Blue MedicareRx SM (PDP) 3-tier 2018 Formulary

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1 P.O. Box 52429, Phoenix, AZ Blue MedicareRx SM (PDP) 3-tier 2018 Formulary (List of Covered Drugs) $5 / $10 / $25 $5 / $15 / $30 $10 / $15 / $30 $10 / $20 / $35 $10 / $25 / $40 $10 / $25 / $45 $10 / $25 / $50 $10 / $30 / $65 $15 / $30 / $50 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 12/01/2017. For more recent information or other questions, please contact Blue MedicareRx, at or, for TTY/TDD users, 711, 24 hours a day, 7 days a week, or visit Groups.RxMedicarePlans.com. 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 Blue MedicareRx SM (PDP). When it refers to plan or our plan, it means Blue MedicareRx. 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. S2893_1703_GRP

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3 What is the Blue MedicareRx Formulary? A formulary is a list of covered drugs selected by Blue MedicareRx 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. Blue MedicareRx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue MedicareRx 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 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 Blue MedicareRx, please contact us. Our contact information appears on the front and back cover pages. If we have other types of mid-year non-maintenance formulary changes unrelated to the reasons stated above (e.g. remove drugs from our formulary, add prior authorization requirements, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier), we will notify you by mail. You may also access our formulary on our website at Groups.RxMedicarePlans.com to get information showing changes to, additions, and/or deletions of medications contained in our formulary. To get updated information about the drugs covered by Blue MedicareRx, please contact us. Our contact information appears on the front and back cover pages. 1

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 7. 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. If you know what your drug is used for, look for the category name in the list that begins on page number 7. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 86. 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? Blue MedicareRx 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: Blue MedicareRx requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, Blue MedicareRx limits the amount of the drug that we will cover. For example, our plan provides 2 units per prescription for FLOVENT HFA. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Blue MedicareRx 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, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 2

5 You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Blue MedicareRx 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 Blue MedicareRx formulary? on page 3 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Care and ask if your drug is covered. If you learn that Blue MedicareRx does not cover your drug, you have two options: You can ask Customer Care for a list of similar drugs that are covered by Blue MedicareRx. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask Blue MedicareRx to make an exception and cover your drug. See below for information about how to request an exception. Compounds may or may not be covered by your plan benefit. How do I request an exception to the Blue MedicareRx Formulary? You can ask us 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, Blue MedicareRx 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, Blue MedicareRx will only approve your request for an exception if the alternative drug is 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. 3

6 You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 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. 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 when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you change your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover up to a temporary 30-day supply (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. After your first 30-day supply, you are required to use the plan's exception process. Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover or drugs that are covered under Medicare Part B. 4

7 For more information For more detailed information about your Blue MedicareRx prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Blue MedicareRx, 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/TDD users should call Or, visit Blue MedicareRx Formulary The formulary that begins on page 7 provides coverage information about the drugs covered by Blue MedicareRx. If you have trouble finding your drug in the list, turn to the Index that begins on page 86. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ADVAIR DISKUS) and generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if Blue MedicareRx has any special requirements for coverage of your drug. The abbreviations you may see in the drug listing include: o B/D stands for drugs covered under Medicare Part B or D. o stands for Quantity Limits. o stands for Prior Authorization. o ST stands for Step Therapy. o LA stands for Limited Access. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Care at , 24 hours a day, 7 days a week. TTY/TDD users should call 711. o NMO stands for No Mail Order. This prescription drug is not available through mail order service. In the drug listing, the Tier column identifies which tier each drug is in. The amount you will pay at the pharmacy, also known as copayment or coinsurance, is determined by the drug tier. 5

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9 ANALGESICS GOUT allopurinol tab 100 (generic of ZYLOPRIM) allopurinol tab 300 (generic of ZYLOPRIM) Drug Tier colchicine w/ probenecid tab COLCRYS TAB 0.6MG Tier 2 (120 tabs / 30 Requirements/ Limits MITIGARE CAP 0.6MG Tier 2 (60 caps / 30 probenecid tab 500 ULORIC TAB 40MG Tier 2 ST ULORIC TAB 80MG Tier 2 ST NSAIDS celecoxib cap 50 (generic of CELEBREX) (240 caps / 30 celecoxib cap 100 (generic of CELEBREX) (120 caps / 30 celecoxib cap 200 (generic of CELEBREX) (60 caps / 30 celecoxib cap 400 (generic of CELEBREX) (30 caps / 30 diclofenac potassium tab 50 (120 tabs / 30 diclofenac sodium tab delayed release 25 diclofenac sodium tab delayed release 50 diclofenac sodium tab delayed release 75 diclofenac sodium tab er 24hr 100 diflunisal tab 500 etodolac cap 200 etodolac cap 300 Drug Tier etodolac tab 400 (generic of LODINE) etodolac tab 500 etodolac tab er 24hr 400 etodolac tab er 24hr 500 etodolac tab er 24hr 600 flurbiprofen tab 50 flurbiprofen tab 100 ibuprofen susp 100 /5ml ibuprofen tab 400 ibuprofen tab 600 ibuprofen tab 800 ketoprofen cap 50 ketoprofen cap 75 meloxicam tab 7.5 (generic of MOBIC) meloxicam tab 15 (generic of MOBIC) nabumetone tab 500 nabumetone tab 750 naproxen sodium tab 275 naproxen sodium tab 550 (generic of ANAPROX DS) naproxen susp 125 /5ml (generic of NAPROSYN) naproxen tab 250 (generic of NAPROSYN) naproxen tab 375 naproxen tab 500 (generic of NAPROSYN) naproxen tab ec 375 (generic of EC- NAPROSYN) naproxen tab ec 500 (generic of EC- NAPROSYN) piroxicam cap 10 (generic of FELDENE) piroxicam cap 20 (generic of FELDENE) sulindac tab 150 sulindac tab 200 OPIOID ANALGESICS B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization Requirements/ Limits 7

10 acetaminophen w/ codeine soln /5ml (5000 ml / 30 acetaminophen w/ codeine tab (400 tabs / 30 acetaminophen w/ codeine tab (generic of TYLENOL/CODEINE #3) (400 tabs / 30 acetaminophen w/ codeine tab (generic of TYLENOL/CODEINE #4) (400 tabs / 30 butorphanol tartrate inj 1 /ml butorphanol tartrate inj 2 /ml Tier 3 Tier 3 nalbuphine hcl inj 10 /ml Tier 3 nalbuphine hcl inj 20 /ml Tier 3 tramadol hcl tab 50 (generic of ULTRAM) (240 tabs / 30 tramadol-acetaminophen tab (generic of ULTRACET) (240 tabs / 30 OPIOID ANALGESICS, CII fentanyl citrate lozenge on a handle 200 mcg (generic of ACTIQ) (120 lozenges / 30 fentanyl citrate lozenge on a handle 400 mcg (generic of ACTIQ) (120 lozenges / 30 fentanyl citrate lozenge on a handle 600 mcg (generic of ACTIQ) (120 lozenges / 30 fentanyl citrate lozenge on a handle 800 mcg (generic of ACTIQ) (120 lozenges / 30 fentanyl citrate lozenge on a handle 1200 mcg (generic of ACTIQ) (120 lozenges / 30 fentanyl citrate lozenge on a handle 1600 mcg (generic of ACTIQ) (120 lozenges / 30 fentanyl td patch 72hr 12 mcg/hr (generic of DURAGESIC) (10 patches / 30 fentanyl td patch 72hr 25 mcg/hr (generic of DURAGESIC) (10 patches / 30 fentanyl td patch 72hr 50 mcg/hr (generic of DURAGESIC) (10 patches / 30 fentanyl td patch 72hr 75 mcg/hr (generic of DURAGESIC) (10 patches / 30 fentanyl td patch 72hr 100 mcg/hr (generic of DURAGESIC) (10 patches / 30 B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 8

