45 ABELCET 24 ABILIFY MAINTENA 41 ABRAXANE 30 acamprosate calcium 7 acarbose 50 acebutolol hcl 61 acetaminophen-codeine 4 acetaminophen-codeine #2 4 acetaminophen-codeine #3 4 acetaminophen-codeine #4 4 acetazolamide 103 acetazolamide er 103 acetazolamide sodium 64 acetic acid 104 acetylcysteine 109 acitretin 70 ACTHIB 10 MCG/0.5 RECON SOLN 96 ACTIMMUNE 96 acyclovir 48 acyclovir sodium 48 ADACEL 96 ADAGEN 78 adapalene 70 ADCIRCA 108 adefovir dipivoxil 47 ADEMPAS 108 adriamycin 30 adrucil 29 ADVAIR DISKUS 109 ADVAIR HFA 109 afeditab cr 62 AFINITOR 34 AFINITOR DISPERZ 34 ala-cort 80 ALBENZA 38 albuterol sulfate 106 alclometasone dipropionate 80 ALDURAZYME 78 ALECENSA 34 alendronate sodium 99 alfuzosin hcl er 79 ALIMTA 29 allopurinol 26 alosetron hcl 76 ALOXI 23 alprazolam 49 alprazolam er 49 alprazolam xr 49 ALREX 102 ALUNBRIG 34 alyacen 1/35 84 amantadine hcl 48 AMBISOME 24 amcinonide 80 amethia 84 amethia lo 84 amikacin sulfate 8 amiloride hcl 65 amiloride-hydrochlorothiazide 65 aminophylline 108 AMINOSYN II 100 aminosyn ii/electrolytes 72 AMINOSYN-HBC 100 AMINOSYN-PF 100 AMINOSYN-RF 100 AMINOSYN/ELECTROLYTES 72 aminosyn/electrolytes 72 amiodarone hcl 60 AMITIZA 76 amitriptyline hcl 22 amlodipine besy-benazepril hcl 62 amlodipine besylate 62 amlodipine besylate-valsartan 62 amlodipine-atorvastatin 62 ammonium lactate 70 amoxapine 22 amoxicillin

118 amoxicillin-pot clavulanate 12 amoxicillin-pot clavulanate er 12 amphetamine-dextroamphet er 67 amphetamine-dextroamphetamine 67 amphotericin b 24 ampicillin 12 ampicillin sodium 12 ampicillin-sulbactam sodium 12 AMPYRA 69 ANADROL anagrelide hcl 56 anastrozole 33 ANDRODERM 83 ANDROGEL 84 ANDROGEL PUMP 84 ANORO ELLIPTA 109 APOKYN 39 apraclonidine hcl 103 aprepitant 23 apri 84 APRISO 98 APTIOM 16 APTIVUS 46 ARALAST NP 109 aranelle 84 ARANESP (ALBUMIN FREE) 56 ARCALYST 96 aripiprazole 41 ARISTADA 41 ARRANON 29 ashlyna 84 ASMANEX 120 METERED DOSES 104 ASMANEX 30 METERED DOSES 104 ASMANEX 60 METERED DOSES 104 ASMANEX HFA 104 aspirin-dipyridamole er 57 atenolol 61 atenolol-chlorthalidone 61 ATGAM 95 atomoxetine hcl 68 atorvastatin calcium 66 atovaquone 38 atovaquone-proguanil hcl 38 ATRIPLA 44 atropine sulfate 101 ATROVENT HFA 106 AUBAGIO 69 aubra 84 AUGMENTIN 13 AVASTIN 37 aviane 84 AVONEX 69 AVONEX PEN 69 AVONEX PREFILLED 70 azacitidine 30 AZACTAM IN DEXTROSE 12 AZASITE 13 azathioprine 92 azathioprine sodium 92 azelastine hcl 102,105 azithromycin 13 AZOPT 103 aztreonam 12 B baciim 9 bacitra-neomycin-polymyxin-hc 9 bacitracin 9 bacitracin-polymyxin b 101 baclofen 44 BACTROBAN NASAL 9 balsalazide disodium 98 balziva 84 BANZEL 18 BARACLUDE 47 BAVENCIO 37 bcg vaccine 96 bekyree 84 BELEODAQ 30 BELSOMRA 110 benazepril hcl 59 benazepril-hydrochlorothiazide

119 BENLYSTA 92 benzoyl peroxide-erythromycin 70 benztropine mesylate 39 BERINERT 92 BESIVANCE 14 betamethasone dipropionate 80 betamethasone dipropionate aug 80 betamethasone valerate 80 betaxolol hcl 61,103 bethanechol chloride 79 BETHKIS 107 BETIMOL 103 bexarotene 38 BEXSERO 96 bicalutamide 29 BICILLIN C-R 13 BICILLIN C-R 900/ BICILLIN L-A 13 BICNU 28 BILTRICIDE 38 bimatoprost 104 bisoprolol fumarate 61 bisoprolol-hydrochlorothiazide 61 BIVIGAM 95 bleomycin sulfate 31 BLEPHAMIDE 102 BLEPHAMIDE S.O.P. 102 blisovi 24 fe 84 blisovi fe 1.5/30 84 blisovi fe 1/20 84 BOOSTRIX 96 BOSULIF 34 BREO ELLIPTA 104 briellyn 84 BRILINTA 57 brimonidine tartrate 103 BRIVIACT 16 bromfenac sodium 102 bromocriptine mesylate 39 budesonide 98,104 bumetanide 65 buprenorphine hcl 7 buprenorphine hcl-naloxone hcl 7 bupropion hcl 20 bupropion hcl er (smoking det) tab er 12h 150 mg 8 bupropion hcl er (sr) 20 bupropion hcl er (xl) 20 buspirone hcl 49 busulfan 28 butalbital-acetaminophen 69 butalbital-aspirin-caffeine 69 butorphanol tartrate 4 BYSTOLIC 61 C cabergoline 90 CABOMETYX 34 calcipotriene 71 calcitonin (salmon) 99 calcitriol 99 calcium acetate (phos binder) 75 camila 89 camrese lo 84 CANASA 98 CANCIDAS 24 candesartan cilexetil 58 candesartan cilexetil-hctz 58 CAPASTAT SULFATE 27 CAPRELSA 34 captopril 59 captopril-hydrochlorothiazide 59 CARBAGLU 72 carbamazepine 18 carbamazepine er 18 carbidopa 40 carbidopa-levodopa 40 carbidopa-levodopa er 40 carboplatin 28 CARIMUNE NF 95 carteolol hcl 103 cartia xt

