2018 Health Insurance Marketplace

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1 2018 Health Insurance Marketplace HOW TO SEARCH THIS DOCUMENT: 1. With the PDF open, press and hold Ctrl+F on your keyboard 2. In the Find Box, type the name of the medication 3. Click Find Next button until you find the medication you re looking for 4. Or go to the Index that begins on page 121. Drug Tier Drug Tier Name 0 Zero cost share preventive drugs 1 Preferred generics 2 Non-preferred generics 3 Preferred brands 4 Non-preferred brands 5 Preferred specialty 6 Non-preferred specialty Requirements/Limits PA = Prior Authorization QL = Quantity Limits ST = Step Therapy OTC = Over The Counter PA** = PA Applies if Step is Not Met Description You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. Available with or without a prescription, but a prescription is required to fill under your prescription benefits. If step therapy conditions are not met, you or your provider may request an exception to the requirement. NOTE: This document should be used as a general reference for what drugs the plan may cover; however, this document does not guarantee coverage. Not all strengths or dosage forms may be covered, and formulary status is subject to change. When an equivalent generic drug becomes available, the brand drug may no longer be covered This formulary was updated on 7/17/2018 with an effective date of 8/1/2018. For more recent information or other questions, please contact Paramount Insurance Company Member Services at or, for TTY users, , 8:00 a.m. to 8:00 p.m., Monday through Friday 1

2 English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call [ ] [(TTY: )]. Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në [ ] [(TTY: )]. Arabic: ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم ] (رقم ھاتف الصم والبكم: ). Bantu: ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona [ ] [(TTY: )]. Bengali: ল য করন যদ আপদন ব ল, কথ বল ত প তন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপল আত ফ ন করন [১ ] [(TTY: ১ )] Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 [ ] [(TTY: )] Cushite: XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa [ ] [(TTY: )]. Dutch: AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel [ ] [(TTY: )]. French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le [ ] [(ATS : )]. German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: [ ] [(TTY: )]. Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero [ ] [(TTY: )]. Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます [ ] [(TTY: )] まで お電話にてご連絡ください Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. [ ] [(TTY: )] 번으로전화해주십시오. 2

3 ܐܝ Nepali: ध य न द न ह स: तप इ ल न प ल ब ल न ह न छ भन तप इ क ननम तत भ ष सह यत स व हर नन श ल क र पम उपलब ध छ फ न गन ह स [ ] (द द व र इ: ) Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call [ ] [(TTY: )]. Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer [ ] [(TTY: )]. Romanian: ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la [ ] [(TTY: )]. Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните [ ] [(телетайп: )]. Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite [ ] [(TTY- Telefon za osobe sa oštećenim govorom ili sluhom: )]. Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al [ ] [(TTY: )]. Syriac: ܐܬ ܐܬ ܕ ܪܝ ܗ ܒ ܫ ܠ ܐܢ ܡ ܠܚ ܬܝ ܢܘ ܬܝ ܠܒܩ ܕ ܨܡ ܢܘ ܡܙ ܡܗ ܬܝ ܐܟܢܘ ܠ ܫ ܢ ܐ ܪ ܘ ܬܐ ܢܐ ܬܚܐ ܢܘ ܗ ܪܐ: ܙ ܘ ܢܐ )[ [(TTY: ] ܘܢ ܥܠ ܡܢ ܝ ܢܐ ܝܬ. ܩܪ ܓ ܡ Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa [ ] [(TTY: )]. Ukrainian: УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером [ ] [(телетайп: )]. Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số [ ] [(TTY: )]. 3

4 Notice of Nondiscrimination and Accessibility: Discrimination is Against the Law Paramount Insurance Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Paramount Insurance Company does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Paramount Insurance Company provides: Free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Paramount Member Services at If you believe that Paramount Insurance Company has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance. You can file a grievance in person or by mail, fax, or . Paramount Member Services 1901 Indian Wood Circle, Maumee OH Phone: Toll Free: TTY: Fax: If you need help filing a grievance, Paramount Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at 4

5 ANALGESICS COX-2 INHIBITORS celecoxib cap 50 2 celecoxib cap celecoxib cap celecoxib cap GOUT allopurinol sodium for inj allopurinol tab allopurinol tab colchicine tab colchicine w/ probenecid tab probenecid tab ULORIC TAB 40MG 4 ST; PA** ULORIC TAB 80MG 4 ST; PA** NON-OPIOID ANALGESICS butalbital-acetaminophen-caffeine cap 50-2 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine cap 50-2 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine tab 50-2 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 2 release diclofenac w/ misoprostol tab delayed 2 release NSAIDS diclofenac potassium tab 50 2 diclofenac sodium tab delayed release 25 2 diclofenac sodium tab delayed release 50 2 diclofenac sodium tab delayed release 75 2 diclofenac sodium tab er 24hr etodolac cap etodolac cap etodolac tab etodolac tab etodolac tab er 24hr

6 etodolac tab er 24hr etodolac tab er 24hr fenoprofen calcium cap fenoprofen calcium tab flurbiprofen tab 50 2 flurbiprofen tab ibuprofen susp 100 /5ml 2 ibuprofen tab ibuprofen tab ibuprofen tab indomethacin cap 25 2 indomethacin cap 50 2 ketoprofen cap 50 2 ketoprofen cap 75 2 ketoprofen cap er 24hr ketorolac tromethamine im inj 60 /2ml 2 (30 /ml) ketorolac tromethamine inj 15 /ml 2 ketorolac tromethamine inj 30 /ml 2 ketorolac tromethamine tab 10 2 QL (20 tabs / 25 days) meclofenamate sodium cap 50 2 meclofenamate sodium cap mefenamic acid cap meloxicam susp 7.5 /5ml 2 meloxicam tab meloxicam tab 15 2 nabumetone tab nabumetone tab naproxen dr tab naproxen dr tab naproxen sodium tab naproxen sodium tab naproxen susp 125 /5ml 2 naproxen tab naproxen tab naproxen tab oxaprozin tab piroxicam cap 10 2 piroxicam cap 20 2 sulindac tab sulindac tab tolmetin sodium cap tolmetin sodium tab tolmetin sodium tab OPIOID AGONIST/ANTAGONIST 6

