CareFirst Exchange Formulary

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1 CareFirst Exchange Formulary 2018 PLEASE READ: This document contains information about the drugs we cover in this plan. This formulary is for: Individuals or families purchasing their own plan with an effective date of January 1, 2018 or after, and Members of an employer group with less than 51 employees purchasing a plan with an effective date of January 1, 2018 or after This formulary was updated 04/01/2018. For more recent information or other questions, please contact CareFirst Pharmacy Services at or visit Last updated 04/01/2018

2 Introduction A formulary is a list of covered prescription drugs. Our drug list is reviewed and approved by an independent national committee comprised of physicians, pharmacists and other health care professionals, known as the Pharmacy and Therapeutics Committee. This committee makes sure the drugs on the formulary are safe and clinically effective. Within the formulary, prescription drugs are divided into tiers as described below. Depending on your plan, prescription drugs fall into one of four drug tiers which determines the price you pay. Check your benefits information to see which tiers are covered in your plan. Using Your Formulary The first column of the formulary lists drugs by name. If the drugs are shown in lowercase italics, they are generic drugs. If the drugs are bold and capitalized, they are BRAND-NAME DRUGS. If the brand drug has a generic drug option available, it is listed under the brand-name drug. You may search the formulary for a drug by pressing CTRL and F at the same time to prompt a search. The second column indicates the drug tier for a covered drug. The third column indicates any prescription guidelines a drug requires such as prior authorization (), step therapy (ST) or quantity limits (QL). Prior Authorization Helps ensure the appropriate use of drugs by requiring provider to request approval for members to obtain certain drugs. Step Therapy Promotes the use of clinically and cost-effective drugs before members try equally effective, but more costly brandname drugs. Quantity Limits Address safety concerns and minimize waste by setting limits on the amount of a covered drug that can be dispensed. Members can view specific cost-share (copay or coinsurance) information and prescription guidelines by logging in to My Account at and click under Quick Links to Drug and Pharmacy Resources and click the Drug Pricing Tool or by reviewing their annual summary of benefits. Tier 0: $0 Drugs Tier 1: Generic Drugs $ Tier 2: Preferred Brand Drugs $$ Tier 3: Non-preferred Brand Drugs $$$ Tier 4: Preferred Specialty Drugs $$$$ Tier 5: Non-Preferred Specialty Drugs $$$$ Preventive drugs (e.g. statins, aspirin, folic acid, fluoride, iron supplements, smoking cessation products and FDA-approved contraceptives for women) are available at a zero-dollar cost share if prescribed under certain medical criteria by your doctor. Oral chemotherapy drugs and diabetic supplies (e.g. insulin syringes, pen needles, lancets, test strips, and alcohol swabs) are also available at a zero-dollar cost share. Generic drugs are the same as brand-name drugs in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. Generic drugs generally cost less than brand-name drugs. Preferred brand drugs are brand-name medications that do not have a generic equivalent. They are chosen for their cost-effectiveness to alternatives. Your cost-share will be more than generic drugs but less than non-preferred brand drugs. If a generic drug becomes available, the preferred brand drug will be moved to the non-preferred brand tier. Non-preferred brand drugs often have a generic or preferred brand drug option where your cost-share will be lower. Preferred specialty drugs are generic and brand-name drugs that are used to treat chronic, complex, and/or rare health conditions. Preferred specialty drugs may have a lower cost-share than non-preferred specialty drugs. Non-preferred specialty drugs have a more cost-effective preferred generic or brand specialty drug alternative available. SUM3814-1S (6/17)

3 ANALGESICS COX-2 INHIBITORS celecoxib cap 50 1 celecoxib cap celecoxib cap celecoxib cap GOUT allopurinol sodium for inj M allopurinol tab allopurinol tab colchicine tab colchicine w/ probenecid tab probenecid tab ULORIC TAB 40MG 3 ST; ** ULORIC TAB 80MG 3 ST; ** NON-OPIOID ANALGESICS butalbital-acetaminophen-caffeine cap 50-1 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine cap 50-1 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine tab 50-1 QL (48 tabs / 25 days) butalbital-aspirin-caffeine cap QL (48 caps / 25 days) tencon tab QL (48 tabs / 25 days) NSAIDS, COMBINATIONS diclofenac w/ misoprostol tab delayed 1 release diclofenac w/ misoprostol tab delayed 1 release NSAIDS diclofenac potassium tab 50 1 diclofenac sodium tab delayed release 25 1 diclofenac sodium tab delayed release 50 1 diclofenac sodium tab delayed release 75 1 diclofenac sodium tab er 24hr

4 etodolac cap etodolac cap etodolac tab etodolac tab etodolac tab er 24hr etodolac tab er 24hr etodolac tab er 24hr fenoprofen calcium cap fenoprofen calcium tab flurbiprofen tab 50 1 flurbiprofen tab ibu tab ibu tab ibuprofen susp 100 /5ml 1 ibuprofen tab ibuprofen tab indomethacin cap 25 1 indomethacin cap 50 1 ketoprofen cap 50 1 ketoprofen cap 75 1 ketoprofen cap er 24hr ketorolac tromethamine im inj 60 /2ml 1 M (30 /ml) ketorolac tromethamine inj 15 /ml 1 M ketorolac tromethamine inj 30 /ml 1 M ketorolac tromethamine inj 60 /2ml (30 1 M /ml) ketorolac tromethamine tab 10 1 QL (20 tabs / 25 days) meclofenamate sodium cap 50 1 meclofenamate sodium cap mefenamic acid cap meloxicam susp 7.5 /5ml 1 meloxicam tab meloxicam tab 15 1 nabumetone tab nabumetone tab naproxen dr tab naproxen dr tab naproxen sodium tab

5 naproxen sodium tab naproxen susp 125 /5ml 1 naproxen tab naproxen tab naproxen tab oxaprozin tab piroxicam cap 10 1 piroxicam cap 20 1 sulindac tab sulindac tab tolmetin sodium cap tolmetin sodium tab tolmetin sodium tab OPIOID AGONIST/ANTAGONIST buprenorphine hcl-naloxone hcl sl tab 2-1 QL (90 tabs / 25 days) 0.5 (base equiv) buprenorphine hcl-naloxone hcl sl tab QL (90 tabs / 25 days) (base equiv) SUBOXONE MIS 2-0.5MG 2 QL (90 units / 25 days) SUBOXONE MIS 4-1MG 2 QL (90 units / 25 days) SUBOXONE MIS 8-2MG 2 QL (90 units / 25 days) SUBOXONE MIS 12-3MG 2 QL (60 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (60 units / 25 days) ZUBSOLV SUB QL (30 units / 25 days) OPIOID ANALGESICS acetaminophen w/ codeine soln /5ml acetaminophen w/ codeine tab acetaminophen w/ codeine tab QL (2700 ml / 25 days), ST; Subject to initial 7- day limit QL (400 tabs / 25 days), ST; Subject to initial 7- day limit QL (360 tabs / 25 days), ST; Subject to initial 7- day limit 3