120 carvedilol 61 CAYSTON 108 caziant 84 cefaclor 10 cefaclor er 10 cefadroxil 10 cefazolin sodium 11 cefdinir 11 cefepime hcl 11 cefixime 11 cefotaxime sodium 11 cefotetan disodium 11 cefoxitin sodium 11 cefpodoxime proxetil 11 cefprozil 11 ceftazidime 11 ceftriaxone sodium 11 cefuroxime axetil 11 cefuroxime sodium 11 CELONTIN 16 cephalexin 11 CERDELGA 78 CEREZYME 78 cetirizine hcl 105 CHANTIX 8 CHANTIX CONTINUING MONTH PAK 8 CHANTIX STARTING MONTH PAK 8 CHENODAL 75 chloramphenicol sod succinate 9 chlordiazepoxide hcl 49 chlordiazepoxide-amitriptyline 22 chlorhexidine gluconate 70 chloroquine phosphate 38 chlorothiazide 65 chlorothiazide sodium 65 chlorpromazine hcl 40 chlorthalidone 65 chlorzoxazone 109 CHOLBAM 75 cholestyramine 66 cholestyramine light 66 ciclopirox 24 ciclopirox olamine 24 ciclopirox solution 8 % 24 cidofovir 47 cilostazol 57 cimetidine 76 cimetidine hcl 76 CINRYZE 92 CIPRODEX 104 ciprofloxacin 14 ciprofloxacin hcl 14 ciprofloxacin in d5w 14 ciprofloxacin-ciproflox hcl er 14 cisplatin 28 citalopram hydrobromide 20 cladribine 29 claravis 71 clarithromycin 14 clarithromycin er 14 clindamycin hcl 9 clindamycin palmitate hcl 9 clindamycin phos-benzoyl perox 71 clindamycin phosphate 9 clindamycin phosphate in d5w 9 clindamycin-tretinoin 71 clobetasol propionate 80 clobetasol propionate e 80 clobetasol propionate emulsion 80 clofarabine 30 CLOLAR 30 clomipramine hcl 22 clonazepam 17 clonidine hcl 57 clopidogrel bisulfate 57 clorazepate dipotassium 49,50 clotrimazole 25 clotrimazole-betamethasone 71 clozapine 43 COARTEM 38 codeine sulfate 4 colchicine

121 colchicine-probenecid 26 colestipol hcl 66 colistimethate sodium 9 colocort 80 COMBIGAN 104 COMBIVENT RESPIMAT 106 COMETRIQ (100 MG DAILY DOSE) 34 COMETRIQ (140 MG DAILY DOSE) 34 COMETRIQ (60 MG DAILY DOSE) 34 COMPLERA 44 compro 23 constulose 76 COPAXONE 70 CORLANOR 63 cormax scalp application 80 cortisone acetate 80 COSENTYX 71 COSENTYX 300 DOSE 71 COSENTYX SENSOREADY 300 DOSE 71 COSENTYX SENSOREADY PEN 71 COTELLIC 31 CREON 78 CRINONE 89 CRIXIVAN 46 cromolyn sodium 75,102,108 cryselle cyclafem 1/35 85 cyclafem 7/7/7 85 cyclobenzaprine hcl 110 cyclophosphamide 28 cyclosporine 92 cyclosporine modified 92 cyproheptadine hcl 105 CYRAMZA 37 CYSTAGON 78 CYSTARAN 101 cytarabine 30 cytarabine (pf) 30 D dacarbazine 28 DALIRESP 108 danazol 84 dantrolene sodium 44 dapsone 27 DAPTACEL 96 daptomycin 9 darifenacin hydrobromide er 79 DARZALEX 37 daunorubicin hcl 31 deblitane 89 decitabine 31 delyla 85 demeclocycline hcl 15 DEMSER 63 DEPEN TITRATABS 74 DEPO-PROVERA 89 DESCOVY 45 desipramine hcl 22 desloratadine 105 desmopressin ace spray refrig 83 desmopressin acetate 83 desmopressin acetate spray 83 desogestrel-ethinyl estradiol 85 desonide 80 desoximetasone 80 desvenlafaxine succinate er 20 dexamethasone 80 DEXAMETHASONE INTENSOL 81 dexamethasone sod phosphate pf 81 dexamethasone sodium phosphate 81,102 DEXILANT CAP DR 30 MG 77 DEXILANT CAP DR 60 MG 77 dexmethylphenidate hcl 68 dexmethylphenidate hcl er 68 dexrazoxane 31 dextroamphetamine sulfate 68 dextroamphetamine sulfate er 68 dextrose 72 dextrose in lactated ringers 72 dextrose-nacl 72 DIASTAT ACUDIAL