7 buprenorphine hcl-naloxone hcl sl tab (base equiv) 2 QL (90 tabs / 25 days) buprenorphine hcl-naloxone hcl sl tab QL (90 tabs / 25 days) (base equiv) SUBOXONE MIS 2-0.5MG 3 QL (90 units / 25 days) SUBOXONE MIS 4-1MG 3 QL (90 units / 25 days) SUBOXONE MIS 8-2MG 3 QL (90 units / 25 days) SUBOXONE MIS 12-3MG 3 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 2 QL (2700 ml / 25 days), PA acetaminophen w/ codeine tab QL (400 tabs / 25 days), PA acetaminophen w/ codeine tab QL (360 tabs / 25 days), PA acetaminophen w/ codeine tab QL (180 tabs / 25 days), PA butalbital-acetaminophen-caff w/ cod cap 2 QL (48 caps / 25 days), PA butorphanol tartrate inj 1 /ml 2 PA butorphanol tartrate inj 2 /ml 2 PA butorphanol tartrate nasal soln 10 /ml 2 QL (2 bottles / 25 days), PA CAPITAL/COD SUS /5 4 QL (2700 ml / 25 days), PA codeine sulfate tab 15 2 QL (42 tabs / 25 days), PA codeine sulfate tab 30 2 QL (42 tabs / 25 days), PA codeine sulfate tab 60 2 QL (42 tabs / 25 days), PA EMBEDA CAP MG 4 PA EMBEDA CAP MG 4 PA EMBEDA CAP 50-2MG 4 PA EMBEDA CAP MG 4 PA EMBEDA CAP MG 4 PA EMBEDA CAP 100-4MG 4 PA endocet tab QL (360 tabs / 25 days), PA endocet tab QL (320 tabs / 25 days), PA endocet tab QL (210 tabs / 25 days), PA endocet tab QL (160 tabs / 25 days), PA fentanyl citrate lozenge on a handle 200 mcg 2 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 400 mcg 2 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 600 mcg 2 QL (120 lozenges / 25 days), PA fentanyl citrate lozenge on a handle 800 mcg 2 QL (120 lozenges / 25 days), PA 7

8 fentanyl citrate lozenge on a handle QL (120 lozenges / 25 days), mcg PA fentanyl citrate lozenge on a handle QL (120 lozenges / 25 days), mcg PA fentanyl td patch 72hr 12 mcg/hr 2 PA fentanyl td patch 72hr 25 mcg/hr 2 PA fentanyl td patch 72hr 50 mcg/hr 2 PA fentanyl td patch 72hr 75 mcg/hr 2 PA fentanyl td patch 72hr 100 mcg/hr 2 PA hydrocodone-acetaminophen soln QL (2700 ml / 25 days), PA /15ml hydrocodone-acetaminophen soln QL (2700 ml / 25 days), PA /15ml hydrocodone-acetaminophen tab QL (360 tabs / 25 days), PA hydrocodone-acetaminophen tab QL (240 tabs / 25 days), PA hydrocodone-acetaminophen tab QL (180 tabs / 25 days), PA hydrocodone-acetaminophen tab QL (180 tabs / 25 days), PA HYDROMORPHON SUP 3MG 4 QL (120 supp / 25 days), PA hydromorphone hcl inj 1 /ml 2 PA hydromorphone hcl inj 2 /ml 2 PA hydromorphone hcl inj 4 /ml 2 PA hydromorphone hcl liqd 1 /ml 2 QL (600 ml / 25 days), PA hydromorphone hcl preservative free (pf) 2 PA inj 10 /ml hydromorphone hcl tab 2 2 QL (180 tabs / 25 days), PA hydromorphone hcl tab 4 2 QL (150 tabs / 25 days), PA hydromorphone hcl tab 8 2 QL (60 tabs / 25 days), PA hydromorphone hcl tab er 24hr deter 8 2 PA hydromorphone hcl tab er 24hr deter 12 2 PA hydromorphone hcl tab er 24hr deter 16 2 PA hydromorphone hcl tab er 24hr deter 32 2 PA HYSINGLA ER TAB 20 MG 3 PA HYSINGLA ER TAB 30 MG 3 PA HYSINGLA ER TAB 40 MG 3 PA HYSINGLA ER TAB 60 MG 3 PA HYSINGLA ER TAB 80 MG 3 PA HYSINGLA ER TAB 100 MG 3 PA HYSINGLA ER TAB 120 MG 3 PA levorphanol tartrate tab 2 2 QL (100 tabs / 25 days), PA lortab tab QL (180 tabs / 25 days), PA 8