6 acetaminophen w/ codeine tab QL (180 tabs / 25 days), ST; Subject to initial 7- day limit butalbital-acetaminophen-caff w/ cod cap 1 QL (48 caps / 25 days) butorphanol tartrate inj 1 /ml 1 M butorphanol tartrate inj 2 /ml 1 M butorphanol tartrate nasal soln 10 /ml 1 QL (2 bottles / 25 days) CAPITAL/COD SUS /5 3 QL (2700 ml / 25 days), ST; Subject to initial 7- day limit codeine sulfate tab 15 1 QL (42 tabs / 25 days), ST; Subject to initial 7- day limit codeine sulfate tab 30 1 QL (42 tabs / 25 days), ST; Subject to initial 7- day limit codeine sulfate tab 60 1 QL (42 tabs / 25 days), ST; Subject to initial 7- day limit EMBEDA CAP MG 3 QL (60 caps / 25 days), ST EMBEDA CAP MG 3 QL (60 caps / 25 days), ST EMBEDA CAP 50-2MG 3 QL (30 caps / 25 days), ST EMBEDA CAP MG 3 QL (30 caps / 25 days), ST EMBEDA CAP MG 3 QL (30 caps / 25 days), ST EMBEDA CAP 100-4MG 3, ST; High Strength Requires endocet tab QL (360 tabs / 25 days), ST; Subject to initial 7- day limit endocet tab QL (360 tabs / 25 days), ST; Subject to initial 7- day limit endocet tab QL (240 tabs / 25 days), ST; Subject to initial 7- day limit 4

7 endocet tab QL (180 tabs / 25 days), ST; Subject to initial 7- day limit fentanyl citrate lozenge on a handle 200 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 400 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 600 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 800 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 1200 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 1600 mcg 1 QL (120 lozenges / 25 days), fentanyl td patch 72hr 12 mcg/hr 1 QL (10 patches / 25 days), ST fentanyl td patch 72hr 25 mcg/hr 1 QL (10 patches / 25 days), ST fentanyl td patch 72hr 50 mcg/hr 1, ST; High Strength Requires fentanyl td patch 72hr 75 mcg/hr 1, ST; High Strength Requires fentanyl td patch 72hr 100 mcg/hr 1, ST; High Strength Requires hydrocodone-acetaminophen soln QL (2700 ml / 25 days), /15ml ST; Subject to initial 7- day limit hydrocodone-acetaminophen soln /15ml hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab QL (2700 ml / 25 days), ST; Subject to initial 7- day limit 1 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit QL (240 tabs / 25 days), ST; Subject to initial 7- day limit 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit 5

8 hydrocodone-acetaminophen tab QL (180 tabs / 25 days), ST; Subject to initial 7- day limit HYDROMORPHON SUP 3MG 3 QL (120 suppositories / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl inj 1 /ml 1 M hydromorphone hcl inj 2 /ml 1 M hydromorphone hcl inj 4 /ml 1 M hydromorphone hcl liqd 1 /ml 1 QL (600 ml / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl preservative free (pf) 1 M inj 10 /ml hydromorphone hcl tab 2 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl tab 4 1 QL (150 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl tab 8 1 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl tab er 24hr deter 8 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 12 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 16 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 32 1, ST; High Strength Requires HYSINGLA ER TAB 20 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 30 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 40 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 60 MG 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 80 MG 2 QL (30 tabs / 25 days), ST 6

9 HYSINGLA ER TAB 100 MG 2, ST; High Strength Requires HYSINGLA ER TAB 120 MG 2, ST; High Strength Requires levorphanol tartrate tab 2 1 QL (120 tabs / 25 days), ST; Subject to initial 7- day limit lortab tab QL (180 tabs / 25 days), ST; Subject to initial 7- day limit methadone con 10/ml 1 QL (60 ml / 25 days), ST; (generic of Methadone Intensol, indicated for pain) methadone hcl conc 10 /ml 1 QL (30 ml / 25 days); (indicated for opioid addiction) methadone hcl inj 10 /ml 1 M methadone hcl soln 5 /5ml 1 QL (450 ml / 25 days), ST methadone hcl soln 10 /5ml 1 QL (300 ml / 25 days), ST methadone hcl tab 5 1 QL (90 tabs / 25 days), ST methadone hcl tab 10 1 QL (60 tabs / 25 days), ST methadone hcl tab for oral susp 40 1 QL (9 tabs / 25 days) METHADONE INJ 10MG/ML 3 M methadose tab 40 1 QL (9 tabs / 25 days) MORPHINE SUL INJ 2MG/ML 3 M MORPHINE SUL INJ 4MG/ML 3 M MORPHINE SUL INJ 5MG/ML 3 M MORPHINE SUL INJ 150/30ML 3 M MORPHINE SUL SUP 30MG 2 QL (90 supp / 25 days), ST; Subject to initial 7- day limit morphine sulfate beads cap er 24hr 30 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 45 1 QL (30 caps / 25 days), ST 7

10 morphine sulfate beads cap er 24hr 60 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 75 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 90 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 120 1, ST; High Strength Requires morphine sulfate cap er 24hr 10 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 20 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 30 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 50 1 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 60 1 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 80 1 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 100 1, ST; High Strength Requires morphine sulfate inj 8 /ml 1 M morphine sulfate inj 10 /ml 1 M morphine sulfate inj pf 0.5 /ml 1 M morphine sulfate inj pf 1 /ml 1 M morphine sulfate iv soln 1 /ml 1 M morphine sulfate iv soln pf 4 /ml 1 M morphine sulfate iv soln pf 8 /ml 1 M morphine sulfate iv soln pf 10 /ml 1 M morphine sulfate iv soln pf 15 /ml 1 M morphine sulfate oral soln 10 /5ml 1 QL (900 ml / 25 days), ST; Subject to initial 7- day limit morphine sulfate oral soln 20 /5ml 1 QL (675 ml / 25 days), ST; Subject to initial 7- day limit morphine sulfate oral soln 100 /5ml (20 1 QL (135 ml / 25 days), /ml) ST; Subject to initial 7- day limit 8

11 morphine sulfate suppos 5 1 QL (180 suppositories / 25 days), ST; Subject to initial 7-day limit morphine sulfate suppos 10 1 QL (180 suppositories / 25 days), ST; Subject to initial 7-day limit morphine sulfate suppos 20 1 QL (120 supp / 25 days), ST; Subject to initial 7-day limit morphine sulfate tab 15 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit morphine sulfate tab 30 1 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit morphine sulfate tab er 15 1 QL (90 tabs / 25 days), ST morphine sulfate tab er 30 1 QL (90 tabs / 25 days), ST morphine sulfate tab er 60 1, ST; High Strength Requires morphine sulfate tab er 100 1, ST; High Strength Requires morphine sulfate tab er 200 1, ST; High Strength Requires nalbuphine hcl inj 10 /ml 1 M nalbuphine hcl inj 20 /ml 1 M NUCYNTA ER TAB 50MG 2 QL (60 tabs / 25 days), ST NUCYNTA ER TAB 100MG 2 QL (60 tabs / 25 days), ST NUCYNTA ER TAB 150MG 2, ST; High Strength Requires NUCYNTA ER TAB 200MG 2, ST; High Strength Requires NUCYNTA ER TAB 250MG 2, ST; High Strength Requires NUCYNTA TAB 50MG 2 QL (120 tabs / 25 days), ST; Subject to initial 7- day limit 9

12 NUCYNTA TAB 75MG 2 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit NUCYNTA TAB 100MG 2 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl cap 5 1 QL (180 caps / 25 days), ST; Subject to initial 7-day limit oxycodone hcl conc 100 /5ml (20 /ml) 1 QL (90 ml / 25 days), ST; Subject to initial 7- day limit oxycodone hcl soln 5 /5ml 1 QL (900 ml / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 5 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 10 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 15 1 QL (120 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 20 1 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab 30 1 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl tab er 12hr deter 10 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 15 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 20 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 30 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 40 1, ST; High Strength Requires 10