122 DIASTAT PEDIATRIC 17 diazepam 17,50 diazepam intensol 50 diclofenac potassium 2 diclofenac sodium 2,71,102 diclofenac sodium er 2 dicloxacillin sodium 13 dicyclomine hcl 75 didanosine 45 DIFICID 14 diflorasone diacetate 81 diflunisal 2 digitek 63,64 digox 64 digoxin 64 dihydroergotamine mesylate 26 DILANTIN 18 dilt-xr 62 diltiazem cd 62 diltiazem hcl 62 diltiazem hcl er 62 diltiazem hcl er beads 62 diltiazem hcl er coated beads 63 DIPENTUM 98 diphenhydramine hcl 105 diphenoxylate-atropine 75 diphtheria-tetanus toxoids dt 96 disopyramide phosphate 60 disulfiram 7 divalproex sodium 17 divalproex sodium 125 mg dr sprinkle cap 17 divalproex sodium er 17 docetaxel 31 dofetilide 60 donepezil hcl 19 dorzolamide hcl 103 dorzolamide hcl-timolol mal 103 doxazosin mesylate 79 doxepin hcl 22 doxercalciferol 99 doxorubicin hcl 31 doxorubicin hcl liposomal 31 doxy doxycycline hyclate 15 doxycycline monohydrate 15 dronabinol 24 drospiren-eth estrad-levomefol 85 drospirenone-ethinyl estradiol 85 DROXIA 30 duloxetine hcl 20,21 duramorph 4 DUREZOL 102 dutasteride 79 E econazole nitrate 25 EDURANT 44 ELAPRASE 78 ELIQUIS 55 ELITEK 38 ELMIRON 80 EMBEDA 3 EMCYT 29 EMEND 24 emoquette 85 EMPLICITI 37 EMSAM 20 EMTRIVA 45 enalapril maleate 59 enalapril-hydrochlorothiazide 59 ENBREL 92 ENBREL SURECLICK 93 endocet 4 ENGERIX-B 96 ENGERIX-B 10 MCG/0.5ML SYRINGE 97 enoxaparin sodium 55 enpresse entacapone 39 entecavir 47 ENTRESTO 64 enulose 77 EPCLUSA

123 epinastine hcl 102 epinephrine 107 epinephrine 0.3 mg/0.3ml soln a-inj (nda019430) 107 epinephrine 0.3 mg/0.3ml soln a-inj (nda020800) 107 EPIPEN 2-PAK 107 EPIPEN JR 2-PAK 107 epirubicin hcl 31 epitol 18 EPIVIR HBV 47 eplerenone 65 eprosartan mesylate 58 EQUETRO 50 ERBITUX 37 ergoloid mesylates 19 ergotamine-caffeine 26 ERIVEDGE 34 errin 89 ERWINAZE 31 ery 14 ERY-TAB 14 ERYTHROCIN LACTOBIONATE 14 ERYTHROCIN STEARATE 14 erythromycin 14 erythromycin base 14 erythromycin ethylsuccinate 14 ESBRIET 109 escitalopram oxalate 21 esomeprazole magnesium 77 esomeprazole sodium 77 estazolam 50 ESTRACE 85 estradiol 85 estradiol valerate 85 estradiol-norethindrone acet 85 ESTRING 85 estropipate 85 ethambutol hcl 27 ethosuximide 16 ethynodiol diac-eth estradiol 85 etidronate disodium 99 etodolac 2 etoposide 33 EVOTAZ 46 exemestane 33 EXJADE 74 EXTAVIA 70 ezetimibe 66 ezetimibe-simvastatin 66 F FABRAZYME 78 falmina 85 famciclovir 48 famotidine 76 FANAPT 41 FANAPT TITRATION PACK 41 FARESTON 29 FARYDAK 31 FASLODEX 29 felbamate 18 felodipine er 63 femynor 85 fenofibrate 65 fenofibrate micronized 66 fentanyl 3 fentanyl citrate 5 FERRIPROX 74 FETZIMA 21 FETZIMA TITRATION 21 finasteride 79 FIRAZYR 92 FIRMAGON 90,91 flavoxate hcl 79 FLEBOGAMMA DIF 95 flecainide acetate 60 FLOVENT DISKUS 105 FLOVENT HFA 105 fluconazole 25 fluconazole in sodium chloride 25 flucytosine

124 fludarabine phosphate 31 fludrocortisone acetate 81 flunisolide 25 mcg/act (0.025%) solution, nasal 105 fluocinolone acetonide 81,104 fluocinonide 81 fluocinonide emulsified base 81 fluorouracil 30,71 fluoxetine hcl 21 fluphenazine decanoate 40 fluphenazine hcl 40 flurandrenolide 81 flurbiprofen 2 flurbiprofen sodium 102 flutamide 29 fluticasone propionate 81 fluticasone propionate nasal susp 50 mcg/act 105 fluvastatin sodium 66 fluvastatin sodium er 66 fluvoxamine maleate 21 FML FORTE 102 FOLOTYN 30 fondaparinux sodium 55 FORTEO 99 fosinopril sodium 59 fosinopril sodium-hctz 59 fosphenytoin sodium 18 FOSRENOL 75 FREAMINE HBC 100 furosemide 65 FUZEON 46 fyavolv 85 FYCOMPA 16 G gabapentin GABITRIL galantamine hydrobromide galantamine hydrobromide er GAMASTAN S/D GAMMAGARD 95 GAMMAGARD S/D LESS IGA 95 GAMMAKED 95 GAMMAPLEX 95 GAMUNEX-C 95 ganciclovir sodium 47 GARDASIL 20-40/0.5 SUSP PRSYR 97 GARDASIL 20-40/0.5 SUSPENSION 97 GARDASIL 9 97 gatifloxacin 14 GAUZE PADS & DRESSINGS - PADS 2 X gavilyte-c 77 gavilyte-g 77 gavilyte-h 77 gavilyte-n with flavor pack 77 gemcitabine hcl 30 gemfibrozil 66 generlac 77 gengraf 93 GENOTROPIN 83 GENOTROPIN MINIQUICK 83 gentak 8 gentamicin in saline 8 gentamicin sulfate 8 GENVOYA 44 GEODON 41 gianvi 85 gildagia 85 GILENYA 70 GILOTRIF 34 glatopa 70 GLEOSTINE 28 glimepiride 50,51 glipizide 51 glipizide er 51 glipizide xl 51 glipizide-metformin hcl 51 GLUCAGEN HYPOKIT 54 GLUCAGON EMERGENCY 54 glyburide