11 FENTORA TAB 100MCG (120 tabs / 30 FENTORA TAB 200MCG (120 tabs / 30 FENTORA TAB 400MCG (120 tabs / 30 FENTORA TAB 600MCG (120 tabs / 30 FENTORA TAB 800MCG (120 tabs / 30 hydrocodoneacetaminophen soln /15ml (generic of HYCET) (5400 ml / 30 hydrocodoneacetaminophen tab (generic of NORCO, LORCET) (360 tabs / 30 hydrocodoneacetaminophen tab (generic of NORCO, LORCET PLUS) (360 tabs / 30 hydrocodoneacetaminophen tab (generic of NORCO, LORCET HD) (360 tabs / 30 hydrocodone-ibuprofen tab (150 tabs / 30 hydromorphone hcl liqd 1 /ml (generic of DILAUDID) Tier 2 Tier 2 Tier 2 Tier 2 Tier 2 hydromorphone hcl preservative free (pf) inj 10 /ml hydromorphone hcl tab 2 (generic of DILAUDID) (270 tabs / 30 hydromorphone hcl tab 4 (generic of DILAUDID) (270 tabs / 30 hydromorphone hcl tab 8 (generic of DILAUDID) (270 tabs / 30 HYSINGLA ER TAB 20 MG Tier 3 B/D Tier 2 (60 tabs / 30 HYSINGLA ER TAB 30 MG Tier 2 (60 tabs / 30 HYSINGLA ER TAB 40 MG Tier 2 (60 tabs / 30 HYSINGLA ER TAB 60 MG Tier 2 (60 tabs / 30 HYSINGLA ER TAB 80 MG Tier 2 (30 tabs / 30 HYSINGLA ER TAB 100 Tier 2 MG (30 tabs / 30 HYSINGLA ER TAB 120 MG (30 tabs / 30 methadone hcl conc 10 /ml (generic of METHADOSE) Tier 2 (120 ml / 30 methadone hcl soln 5 /5ml (450 ml / 30 methadone hcl soln 10 /5ml (450 ml / 30 methadone hcl tab 5 (generic of DOLOPHINE) (180 tabs / 30 B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 9

12 methadone hcl tab 10 (generic of DOLOPHINE) (180 tabs / 30 MORPHINE SUL INJ 2MG/ML MORPHINE SUL INJ 4MG/ML MORPHINE SUL INJ 8MG/ML MORPHINE SUL INJ 10MG/ML MORPHINE SUL INJ 150/30ML morphine sulfate iv soln 1 /ml morphine sulfate iv soln pf 4 /ml (generic of MORPHINE SULFATE) morphine sulfate iv soln pf 8 /ml (generic of MORPHINE SULFATE) morphine sulfate iv soln pf 10 /ml (generic of MORPHINE SULFATE) morphine sulfate iv soln pf 15 /ml morphine sulfate oral soln 10 /5ml morphine sulfate oral soln 20 /5ml morphine sulfate oral soln 100 /5ml (20 /ml) morphine sulfate tab 15 (180 tabs / 30 morphine sulfate tab 30 (180 tabs / 30 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 Tier 3 morphine sulfate tab er 15 (generic of MS CONTIN) (90 tabs / 30 morphine sulfate tab er 30 (generic of MS CONTIN) (90 tabs / 30 B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D morphine sulfate tab er 60 (generic of MS CONTIN) (90 tabs / 30 morphine sulfate tab er 100 (generic of MS CONTIN) (90 tabs / 30 morphine sulfate tab er 200 (generic of MS CONTIN) (60 tabs / 30 NUCYNTA ER TAB 50MG (120 tabs / 30 Tier 2 NUCYNTA ER TAB 100MG Tier 2 (120 tabs / 30 NUCYNTA ER TAB 150MG Tier 2 (60 tabs / 30 NUCYNTA ER TAB 200MG Tier 2 (60 tabs / 30 NUCYNTA ER TAB 250MG Tier 2 (60 tabs / 30 oxycodone hcl cap 5 (180 caps / 30 oxycodone hcl conc 100 /5ml (20 /ml) oxycodone hcl soln 5 /5ml oxycodone hcl tab 5 (generic of ROXICODONE) (180 tabs / 30 oxycodone hcl tab 10 (180 tabs / 30 oxycodone hcl tab 15 (generic of ROXICODONE) (180 tabs / 30 oxycodone hcl tab 20 (180 tabs / 30 oxycodone hcl tab 30 (generic of ROXICODONE) (180 tabs / 30 B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 10

13 oxycodone w/ acetaminophen soln /5ml (1800 ml / 30 oxycodone w/ acetaminophen tab (generic of PERCOCET) (360 tabs / 30 oxycodone w/ acetaminophen tab (generic of PERCOCET) (360 tabs / 30 oxycodone w/ acetaminophen tab (generic of PERCOCET) (360 tabs / 30 oxycodone w/ acetaminophen tab (generic of PERCOCET) (360 tabs / 30 ANESTHETICS LOCAL ANESTHETICS lidocaine hcl local inj 0.5% (generic of XYLOCAINE) lidocaine hcl local inj 1% (generic of XYLOCAINE) lidocaine hcl local inj 2% (generic of XYLOCAINE) lidocaine hcl local preservative free (pf) inj 0.5% (generic of XYLOCAINE-MPF) lidocaine hcl local preservative free (pf) inj 1% (generic of XYLOCAINE- MPF) lidocaine hcl local preservative free (pf) inj 1.5% (generic of XYLOCAINE-MPF) B/D B/D B/D B/D B/D B/D ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 /ml) amikacin sulfate inj 500 /2ml (250 /ml) gentamicin in saline inj 0.8 /ml gentamicin in saline inj 1 /ml gentamicin in saline inj 1.2 /ml gentamicin in saline inj 1.6 /ml gentamicin in saline inj 2 /ml gentamicin sulfate inj 10 /ml gentamicin sulfate inj 40 /ml gentamicin sulfate iv soln 10 /ml neomycin sulfate tab 500 paromomycin sulfate cap 250 streptomycin sulfate for inj 1 gm SULFADIAZINE TAB Tier 3 500MG tobramycin nebu soln 300 /5ml (generic of KITABIS K) NMO tobramycin sulfate for inj 1.2 gm tobramycin sulfate inj 1.2 gm/30ml (40 /ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 /ml) (base equiv) tobramycin sulfate inj 10 /ml (base equivalent) tobramycin sulfate inj 80 /2ml (40 /ml) (base equiv) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG Tier 2 B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 11