13 oxycodone hcl tab er 12hr deter 60 1, ST; High Strength Requires oxycodone hcl tab er 12hr deter 80 1, ST; High Strength Requires oxycodone w/ acetaminophen soln /5ml 1 QL (1800 ml / 25 days), ST; Subject to initial 7- day limit oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab QL (360 tabs / 25 days), ST; Subject to initial 7- day limit 1 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit 1 QL (240 tabs / 25 days), ST; Subject to initial 7- day limit 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone-aspirin tab QL (360 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone-ibuprofen tab QL (28 tabs / 25 days), ST; Subject to initial 7- day limit OXYCONTIN TAB 10MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 15MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 20MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 30MG CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 40MG CR 2, ST; High Strength Requires OXYCONTIN TAB 60MG CR 2, ST; High Strength Requires OXYCONTIN TAB 80MG CR 2, ST; High Strength Requires 11

14 oxymorphone hcl tab 5 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxymorphone hcl tab 10 1 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit oxymorphone hcl tab er 12hr 5 1 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 10 1 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 15 1 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 20 1, ST; High Strength Requires oxymorphone hcl tab er 12hr 30 1, ST; High Strength Requires oxymorphone hcl tab er 12hr 40 1, ST; High Strength Requires PRIMLEV TAB 5-300MG 3 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit PRIMLEV TAB QL (240 tabs / 25 days), ST; Subject to initial 7- day limit PRIMLEV TAB MG 3 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit tramadol hcl tab 50 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit tramadol hcl tab er 24hr QL (30 tabs / 25 days), ST tramadol hcl tab er 24hr 200 1, ST; High Strength Requires tramadol hcl tab er 24hr 300 1, ST; High Strength Requires XARTEMIS XR TAB QL (120 tabs / 25 days) 12

15 xylon tab QL (50 tabs / 25 days), ST; Subject to initial 7- day limit OPIOID RTIAL AGONISTS BELBUCA MIS 75MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 150MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 300MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 450MCG 2 QL (60 films / 25 days), ST BELBUCA MIS 600MCG 2, ST; High Strength Requires Prior Auth BELBUCA MIS 750MCG 2, ST; High Strength Requires Prior Auth BELBUCA MIS 900MCG 2, ST; High Strength Requires Prior Auth buprenorphine hcl inj 0.3 /ml (base equiv) 1 M buprenorphine hcl sl tab 2 (base equiv) 1 QL (90 tabs / 25 days); Must obtain approval after the initial fill buprenorphine hcl sl tab 8 (base equiv) 1 QL (90 tabs / 25 days); Must obtain approval after the initial fill SALICYLATES aspirin chw 81 0 QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply aspirin low tab 81 ec 0 QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply diflunisal tab ANESTHETICS LOCAL ANESTHETICS LIDO/DEXTROS INJ 5-7.5% 3 M lidocaine hcl local inj 0.5% 1 M lidocaine hcl local inj 1% 1 M lidocaine hcl local inj 2% 1 M 13

16 lidocaine hcl local preservative free (pf) inj 1 M 0.5% lidocaine hcl local preservative free (pf) inj 1 M 1% lidocaine hcl local preservative free (pf) inj 1 M 1.5% lidocaine hcl local preservative free (pf) inj 1 M 2% lidocaine hcl local preservative free (pf) inj 1 M 4% ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 /ml) 1 M amikacin sulfate inj 500 /2ml (250 /ml) 1 M chloramphenicol sodium succinate for iv inj 1 M 1 gm GENTAM/NACL INJ 0.9MG/ML 3 M GENTAM/NACL INJ 1.4MG/ML 3 M gentamicin in saline inj 0.8 /ml 1 M gentamicin in saline inj 1 /ml 1 M gentamicin in saline inj 1.2 /ml 1 M gentamicin in saline inj 1.6 /ml 1 M gentamicin in saline inj 2 /ml 1 M gentamicin sulfate inj 10 /ml 1 M gentamicin sulfate inj 40 /ml 1 M gentamicin sulfate iv soln 10 /ml 1 M KETEK TAB 300MG 3 KETEK TAB 400MG 3 MONUROL K GRANULES 3 neomycin sulfate tab paromomycin sulfate cap streptomycin sulfate for inj 1 gm 1 M SULFADIAZINE TAB 500MG 3 tinidazole tab tinidazole tab tobramycin nebu soln 300 /5ml 1 QL (280 ml / 28 days), tobramycin sulfate for inj 1.2 gm 1 M 14

17 tobramycin sulfate inj 1.2 gm/30ml (40 1 M /ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 1 M /ml) (base equiv) tobramycin sulfate inj 10 /ml (base 1 M equivalent) tobramycin sulfate inj 80 /2ml (40 1 M /ml) (base equiv) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG 2 ALINIA SUS 100/5ML 2 ALINIA TAB 500MG 2 atovaquone susp 750 /5ml 1 AZACTAM/DEX INJ 1GM 3 M AZACTAM/DEX INJ 2GM 3 M aztreonam for inj 1 gm 1 M aztreonam for inj 2 gm 1 M BILTRICIDE TAB 600MG 3 CAYSTON INH 75MG 4 QL (84 vials / 28 days), clindamycin hcl cap 75 1 clindamycin hcl cap clindamycin hcl cap clindamycin palmitate hcl for soln 75 1 /5ml (base equiv) clindamycin phosphate inj 9 gm/60ml 1 M clindamycin phosphate inj 300 /2ml 1 M clindamycin phosphate inj 600 /4ml 1 M clindamycin phosphate inj 900 /6ml 1 M clindamycin phosphate iv soln 300 /2ml 1 M clindamycin phosphate iv soln 900 /6ml 1 M dapsone tab 25 1 dapsone tab daptomycin for iv soln M DARAPRIM TAB 25MG 3 doripenem for iv infusion M doripenem for iv infusion M EMVERM CHW 100MG 3 15

18 imipenem-cilastatin intravenous for soln 1 M 250 imipenem-cilastatin intravenous for soln 1 M 500 INVANZ INJ 1GM 3 M ivermectin tab 3 1 linezolid for susp 100 /5ml 1 linezolid in sodium chloride iv soln 600 /300ml-0.9% 1 M linezolid iv soln 600 /300ml (2 /ml) 1 M linezolid tab meropenem iv for soln 1 gm 1 M meropenem iv for soln M methenamine hippurate tab 1 gm 1 metronidazole cap metronidazole in nacl 0.79% iv soln M /100ml metronidazole tab metronidazole tab NEBUPENT INH 300MG 3 nitrofurantoin macrocrystalline cap 25 1 ; High Risk Medications require for members age 65 and nitrofurantoin macrocrystalline cap 50 1 ; High Risk Medications require for members age 65 and nitrofurantoin macrocrystalline cap ; High Risk Medications require for members age 65 and nitrofurantoin monohydrate macrocrystalline cap ; High Risk Medications require for members age 65 and nitrofurantoin susp 25 /5ml 1 ; High Risk Medications require for members age 65 and PENTAM 300 INJ 300MG 3 M 16