125 glyburide micronized glyburide-metformin glycopyrrolate granisetron hcl griseofulvin microsize griseofulvin ultramicrosize guanfacine hcl guanfacine hcl er guanidine hcl H HALAVEN halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX heparin (porcine) in d5w heparin (porcine) in nacl heparin sodium (porcine) HEPATAMINE HERCEPTIN HETLIOZ HEXALEN HIBERIX HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50/50 HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/25 HUMALOG MIX 75/25 KWIKPEN HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN-CROHNS STARTER HUMIRA PEN-PSORIASIS STARTER HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN 70/30 PEN HUMULIN N HUMULIN N KWIKPEN 54 HUMULIN N PEN 54 HUMULIN R 54 HUMULIN R U-500 (CONCENTRATED) 54 HUMULIN R U-500 KWIKPEN 54 hydralazine hcl 67 hydrochlorothiazide 65 hydrocodone-acetaminophen 5 hydrocortisone 81 hydrocortisone butyr lipo base 81 hydrocortisone butyrate 81 hydrocortisone valerate 81 hydrocortisone-acetic acid 104 hydromorphone hcl 5 hydromorphone hcl pf 5 hydroxychloroquine sulfate 38 hydroxyprogesterone caproate 89 hydroxyurea 30 hydroxyzine hcl 105 hydroxyzine pamoate 49 I ibandronate sodium 99 IBRANCE 31 ibuprofen 2 ICLUSIG 34,35 idarubicin hcl 31 ifosfamide 28 ILARIS 96 ILEVRO 102 imatinib mesylate 35 IMBRUVICA 35 IMFINZI 37 imipenem-cilastatin 12 imipramine hcl 22 imiquimod 71 IMOVAX RABIES 97 INCRELEX 83 indapamide 65 indomethacin 2 INFANRIX

126 INFLECTRA 93 INGREZZA 69 INLYTA 35 INSULIN PEN NEEDLE 100 INSULIN SYRINGE (DISP) U ML 100 INSULIN SYRINGE (DISP) U ML 100 INSULIN SYRINGE (DISP) U-100 1/2 ML 100 INTELENCE 44 INTRALIPID 100 INTRON A 47 introvale 86 INVANZ 12 INVEGA SUSTENNA 41 INVEGA TRINZA 42 INVIRASE 46 INVOKAMET 52 INVOKAMET XR 52 INVOKANA 52 IONOSOL-B IN D5W 72 IONOSOL-MB IN D5W 72 IPOL INJECTABLE 97 ipratropium bromide 106 ipratropium-albuterol 106 irbesartan 58 irbesartan-hydrochlorothiazide 58 IRESSA 35 irinotecan hcl 31 ISENTRESS 44 ISOLYTE-P IN D5W 72 ISOLYTE-S 72 ISOLYTE-S PH isoniazid 27 ISOPROPYL ALCOHOL 0.7 ML/ML MEDICATED PAD 100 isosorbide dinitrate 67 isosorbide dinitrate er 67 isosorbide mononitrate 67 isosorbide mononitrate er 67 ISTODAX 31 ISTODAX (OVERFILL) 32 itraconazole 25 ivermectin 38 IXIARO 97 J JADENU 74 JADENU SPRINKLE 74 JAKAFI 35 jantoven 56 JANUMET 52 JANUMET XR 52 JANUVIA 52 JARDIANCE 52 JENTADUETO 52 JENTADUETO XR 52 JEVTANA 32 jinteli 86 jolivette 89 juleber 86 junel 1.5/30 86 junel 1/20 86 junel fe 1.5/30 86 junel fe 1/20 86 junel fe K KADCYLA 37 kaitlib fe 86 KALETRA 46 KALYDECO 108 kariva 86 kcl in dextrose-nacl 73 kcl-lactated ringers-d5w 73 kelnor 1/35 86 ketoconazole 25 ketoprofen 2 ketorolac tromethamine 2,102 KEYTRUDA 37 kimidess 86 KINRIX PREFILLED SYRINGE 97 KINRIX INJECTABLE SUSPENSION 97 kionex