9 methadone con 10/ml 2 PA; (generic of Methadone Intensol, indicated for pain) methadone hcl conc 10 /ml 2 PA; (indicated for opioid addiction) methadone hcl inj 10 /ml 2 PA methadone hcl soln 5 /5ml 2 PA methadone hcl soln 10 /5ml 2 PA methadone hcl tab 5 2 PA methadone hcl tab 10 2 PA methadone hcl tab for oral susp 40 2 QL (9 tabs / 25 days), PA methadose tab 40 2 QL (9 tabs / 25 days), PA MORPHINE SUL INJ 2MG/ML 4 PA MORPHINE SUL INJ 4MG/ML 4 PA MORPHINE SUL INJ 5MG/ML 4 PA MORPHINE SUL INJ 150/30ML 4 PA MORPHINE SUL SUP 30MG 3 QL (80 supp / 25 days), PA morphine sulfate beads cap er 24hr 30 2 PA morphine sulfate beads cap er 24hr 45 2 PA morphine sulfate beads cap er 24hr 60 2 PA morphine sulfate beads cap er 24hr 75 2 PA morphine sulfate beads cap er 24hr 90 2 PA morphine sulfate beads cap er 24hr PA morphine sulfate cap er 24hr 10 2 PA morphine sulfate cap er 24hr 20 2 PA morphine sulfate cap er 24hr 30 2 PA morphine sulfate cap er 24hr 50 2 PA morphine sulfate cap er 24hr 60 2 PA morphine sulfate cap er 24hr 80 2 PA morphine sulfate cap er 24hr PA morphine sulfate inj 8 /ml 2 PA morphine sulfate inj 10 /ml 2 PA morphine sulfate inj pf 0.5 /ml 2 PA morphine sulfate inj pf 1 /ml 2 PA morphine sulfate iv soln 1 /ml 2 PA morphine sulfate iv soln pf 4 /ml 2 PA morphine sulfate iv soln pf 8 /ml 2 PA morphine sulfate iv soln pf 10 /ml 2 PA morphine sulfate iv soln pf 15 /ml 2 PA morphine sulfate oral soln 10 /5ml 2 QL (900 ml / 25 days), PA morphine sulfate oral soln 20 /5ml 2 QL (600 ml / 25 days), PA morphine sulfate oral soln 100 /5ml 2 QL (120 ml / 25 days), PA (20 /ml) morphine sulfate suppos 5 2 QL (180 supp / 25 days), PA morphine sulfate suppos 10 2 QL (180 supp / 25 days), PA morphine sulfate suppos 20 2 QL (120 supp / 25 days), PA 9

10 morphine sulfate tab 15 2 QL (160 tabs / 25 days), PA morphine sulfate tab 30 2 QL (80 tabs / 25 days), PA morphine sulfate tab er 15 2 PA morphine sulfate tab er 30 2 PA morphine sulfate tab er 60 2 PA morphine sulfate tab er PA morphine sulfate tab er PA nalbuphine hcl inj 10 /ml 2 PA nalbuphine hcl inj 20 /ml 2 PA NUCYNTA ER TAB 50MG 3 PA NUCYNTA ER TAB 100MG 3 PA NUCYNTA ER TAB 150MG 3 PA NUCYNTA ER TAB 200MG 3 PA NUCYNTA ER TAB 250MG 3 PA NUCYNTA TAB 50MG 3 QL (120 tabs / 25 days), PA NUCYNTA TAB 75MG 3 QL (80 tabs / 25 days), PA NUCYNTA TAB 100MG 3 QL (60 tabs / 25 days), PA oxycodone hcl cap 5 2 QL (180 caps / 25 days), PA oxycodone hcl conc 100 /5ml (20 2 QL (80 ml / 25 days), PA /ml) oxycodone hcl soln 5 /5ml 2 QL (900 ml / 25 days), PA oxycodone hcl tab 5 2 QL (180 tabs / 25 days), PA oxycodone hcl tab 10 2 QL (160 tabs / 25 days), PA oxycodone hcl tab 15 2 QL (100 tabs / 25 days), PA oxycodone hcl tab 20 2 QL (80 tabs / 25 days), PA oxycodone hcl tab 30 2 QL (50 tabs / 25 days), PA oxycodone hcl tab er 12hr deter 10 2 PA oxycodone hcl tab er 12hr deter 15 2 PA oxycodone hcl tab er 12hr deter 20 2 PA oxycodone hcl tab er 12hr deter 30 2 PA oxycodone hcl tab er 12hr deter 40 2 PA oxycodone hcl tab er 12hr deter 60 2 PA oxycodone hcl tab er 12hr deter 80 2 PA oxycodone w/ acetaminophen soln /5ml 2 QL (1600 ml / 25 days), PA oxycodone w/ acetaminophen tab QL (360 tabs / 25 days), PA oxycodone w/ acetaminophen tab QL (320 tabs / 25 days), PA oxycodone w/ acetaminophen tab QL (210 tabs / 25 days), PA oxycodone w/ acetaminophen tab QL (160 tabs / 25 days), PA oxycodone-aspirin tab QL (330 tabs / 25 days), PA oxycodone-ibuprofen tab QL (28 tabs / 25 days), PA OXYCONTIN TAB 10MG CR 3 PA OXYCONTIN TAB 15MG CR 3 PA 10

11 OXYCONTIN TAB 20MG CR 3 PA OXYCONTIN TAB 30MG CR 3 PA OXYCONTIN TAB 40MG CR 3 PA OXYCONTIN TAB 60MG CR 3 PA OXYCONTIN TAB 80MG CR 3 PA oxymorphone hcl tab 5 2 QL (160 tabs / 25 days), PA oxymorphone hcl tab 10 2 QL (80 tabs / 25 days), PA oxymorphone hcl tab er 12hr 5 2 PA oxymorphone hcl tab er 12hr PA oxymorphone hcl tab er 12hr 10 2 PA oxymorphone hcl tab er 12hr 15 2 PA oxymorphone hcl tab er 12hr 20 2 PA oxymorphone hcl tab er 12hr 30 2 PA oxymorphone hcl tab er 12hr 40 2 PA PRIMLEV TAB 5-300MG 4 QL (320 tabs / 25 days), PA PRIMLEV TAB QL (210 tabs / 25 days), PA PRIMLEV TAB MG 4 QL (160 tabs / 25 days), PA tramadol hcl tab 50 2 QL (180 tabs / 25 days), PA tramadol hcl tab er 24hr PA tramadol hcl tab er 24hr PA tramadol hcl tab er 24hr PA XARTEMIS XR TAB QL (120 tabs / 25 days), PA xylon tab QL (50 tabs / 25 days), PA OPIOID PARTIAL AGONISTS BELBUCA MIS 75MCG 3 PA BELBUCA MIS 150MCG 3 PA BELBUCA MIS 300MCG 3 PA BELBUCA MIS 450MCG 3 PA BELBUCA MIS 600MCG 3 PA BELBUCA MIS 750MCG 3 PA BELBUCA MIS 900MCG 3 PA buprenorphine hcl inj 0.3 /ml (base 2 equiv) buprenorphine hcl sl tab 2 (base equiv) 2 QL (90 tabs / 25 days); Must obtain approval after the initial fill buprenorphine hcl sl tab 8 (base equiv) 2 QL (90 tabs / 25 days); Must obtain approval after the initial fill SALICYLATES aspirin chw 81 0 OTC, QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply aspirin low tab 81 ec 0 OTC, QL (100 tabs / 30 days); OTC; $0 copay-age and gender restrictions apply 11