19 polymyxin b sulfate for inj unit 1 M PRIMSOL SOL 50MG/5ML 2 SIVEXTRO INJ 200MG 3 M SIVEXTRO TAB 200MG 3 sulfamethoxazole-trimethoprim iv soln 1 M /5ml sulfamethoxazole-trimethoprim susp /5ml 1 sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim tab trimethoprim tab vancomycin hcl cap QL (80 caps / 14 days), ST; ** vancomycin hcl cap QL (80 caps / 14 days), ST; ** vancomycin hcl for inj 10 gm 1 M vancomycin hcl for inj M vancomycin hcl for inj M vancomycin hcl for inj M vancomycin hcl for inj M XIFAXAN TAB 200MG 2 XIFAXAN TAB 550MG 2 ANTIFUNGALS amphotericin b for inj 50 1 M BIO-STATIN CAP BIO-STATIN CAP CRESEMBA CAP 186 MG 3 fluconazole for susp 10 /ml 1 fluconazole for susp 40 /ml 1 fluconazole in dextrose inj 200 /100ml 1 M fluconazole in dextrose inj 400 /200ml 1 M fluconazole in nacl 0.9% inj 200 /100ml 1 M fluconazole in nacl 0.9% inj 400 /200ml 1 M fluconazole tab 50 1 fluconazole tab fluconazole tab fluconazole tab

20 FLUCONAZOLE/ INJ NACL M griseofulvin microsize susp 125 /5ml 1 griseofulvin microsize tab griseofulvin ultramicrosize tab griseofulvin ultramicrosize tab itraconazole cap LAMISIL GRA 125MG 3 LAMISIL GRA 187.5MG 3 NOXAFIL SUS 40MG/ML 2 NOXAFIL TAB 100MG 2 nystatin oral powder 1 nystatin tab unit 1 SPORANOX SOL 10MG/ML 2 terbinafine hcl tab voriconazole for susp 40 /ml 1 voriconazole tab 50 1 voriconazole tab ANTIMALARIALS atovaquone-proguanil hcl tab atovaquone-proguanil hcl tab chloroquine phosphate tab chloroquine phosphate tab COARTEM TAB MG 3 mefloquine hcl tab PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap ANTIRETROVIRAL AGENTS abacavir sulfate soln 20 /ml (base 1 QL (900 ml / 30 days) equiv) abacavir sulfate tab 300 (base equiv) 1 QL (60 tabs / 30 days) APTIVUS CAP 250MG 2 QL (120 caps / 30 days) APTIVUS SOL 2 QL (300 ml / 30 days) atazanavir sulfate cap 150 (base equiv) 1 QL (30 caps / 30 days) atazanavir sulfate cap 200 (base equiv) 1 QL (60 caps / 30 days) atazanavir sulfate cap 300 (base equiv) 1 QL (30 caps / 30 days) CRIXIVAN CAP 200MG 2 QL (450 caps / 30 days) CRIXIVAN CAP 400MG 2 QL (180 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) 18

21 didanosine delayed release capsule QL (30 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) EDURANT TAB 25MG 2 QL (60 tabs / 30 days) efavirenz cap 50 1 QL (90 caps / 30 days) efavirenz cap QL (90 caps / 30 days) efavirenz tab QL (30 tabs / 30 days) EMTRIVA CAP 200MG 2 QL (30 caps / 30 days) EMTRIVA SOL 10MG/ML 2 QL (680 ml / 28 days) fosamprenavir calcium tab 700 (base 1 QL (120 tabs / 30 days) equiv) FUZEON INJ 90MG 4 QL (60 vials / 30 days) INTELENCE TAB 25MG 2 QL (120 tabs / 30 days) INTELENCE TAB 100MG 2 QL (120 tabs / 30 days) INTELENCE TAB 200MG 2 QL (60 tabs / 30 days) INVIRASE CAP 200MG 2 QL (300 caps / 30 days) INVIRASE TAB 500MG 2 QL (120 tabs / 30 days) ISENTRESS CHW 25MG 2 QL (180 tabs / 30 days) ISENTRESS CHW 100MG 2 QL (180 tabs / 30 days) ISENTRESS HD TAB 600MG 2 QL (60 tabs / 30 days) ISENTRESS POW 100MG 2 QL (60 packets / 30 days) ISENTRESS TAB 400MG 2 QL (120 tabs / 30 days) lamivudine oral soln 10 /ml 1 QL (900 ml / 30 days) lamivudine tab QL (60 tabs / 30 days) lamivudine tab QL (30 tabs / 30 days) LEXIVA SUS 50MG/ML 2 QL (1680 ml / 30 days) LEXIVA TAB 700MG 2 QL (120 tabs / 30 days) nevirapine susp 50 /5ml 1 QL (1200 ml / 30 days) nevirapine tab QL (60 tabs / 30 days) nevirapine tab er 24hr QL (90 tabs / 30 days) nevirapine tab er 24hr QL (30 tabs / 30 days) NORVIR CAP 100MG 2 QL (360 caps / 30 days) NORVIR SOL 80MG/ML 2 QL (450 ml / 30 days) NORVIR TAB 100MG 2 QL (360 tabs / 30 days) PREZISTA SUS 100MG/ML 2 QL (400 ml / 30 days) PREZISTA TAB 75MG 2 QL (300 tabs / 30 days) PREZISTA TAB 150MG 2 QL (180 tabs / 30 days) PREZISTA TAB 600MG 2 QL (60 tabs / 30 days) PREZISTA TAB 800MG 2 QL (30 tabs / 30 days) 19

22 RESCRIPTOR TAB 100 MG 3 QL (900 tabs / 30 days) RESCRIPTOR TAB 200MG 3 QL (450 tabs / 30 days) RETROVIR INJ 10MG/ML 2 M REYATAZ CAP 150MG 2 QL (30 caps / 30 days) REYATAZ CAP 200MG 2 QL (60 caps / 30 days) REYATAZ CAP 300MG 2 QL (30 caps / 30 days) REYATAZ POW 50MG 2 QL (180 packets / 30 days) SELZENTRY SOL 20MG/ML 2 QL (1840 ml / 30 days) SELZENTRY TAB 25MG 2 QL (240 tabs / 30 days) SELZENTRY TAB 75MG 2 QL (60 tabs / 30 days) SELZENTRY TAB 150MG 2 QL (60 tabs / 30 days) SELZENTRY TAB 300MG 2 QL (120 tabs / 30 days) stavudine cap 15 1 QL (60 caps / 30 days) stavudine cap 20 1 QL (60 caps / 30 days) stavudine cap 30 1 QL (60 caps / 30 days) stavudine cap 40 1 QL (60 caps / 30 days) SUSTIVA CAP 50MG 2 QL (90 caps / 30 days) SUSTIVA CAP 200MG 2 QL (90 caps / 30 days) SUSTIVA TAB 600MG 2 QL (30 tabs / 30 days) tenofovir disoproxil fumarate tab QL (30 tabs / 30 days) TIVICAY TAB 10MG 2 QL (60 tabs / 30 days) TIVICAY TAB 25MG 2 QL (60 tabs / 30 days) TIVICAY TAB 50MG 2 QL (60 tabs / 30 days) TYBOST TAB 150MG 2 QL (30 tabs / 30 days) VIDEX SOL 2GM 2 QL (1200 ml / 30 days) VIDEX SOL 4GM 2 QL (1200 ml / 30 days) VIRACEPT TAB 250MG 2 QL (300 tabs / 30 days) VIRACEPT TAB 625MG 2 QL (120 tabs / 30 days) VIRAMUNE SUS 50MG/5ML 2 QL (1200 ml / 30 days) VIREAD POW 40MG/GM 2 QL (240 gm / 30 days) VIREAD TAB 150MG 2 QL (30 tabs / 30 days) VIREAD TAB 200MG 2 QL (30 tabs / 30 days) VIREAD TAB 250MG 2 QL (30 tabs / 30 days) VIREAD TAB 300MG 2 QL (30 tabs / 30 days) ZERIT SOL 1MG/ML 2 QL (2400 ml / 30 days) ZIAGEN SOL 20MG/ML 2 QL (900 ml / 30 days) zidovudine cap QL (180 caps / 30 days) zidovudine syrup 10 /ml 1 QL (1800 ml / 30 days) 20