127 KISQALI 200 DOSE 35 KISQALI 400 DOSE 35 KISQALI 600 DOSE 35 KISQALI FEMARA 200 DOSE 32 KISQALI FEMARA 400 DOSE 32 KISQALI FEMARA 600 DOSE 32 klor-con 73 klor-con klor-con m10 73 KLOR-CON M15 73 klor-con m20 73 klor-con sprinkle 73 KORLYM 83 KUVAN 78 KYPROLIS 33 L labetalol hcl 61 lactated ringers 73,100 lactulose 77 lamivudine 45,47 lamivudine-zidovudine 45 lamotrigine 18 LANOXIN 64 LANTUS 54 LANTUS SOLOSTAR 55 larin 1.5/30 86 larin 1/20 86 larin fe 1.5/30 86 larin fe 1/20 86 larissia 86 LARTRUVO 37 latanoprost 104 LATUDA 42 layolis fe 86 leena 86 leflunomide 96 LENVIMA 10 MG DAILY DOSE 35 LENVIMA 14 MG DAILY DOSE 35 LENVIMA 18 MG DAILY DOSE 35 LENVIMA 20 MG DAILY DOSE 35 LENVIMA 24 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide acetate levalbuterol hcl levetiracetam levetiracetam er levetiracetam in nacl levobunolol hcl levocarnitine levocetirizine dihydrochloride levofloxacin levofloxacin 25 mg/ml oral solution levofloxacin 25 mg/ml solution inj levofloxacin in d5w levoleucovorin calcium levoleucovorin calcium pf levonest levonorg-eth estrad triphasic levonorgest-eth estrad 91-day levonorgestrel-ethinyl estrad levora 0.15/30 (28) levothyroxine sodium levoxyl LEXIVA LIALDA lidocaine lidocaine hcl lidocaine hcl (pf) lidocaine viscous lidocaine-prilocaine cream % lindane linezolid LINZESS liothyronine sodium lisinopril

128 lisinopril-hydrochlorothiazide 59 lithium 50 lithium carbonate 50 lithium carbonate er 50 lokara 81 lomedia 24 fe 86 LONSURF 30 loperamide hcl 76 lopinavir-ritonavir 46 lorazepam 50 lorazepam intensol 50 lorcet 5 lorcet hd 5 lorcet plus 5 lortab 5 loryna 87 losartan potassium 58 losartan potassium-hctz 58 LOTEMAX 102 lovastatin 66 low-ogestrel 87 loxapine succinate 40 LUMIGAN 104 LUMIZYME 78 LUPRON DEPOT 91 LUPRON DEPOT (6-MONTH) 91 LUPRON DEPOT-PED 91 lutera 87 LYNPARZA 32 LYRICA 16,17 LYSODREN 90 lyza 89 M M-M-R II 97 magnesium sulfate 73 magnesium sulfate 50 % syringe 73 MAKENA 89 malathion 39 maprotiline hcl 21 marlissa 87 MARPLAN 20 MATULANE 28 matzim la 63 meclizine hcl 23 meclofenamate sodium 2 medroxyprogesterone acetate 89 mefenamic acid 2 mefloquine hcl 38 megestrol acetate 89 MEKINIST 35 meloxicam 2 melphalan hcl 28 memantine hcl 19 MENACTRA 4MCG/0.5ML INJECTABLE 97 MENOMUNE 97 MENVEO 97 mercaptopurine 30 meropenem 12 mesalamine 98 mesalamine-cleanser 98 mesna 38 MESNEX 38 metadate er 68 metaproterenol sulfate 107 metformin hcl 52,53 metformin hcl er 53 methadone hcl 3 methazolamide 64 methenamine hippurate tab 1 gm 9 methimazole 92 methotrexate 93 methotrexate sodium 93 methotrexate sodium (pf) 93 methscopolamine bromide 75 methyclothiazide 65 methyldopa 58 methyldopa-hydrochlorothiazide 58 methylphenidate hcl 68 methylphenidate hcl er 68,69 methylphenidate hcl er (cd) 69 methylphenidate hcl er (la)

129 methylprednisolone 81 methylprednisolone acetate 82 methylprednisolone sodium succ 82 metipranolol 103 metoclopramide hcl 76 metolazone 65 metoprolol succinate er 61 metoprolol tartrate 61 metronidazole 9 metronidazole in nacl 10 mexiletine hcl 60 MIACALCIN 99 MICONAZOLE 3 25 microgestin 1.5/30 87 microgestin 1/20 87 microgestin fe 1.5/30 87 microgestin fe 1/20 87 midodrine hcl 58 MIGERGOT 26 mimvey 87 mimvey lo 87 minitran 67 minocycline hcl 15 minoxidil 67 mirtazapine 20 MIRVASO 71 misoprostol 77 mitomycin 32 mitoxantrone hcl 32 modafinil 110 moderiba 47 moexipril hcl 59 moexipril-hydrochlorothiazide 59 molindone hcl 40 mometasone furoate 82 mononessa 87 montelukast sodium 106 morgidox 15 morphine sulfate 5 morphine sulfate (concentrate) 5 morphine sulfate (pf) 6 morphine sulfate er 3,4 MOVIPREP 77 moxifloxacin hcl 15 MOZOBIL 57 mupirocin 10 MUSTARGEN 28 MYALEPT 100 mycophenolate mofetil 93 mycophenolate mofetil hcl 93 mycophenolate sodium 93 myorisan 71 MYRBETRIQ 79 N nabumetone 2 nadolol 61 nafcillin sodium 13 NAGLAZYME 78 nalbuphine hcl 6 naloxone hcl 7 naltrexone hcl 7 NAMENDA XR 19 NAMENDA XR TITRATION PACK 19 naproxen 2 naproxen dr 2 naproxen sodium 2 naratriptan hcl 26 NARCAN 7 NATACYN 25 nateglinide 53 NATPARA 99 NEBUPENT 38 necon 0.5/35 (28) 87 NECON 1/50 (28) 87 NECON 10/11 (28) 87 necon 7/7/7 87 NEEDLES, INSULIN DISP., SAFETY 100 nefazodone hcl 21 neomycin sulfate 8 neomycin-bacitracin zn-polymyx 101 neomycin-polymyxin b gu 8 123