12 diflunisal tab ANESTHETICS LOCAL ANESTHETICS LIDO/DEXTROS INJ 5-7.5% 4 lidocaine hcl local inj 0.5% 2 lidocaine hcl local inj 1% 2 lidocaine hcl local inj 2% 2 lidocaine hcl local preservative free (pf) inj 2 0.5% lidocaine hcl local preservative free (pf) inj 2 1% lidocaine hcl local preservative free (pf) inj 2 1.5% lidocaine hcl local preservative free (pf) inj 2 2% lidocaine hcl local preservative free (pf) inj 2 4% ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 2 /ml) amikacin sulfate inj 500 /2ml (250 2 /ml) chloramphenicol sodium succinate for iv 2 inj 1 gm GENTAM/NACL INJ 0.9MG/ML 4 GENTAM/NACL INJ 1.4MG/ML 4 gentamicin in saline inj 0.8 /ml 2 gentamicin in saline inj 1 /ml 2 gentamicin in saline inj 1.2 /ml 2 gentamicin in saline inj 1.6 /ml 2 gentamicin in saline inj 2 /ml 2 gentamicin sulfate inj 10 /ml 2 gentamicin sulfate inj 40 /ml 2 gentamicin sulfate iv soln 10 /ml 2 KETEK TAB 300MG 4 KETEK TAB 400MG 4 MONUROL PAK GRANULES 4 neomycin sulfate tab paromomycin sulfate cap streptomycin sulfate for inj 1 gm 2 SULFADIAZINE TAB 500MG 4 tinidazole tab tinidazole tab tobramycin nebu soln 300 /5ml 2 QL (280 ml / 28 days), PA tobramycin sulfate for inj 1.2 gm 2 12

13 tobramycin sulfate inj 1.2 gm/30ml (40 2 /ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 2 /ml) (base equiv) tobramycin sulfate inj 10 /ml (base 2 equivalent) tobramycin sulfate inj 80 /2ml (40 2 /ml) (base equiv) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG 3 ALINIA SUS 100/5ML 3 ALINIA TAB 500MG 3 atovaquone susp 750 /5ml 2 AZACTAM/DEX INJ 1GM 4 AZACTAM/DEX INJ 2GM 4 aztreonam for inj 1 gm 2 aztreonam for inj 2 gm 2 BILTRICIDE TAB 600MG 4 CAYSTON INH 75MG 5 QL (84 vials / 28 days), PA clindamycin hcl cap 75 2 clindamycin hcl cap clindamycin hcl cap clindamycin palmitate hcl for soln 75 2 /5ml (base equiv) clindamycin phosphate inj 9 gm/60ml 2 clindamycin phosphate inj 300 /2ml 2 clindamycin phosphate inj 600 /4ml 2 clindamycin phosphate inj 900 /6ml 2 clindamycin phosphate iv soln 300 /2ml 2 clindamycin phosphate iv soln 900 /6ml 2 dapsone tab 25 2 dapsone tab daptomycin for iv soln DARAPRIM TAB 25MG 4 doripenem for iv infusion doripenem for iv infusion EMVERM CHW 100MG 4 imipenem-cilastatin intravenous for soln imipenem-cilastatin intravenous for soln INVANZ INJ 1GM 4 ivermectin tab 3 2 linezolid for susp 100 /5ml 2 linezolid in sodium chloride iv soln /300ml-0.9% linezolid iv soln 600 /300ml (2 /ml) 2 13

14 linezolid tab meropenem iv for soln 1 gm 2 meropenem iv for soln methenamine hippurate tab 1 gm 2 metronidazole cap metronidazole in nacl 0.79% iv soln /100ml metronidazole tab metronidazole tab NEBUPENT INH 300MG 4 nitrofurantoin macrocrystalline cap 25 2 PA; High Risk Medications require PA for members age 70 and older nitrofurantoin macrocrystalline cap 50 2 PA; High Risk Medications require PA for members age 70 and older nitrofurantoin macrocrystalline cap 100 nitrofurantoin monohydrate macrocrystalline cap PA; High Risk Medications require PA for members age 70 and older 2 PA; High Risk Medications require PA for members age 70 and older nitrofurantoin susp 25 /5ml 2 PA; High Risk Medications require PA for members age 70 and older PENTAM 300 INJ 300MG 4 polymyxin b sulfate for inj unit 2 praziquantel tab PRIMSOL SOL 50MG/5ML 3 SIVEXTRO INJ 200MG 4 SIVEXTRO TAB 200MG 4 sulfamethoxazole-trimethoprim iv soln /5ml sulfamethoxazole-trimethoprim susp /5ml sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim tab trimethoprim tab vancomycin hcl cap QL (80 caps / 10 days) vancomycin hcl cap QL (80 caps / 10 days) vancomycin hcl for inj 10 gm 2 vancomycin hcl for inj vancomycin hcl for inj vancomycin hcl for inj vancomycin hcl for inj