14 Drug Tier ALINIA SUS 100/5ML Tier 2 ALINIA TAB 500MG Tier 2 atovaquone susp 750 /5ml (generic of MEPRON) Requirements/ Limits AZACTAM/DEX INJ 1GM Tier 3 AZACTAM/DEX INJ 2GM Tier 3 aztreonam for inj 1 gm (generic of AZACTAM) aztreonam for inj 2 gm (generic of AZACTAM) BILTRICIDE TAB 600MG Tier 2 CAYSTON INH 75MG Tier 2 NMO LA clindamycin hcl cap 75 (generic of CLEOCIN) clindamycin hcl cap 150 (generic of CLEOCIN) clindamycin hcl cap 300 (generic of CLEOCIN) clindamycin palmitate hcl for soln 75 /5ml (base equiv) (generic of CLEOCIN PEDIATRIC GRANULE) clindamycin phosphate in d5w iv soln 300 /50ml (generic of CLEOCIN IN D5W) clindamycin phosphate in d5w iv soln 600 /50ml (generic of CLEOCIN IN D5W) clindamycin phosphate in d5w iv soln 900 /50ml (generic of CLEOCIN IN D5W) clindamycin phosphate inj 9 gm/60ml (generic of CLEOCIN PHOSPHATE) clindamycin phosphate inj 300 /2ml (generic of CLEOCIN PHOSPHATE) clindamycin phosphate inj 600 /4ml (generic of CLEOCIN PHOSPHATE) clindamycin phosphate inj 900 /6ml (generic of CLEOCIN PHOSPHATE) clindamycin phosphate iv soln 300 /2ml (generic of CLEOCIN PHOSPHATE) clindamycin phosphate iv soln 900 /6ml (generic of CLEOCIN PHOSPHATE) CLINDMYC/NAC INJ 300/50ML CLINDMYC/NAC INJ 600/50ML CLINDMYC/NAC INJ 900/50ML colistimethate sodium for inj 150 (generic of COLY- MYCIN M) Drug Tier Tier 3 Tier 3 Tier 3 dapsone tab 25 dapsone tab 100 daptomycin for iv soln 500 (generic of CUBICIN) EMVERM CHW 100MG imipenem-cilastatin intravenous for soln 250 (generic of PRIMAXIN IV) imipenem-cilastatin intravenous for soln 500 (generic of PRIMAXIN IV) INVANZ INJ 1GM Tier 3 ivermectin tab 3 (generic of STROMECTOL) linezolid for susp 100 /5ml (generic of ZYVOX) linezolid in sodium chloride iv soln 600 /300ml-0.9% linezolid iv soln 600 /300ml (2 /ml) (generic of ZYVOX) linezolid tab 600 (generic of ZYVOX) meropenem iv for soln 1 gm (generic of MERREM) meropenem iv for soln 500 (generic of MERREM) Requirements/ Limits B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 12

15 methenamine hippurate tab 1 gm (generic of HIPREX) metronidazole in nacl 0.79% iv soln 500 /100ml metronidazole tab 250 (generic of FLAGYL) metronidazole tab 500 (generic of FLAGYL) NEBUPENT INH 300MG Tier 3 B/D nitrofurantoin macrocrystalline cap 50 (generic of MACRODANTIN) Tier 3 applies if 65 years and older after a 90 day supply in a calendar year nitrofurantoin macrocrystalline cap 100 (generic of MACRODANTIN) Tier 3 applies if 65 years and older after a 90 day supply in a calendar year nitrofurantoin monohydrate Tier 3 macrocrystalline cap 100 (generic of MACROBID) applies if 65 years and older after a 90 day supply in a calendar year PENTAM 300 INJ 300MG Tier 3 SIVEXTRO INJ 200MG Tier 2 SIVEXTRO TAB 200MG Tier 2 sulfamethoxazoletrimethoprim iv soln /5ml sulfamethoxazoletrimethoprim susp /5ml sulfamethoxazoletrimethoprim tab (generic of BACTRIM) sulfamethoxazoletrimethoprim tab (generic of BACTRIM DS) SYNERCID INJ 500MG Tier 2 Drug Tier TIGECYCLINE INJ 50MG Tier 2 trimethoprim tab 100 vancomycin hcl cap 125 (generic of VANCOCIN HCL) vancomycin hcl cap 250 (generic of VANCOCIN HCL) Requirements/ Limits vancomycin hcl for inj 10 gm vancomycin hcl for inj 500 vancomycin hcl for inj 750 vancomycin hcl for inj 1000 vancomycin hcl for inj 5000 VANCOMYCIN INJ 1 GM Tier 3 VANCOMYCIN INJ 500MG Tier 3 VANCOMYCIN INJ 750MG Tier 3 ANTIFUNGALS ABELCET INJ 5MG/ML Tier 2 B/D AMBISOME INJ 50MG Tier 2 B/D amphotericin b for inj 50 CANCIDAS INJ 50MG Tier 2 CANCIDAS INJ 70MG Tier 2 CASPOFUNGIN INJ 50MG Tier 2 CASPOFUNGIN INJ 70MG Tier 2 fluconazole for susp 10 /ml (generic of DIFLUCAN) fluconazole for susp 40 /ml (generic of DIFLUCAN) fluconazole in dextrose inj 200 /100ml fluconazole in dextrose inj 400 /200ml fluconazole in nacl 0.9% inj 200 /100ml fluconazole in nacl 0.9% inj 400 /200ml fluconazole tab 50 (generic of DIFLUCAN) B/D B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 13

16 fluconazole tab 100 (generic of DIFLUCAN) fluconazole tab 150 (generic of DIFLUCAN) fluconazole tab 200 (generic of DIFLUCAN) FLUCONAZOLE/ INJ NACL Tier flucytosine cap 250 (generic of ANCOBON) flucytosine cap 500 (generic of ANCOBON) griseofulvin microsize susp 125 /5ml griseofulvin microsize tab 500 griseofulvin ultramicrosize tab 125 (generic of GRIS-PEG) griseofulvin ultramicrosize tab 250 (generic of GRIS-PEG) itraconazole cap 100 (generic of SPORANOX) ketoconazole tab 200 MYCAMINE INJ 50MG Tier 2 MYCAMINE INJ 100MG Tier 2 NOXAFIL SUS 40MG/ML Tier 2 (630 ml / 30 NOXAFIL TAB 100MG Tier 2 (93 tabs / 30 nystatin tab unit terbinafine hcl tab 250 (generic of LAMISIL) (90 tabs / 365 voriconazole for inj 200 (generic of VFEND IV) voriconazole for susp 40 /ml (generic of VFEND) voriconazole tab 50 (generic of VFEND) voriconazole tab 200 (generic of VFEND) ANTIMALARIALS atovaquone-proguanil hcl tab (generic of MALARONE) atovaquone-proguanil hcl tab (generic of MALARONE) chloroquine phosphate tab 250 chloroquine phosphate tab Drug Tier 500 COARTEM TAB MG Tier 3 mefloquine hcl tab 250 PRIMAQUINE TAB 26.3MG Tier 2 Requirements/ Limits quinine sulfate cap 324 (generic of QUALAQUIN) ANTIRETROVIRAL AGENTS abacavir sulfate soln 20 NMO /ml (base equiv) (generic of ZIAGEN) abacavir sulfate tab 300 NMO (base equiv) (generic of ZIAGEN) APTIVUS CAP 250MG Tier 2 NMO APTIVUS SOL Tier 2 NMO CRIXIVAN CAP 200MG Tier 3 NMO CRIXIVAN CAP 400MG Tier 3 NMO didanosine delayed release NMO capsule 125 (generic of VIDEX EC) didanosine delayed release NMO capsule 200 (generic of VIDEX EC) didanosine delayed release NMO capsule 250 (generic of VIDEX EC) didanosine delayed release NMO capsule 400 (generic of VIDEX EC) EDURANT TAB 25MG Tier 2 NMO EMTRIVA CAP 200MG Tier 2 NMO EMTRIVA SOL 10MG/ML Tier 2 NMO fosamprenavir calcium tab NMO 700 (base equiv) (generic of LEXIVA) FUZEON INJ 90MG Tier 2 NMO INTELENCE TAB 25MG Tier 3 NMO B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 14