130 neomycin-polymyxin-dexameth 102 neomycin-polymyxin-gramicidin 101 neomycin-polymyxin-hc 10,104 NEPHRAMINE 100 NEULASTA 57 NEULASTA ONPRO 57 NEUPOGEN 57 NEUPRO 39 nevirapine 44 nevirapine er 44 NEXAVAR 35 niacin er (antihyperlipidemic) 66 NIACOR 66 nicardipine hcl 63 NICOTROL NS 8 nifedipine er 63 nifedipine er osmotic release 63 nikki 87 nilutamide 29 nimodipine 63 NINLARO 32 NIPENT 30 NITRO-BID 67 nitrofurantoin 10 nitrofurantoin macrocrystal 10 nitrofurantoin monohyd macro 10 nitroglycerin 67 NITROSTAT 67 nizatidine 76 nora-be 89 norethin ace-eth estrad-fe 87 norethin-eth estradiol-fe 87 norethindrone 90 norethindrone acet-ethinyl est 87 norethindrone acetate 90 norethindrone-eth estradiol 87 norgestim-eth estrad triphasic 87 norlyroc 90 NORMOSOL-M IN D5W 73 NORMOSOL-R 73 NORMOSOL-R IN D5W 73 NORMOSOL-R PH NORPACE CR 60 NORTHERA 64 nortrel 0.5/35 (28) 87 nortrel 1/35 (21) 87 nortrel 1/35 (28) 87 nortrel 7/7/7 87 nortriptyline hcl 22 NORVIR 46 NOXAFIL 25 NUCALA 105 NUCYNTA ER 4 NUEDEXTA 69 NULOJIX 93 NUPLAZID 42 nutrilipid 101 NUVARING 88 nyamyc 25 nyata 25 nystatin 25 nystatin-triamcinolone 25 nystop 25 O ocella 88 OCTAGAM 96 octreotide acetate 91 ODEFSEY 45 ODOMZO 36 OFEV 109 ofloxacin 15 ofloxacin 0.3 % ophthalmic solution 15 ofloxacin 0.3 % otic solution 15 OGESTREL 88 olanzapine 42 olmesartan medoxomil 58,110 olmesartan medoxomil-hctz 110 olopatadine hcl 102,105 omega-3-acid ethyl esters 67 omeprazole 77 ondansetron

131 ondansetron hcl 24 ONFI 17 OPDIVO 37 OPSUMIT 108 ORENCIA 93 ORENCIA CLICKJECT 94 ORENITRAM 108 ORFADIN 78 ORKAMBI 108 orsythia 88 oseltamivir phosphate 48 OTEZLA 96 oxacillin sodium 13 oxaliplatin 28 oxandrolone 83 oxaprozin 3 oxcarbazepine 18 oxiconazole nitrate 25 oxybutynin chloride 79 oxybutynin chloride er 79 oxycodone hcl 6 oxycodone-acetaminophen 6 oxycodone-aspirin 6 oxycodone-ibuprofen 6 oxymorphone hcl er 4 P paclitaxel 32 paliperidone er 42 pamidronate disodium 99 PANRETIN 38 pantoprazole sodium 77 paricalcitol 99 paromomycin sulfate 8 paroxetine hcl 21 paroxetine hcl er 21 PASER 27 PATADAY 102 PAXIL 21 PAZEO 102 PEDIARIX 97 PEDVAX HIB 97 peg 3350-kcl-na bicarb-nacl 77 peg-3350/electrolytes 77 PEGANONE 18 PEGASYS 47 PEGASYS PROCLICK 47 penicillin g pot in dextrose 13 penicillin g potassium 13 penicillin g sodium 13 penicillin v potassium 13 PENTAM 39 pentoxifylline er 64 PERFOROMIST 107 perindopril erbumine 59 periogard 70 PERJETA 37 permethrin 39 perphenazine 41 perphenazine-amitriptyline 22 phenadoz 23 phenelzine sulfate 20 phenergan 23 phenobarbital 17 phenoxybenzamine hcl 58 phenytoin 18 phenytoin infatabs 19 phenytoin sodium extended 19 PHOSPHOLINE IODIDE 103 pilocarpine hcl 70,103 pimozide 41 pimtrea 88 pindolol 61 pioglitazone hcl 53 piperacillin sod-tazobactam so 13 pirmella 1/35 88 piroxicam 3 PLASMA-LYTE PLASMA-LYTE A 73 PLEGRIDY 70 PLEGRIDY STARTER PACK 70 podofilox

132 polyethylene glycol polymyxin b sulfate 10 polymyxin b-trimethoprim 101 POMALYST 29 portia potassium chloride 73 potassium chloride crys er 73 potassium chloride er 73 potassium chloride in dextrose 73 potassium chloride in nacl 74 potassium chloride solution 20 meq/15ml (10%) 74 potassium chloride solution 40 meq/15ml (20%) 74 potassium citrate er 74 POTIGA 16 PRADAXA 56 PRALUENT 64 pramipexole dihydrochloride 39 pravastatin sodium 66 prazosin hcl 58 prednicarbate 82 prednisolone 82 prednisolone acetate 102 prednisolone sodium phosphate 82,102 prednisone 82 PREDNISONE INTENSOL 82 PREMARIN 88 premasol 101 PREMPHASE 88 PREMPRO 88 PRENATAL VITAMIN WITH MINERALS AND FOLIC ACID GREATER THAN 0.8 MG ORAL TABLET 75 prevalite 67 previfem 88 PREZCOBIX 46 PREZISTA 46 PRIFTIN 27 primaquine phosphate 39 primidone 17 PRIVIGEN 96 PROAIR HFA 107 PROAIR RESPICLICK 107 probenecid 26 procainamide hcl 60 PROCALAMINE 74 prochlorperazine 23 prochlorperazine edisylate 23 prochlorperazine maleate 23 PROCRIT 57 procto-med hc 82 procto-pak 82 proctosol hc 82 proctozone-hc 82 PROCYSBI 101 progesterone micronized 90 PROGLYCEM 54 PROGRAF 94 PROLASTIN-C 109 PROLEUKIN 32 PROLIA 99 PROMACTA 57 promethazine hcl 23 promethegan 23 propafenone hcl 60 propafenone hcl er 60 proparacaine hcl 101 propranolol hcl 61 propranolol hcl er 61 propranolol-hctz 61 propylthiouracil 92 PROQUAD INJECTABLE 97 PROSOL 101 protriptyline hcl 22 PULMOZYME 108 PURIXAN 30 pyrazinamide 27 pyridostigmine bromide 27 Q QUADRACEL