23 zidovudine tab QL (60 tabs / 30 days) ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine tab QL (30 tabs / 30 days) abacavir sulfate-lamivudine-zidovudine tab 1 QL (60 tabs / 30 days) ATRIPLA TAB 2 QL (30 tabs / 30 days) COMPLERA TAB 2 QL (30 tabs / 30 days) DESCOVY TAB 200/25 2 QL (30 tabs / 30 days) EVOTAZ TAB QL (30 tabs / 30 days) GENVOYA TAB 2 QL (30 tabs / 30 days) KALETRA TAB MG 2 QL (240 tabs / 30 days) KALETRA TAB MG 2 QL (120 tabs / 30 days) lamivudine-zidovudine tab QL (60 tabs / 30 days) lopinavir-ritonavir soln /5ml 1 QL (390 ml / 30 days) (80-20 /ml) ODEFSEY TAB 2 QL (30 tabs / 30 days) PREZCOBIX TAB QL (30 tabs / 30 days) STRIBILD TAB 2 QL (30 tabs / 30 days) TRIUMEQ TAB 2 QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) ANTITUBERCULAR AGENTS cycloserine cap ethambutol hcl tab ethambutol hcl tab isoniazid inj 100 /ml 1 M isoniazid syrup 50 /5ml 1 isoniazid tab isoniazid tab SER GRA 4GM 3 PRIFTIN TAB 150MG 2 pyrazinamide tab rifabutin cap RIFAMATE CAP 2 rifampin cap rifampin cap

24 rifampin for inj M RIFATER TAB 2 SIRTURO TAB 100MG 3 TRECATOR TAB 250MG 2 ANTIVIRALS acyclovir cap acyclovir sodium for inj M acyclovir sodium iv soln 50 /ml 1 M acyclovir susp 200 /5ml 1 acyclovir tab acyclovir tab adefovir dipivoxil tab 10 1 BARACLUDE SOL.05MG/ML 2 cidofovir iv inj 75 /ml 1 M entecavir tab entecavir tab 1 1 EPCLUSA TAB QL (28 tabs / 28 days), EPIVIR HBV SOL 5MG/ML 2 famciclovir tab famciclovir tab famciclovir tab HARVONI TAB MG 4 QL (28 tabs / 28 days), lamivudine tab 100 (hbv) 1 oseltamivir phosphate cap 30 (base 1 QL (40 caps / 90 days) equiv) oseltamivir phosphate cap 45 (base 1 QL (20 caps / 90 days) equiv) oseltamivir phosphate cap 75 (base 1 QL (20 caps / 90 days) equiv) oseltamivir phosphate for susp 6 /ml 1 QL (300 ml / 90 days) (base equiv) PEGASYS INJ 4 QL (4 injections / 28 days), PEGASYS INJ 180MCG/M 4 QL (4 injections / 28 days), PEGASYS INJ PROCLICK 4 QL (4 injections / 28 days), REBETOL SOL 40MG/ML 4 22

25 RELENZA MIS DISKHALE 2 QL (2 inhalers / 90 days) ribasphere cap ribasphere tab ribasphere tab ribasphere tab ribavirin cap ribavirin for inhal soln 6 gm 1 ribavirin tab rimantadine hydrochloride tab SOVALDI TAB 400MG 5 QL (28 tabs / 28 days),, ST TAMIFLU SUS 6MG/ML 2 QL (300 ml / 90 days) TECHNIVIE TAB 5 QL (56 tabs / 28 days),, ST valacyclovir hcl tab 1 gm 1 valacyclovir hcl tab valganciclovir hcl for soln 50 /ml (base 1 equiv) valganciclovir hcl tab 450 (base 1 equivalent) VOSEVI TAB 4 QL (28 tabs / 28 days), ZETIER TAB MG 5 QL (28 tabs / 28 days),, ST CEPHALOSPORINS cefaclor cap cefaclor cap CEFACLOR ER TAB 500MG 2 cefaclor for susp 125 /5ml 1 cefaclor for susp 250 /5ml 1 cefaclor for susp 375 /5ml 1 cefadroxil cap cefadroxil for susp 250 /5ml 1 cefadroxil for susp 500 /5ml 1 cefadroxil tab 1 gm 1 cefazolin sodium for inj 1 gm 1 M cefazolin sodium for inj 10 gm 1 M cefazolin sodium for inj 20 gm 1 M 23

26 cefazolin sodium for inj M cefazolin sodium for iv soln 1 gm 1 M cefdinir cap cefdinir for susp 125 /5ml 1 cefdinir for susp 250 /5ml 1 cefditoren pivoxil tab 200 (base 1 equivalent) cefditoren pivoxil tab 400 (base 1 equivalent) cefepime hcl for inj 1 gm 1 M cefepime hcl for inj 2 gm 1 M cefixime for susp 100 /5ml 1 cefixime for susp 200 /5ml 1 cefotaxime sodium for inj 1 gm 1 M cefotaxime sodium for inj 2 gm 1 M cefotaxime sodium for inj 10 gm 1 M cefotaxime sodium for inj M cefotetan disodium for inj 1 gm 1 M cefotetan disodium for inj 2 gm 1 M cefotetan disodium for inj 10 gm 1 M cefoxitin sodium for inj 10 gm 1 M cefoxitin sodium for iv soln 1 gm 1 M cefoxitin sodium for iv soln 2 gm 1 M cefpodoxime proxetil for susp 50 /5ml 1 cefpodoxime proxetil for susp 100 /5ml 1 cefpodoxime proxetil tab cefpodoxime proxetil tab cefprozil for susp 125 /5ml 1 cefprozil for susp 250 /5ml 1 cefprozil tab cefprozil tab ceftazidime for inj 2 gm 1 M ceftibuten cap ceftibuten for susp 180 /5ml 1 CEFTIN SUS 125/5ML 2 CEFTIN SUS 250/5ML 2 ceftriaxone sodium for inj 1 gm 1 M ceftriaxone sodium for inj 2 gm 1 M ceftriaxone sodium for inj 10 gm 1 M 24