17 INTELENCE TAB 100MG Tier 2 NMO INTELENCE TAB 200MG Tier 2 NMO INVIRASE CAP 200MG Tier 2 NMO INVIRASE TAB 500MG Tier 2 NMO ISENTRESS CHW 25MG Tier 2 NMO ISENTRESS CHW 100MG Tier 2 NMO ISENTRESS HD TAB 600MG Tier 2 NMO ISENTRESS POW 100MG Tier 2 NMO ISENTRESS TAB 400MG Tier 2 NMO lamivudine oral soln 10 NMO /ml (generic of EPIVIR) lamivudine tab 150 NMO (generic of EPIVIR) lamivudine tab 300 NMO (generic of EPIVIR) LEXIVA SUS 50MG/ML Tier 3 NMO LEXIVA TAB 700MG Tier 2 NMO nevirapine susp 50 /5ml NMO nevirapine tab 200 NMO (generic of VIRAMUNE) nevirapine tab er 24hr 100 NMO (generic of VIRAMUNE XR) nevirapine tab er 24hr 400 NMO (generic of VIRAMUNE XR) NORVIR CAP 100MG Tier 2 NMO NORVIR SOL 80MG/ML Tier 2 NMO NORVIR TAB 100MG Tier 2 NMO PREZISTA SUS 100MG/ML Tier 2 NMO (400 ml / 30 Tier 2 PREZISTA TAB 75MG (480 tabs / 30 PREZISTA TAB 150MG (240 tabs / 30 Tier 2 NMO NMO PREZISTA TAB 600MG Tier 2 NMO (60 tabs / 30 PREZISTA TAB 800MG Tier 2 NMO (30 tabs / 30 RESCRIPTOR TAB 100 MG Tier 3 NMO RESCRIPTOR TAB 200MG Tier 3 NMO RETROVIR INJ 10MG/ML Tier 3 NMO REYATAZ CAP 150MG Tier 2 NMO REYATAZ CAP 200MG Tier 2 NMO REYATAZ CAP 300MG Tier 2 NMO REYATAZ POW 50MG Tier 2 NMO SELZENTRY SOL Tier 2 NMO 20MG/ML SELZENTRY TAB 25MG Tier 3 NMO SELZENTRY TAB 75MG Tier 2 NMO SELZENTRY TAB 150MG Tier 2 NMO SELZENTRY TAB 300MG Tier 2 NMO stavudine cap 15 NMO (generic of ZERIT) stavudine cap 20 NMO (generic of ZERIT) stavudine cap 30 NMO (generic of ZERIT) stavudine cap 40 NMO (generic of ZERIT) SUSTIVA CAP 50MG Tier 3 NMO SUSTIVA CAP 200MG Tier 2 NMO SUSTIVA TAB 600MG Tier 2 NMO TIVICAY TAB 10MG Tier 2 NMO TIVICAY TAB 25MG Tier 2 NMO TIVICAY TAB 50MG Tier 2 NMO TYBOST TAB 150MG Tier 2 NMO VIDEX SOL 2GM Tier 3 NMO VIDEX SOL 4GM Tier 3 NMO VIRACEPT TAB 250MG Tier 2 NMO VIRACEPT TAB 625MG Tier 2 NMO VIRAMUNE SUS Tier 3 NMO 50MG/5ML VIREAD POW 40MG/GM Tier 2 NMO VIREAD TAB 150MG Tier 2 NMO VIREAD TAB 200MG Tier 2 NMO VIREAD TAB 250MG Tier 2 NMO VIREAD TAB 300MG Tier 2 NMO ZERIT SOL 1MG/ML Tier 2 NMO ZIAGEN SOL 20MG/ML Tier 2 NMO zidovudine cap 100 (generic of RETROVIR) NMO zidovudine syrup 10 /ml NMO (generic of RETROVIR) zidovudine tab 300 NMO ANTIRETROVIRAL COMBINATION AGENTS B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 15

18 abacavir sulfate-lamivudine tab (generic of EPZICOM) abacavir sulfate-lamivudinezidovudine tab (generic of TRIZIVIR) NMO NMO ATRIPLA TAB Tier 2 NMO COMPLERA TAB Tier 2 NMO DESCOVY TAB 200/25 Tier 2 NMO EVOTAZ TAB Tier 2 NMO GENVOYA TAB Tier 2 NMO KALETRA TAB MG Tier 3 KALETRA TAB MG Tier 2 lamivudine-zidovudine tab (generic of COMBIVIR) lopinavir-ritonavir soln /5ml (80-20 /ml) (generic of KALETRA) NMO NMO NMO NMO ODEFSEY TAB Tier 2 NMO PREZCOBIX TAB Tier 2 NMO STRIBILD TAB Tier 2 NMO TRIUMEQ TAB Tier 2 NMO TRUVADA TAB Tier 2 NMO (60 tabs / 30 TRUVADA TAB Tier 2 NMO (30 tabs / 30 TRUVADA TAB Tier 2 NMO (30 tabs / 30 TRUVADA TAB Tier 2 NMO (30 tabs / 30 ANTITUBERCULAR AGENTS CASTAT SUL INJ 1GM Tier 3 cycloserine cap 250 ethambutol hcl tab 100 (generic of MYAMBUTOL) ethambutol hcl tab 400 (generic of MYAMBUTOL) isoniazid inj 100 /ml isoniazid syrup 50 /5ml isoniazid tab 100 isoniazid tab 300 SER GRA 4GM Tier 3 PRIFTIN TAB 150MG Tier 3 pyrazinamide tab 500 Drug Tier B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization Requirements/ Limits rifabutin cap 150 (generic of MYCOBUTIN) rifampin cap 150 (generic of RIFADIN) rifampin cap 300 (generic of RIFADIN) rifampin for inj 600 (generic of RIFADIN) RIFATER TAB Tier 3 SIRTURO TAB 100MG Tier 2 LA TRECATOR TAB 250MG Tier 3 ANTIVIRALS acyclovir cap 200 (generic of ZOVIRAX) acyclovir sodium for inj 500 B/D acyclovir sodium iv soln 50 B/D /ml acyclovir susp 200 /5ml (generic of ZOVIRAX) acyclovir tab 400 (generic of ZOVIRAX) acyclovir tab 800 (generic of ZOVIRAX) adefovir dipivoxil tab 10 NMO (generic of HEPSERA) BARACLUDE SOL Tier 2 NMO.05MG/ML DAKLINZA TAB 30MG Tier 2 NMO DAKLINZA TAB 60MG Tier 2 NMO DAKLINZA TAB 90MG Tier 2 NMO entecavir tab 0.5 (generic of BARACLUDE) NMO entecavir tab 1 (generic NMO of BARACLUDE) EPCLUSA TAB Tier 2 NMO EPIVIR HBV SOL 5MG/ML Tier 3 NMO famciclovir tab 125 famciclovir tab 250 famciclovir tab 500 ganciclovir sodium for inj 500 (generic of CYTOVENE) B/D HARVONI TAB MG Tier 2 lamivudine tab 100 (hbv) (generic of EPIVIR HBV) NMO NMO 16