133 quasense 88 quetiapine fumarate 42 quetiapine fumarate er 42 quinapril hcl 59 quinapril-hydrochlorothiazide 59 quinidine gluconate 60 quinidine gluconate er 60 quinidine sulfate 60 quinine sulfate 39 QVAR 105 R RABAVERT 2.5 UNIT RECON SUSP 97 raloxifene hcl 90 ramipril 59 RANEXA 64 ranitidine hcl 76 RAPAMUNE 94 rasagiline mesylate 40 RASUVO 94 RAVICTI 78 reclipsen 88 RECOMBIVAX HB 97 RELENZA DISKHALER 48 RELISTOR 76 REMICADE 94 REMODULIN 108 RENAGEL 75 RENVELA 75 repaglinide 53 REPATHA 64 REPATHA PUSHTRONEX SYSTEM 64 REPATHA SURECLICK 64 RESCRIPTOR 45 RESTASIS 101 RETROVIR 45 REVATIO 109 REVLIMID 29 REXULTI 42 REYATAZ 46 RIBASPHERE 47,48 ribasphere 48 ribavirin 48 rifabutin 27 rifampin 27 RIFATER 27 riluzole 69 rimantadine hcl 48 ringers 74 ringers irrigation 101 RISPERDAL CONSTA 42 risperidone 43 RITUXAN 37 rivastigmine 19 rivastigmine tartrate 19 rizatriptan benzoate 26 ropinirole hcl 40 rosuvastatin calcium 66 ROTARIX 10E6/ML RECON SUSP 97 ROTATEQ 97 roweepra 16 RUBRACA 32 RYDAPT 32 S SABRIL 17 SANDIMMUNE 94 SANDOSTATIN LAR DEPOT 91 SANTYL 71 SAPHRIS 43 selegiline hcl 40 selenium sulfide 71 SELZENTRY 46 SENSIPAR 99 SEREVENT DISKUS 107 sertraline hcl 21 setlakin 88 sevelamer carbonate 75 sharobel 90 SIGNIFOR 91 SIGNIFOR LAR 91 sildenafil citrate

134 silver sulfadiazine 10 SIMBRINZA 103 simvastatin 66 sirolimus 94 SIRTURO 28 sodium chloride 74,101 sodium fluoride 2.2 mg (fluoride ion 1 mg) oral tablet 74 sodium lactate 74 sodium phenylbutyrate 78 sodium polystyrene sulfonate 74 SOLTAMOX 29 SOMATULINE DEPOT 91 SOMAVERT 91 sorine 60 sotalol hcl 60 sotalol hcl (af) 60 SPIRIVA HANDIHALER 106 SPIRIVA RESPIMAT 106 spironolactone 65 spironolactone-hctz 65 SPORANOX 25 sprintec SPRITAM 16 SPRYCEL 36 sps 74 sronyx 88 ssd 10 stavudine 45 sterile water for irrigation solution 101 STIOLTO RESPIMAT 109 STIVARGA 36 streptomycin sulfate 8 STRIBILD 44 SUBOXONE 7 sucralfate 77 sulfacetamide sodium 15 sulfacetamide-prednisolone 103 sulfadiazine 15 sulfamethoxazole-trimethoprim 15 sulfasalazine 98 sulindac 3 sumatriptan 26 sumatriptan succinate 26,27 sumatriptan succinate refill 27 SUPRAX 11 SUPREP BOWEL PREP KIT 77 SURE COMFORT ALCOHOL PREP 101 SUSTIVA 45 SUTENT 36 SYLATRON 33 SYLVANT 96 SYMBICORT 109 SYMLINPEN SYMLINPEN SYNAGIS 96 SYNERCID 10 SYNJARDY 53 SYNRIBO 33 SYPRINE 74 T TABLOID 30 tacrolimus 71,94 TAFINLAR 36 TAGRISSO 36 TAMIFLU 48 tamoxifen citrate 29 tamsulosin hcl 79 TARCEVA 36 TARGRETIN 38 tarina fe 1/20 88 TASIGNA 36 tazarotene 71 tazicef 11 taztia xt 63 TECENTRIQ 37 TECFIDERA 70 TEFLARO 12 telmisartan 58 telmisartan-hctz 58 temazepam