27 ceftriaxone sodium for inj M ceftriaxone sodium for inj M ceftriaxone sodium for iv soln 1 gm 1 M ceftriaxone sodium for iv soln 2 gm 1 M cefuroxime axetil tab cefuroxime axetil tab CEFUROXIME INJ 75GM 3 M CEFUROXIME INJ 225GM 3 M cefuroxime sodium for inj 1.5 gm 1 M cefuroxime sodium for inj 7.5 gm 1 M cefuroxime sodium for inj M cefuroxime sodium for iv soln 1.5 gm 1 M cephalexin cap cephalexin cap cephalexin cap cephalexin for susp 125 /5ml 1 cephalexin for susp 250 /5ml 1 cephalexin tab cephalexin tab SUPRAX CAP 400MG 2 SUPRAX CHW 100MG 2 SUPRAX CHW 200MG 2 SUPRAX SUS 500/5ML 2 tazicef inj 1gm 1 M tazicef inj 2gm 1 M tazicef inj 6gm 1 M ZINACEF INJ 750MG 3 M ZINACEF/H20 INJ 1.5GM PB 3 M ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 /5ml 1 azithromycin for susp 200 /5ml 1 azithromycin iv for soln M azithromycin powd pack for susp 1 gm 1 azithromycin tab azithromycin tab azithromycin tab clarithromycin for susp 125 /5ml 1 clarithromycin for susp 250 /5ml 1 clarithromycin tab

28 clarithromycin tab clarithromycin tab er 24hr DIFICID TAB 200MG 2 e.e.s. 400 tab ery-tab tab 250 ec 1 ery-tab tab 333 ec 1 ery-tab tab 500 ec 1 ERYPED SUS 400/5ML 2 ERYTHROCIN INJ 500MG 3 M erythrocin tab erythromycin ethylsuccinate for susp /5ml erythromycin ethylsuccinate tab erythromycin tab erythromycin tab erythromycin w/ delayed release particles 1 cap 250 PCE TAB 333MG EC 3 PCE TAB 500MG EC 3 ZMAX SUS 2GM 3 FLUOROQUINOLONES AVELOX INJ 3 M ciprofloxacin 200 /100ml in d5w 1 M ciprofloxacin 400 /200ml in d5w 1 M ciprofloxacin for oral susp 250 /5ml 1 (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 /5ml (10%) (10 gm/100ml) 1 ciprofloxacin hcl tab 100 (base equiv) 1 ciprofloxacin hcl tab 250 (base equiv) 1 ciprofloxacin hcl tab 500 (base equiv) 1 ciprofloxacin hcl tab 750 (base equiv) 1 ciprofloxacin iv soln 200 /20ml (1%) 1 M ciprofloxacin iv soln 400 /40ml (1%) 1 M ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) FACTIVE TAB 320MG 3 26

29 levofloxacin in d5w iv soln 250 /50ml 1 M levofloxacin in d5w iv soln 500 /100ml 1 M levofloxacin in d5w iv soln 750 /150ml 1 M levofloxacin iv soln 25 /ml 1 M levofloxacin oral soln 25 /ml 1 levofloxacin tab levofloxacin tab levofloxacin tab moxifloxacin hcl 400 /250ml in sodium 1 M chloride 0.8% inj moxifloxacin hcl tab 400 (base equiv) 1 ofloxacin tab ofloxacin tab PENICILLINS amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab er 12hr amoxicillin (trihydrate) cap amoxicillin (trihydrate) cap amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml 27

30 amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) tab amoxicillin (trihydrate) tab ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm 1 M ampicillin & sulbactam sodium for inj 3 (2-1 M 1) gm ampicillin & sulbactam sodium for inj 15 1 M (10-5) gm ampicillin & sulbactam sodium for iv soln 1 M 15 (10-5) gm ampicillin cap ampicillin cap ampicillin for susp 125 /5ml 1 ampicillin for susp 250 /5ml 1 ampicillin sodium for inj 1 gm 1 M ampicillin sodium for inj 2 gm 1 M ampicillin sodium for inj 10 gm 1 M ampicillin sodium for inj M ampicillin sodium for inj M ampicillin sodium for inj M ampicillin sodium for iv soln 1 gm 1 M ampicillin sodium for iv soln 2 gm 1 M ampicillin sodium for iv soln 10 gm 1 M AUGMENTIN SUS 125/5ML 2 dicloxacillin sodium cap dicloxacillin sodium cap nafcillin sodium for inj 1 gm 1 M nafcillin sodium for inj 2 gm 1 M nafcillin sodium for inj 10 gm 1 M nafcillin sodium for iv soln 1 gm 1 M nafcillin sodium for iv soln 2 gm 1 M oxacillin sodium for inj 1 gm (base 1 M equivalent) oxacillin sodium for inj 2 gm (base equivalent) 1 M 28

31 oxacillin sodium for inj 10 gm (base 1 M equivalent) penicillin g potassium for inj unit 1 M penicillin g potassium for inj unit 1 M penicillin g sodium for inj unit 1 M penicillin v potassium for soln 125 /5ml 1 penicillin v potassium for soln 250 /5ml 1 penicillin v potassium tab penicillin v potassium tab pfizerpen-g inj 20mu 1 M piperacillin sod-tazobactam na for inj M gm ( gm) piperacillin sod-tazobactam sod for inj M gm ( gm) piperacillin sod-tazobactam sod for inj M gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj M gm ( gm) TETRACYCLINES avidoxy tab demeclocycline hcl tab demeclocycline hcl tab doxy 100 inj M doxycycline hyclate cap 50 1 doxycycline hyclate cap doxycycline hyclate for inj M doxycycline hyclate tab 20 1 doxycycline hyclate tab doxycycline hyclate tab delayed release 75 1 doxycycline hyclate tab delayed release doxycycline hyclate tab delayed release doxycycline monohydrate cap 50 1 doxycycline monohydrate cap 75 1 doxycycline monohydrate cap doxycycline monohydrate cap doxycycline monohydrate for susp 25 1 /5ml 29

32 doxycycline monohydrate tab 50 1 doxycycline monohydrate tab 75 1 doxycycline monohydrate tab minocycline hcl cap 50 1 minocycline hcl cap 75 1 minocycline hcl cap minocycline hcl tab 50 1 minocycline hcl tab 75 1 minocycline hcl tab morgidox cap 1x100 1 tetracycline hcl cap tetracycline hcl cap VIBRAMYCIN SYP 50MG/5ML 3 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU INJ 100MG 2 M busulfan inj 6 /ml 1 M CYCLOPHOSPH CAP 25MG 0 CYCLOPHOSPH CAP 50MG 0 cyclophosphamide for inj 1 gm 1 M cyclophosphamide for inj 2 gm 1 M cyclophosphamide for inj M dacarbazine for inj M dacarbazine for inj M EMCYT CAP 140MG 0 GLEOSTINE CAP 5MG 0 GLEOSTINE CAP 10MG 0 GLEOSTINE CAP 40MG 0 GLEOSTINE CAP 100MG 0 GLIADEL WAF 7.7MG 2 M HEXALEN CAP 50MG 0 ifosfamide for inj 1 gm 1 M ifosfamide iv inj 1 gm/20ml (50 /ml) 1 M ifosfamide iv inj 3 gm/60ml (50 /ml) 1 M LEUKERAN TAB 2MG 0 melphalan hcl for inj 50 (base equiv) 1 M melphalan tab 2 0 TEMODAR INJ 100MG 4 M temozolomide cap