19 MAVYRET TAB MG Tier 2 NMO oseltamivir phosphate cap 30 (base equiv) (generic of TAMIFLU) (168 caps / year) oseltamivir phosphate cap 45 (base equiv) (generic of TAMIFLU) (84 caps / year) oseltamivir phosphate cap 75 (base equiv) (generic of TAMIFLU) (84 caps / year) PEGASYS INJ Tier 2 NMO PEGASYS INJ 180MCG/M Tier 2 NMO PEGASYS INJ PROCLICK Tier 2 NMO REBETOL SOL 40MG/ML Tier 2 NMO RELENZA MIS DISKHALE Tier 2 (6 inhalers / year) ribavirin cap 200 NMO (generic of REBETOL) ribavirin tab 200 NMO (generic of COPEGUS) ribavirin tab 400 NMO ribavirin tab 600 NMO rimantadine hydrochloride tab 100 (generic of FLUMADINE) SOVALDI TAB 400MG Tier 2 NMO TAMIFLU SUS 6MG/ML Tier 2 (1080 ml / year) valacyclovir hcl tab 1 gm (generic of VALTREX) valacyclovir hcl tab 500 (generic of VALTREX) valganciclovir hcl for soln 50 /ml (base equiv) (generic of VALCYTE) valganciclovir hcl tab 450 (base equivalent) (generic of VALCYTE) VEMLIDY TAB 25MG Tier 2 NMO VOSEVI TAB Tier 2 NMO ZETIER TAB MG Tier 2 NMO CEPHALOSPORINS cefaclor cap 250 Drug Tier cefaclor cap 500 CEFACLOR ER TAB Tier 3 500MG cefaclor for susp 125 /5ml cefaclor for susp 250 /5ml cefaclor for susp 375 /5ml cefadroxil cap 500 cefadroxil for susp 250 /5ml cefadroxil for susp 500 /5ml cefadroxil tab 1 gm CEFAZOLIN INJ 1GM/50ML Tier 2 cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 20 gm cefazolin sodium for inj 500 cefazolin sodium for iv soln 1 gm CEFAZOLIN SOL Tier 2 cefdinir cap 300 cefdinir for susp 125 /5ml cefdinir for susp 250 /5ml cefepime hcl for inj 1 gm (generic of MAXIPIME) cefepime hcl for inj 2 gm (generic of MAXIPIME) cefixime for susp 100 /5ml (generic of SUPRAX) cefixime for susp 200 /5ml (generic of SUPRAX) cefotaxime sodium for inj 1 gm cefotaxime sodium for inj 2 gm cefotaxime sodium for inj 500 B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization Requirements/ Limits 17

20 cefoxitin sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln 2 gm cefpodoxime proxetil for susp 50 /5ml cefpodoxime proxetil for susp 100 /5ml cefpodoxime proxetil tab 100 cefpodoxime proxetil tab 200 cefprozil for susp 125 /5ml cefprozil for susp 250 /5ml cefprozil tab 250 cefprozil tab 500 ceftazidime for inj 1 gm ceftazidime for inj 2 gm ceftazidime for inj 6 gm ceftazidime for iv soln 1 gm ceftazidime for iv soln 2 gm CEFTAZIDIME/ SOL D5W Tier 3 1GM CEFTAZIDIME/ SOL D5W Tier 3 2GM ceftriaxone sodium for inj 1 gm (generic of ROCEPHIN) ceftriaxone sodium for inj 2 gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 250 ceftriaxone sodium for inj 500 ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln 2 gm cefuroxime axetil tab 250 (generic of CEFTIN) Drug Tier cefuroxime axetil tab 500 cefuroxime sodium for inj 1.5 gm cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj 750 cefuroxime sodium for iv soln 1.5 gm cephalexin cap 250 (generic of KEFLEX) cephalexin cap 500 (generic of KEFLEX) cephalexin for susp 125 /5ml cephalexin for susp 250 /5ml SUPRAX CAP 400MG Tier 2 SUPRAX CHW 100MG Tier 3 SUPRAX CHW 200MG Tier 3 SUPRAX SUS 500/5ML Tier 2 TEFLARO INJ 400MG Tier 2 TEFLARO INJ 600MG Tier 2 ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 /5ml (generic of ZITHROMAX) azithromycin for susp 200 /5ml (generic of ZITHROMAX) azithromycin iv for soln 500 (generic of ZITHROMAX) azithromycin powd pack for susp 1 gm azithromycin tab 250 (generic of ZITHROMAX) azithromycin tab 500 (generic of ZITHROMAX) azithromycin tab 600 (generic of ZITHROMAX) clarithromycin for susp 125 /5ml clarithromycin for susp 250 /5ml B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization Requirements/ Limits 18

21 clarithromycin tab 250 (generic of BIAXIN) clarithromycin tab 500 (generic of BIAXIN) clarithromycin tab er 24hr 500 (generic of BIAXIN XL) DIFICID TAB 200MG Tier 2 ERYTHROCIN INJ 500MG Tier 3 erythromycin ethylsuccinate tab 400 erythromycin stearate tab 250 erythromycin tab 250 erythromycin tab 500 erythromycin tab delayed release 250 erythromycin tab delayed release 333 erythromycin tab delayed release 500 erythromycin w/ delayed release particles cap 250 FLUOROQUINOLONES ciprofloxacin 200 /100ml in d5w ciprofloxacin 400 /200ml in d5w (generic of CIPRO I.V.-IN D5W) ciprofloxacin for oral susp 250 /5ml (5%) (5 gm/100ml) (generic of CIPRO) ciprofloxacin for oral susp 500 /5ml (10%) (10 gm/100ml) (generic of CIPRO) ciprofloxacin hcl tab 100 (base equiv) ciprofloxacin hcl tab 250 (base equiv) (generic of CIPRO) ciprofloxacin hcl tab 500 (base equiv) (generic of CIPRO) Drug Tier ciprofloxacin hcl tab 750 (base equiv) ciprofloxacin iv soln 200 /20ml (1%) ciprofloxacin iv soln 400 /40ml (1%) levofloxacin in d5w iv soln 250 /50ml levofloxacin in d5w iv soln 500 /100ml levofloxacin in d5w iv soln 750 /150ml levofloxacin iv soln 25 /ml levofloxacin oral soln 25 /ml levofloxacin tab 250 (generic of LEVAQUIN) levofloxacin tab 500 (generic of LEVAQUIN) levofloxacin tab 750 (generic of LEVAQUIN) PENICILLINS amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (generic of AUGMENTIN) amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (generic of AUGMENTIN ES-600) amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab (generic of AUGMENTIN) amoxicillin & k clavulanate tab (generic of AUGMENTIN) Requirements/ Limits B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 19