15 XIFAXAN TAB 200MG 3 XIFAXAN TAB 550MG 3 PA ANTIFUNGALS amphotericin b for inj 50 2 BIO-STATIN CAP BIO-STATIN CAP CRESEMBA CAP 186 MG 4 fluconazole for susp 10 /ml 2 fluconazole for susp 40 /ml 2 fluconazole in dextrose inj 200 /100ml 2 fluconazole in dextrose inj 400 /200ml 2 fluconazole in nacl 0.9% inj /100ml fluconazole in nacl 0.9% inj /200ml fluconazole tab 50 2 fluconazole tab fluconazole tab fluconazole tab FLUCONAZOLE/ INJ NACL griseofulvin microsize susp 125 /5ml 2 griseofulvin microsize tab griseofulvin ultramicrosize tab griseofulvin ultramicrosize tab itraconazole cap PA LAMISIL GRA 125MG 4 PA LAMISIL GRA 187.5MG 4 PA NOXAFIL SUS 40MG/ML 3 NOXAFIL TAB 100MG 3 nystatin oral powder 2 nystatin tab unit 2 SPORANOX SOL 10MG/ML 3 PA terbinafine hcl tab PA voriconazole for susp 40 /ml 2 PA voriconazole tab 50 2 PA voriconazole tab PA ANTIMALARIALS atovaquone-proguanil hcl tab atovaquone-proguanil hcl tab chloroquine phosphate tab chloroquine phosphate tab COARTEM TAB MG 4 mefloquine hcl tab PRIMAQUINE TAB 26.3MG 4 quinine sulfate cap ANTIRETROVIRAL AGENTS 15

16 abacavir sulfate soln 20 /ml (base equiv) 2 QL (900 ml / 30 days) abacavir sulfate tab 300 (base equiv) 2 QL (60 tabs / 30 days) APTIVUS CAP 250MG 3 QL (120 caps / 30 days) APTIVUS SOL 3 QL (300 ml / 30 days) atazanavir sulfate cap 150 (base 2 QL (30 caps / 30 days) equiv) atazanavir sulfate cap 200 (base 2 QL (60 caps / 30 days) equiv) atazanavir sulfate cap 300 (base 2 QL (30 caps / 30 days) equiv) CRIXIVAN CAP 200MG 3 QL (450 caps / 30 days) CRIXIVAN CAP 400MG 3 QL (180 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) EDURANT TAB 25MG 3 QL (60 tabs / 30 days) efavirenz cap 50 2 QL (90 caps / 30 days) efavirenz cap QL (90 caps / 30 days) efavirenz tab QL (30 tabs / 30 days) EMTRIVA CAP 200MG 3 QL (30 caps / 30 days) EMTRIVA SOL 10MG/ML 3 QL (680 ml / 28 days) fosamprenavir calcium tab 700 (base 2 QL (120 tabs / 30 days) equiv) FUZEON INJ 90MG 5 QL (60 vials / 30 days) INTELENCE TAB 25MG 3 QL (120 tabs / 30 days) INTELENCE TAB 100MG 3 QL (120 tabs / 30 days) INTELENCE TAB 200MG 3 QL (60 tabs / 30 days) INVIRASE CAP 200MG 3 QL (300 caps / 30 days) INVIRASE TAB 500MG 3 QL (120 tabs / 30 days) ISENTRESS CHW 25MG 3 QL (180 tabs / 30 days) ISENTRESS CHW 100MG 3 QL (180 tabs / 30 days) ISENTRESS HD TAB 600MG 3 QL (60 tabs / 30 days) ISENTRESS POW 100MG 3 QL (60 packets / 30 days) ISENTRESS TAB 400MG 3 QL (120 tabs / 30 days) lamivudine oral soln 10 /ml 2 QL (900 ml / 30 days) lamivudine tab QL (60 tabs / 30 days) lamivudine tab QL (30 tabs / 30 days) LEXIVA SUS 50MG/ML 3 QL (1680 ml / 30 days) nevirapine susp 50 /5ml 2 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 3 QL (360 caps / 30 days) 16

17 NORVIR SOL 80MG/ML 3 QL (480 ml / 30 days) NORVIR TAB 100MG 3 QL (360 tabs / 30 days) PREZISTA SUS 100MG/ML 3 QL (400 ml / 30 days) PREZISTA TAB 75MG 3 QL (300 tabs / 30 days) PREZISTA TAB 150MG 3 QL (180 tabs / 30 days) PREZISTA TAB 600MG 3 QL (60 tabs / 30 days) PREZISTA TAB 800MG 3 QL (30 tabs / 30 days) RESCRIPTOR TAB 100 MG 4 QL (900 tabs / 30 days) RESCRIPTOR TAB 200MG 4 QL (450 tabs / 30 days) RETROVIR INJ 10MG/ML 3 REYATAZ POW 50MG 3 QL (180 packets / 30 days) ritonavir tab QL (360 tabs / 30 days) SELZENTRY SOL 20MG/ML 3 QL (1840 ml / 30 days) SELZENTRY TAB 25MG 3 QL (240 tabs / 30 days) SELZENTRY TAB 75MG 3 QL (60 tabs / 30 days) SELZENTRY TAB 150MG 3 QL (60 tabs / 30 days) SELZENTRY TAB 300MG 3 QL (120 tabs / 30 days) stavudine cap 15 2 QL (60 caps / 30 days) stavudine cap 20 2 QL (60 caps / 30 days) stavudine cap 30 2 QL (60 caps / 30 days) stavudine cap 40 2 QL (60 caps / 30 days) tenofovir disoproxil fumarate tab QL (30 tabs / 30 days) TIVICAY TAB 10MG 3 QL (60 tabs / 30 days) TIVICAY TAB 25MG 3 QL (60 tabs / 30 days) TIVICAY TAB 50MG 3 QL (60 tabs / 30 days) TROGARZO INJ 150MG/ML 5 TYBOST TAB 150MG 3 QL (30 tabs / 30 days) VIDEX EC CAP 125MG 3 QL (30 caps / 30 days) VIDEX SOL 2GM 3 QL (1200 ml / 30 days) VIDEX SOL 4GM 3 QL (1200 ml / 30 days) VIRACEPT TAB 250MG 3 QL (300 tabs / 30 days) VIRACEPT TAB 625MG 3 QL (120 tabs / 30 days) VIRAMUNE SUS 50MG/5ML 3 QL (1200 ml / 30 days) VIREAD POW 40MG/GM 3 QL (240 gm / 30 days) VIREAD TAB 150MG 3 QL (30 tabs / 30 days) VIREAD TAB 200MG 3 QL (30 tabs / 30 days) VIREAD TAB 250MG 3 QL (30 tabs / 30 days) ZERIT SOL 1MG/ML 3 QL (2400 ml / 30 days) zidovudine cap QL (180 caps / 30 days) zidovudine syrup 10 /ml 2 QL (1800 ml / 30 days) zidovudine tab QL (60 tabs / 30 days) ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine tab QL (30 tabs / 30 days) abacavir sulfate-lamivudine-zidovudine tab 2 QL (60 tabs / 30 days)