33 temozolomide cap 20 0 temozolomide cap temozolomide cap temozolomide cap temozolomide cap ANTHRACYCLINES daunorubicin hcl inj 5 /ml (base equiv) 1 M DAUNOXOME INJ 2MG/ML 2 M doxorubicin hcl for inj 10 1 M doxorubicin hcl for inj 50 1 M doxorubicin hcl inj 2 /ml 1 M doxorubicin hcl liposomal inj (for iv 1 M infusion) 2 /ml epirubicin hcl iv soln 50 /25ml (2 1 M /ml) epirubicin hcl iv soln 200 /100ml (2 1 M /ml) idarubicin hcl iv inj 5 /5ml (1 /ml) 1 M idarubicin hcl iv inj 10 /10ml (1 /ml) 1 M idarubicin hcl iv inj 20 /20ml (1 /ml) 1 M ANTIBIOTICS bleomycin sulfate for inj 15 unit 1 M bleomycin sulfate for inj 30 unit 1 M mitomycin for iv soln 5 1 M mitomycin for iv soln 20 1 M mitomycin for iv soln 40 1 M ANTIMETABOLITES adrucil inj 500/10ml 1 M ALIMTA INJ 100MG 2 M ALIMTA INJ 500MG 2 M ARRANON INJ 5MG/ML 2 M azacitidine for inj M capecitabine tab QL (120 tabs / 30 days), capecitabine tab QL (300 tabs / 30 days), cladribine iv soln 10 /10ml (1 /ml) 1 M clofarabine iv soln 1 /ml 1 M cytarabine inj 20 /ml 1 M 31

34 cytarabine inj pf 20 /ml 1 M cytarabine inj pf 100 /ml 1 M decitabine for inj 50 4 M DEPOCYT INJ 50MG/5ML 2 M floxuridine for inj 0.5 gm 1 M fludarabine phosphate for inj 50 1 M fludarabine phosphate inj 25 /ml 1 M fluorouracil iv soln 1 gm/20ml (50 /ml) 1 M fluorouracil iv soln 2.5 gm/50ml (50 /ml) 1 M fluorouracil iv soln 5 gm/100ml (50 /ml) 1 M fluorouracil iv soln 500 /10ml (50 1 M /ml) gemcitabine hcl for inj 1 gm 1 M gemcitabine hcl for inj 2 gm 1 M gemcitabine hcl for inj M gemcitabine hcl inj 1 gm/26.3ml (38 1 M /ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 1 M /ml) (base equiv) gemcitabine hcl inj 200 /5.26ml (38 1 M /ml) (base equiv) mercaptopurine tab 50 0 methotrexate sodium for inj 1 gm 1 M methotrexate sodium inj 50 /2ml (25 /ml) 1 M methotrexate sodium inj 250 /10ml (25 1 M /ml) methotrexate sodium inj pf 50 /2ml (25 1 M /ml) methotrexate sodium inj pf 100 /4ml 1 M (25 /ml) methotrexate sodium inj pf 200 /8ml 1 M (25 /ml) methotrexate sodium inj pf 250 /10ml (25 /ml) 1 M methotrexate sodium inj pf 1000 /40ml 1 M (25 /ml) NIPENT INJ 10MG 2 M TABLOID TAB 40MG 0 32

35 ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG 2 M DOCEFREZ INJ 20MG 2 M docetaxel for inj conc 20 /ml 1 M docetaxel for inj conc 80 /4ml (20 1 M /ml) DOCETAXEL INJ 20/0.5ML 2 M DOCETAXEL INJ 20MG/2ML 2 M DOCETAXEL INJ 80MG/2ML 2 M DOCETAXEL INJ 80MG/8ML 2 M DOCETAXEL INJ 140/7ML 2 M DOCETAXEL INJ 160/8ML 2 M DOCETAXEL INJ 160/16ML 2 M DOCETAXEL INJ 200MG/20 2 M DOCETAXEL INJ NON-ALCO 2 M paclitaxel iv conc 30 /5ml (6 /ml) 1 M paclitaxel iv conc 100 /16.7ml (6 /ml) 1 M paclitaxel iv conc 150 /25ml (6 /ml) 1 M paclitaxel iv conc 300 /50ml (6 /ml) 1 M ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate inj 1 /ml 1 M vincasar pfs inj 1/ml 1 M vincristine sulfate iv soln 1 /ml 1 M vinorelbine tartrate inj 10 /ml (base 1 M equiv) vinorelbine tartrate inj 50 /5ml (10 1 M /ml) (base equiv) BIOLOGIC RESPONSE MODIFIERS ERBITUX INJ 100MG 4 M ERBITUX INJ 200MG 4 M ERIVEDGE CAP 150MG 0 QL (30 caps / 30 days), FARYDAK CAP 10MG 0 FARYDAK CAP 15MG 0 FARYDAK CAP 20MG 0 GAZYVA INJ 25MG/ML 4 M IBRANCE CAP 75MG 0 QL (21 caps / 28 days), 33

36 IBRANCE CAP 100MG 0 QL (21 caps / 28 days), IBRANCE CAP 125MG 0 QL (21 caps / 28 days), KADCYLA INJ 100MG 4 M KADCYLA INJ 160MG 4 M KEYTRUDA INJ 100MG/4M 4 M KEYTRUDA SOL 50MG 4 M LYNRZA CAP 50MG 0 QL (480 caps / 30 days), LYNRZA TAB 100MG 0 QL (180 tabs / 30 days), LYNRZA TAB 150MG 0 QL (120 tabs / 30 days), RYDAPT CAP 25MG 0 QL (224 caps / 28 days), ZEJULA CAP 100MG 0 QL (90 caps / 30 days), ZOLINZA CAP 100MG 0 QL (120 caps / 30 days), HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 0 bicalutamide tab 50 0 DEPO-PROVERA INJ 400/ML 3 M ELIGARD INJ 7.5MG 4 ELIGARD INJ 22.5MG 4 ELIGARD INJ 30MG 4 ELIGARD INJ 45MG 4 exemestane tab 25 0 FARESTON TAB 60MG 0 FASLODEX INJ 250/5ML 2 M flutamide cap letrozole tab leuprolide acetate inj kit 5 /ml 4 LUPR DEP-PED INJ 3M 30MG 4 M LUPR DEP-PED INJ 7.5MG 4 M LUPR DEP-PED INJ 11.25MG 4 M LUPR DEP-PED INJ 15MG 4 M LUPRON DEPOT INJ 3.75MG 4 M LUPRON DEPOT INJ 7.5MG 4 M 34

37 LUPRON DEPOT INJ 11.25MG 4 M LUPRON DEPOT INJ 22.5MG 4 M LUPRON DEPOT INJ 30MG 4 M LUPRON DEPOT INJ 45MG 4 M LYSODREN TAB 500MG 0 megestrol acetate susp 40 /ml 0 megestrol acetate susp 625 /5ml 0 megestrol acetate tab 20 0 megestrol acetate tab 40 0 nilutamide tab tamoxifen citrate tab 10 (base equivalent) 0 $0 copay for women > 35 years for the primary prevention of breast cancer tamoxifen citrate tab 20 (base equivalent) 0 $0 copay for women > 35 years for the primary prevention of breast cancer XTANDI CAP 40MG 0 QL (120 caps / 30 days), ZYTIGA TAB 250MG 0 QL (120 tabs / 30 days), ZYTIGA TAB 500MG 0 QL (60 tabs / 30 days), KINASE INHIBITORS AFINITOR DIS TAB 2MG 0 QL (60 tabs / 30 days), AFINITOR DIS TAB 3MG 0 QL (90 tabs / 30 days), AFINITOR DIS TAB 5MG 0 QL (60 tabs / 30 days), AFINITOR TAB 2.5MG 0 QL (30 tabs / 30 days), AFINITOR TAB 5MG 0 QL (30 tabs / 30 days), AFINITOR TAB 7.5MG 0 QL (30 tabs / 30 days), AFINITOR TAB 10MG 0 QL (30 tabs / 30 days), 35