22 amoxicillin & k clavulanate tab er 12hr (generic of AUGMENTIN XR) amoxicillin (trihydrate) cap 250 amoxicillin (trihydrate) cap 500 Drug Tier amoxicillin (trihydrate) chew tab 125 amoxicillin (trihydrate) chew tab 250 amoxicillin (trihydrate) for susp 125 /5ml amoxicillin (trihydrate) for susp 200 /5ml amoxicillin (trihydrate) for susp 250 /5ml amoxicillin (trihydrate) for susp 400 /5ml amoxicillin (trihydrate) tab 500 amoxicillin (trihydrate) tab 875 ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm (generic of UNASYN) ampicillin & sulbactam sodium for inj 3 (2-1) gm (generic of UNASYN) ampicillin & sulbactam sodium for inj 15 (10-5) gm (generic of UNASYN BULK CK) ampicillin & sulbactam sodium for iv soln 15 (10-5) gm Requirements/ Limits ampicillin sodium for inj 10 gm ampicillin sodium for inj 125 ampicillin sodium for inj 250 ampicillin sodium for inj 500 ampicillin sodium for iv soln 1 gm ampicillin sodium for iv soln 2 gm ampicillin sodium for iv soln 10 gm BICILLIN L-A INJ Tier 3 BICILLIN L-A INJ Tier 3 BICILLIN L-A INJ Tier 3 dicloxacillin sodium cap 250 dicloxacillin sodium cap 500 nafcillin sodium for inj 1 gm nafcillin sodium for inj 2 gm nafcillin sodium for inj 10 gm nafcillin sodium for iv soln 1 gm nafcillin sodium for iv soln 2 gm oxacillin sodium for inj 1 gm (base equivalent) oxacillin sodium for inj 2 gm (base equivalent) oxacillin sodium for inj 10 gm (base equivalent) PEN G PROC INJ Tier 3 PENICILL GK/ INJ DEX Tier 3 ampicillin cap 250 2MU ampicillin cap 500 PENICILL GK/ INJ DEX Tier 3 ampicillin for susp 125 3MU /5ml penicillin g potassium for inj ampicillin for susp unit /5ml penicillin g potassium for inj ampicillin sodium for inj unit gm penicillin g sodium for inj ampicillin sodium for inj unit gm B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 20

23 penicillin v potassium for soln 125 /5ml penicillin v potassium for soln 250 /5ml penicillin v potassium tab 250 penicillin v potassium tab 500 PIPER/TAZOBA INJ GM piperacillin sod-tazobactam na for inj gm ( gm) (generic of ZOSYN) piperacillin sod-tazobactam sod for inj 2.25 gm ( gm) (generic of ZOSYN) Drug Tier Tier 3 piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) (generic of ZOSYN) piperacillin sod-tazobactam sod for inj 40.5 gm ( gm) (generic of ZOSYN) TETRACYCLINES doxycycline hyclate cap 50 doxycycline hyclate cap 100 (generic of VIBRAMYCIN) doxycycline hyclate for inj 100 doxycycline hyclate tab 20 doxycycline hyclate tab 100 doxycycline monohydrate cap 50 doxycycline monohydrate cap 100 (generic of MONODOX) doxycycline monohydrate tab 50 Requirements/ Limits Drug Tier minocycline hcl cap 50 (generic of MINOCIN) minocycline hcl cap 75 minocycline hcl cap 100 (generic of MINOCIN) ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA INJ 100/4ML Tier 2 B/D NMO Requirements/ Limits busulfan inj 6 /ml B/D (generic of BUSULFEX) CYCLOPHOSPH CAP Tier 3 B/D 25MG CYCLOPHOSPH CAP Tier 3 B/D 50MG cyclophosphamide for inj 1 B/D gm cyclophosphamide for inj 2 B/D gm cyclophosphamide for inj 500 B/D dacarbazine for inj 100 B/D dacarbazine for inj 200 B/D EMCYT CAP 140MG Tier 3 GLEOSTINE CAP 5MG Tier 3 GLEOSTINE CAP 10MG Tier 3 GLEOSTINE CAP 40MG Tier 3 GLEOSTINE CAP 100MG Tier 3 HEXALEN CAP 50MG Tier 2 IFEX INJ 3GM Tier 3 B/D ifosfamide for inj 1 gm B/D (generic of IFEX) IFOSFAMIDE INJ 3GM Tier 3 B/D ifosfamide iv inj 1 gm/20ml B/D (50 /ml) ifosfamide iv inj 3 gm/60ml B/D (50 /ml) LEUKERAN TAB 2MG Tier 3 melphalan hcl for inj 50 B/D (base equiv) (generic of ALKERAN) doxycycline monohydrate MUSTARGEN INJ 10MG Tier 2 B/D tab 75 ANTHRACYCLINES doxycycline monohydrate doxorubicin hcl for inj 10 B/D tab 100 doxorubicin hcl for inj 50 B/D doxycycline monohydrate doxorubicin hcl inj 2 /ml B/D tab 150 B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 21