18 ATRIPLA TAB 3 QL (30 tabs / 30 days) BIKTARVY TAB 3 QL (30 tabs / 30 days) COMPLERA TAB 3 QL (30 tabs / 30 days) DESCOVY TAB 200/25 3 QL (30 tabs / 30 days) EVOTAZ TAB QL (30 tabs / 30 days) GENVOYA TAB 3 QL (30 tabs / 30 days) KALETRA TAB MG 3 QL (240 tabs / 30 days) KALETRA TAB MG 3 QL (120 tabs / 30 days) lamivudine-zidovudine tab QL (60 tabs / 30 days) lopinavir-ritonavir soln /5ml 2 QL (390 ml / 30 days) (80-20 /ml) ODEFSEY TAB 3 QL (30 tabs / 30 days) PREZCOBIX TAB QL (30 tabs / 30 days) STRIBILD TAB 3 QL (30 tabs / 30 days) TRIUMEQ TAB 3 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 2 isoniazid syrup 50 /5ml 2 isoniazid tab isoniazid tab PASER GRA 4GM 4 PRIFTIN TAB 150MG 3 pyrazinamide tab rifabutin cap RIFAMATE CAP 3 rifampin cap rifampin cap rifampin for inj RIFATER TAB 3 SIRTURO TAB 100MG 4 TRECATOR TAB 250MG 3 ANTIVIRALS acyclovir cap acyclovir sodium for inj acyclovir sodium iv soln 50 /ml 2 acyclovir susp 200 /5ml 2 acyclovir tab acyclovir tab adefovir dipivoxil tab

19 BARACLUDE SOL.05MG/ML 3 cidofovir iv inj 75 /ml 2 entecavir tab entecavir tab 1 2 EPCLUSA TAB QL (28 tabs / 28 days), PA EPIVIR HBV SOL 5MG/ML 3 famciclovir tab famciclovir tab famciclovir tab HARVONI TAB MG 5 QL (28 tabs / 28 days), PA lamivudine tab 100 (hbv) 2 oseltamivir phosphate cap 30 (base 2 QL (40 caps / 90 days) equiv) oseltamivir phosphate cap 45 (base 2 QL (20 caps / 90 days) equiv) oseltamivir phosphate cap 75 (base 2 QL (20 caps / 90 days) equiv) oseltamivir phosphate for susp 6 /ml 2 QL (300 ml / 90 days) (base equiv) PEGASYS INJ 5 QL (4 injections / 28 days), PA PEGASYS INJ 180MCG/M 5 QL (4 injections / 28 days), PA PEGASYS INJ PROCLICK 5 QL (4 injections / 28 days), PA REBETOL SOL 40MG/ML 5 PA RELENZA MIS DISKHALE 3 QL (2 inhalers / 90 days) ribasphere cap PA ribasphere tab PA ribasphere tab PA ribasphere tab PA ribavirin cap PA ribavirin for inhal soln 6 gm 2 ribavirin tab PA rimantadine hydrochloride tab SOVALDI TAB 400MG 6 QL (28 tabs / 28 days), PA, ST TECHNIVIE TAB 6 QL (56 tabs / 28 days), PA, ST valacyclovir hcl tab 1 gm 2 valacyclovir hcl tab valganciclovir hcl for soln 50 /ml (base 2 equiv) valganciclovir hcl tab 450 (base 2 equivalent) VOSEVI TAB 5 QL (28 tabs / 28 days), PA ZEPATIER TAB MG 6 QL (28 tabs / 28 days), PA, ST CEPHALOSPORINS cefaclor cap cefaclor cap CEFACLOR ER TAB 500MG 3 19

20 cefaclor for susp 125 /5ml 2 cefaclor for susp 250 /5ml 2 cefaclor for susp 375 /5ml 2 cefadroxil cap cefadroxil for susp 250 /5ml 2 cefadroxil for susp 500 /5ml 2 cefadroxil tab 1 gm 2 cefazolin sodium for inj 1 gm 2 cefazolin sodium for inj 10 gm 2 cefazolin sodium for inj 20 gm 2 cefazolin sodium for inj cefazolin sodium for iv soln 1 gm 2 cefdinir cap cefdinir for susp 125 /5ml 2 cefdinir for susp 250 /5ml 2 cefditoren pivoxil tab 200 (base 2 equivalent) cefditoren pivoxil tab 400 (base 2 equivalent) cefepime hcl for inj 1 gm 2 cefepime hcl for inj 2 gm 2 cefixime for susp 100 /5ml 2 cefixime for susp 200 /5ml 2 cefotaxime sodium for inj 1 gm 2 cefotaxime sodium for inj 2 gm 2 cefotaxime sodium for inj 10 gm 2 cefotaxime sodium for inj cefotetan disodium for inj 1 gm 2 cefotetan disodium for inj 2 gm 2 cefotetan disodium for inj 10 gm 2 cefoxitin sodium for inj 10 gm 2 cefoxitin sodium for iv soln 1 gm 2 cefoxitin sodium for iv soln 2 gm 2 cefpodoxime proxetil for susp 50 /5ml 2 cefpodoxime proxetil for susp 100 /5ml 2 cefpodoxime proxetil tab cefpodoxime proxetil tab cefprozil for susp 125 /5ml 2 cefprozil for susp 250 /5ml 2 cefprozil tab cefprozil tab ceftazidime for inj 2 gm 2 ceftibuten cap ceftibuten for susp 180 /5ml 2 CEFTIN SUS 125/5ML 3 CEFTIN SUS 250/5ML 3 20