38 ALECENSA CAP 150MG 0 QL (240 caps / 30 days), BOSULIF TAB 100MG 0 QL (120 tabs / 30 days), BOSULIF TAB 400MG 0 QL (30 tabs / 30 days), BOSULIF TAB 500MG 0 QL (30 tabs / 30 days), CALQUENCE CAP 100MG 0 QL (60 caps / 30 days), CAPRELSA TAB 100MG 0 QL (60 tabs / 30 days), CAPRELSA TAB 300MG 0 QL (30 tabs / 30 days), COMETRIQ KIT 60MG 0 QL (1 kit / 28 days), COMETRIQ KIT 100MG 0 QL (1 kit / 28 days), COMETRIQ KIT 140MG 0 QL (1 kit / 28 days), ICLUSIG TAB 15MG 0 QL (60 tabs / 30 days), ICLUSIG TAB 45MG 0 QL (30 tabs / 30 days), IDHIFA TAB 50MG 0 QL (30 tabs / 30 days), IDHIFA TAB 100MG 0 QL (30 tabs / 30 days), imatinib mesylate tab 100 (base equivalent) 0 QL (90 tabs / 30 days), imatinib mesylate tab 400 (base equivalent) 0 QL (60 tabs / 30 days), IMBRUVICA CAP 140MG 0 QL (120 caps / 30 days), INLYTA TAB 1MG 0 QL (180 tabs / 30 days), INLYTA TAB 5MG 0 QL (120 tabs / 30 days), JAKAFI TAB 5MG 0 QL (60 tabs / 30 days), JAKAFI TAB 10MG 0 QL (60 tabs / 30 days), JAKAFI TAB 15MG 0 QL (60 tabs / 30 days), 36

39 JAKAFI TAB 20MG 0 QL (60 tabs / 30 days), JAKAFI TAB 25MG 0 QL (60 tabs / 30 days), LENVIMA CAP 8 MG 0 QL (60 caps / 30 days), LENVIMA CAP 10 MG 0 QL (30 caps / 30 days), LENVIMA CAP 14 MG 0 QL (60 caps / 30 days), LENVIMA CAP 18 MG 0 QL (90 caps / 30 days), LENVIMA CAP 20 MG 0 QL (60 caps / 30 days), LENVIMA CAP 24 MG 0 QL (90 caps / 30 days), MEKINIST TAB 0.5MG 0 QL (90 tabs / 30 days), MEKINIST TAB 2MG 0 QL (30 tabs / 30 days), NEXAVAR TAB 200MG 0 QL (120 tabs / 30 days), SPRYCEL TAB 20MG 0 QL (90 tabs / 30 days), SPRYCEL TAB 50MG 0 QL (30 tabs / 30 days), SPRYCEL TAB 70MG 0 QL (30 tabs / 30 days), SPRYCEL TAB 80MG 0 QL (30 tabs / 30 days), SPRYCEL TAB 100MG 0 QL (30 tabs / 30 days), SPRYCEL TAB 140MG 0 QL (30 tabs / 30 days), STIVARGA TAB 40MG 0 QL (112 tabs / 28 days), SUTENT CAP 12.5MG 0 QL (30 caps / 30 days), SUTENT CAP 25MG 0 QL (30 caps / 30 days), 37

40 SUTENT CAP 37.5MG 0 QL (30 caps / 30 days), SUTENT CAP 50MG 0 QL (30 caps / 30 days), TAFINLAR CAP 50MG 0 QL (120 caps / 30 days), TAFINLAR CAP 75MG 0 QL (120 caps / 30 days), TARCEVA TAB 25MG 0 QL (60 tabs / 30 days), TARCEVA TAB 100MG 0 QL (30 tabs / 30 days), TARCEVA TAB 150MG 0 QL (30 tabs / 30 days), TYKERB TAB 250MG 0 QL (180 tabs / 30 days), VOTRIENT TAB 200MG 0 QL (120 tabs / 30 days), XALKORI CAP 200MG 0 QL (60 caps / 30 days), XALKORI CAP 250MG 0 QL (60 caps / 30 days), ZELBORAF TAB 240MG 0 QL (240 tabs / 30 days), ZYDELIG TAB 100MG 0 QL (60 tabs / 30 days), ZYDELIG TAB 150MG 0 QL (60 tabs / 30 days), ZYKADIA CAP 150MG 0 QL (150 caps / 30 days), MISCELLANEOUS bexarotene cap 75 0 DROXIA CAP 200MG 0 DROXIA CAP 300MG 0 DROXIA CAP 400MG 0 hydroxyurea cap MATULANE CAP 50MG 0 mitoxantrone hcl inj conc 20 /10ml (2 4 M /ml) mitoxantrone hcl inj conc 25 /12.5ml (2 4 M /ml) 38

41 mitoxantrone hcl inj conc 30 /15ml (2 4 M /ml) ONCASR INJ 750/ML 4 M PHOTOFRIN INJ 75MG 2 M QUADRAMET INJ 2 M THERACYS INJ 2 M TICE BCG INJ 2 M tretinoin cap 10 0 TRISENOX INJ 12MG/6ML 2 M TRISENOX SOL 10MG/10M 2 M UVADEX INJ 20MCG/ML 2 M VISTOGARD K 10GM 2 PLATINUM-BASED AGENTS carboplatin iv soln 50 /5ml 1 M carboplatin iv soln 150 /15ml 1 M carboplatin iv soln 450 /45ml 1 M carboplatin iv soln 600 /60ml 1 M cisplatin inj 50 /50ml (1 /ml) 1 M cisplatin inj 100 /100ml (1 /ml) 1 M cisplatin inj 200 /200ml (1 /ml) 1 M oxaliplatin for iv inj 50 1 M oxaliplatin for iv inj M oxaliplatin iv soln 50 /10ml 1 M oxaliplatin iv soln 100 /20ml 1 M PROTECTIVE AGENTS amifostine for inj M dexrazoxane for inj M dexrazoxane for inj M leucovorin calcium for inj 50 1 M leucovorin calcium for inj M leucovorin calcium for inj M leucovorin calcium for inj M leucovorin calcium for inj M leucovorin calcium tab 5 0 leucovorin calcium tab 10 0 leucovorin calcium tab 15 0 leucovorin calcium tab 25 0 mesna inj 100 /ml 1 M MESNEX TAB 400MG 0 39

42 TOPOISOMERASE INHIBITORS CAMPTOSAR INJ 300/15ML 2 M etoposide cap 50 0 etoposide inj 100 /5ml (20 /ml) 1 M irinotecan hcl inj 40 /2ml (20 /ml) 1 M irinotecan hcl inj 100 /5ml (20 /ml) 1 M irinotecan hcl inj 500 /25ml (20 /ml) 1 M TENIPOSIDE INJ 50MG/5ML 2 M toposar inj 20/ml 1 M toposar inj 100/5ml 1 M topotecan hcl for inj 4 1 M ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC, BCL-2 INHIBITORS VENCLEXTA TAB 10MG 0 VENCLEXTA TAB 50MG 0 VENCLEXTA TAB 100MG 0 VENCLEXTA TAB START PK 0 CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab

43 captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er ACE INHIBITORS benazepril hcl tab 5 1 benazepril hcl tab

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