24 doxorubicin hcl liposomal inj (for iv infusion) 2 /ml (generic of DOXIL) epirubicin hcl iv soln 50 /25ml (2 /ml) (generic of ELLENCE) epirubicin hcl iv soln 200 /100ml (2 /ml) (generic of ELLENCE) ANTIBIOTICS bleomycin sulfate for inj 15 unit B/D B/D B/D B/D bleomycin sulfate for inj 30 B/D unit mitomycin for iv soln 5 B/D mitomycin for iv soln 20 B/D mitomycin for iv soln 40 B/D ANTIMETABOLITES ALIMTA INJ 100MG Tier 2 B/D ALIMTA INJ 500MG Tier 2 B/D azacitidine for inj 100 B/D NMO (generic of VIDAZA) cladribine iv soln 10 B/D /10ml (1 /ml) cytarabine inj 20 /ml B/D fludarabine phosphate for inj B/D 50 fludarabine phosphate inj 25 B/D /ml fluorouracil inj 1 gm/20ml (50 /ml) B/D fluorouracil inj 2.5 gm/50ml B/D (50 /ml) fluorouracil inj 5 gm/100ml (50 /ml) B/D fluorouracil inj 500 /10ml B/D (50 /ml) gemcitabine hcl for inj 1 gm B/D (generic of GEMZAR) gemcitabine hcl for inj 2 gm B/D gemcitabine hcl for inj 200 B/D (generic of GEMZAR) gemcitabine hcl inj 1 B/D gm/26.3ml (38 /ml) (base equiv) gemcitabine hcl inj 2 B/D gm/52.6ml (38 /ml) (base equiv) gemcitabine hcl inj 200 B/D /5.26ml (38 /ml) (base equiv) mercaptopurine tab 50 methotrexate sodium for inj B/D 1 gm methotrexate sodium inj 50 B/D /2ml (25 /ml) methotrexate sodium inj 250 B/D /10ml (25 /ml) methotrexate sodium inj pf B/D 50 /2ml (25 /ml) methotrexate sodium inj pf B/D 100 /4ml (25 /ml) methotrexate sodium inj pf B/D 200 /8ml (25 /ml) methotrexate sodium inj pf B/D 250 /10ml (25 /ml) methotrexate sodium inj pf 1000 /40ml (25 /ml) B/D NIPENT INJ 10MG Tier 2 B/D PURIXAN SUS 20MG/ML Tier 2 NMO TABLOID TAB 40MG Tier 3 ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG Tier 2 B/D DOCEFREZ INJ 20MG Tier 2 B/D docetaxel for inj conc 20 /ml (generic of TAXOTERE) docetaxel for inj conc 80 /4ml (20 /ml) (generic of TAXOTERE) B/D B/D DOCETAXEL INJ Tier 2 B/D 20MG/2ML DOCETAXEL INJ Tier 2 B/D 80MG/4ML DOCETAXEL INJ 80MG/8ML Tier 2 B/D DOCETAXEL INJ 160/8ML Tier 2 B/D DOCETAXEL INJ 160/16ML Tier 2 B/D DOCETAXEL INJ 200/10 B/D paclitaxel iv conc 30 /5ml B/D (6 /ml) B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 22

25 paclitaxel iv conc 100 B/D /16.7ml (6 /ml) paclitaxel iv conc 150 B/D /25ml (6 /ml) paclitaxel iv conc 300 /50ml (6 /ml) B/D TAXOTERE INJ 80MG/4ML Tier 2 B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate inj 1 B/D /ml vincristine sulfate iv soln 1 B/D /ml vinorelbine tartrate inj 10 B/D /ml (base equiv) (generic of NAVELBINE) vinorelbine tartrate inj 50 /5ml (10 /ml) (base equiv) (generic of NAVELBINE) B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN INJ Tier 2 NMO LA AVASTIN INJ 400/16ML Tier 2 NMO LA BELEODAQ INJ 500MG Tier 2 NMO ERIVEDGE CAP 150MG Tier 2 NMO LA FARYDAK CAP 10MG Tier 2 NMO LA FARYDAK CAP 15MG Tier 2 NMO LA FARYDAK CAP 20MG Tier 2 NMO LA HERCEPTIN INJ 150MG Tier 2 NMO HERCEPTIN INJ 440MG Tier 2 NMO IBRANCE CAP 75MG Tier 2 NMO LA IBRANCE CAP 100MG Tier 2 NMO LA IBRANCE CAP 125MG Tier 2 NMO LA IDHIFA TAB 50MG Tier 2 NMO LA IDHIFA TAB 100MG Tier 2 NMO LA KADCYLA INJ 100MG Tier 2 B/D NMO KADCYLA INJ 160MG Tier 2 B/D NMO KEYTRUDA INJ 100MG/4M Tier 2 NMO KEYTRUDA SOL 50MG Tier 2 NMO KISQALI 200 K FEMARA Tier 2 NMO KISQALI 400 K FEMARA Tier 2 NMO KISQALI 600 K FEMARA Tier 2 NMO KISQALI TAB 200DOSE Tier 2 NMO KISQALI TAB 400DOSE Tier 2 NMO KISQALI TAB 600DOSE Tier 2 NMO LYNRZA CAP 50MG Tier 2 NMO LA LYNRZA TAB 100MG Tier 2 NMO LA LYNRZA TAB 150MG Tier 2 NMO LA NINLARO CAP 2.3MG Tier 2 NMO NINLARO CAP 3MG Tier 2 NMO NINLARO CAP 4MG Tier 2 NMO ODOMZO CAP 200MG Tier 2 NMO LA RITUXAN INJ 100MG Tier 2 NMO LA RITUXAN INJ 500MG Tier 2 NMO LA RITUXAN INJ HYCELA Tier 2 NMO LA RUBRACA TAB 200MG Tier 2 NMO LA RUBRACA TAB 250MG Tier 2 NMO LA RUBRACA TAB 300MG Tier 2 NMO LA TECENTRIQ INJ 1200/20 Tier 2 NMO LA VELCADE INJ 3.5MG Tier 2 NMO VENCLEXTA TAB 10MG Tier 3 NMO LA VENCLEXTA TAB 50MG Tier 3 NMO LA VENCLEXTA TAB 100MG Tier 2 NMO LA VENCLEXTA TAB START Tier 2 NMO LA PK VERZENIO TAB 50MG Tier 2 NMO LA VERZENIO TAB 100MG Tier 2 NMO LA VERZENIO TAB 150MG Tier 2 NMO LA VERZENIO TAB 200MG Tier 2 NMO LA YERVOY INJ 50MG Tier 2 NMO YERVOY INJ 200MG Tier 2 NMO ZEJULA CAP 100MG Tier 2 NMO LA ZOLINZA CAP 100MG Tier 2 NMO HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 (generic of ARIMIDEX) bicalutamide tab 50 (generic of CASODEX) DEPO-PROVERA INJ Tier 3 B/D 400/ML exemestane tab 25 (generic of AROMASIN) FARESTON TAB 60MG Tier 2 FASLODEX INJ 250/5ML Tier 2 B/D flutamide cap 125 hydroxyprogesterone B/D caproate im in oil 1.25 gm/5ml letrozole tab 2.5 (generic of FEMARA) leuprolide acetate inj kit 5 /ml NMO B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 23