21 ceftriaxone sodium for inj 1 gm 2 ceftriaxone sodium for inj 2 gm 2 ceftriaxone sodium for inj 10 gm 2 ceftriaxone sodium for inj ceftriaxone sodium for inj ceftriaxone sodium for iv soln 1 gm 2 ceftriaxone sodium for iv soln 2 gm 2 cefuroxime axetil tab cefuroxime axetil tab CEFUROXIME INJ 75GM 4 CEFUROXIME INJ 225GM 4 cefuroxime sodium for inj 7.5 gm 2 cefuroxime sodium for inj cefuroxime sodium for iv soln 1.5 gm 2 cephalexin cap cephalexin cap cephalexin cap cephalexin for susp 125 /5ml 2 cephalexin for susp 250 /5ml 2 cephalexin tab cephalexin tab SUPRAX CAP 400MG 3 SUPRAX CHW 100MG 3 SUPRAX CHW 200MG 3 SUPRAX SUS 500/5ML 3 tazicef inj 1gm 2 tazicef inj 2gm 2 tazicef inj 6gm 2 ZINACEF INJ 750MG 4 ZINACEF/H20 INJ 1.5GM PB 4 ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 /5ml 2 azithromycin for susp 200 /5ml 2 azithromycin iv for soln azithromycin powd pack for susp 1 gm 2 azithromycin tab azithromycin tab azithromycin tab clarithromycin for susp 125 /5ml 2 clarithromycin for susp 250 /5ml 2 clarithromycin tab clarithromycin tab clarithromycin tab er 24hr DIFICID TAB 200MG 3 PA e.e.s. 400 tab ery-tab tab 250 ec 2 21

22 ery-tab tab 333 ec 2 ery-tab tab 500 ec 2 ERYPED SUS 400/5ML 3 ERYTHROCIN INJ 500MG 4 erythrocin tab erythromycin ethylsuccinate for susp /5ml erythromycin ethylsuccinate tab erythromycin tab erythromycin tab erythromycin w/ delayed release particles 2 cap 250 PCE TAB 333MG EC 4 PCE TAB 500MG EC 4 ZMAX SUS 2GM 4 FLUOROQUINOLONES ciprofloxacin 200 /100ml in d5w 2 ciprofloxacin 400 /200ml in d5w 2 ciprofloxacin for oral susp 250 /5ml 2 (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 /5ml 2 (10%) (10 gm/100ml) ciprofloxacin hcl tab 100 (base equiv) 2 ciprofloxacin hcl tab 250 (base equiv) 2 ciprofloxacin hcl tab 500 (base equiv) 2 ciprofloxacin hcl tab 750 (base equiv) 2 ciprofloxacin iv soln 200 /20ml (1%) 2 ciprofloxacin iv soln 400 /40ml (1%) 2 ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) FACTIVE TAB 320MG 4 levofloxacin in d5w iv soln 250 /50ml 2 levofloxacin in d5w iv soln 500 /100ml 2 levofloxacin in d5w iv soln 750 /150ml 2 levofloxacin iv soln 25 /ml 2 levofloxacin oral soln 25 /ml 2 levofloxacin tab levofloxacin tab levofloxacin tab moxifloxacin hcl 400 /250ml in sodium 2 chloride 0.8% inj moxifloxacin hcl tab 400 (base equiv) 2 ofloxacin tab ofloxacin tab

23 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 amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) tab amoxicillin (trihydrate) tab ampicillin & sulbactam sodium for inj (1-0.5) gm ampicillin & sulbactam sodium for inj 3 (2-2 1) gm ampicillin & sulbactam sodium for inj 15 2 (10-5) gm ampicillin & sulbactam sodium for iv soln 2 15 (10-5) gm ampicillin cap ampicillin cap ampicillin for susp 125 /5ml 2 ampicillin for susp 250 /5ml 2 ampicillin sodium for inj 1 gm 2 23

24 ampicillin sodium for inj 2 gm 2 ampicillin sodium for inj 10 gm 2 ampicillin sodium for inj ampicillin sodium for inj ampicillin sodium for inj ampicillin sodium for iv soln 1 gm 2 ampicillin sodium for iv soln 2 gm 2 ampicillin sodium for iv soln 10 gm 2 AUGMENTIN SUS 125/5ML 3 dicloxacillin sodium cap dicloxacillin sodium cap nafcillin sodium for inj 1 gm 2 nafcillin sodium for inj 2 gm 2 nafcillin sodium for iv soln 1 gm 2 nafcillin sodium for iv soln 2 gm 2 nafcillin sodium for iv soln 10 gm 2 oxacillin sodium for inj 1 gm (base 2 equivalent) oxacillin sodium for inj 2 gm (base 2 equivalent) oxacillin sodium for inj 10 gm (base 2 equivalent) penicillin g potassium for inj unit 2 penicillin g potassium for inj unit penicillin g sodium for inj unit 2 penicillin v potassium for soln 125 /5ml 2 penicillin v potassium for soln 250 /5ml 2 penicillin v potassium tab penicillin v potassium tab pfizerpen inj 20mu 2 piperacillin sod-tazobactam na for inj gm ( gm) piperacillin sod-tazobactam sod for inj gm ( gm) piperacillin sod-tazobactam sod for inj gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj gm ( gm) TETRACYCLINES avidoxy tab demeclocycline hcl tab demeclocycline hcl tab doxy 100 inj doxycycline hyclate cap 50 2 doxycycline hyclate cap doxycycline hyclate for inj