135 TENCON 69 TENIVAC 98 terazosin hcl 79 terbinafine hcl 26 terbutaline sulfate 107 terconazole 26 testosterone cypionate 84 testosterone enanthate 84 tetanus-diphtheria toxoids td 98 tetrabenazine 69 tetracycline hcl 15 THALOMID 29 theophylline er 108 thioridazine hcl 41 thiotepa 28 thiothixene 41 tiagabine hcl 17 timolol maleate 61,103 tinidazole 39 TIVICAY 44 tizanidine hcl 44 TOBRADEX 103 TOBRADEX ST 103 tobramycin 8,108 tobramycin sulfate 8 tobramycin-dexamethasone 103 TOBREX 8 tolazamide 53 tolbutamide 53 tolcapone 39 tolmetin sodium 3 tolterodine tartrate 79 tolterodine tartrate 2 mg cap er 24h 79 tolterodine tartrate 4 mg cap er 24h 79 topiramate 18 toposar 33 topotecan hcl 34 TORISEL 36 torsemide 65 TOUJEO SOLOSTAR 55 TRADJENTA 53 tramadol hcl 6 tramadol-acetaminophen 6 trandolapril 59 trandolapril-verapamil hcl er 60 tranexamic acid 57 TRANSDERM-SCOP (1.5 MG) 23 tranylcypromine sulfate 20 TRAVASOL 101 TRAVATAN Z 104 trazodone hcl 21 TREANDA 28 TRECATOR 28 TRELSTAR MIXJECT 91,92 tretinoin 38,72 tretinoin microsphere 72 tri-legest fe 88 tri-lo-estarylla 88 tri-lo-sprintec 88 tri-previfem 88 tri-sprintec 88 triamcinolone acetonide 70,82,105 triamterene-hctz 65 triderm 82 trifluoperazine hcl 41 trifluridine 48 trihexyphenidyl hcl 39 trilyte 77 trimethoprim 10 trimipramine maleate 22 trinessa (28) 88 TRINTELLIX 21 TRISENOX 33 TRIUMEQ 44 trivora (28) 88 TROPHAMINE 101 trospium chloride 79 trospium chloride er 79 TRULICITY 53 TRUMENBA 98 TRUVADA 45 TWINRIX

136 TYBOST 46 TYGACIL 10 TYKERB 36 TYPHIM VI 98 TYSABRI 70 U ULORIC 26 unithroid 90 ursodiol 76 V valacyclovir hcl 48 VALCHLOR 28 valganciclovir hcl 47 valproate sodium 18 valproic acid 18 valsartan 58 valsartan-hydrochlorothiazide 58 vancomycin hcl 10 vandazole 10 VAQTA 98 VARIVAX 98 VARIZIG 98 VECTIBIX 37 VELCADE 33 velivet 88 VELPHORO 75 VENCLEXTA 36 VENCLEXTA STARTING PACK 36 venlafaxine hcl 21 venlafaxine hcl er 22 VENTAVIS 109 verapamil hcl 63 verapamil hcl er 63 VERSACLOZ 43 VESICARE 79 vestura 89 vicodin 6 vicodin es 6 vicodin hp 6 VICTOZA 53 VIDEX 45 vienva 89 VIGAMOX 15 VIIBRYD 22 VIIBRYD STARTER PACK 22 VIMPAT 19 vinblastine sulfate 33 vincasar pfs 33 vincristine sulfate 33 vinorelbine tartrate 33 VIRACEPT 46 VIREAD 45 VIVITROL 7 voriconazole 26 VOTRIENT 36 VPRIV 78 VRAYLAR 43 vyfemla 89 W warfarin sodium 56 wymzya fe 89 X XALKORI 36 XARELTO 56 XARELTO STARTER PACK 56 XELJANZ 96 XELJANZ XR 96 XGEVA 99 XIFAXAN 10 XOLAIR 109 XTANDI 29 XULANE 89 XYREM 110 Y YERVOY 38 YF-VAX 10E4.74 INJECTABLE 98 YONDELIS

137 Z zafirlukast 106 zaleplon 110 ZALTRAP 33 ZANOSAR 29 zarah 89 ZAVESCA 78 zazole 26 ZEJULA 33 ZELBORAF 36 ZEMAIRA 109 zenatane 72 zenchent 89 zenchent fe 89 ZENPEP 78 ZERIT 45 ZIAGEN 46 zidovudine 46 ziprasidone hcl 43 ZIRGAN 47 zoledronic acid 99 ZOLINZA 33 zolmitriptan 27 zolpidem tartrate 110 zonisamide 17 ZORTRESS 95 ZOSTAVAX 98 zovia 1/35e (28) 89 zovia 1/50e (28) 89 ZYDELIG 34 ZYKADIA 37 ZYLET 103 ZYPREXA RELPREVV 43 ZYTIGA

138 Discrimination is against the law Magellan* follows the law. We treat all people equally. We do not discriminate against anyone based on: Race. Color. National origin. Age. Disability. Sex. We provide free help and services to people with disabilities. We want you to be able to communicate with us easily. We offer: Qualified sign language interpreters. Written information in many formats. These may include: o Large print. o Audio. o Accessible electronic formats. o Other formats. We also provide free language services to people whose first language is not English. We offer: o Qualified interpreters. o Information that is written in other languages. Contact us at if you need any of these services. If you believe we have not provided these services or discriminated in another way, you can file a grievance with: Civil Rights Coordinator, Corporate Compliance Department 6950 Columbia Gateway Drive Columbia MD Fax: You can file a grievance in one of three ways. By mail. By fax. By . The civil rights coordinator is available if you need help with any of this. Magellan* refers to all applicable subsidiaries and affiliates of Magellan Health, Inc. including but not limited to Magellan Healthcare, Inc., National Imaging Associates, Inc., Magellan Rx Management, LLC and Magellan Complete Care.

139 You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. You may do this online at Or you may do this by mail or phone. U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C TDD: Complaint forms are available online. You may find them at Magellan* refers to all applicable subsidiaries and affiliates of Magellan Health, Inc. including but not limited to Magellan Healthcare, Inc., National Imaging Associates, Inc., Magellan Rx Management, LLC and Magellan Complete Care.

140 ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 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:711) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ملحوظة : إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم : 117). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کریں (TTY: 711). אויפמערקזאם : אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט (TTY: 711)

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