26 LUPRON DEPOT INJ Tier 2 NMO 3.75MG LUPRON DEPOT INJ Tier 2 NMO 11.25MG LYSODREN TAB 500MG Tier 2 megestrol acetate susp 40 /ml if 65 years and older Tier 3 megestrol acetate susp 625 Tier 3 /5ml (generic of MEGACE ES) megestrol acetate tab 20 Tier 3 if 65 years and older megestrol acetate tab 40 Tier 3 if 65 years and older nilutamide tab 150 (generic of NILANDRON) SOLTAMOX SOL 10MG/5ML Tier 3 tamoxifen citrate tab 10 (base equivalent) tamoxifen citrate tab 20 (base equivalent) TRELSTAR MIX INJ Tier 2 NMO 3.75MG TRELSTAR MIX INJ 11.25MG Tier 2 NMO XTANDI CAP 40MG Tier 2 NMO LA ZYTIGA TAB 250MG Tier 2 NMO LA ZYTIGA TAB 500MG Tier 2 NMO LA IMMUNOMODULATORS POMALYST CAP 1MG Tier 2 NMO LA POMALYST CAP 2MG Tier 2 NMO LA POMALYST CAP 3MG Tier 2 NMO LA POMALYST CAP 4MG Tier 2 NMO LA REVLIMID CAP 2.5MG Tier 2 NMO LA (28 caps / 28 REVLIMID CAP 5MG Tier 2 NMO LA (28 caps / 28 REVLIMID CAP 10MG Tier 2 NMO LA (28 caps / 28 REVLIMID CAP 15MG Tier 2 NMO LA (28 caps / 28 REVLIMID CAP 20MG Tier 2 NMO LA (28 caps / 28 REVLIMID CAP 25MG Tier 2 NMO LA (28 caps / 28 THALOMID CAP 50MG Tier 2 NMO (30 caps / 30 THALOMID CAP 100MG Tier 2 NMO (30 caps / 30 THALOMID CAP 150MG Tier 2 NMO (60 caps / 30 THALOMID CAP 200MG Tier 2 NMO (60 caps / 30 KINASE INHIBITORS AFINITOR DIS TAB 2MG Tier 2 NMO (150 tabs / 30 AFINITOR DIS TAB 3MG Tier 2 NMO (90 tabs / 30 AFINITOR DIS TAB 5MG Tier 2 NMO (60 tabs / 30 AFINITOR TAB 2.5MG Tier 2 NMO (30 tabs / 30 AFINITOR TAB 5MG Tier 2 NMO (30 tabs / 30 AFINITOR TAB 7.5MG Tier 2 NMO (30 tabs / 30 AFINITOR TAB 10MG Tier 2 NMO (30 tabs / 30 ALECENSA CAP 150MG Tier 2 NMO LA ALUNBRIG TAB 30MG Tier 2 NMO LA BOSULIF TAB 100MG Tier 2 NMO BOSULIF TAB 500MG Tier 2 NMO CABOMETYX TAB 20MG Tier 2 NMO LA (30 tabs / 30 CABOMETYX TAB 40MG Tier 2 NMO LA (30 tabs / 30 CABOMETYX TAB 60MG Tier 2 NMO LA (30 tabs / 30 CAPRELSA TAB 100MG Tier 2 NMO LA CAPRELSA TAB 300MG Tier 2 NMO LA COMETRIQ KIT 60MG Tier 2 NMO LA COMETRIQ KIT 100MG Tier 2 NMO LA COMETRIQ KIT 140MG Tier 2 NMO LA COTELLIC TAB 20MG Tier 2 NMO LA GILOTRIF TAB 20MG Tier 2 NMO LA GILOTRIF TAB 30MG Tier 2 NMO LA B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 24

27 GILOTRIF TAB 40MG Tier 2 NMO LA ICLUSIG TAB 15MG Tier 2 NMO LA ICLUSIG TAB 45MG Tier 2 NMO LA imatinib mesylate tab 100 NMO (base equivalent) (generic of GLEEVEC) (90 tabs / 30 imatinib mesylate tab 400 NMO (base equivalent) (generic of GLEEVEC) (60 tabs / 30 IMBRUVICA CAP 140MG Tier 2 NMO LA INLYTA TAB 1MG Tier 2 NMO LA (180 tabs / 30 INLYTA TAB 5MG (120 tabs / 30 Tier 2 NMO LA IRESSA TAB 250MG Tier 2 NMO LA JAKAFI TAB 5MG Tier 2 NMO LA (60 tabs / 30 JAKAFI TAB 10MG Tier 2 NMO LA (60 tabs / 30 JAKAFI TAB 15MG Tier 2 NMO LA (60 tabs / 30 JAKAFI TAB 20MG Tier 2 NMO LA (60 tabs / 30 JAKAFI TAB 25MG Tier 2 NMO LA (60 tabs / 30 LENVIMA CAP 8 MG Tier 2 NMO LA LENVIMA CAP 10 MG Tier 2 NMO LA LENVIMA CAP 14 MG Tier 2 NMO LA LENVIMA CAP 18 MG Tier 2 NMO LA LENVIMA CAP 20 MG Tier 2 NMO LA LENVIMA CAP 24 MG Tier 2 NMO LA MEKINIST TAB 0.5MG Tier 2 NMO LA MEKINIST TAB 2MG Tier 2 NMO LA NERLYNX TAB 40MG Tier 2 NMO LA NEXAVAR TAB 200MG Tier 2 NMO LA RYDAPT CAP 25MG Tier 2 NMO SPRYCEL TAB 20MG Tier 2 NMO SPRYCEL TAB 50MG Tier 2 NMO SPRYCEL TAB 70MG Tier 2 NMO SPRYCEL TAB 80MG Tier 2 NMO SPRYCEL TAB 100MG Tier 2 NMO SPRYCEL TAB 140MG Tier 2 NMO STIVARGA TAB 40MG Tier 2 NMO LA SUTENT CAP 12.5MG Tier 2 NMO SUTENT CAP 25MG Tier 2 NMO SUTENT CAP 37.5MG Tier 2 NMO SUTENT CAP 50MG Tier 2 NMO TAFINLAR CAP 50MG Tier 2 NMO LA TAFINLAR CAP 75MG Tier 2 NMO LA TAGRISSO TAB 40MG Tier 2 NMO LA TAGRISSO TAB 80MG Tier 2 NMO LA TARCEVA TAB 25MG Tier 2 NMO LA (90 tabs / 30 TARCEVA TAB 100MG Tier 2 NMO LA (30 tabs / 30 TARCEVA TAB 150MG Tier 2 NMO LA (30 tabs / 30 TASIGNA CAP 150MG Tier 2 NMO TASIGNA CAP 200MG Tier 2 NMO TYKERB TAB 250MG Tier 2 NMO LA VOTRIENT TAB 200MG Tier 2 NMO LA XALKORI CAP 200MG Tier 2 NMO LA XALKORI CAP 250MG Tier 2 NMO LA ZELBORAF TAB 240MG Tier 2 NMO LA ZYDELIG TAB 100MG Tier 2 NMO LA ZYDELIG TAB 150MG Tier 2 NMO LA ZYKADIA CAP 150MG Tier 2 NMO LA MISCELLANEOUS bexarotene cap 75 NMO (generic of TARGRETIN) DROXIA CAP 200MG Tier 2 DROXIA CAP 300MG Tier 2 DROXIA CAP 400MG Tier 2 hydroxyurea cap 500 (generic of HYDREA) LONSURF TAB Tier 2 NMO LONSURF TAB Tier 2 NMO MATULANE CAP 50MG Tier 2 LA mitoxantrone hcl inj conc 20 B/D NMO /10ml (2 /ml) mitoxantrone hcl inj conc 25 B/D NMO /12.5ml (2 /ml) mitoxantrone hcl inj conc 30 B/D NMO /15ml (2 /ml) SYLATRON KIT 200MCG Tier 2 NMO SYLATRON KIT 300MCG Tier 2 NMO SYLATRON KIT 600MCG Tier 2 NMO B/D Covered under Medicare Part B or D Quantity Limits Prior Authorization 25

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