25 doxycycline hyclate tab 20 2 doxycycline hyclate tab doxycycline hyclate tab delayed release 75 2 doxycycline hyclate tab delayed release doxycycline hyclate tab delayed release doxycycline monohydrate cap 50 2 doxycycline monohydrate cap 75 2 doxycycline monohydrate cap doxycycline monohydrate cap doxycycline monohydrate for susp 25 2 /5ml doxycycline monohydrate tab 50 2 doxycycline monohydrate tab 75 2 doxycycline monohydrate tab minocycline hcl cap 50 2 minocycline hcl cap 75 2 minocycline hcl cap minocycline hcl tab 50 2 minocycline hcl tab 75 2 minocycline hcl tab morgidox cap 1x100 2 tetracycline hcl cap tetracycline hcl cap VIBRAMYCIN SYP 50MG/5ML 4 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU INJ 100MG 3 busulfan inj 6 /ml 2 CYCLOPHOSPH CAP 25MG 3 CYCLOPHOSPH CAP 50MG 3 cyclophosphamide cap 25 2 cyclophosphamide cap 50 2 cyclophosphamide for inj 1 gm 2 cyclophosphamide for inj 2 gm 2 cyclophosphamide for inj dacarbazine for inj dacarbazine for inj EMCYT CAP 140MG 3 GLEOSTINE CAP 5MG 3 GLEOSTINE CAP 10MG 3 GLEOSTINE CAP 40MG 3 GLEOSTINE CAP 100MG 3 GLIADEL WAF 7.7MG 3 25

26 HEXALEN CAP 50MG 3 ifosfamide for inj 1 gm 2 ifosfamide iv inj 1 gm/20ml (50 /ml) 2 ifosfamide iv inj 3 gm/60ml (50 /ml) 2 LEUKERAN TAB 2MG 3 melphalan hcl for inj 50 (base equiv) 2 melphalan tab 2 2 TEMODAR INJ 100MG 5 PA temozolomide cap 5 5 PA temozolomide cap 20 5 PA temozolomide cap PA temozolomide cap PA temozolomide cap PA temozolomide cap PA ANTHRACYCLINES daunorubicin hcl inj 5 /ml (base equiv) 2 DAUNOXOME INJ 2MG/ML 3 doxorubicin hcl for inj 10 2 doxorubicin hcl for inj 50 2 doxorubicin hcl inj 2 /ml 2 doxorubicin hcl liposomal inj (for iv 2 infusion) 2 /ml epirubicin hcl iv soln 50 /25ml (2 2 /ml) epirubicin hcl iv soln 200 /100ml (2 2 /ml) idarubicin hcl iv inj 5 /5ml (1 /ml) 2 idarubicin hcl iv inj 10 /10ml (1 /ml) 2 idarubicin hcl iv inj 20 /20ml (1 /ml) 2 ANTIBIOTICS bleomycin sulfate for inj 15 unit 2 bleomycin sulfate for inj 30 unit 2 mitomycin for iv soln 5 2 mitomycin for iv soln 20 2 mitomycin for iv soln 40 2 ANTIMETABOLITES adrucil inj 500/10ml 2 ALIMTA INJ 100MG 3 ALIMTA INJ 500MG 3 ARRANON INJ 5MG/ML 3 azacitidine for inj PA capecitabine tab QL (120 tabs / 30 days), PA capecitabine tab QL (300 tabs / 30 days), PA cladribine iv soln 10 /10ml (1 /ml) 2 clofarabine iv soln 1 /ml 2 cytarabine inj 20 /ml 2 26

27 cytarabine inj pf 20 /ml 2 cytarabine inj pf 100 /ml 2 decitabine for inj 50 5 PA DEPOCYT INJ 50MG/5ML 3 floxuridine for inj 0.5 gm 2 fludarabine phosphate for inj 50 2 fludarabine phosphate inj 25 /ml 2 fluorouracil iv soln 1 gm/20ml (50 /ml) 2 fluorouracil iv soln 2.5 gm/50ml (50 2 /ml) fluorouracil iv soln 5 gm/100ml (50 2 /ml) fluorouracil iv soln 500 /10ml (50 2 /ml) gemcitabine hcl for inj 1 gm 2 gemcitabine hcl for inj 2 gm 2 gemcitabine hcl for inj gemcitabine hcl inj 1 gm/26.3ml (38 2 /ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 2 /ml) (base equiv) gemcitabine hcl inj 200 /5.26ml (38 2 /ml) (base equiv) mercaptopurine tab 50 2 methotrexate sodium for inj 1 gm 2 methotrexate sodium inj 50 /2ml (25 2 /ml) methotrexate sodium inj 250 /10ml (252 /ml) methotrexate sodium inj pf 50 /2ml (252 /ml) methotrexate sodium inj pf 100 /4ml 2 (25 /ml) methotrexate sodium inj pf 200 /8ml 2 (25 /ml) methotrexate sodium inj pf 250 /10ml 2 (25 /ml) methotrexate sodium inj pf 1000 /40ml 2 (25 /ml) NIPENT INJ 10MG 3 TABLOID TAB 40MG 3 ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG 3 DOCEFREZ INJ 20MG 3 docetaxel for inj conc 20 /ml 2 docetaxel for inj conc 80 /4ml (20 2 /ml) 27

28 DOCETAXEL INJ 20/0.5ML 3 DOCETAXEL INJ 20MG/2ML 3 DOCETAXEL INJ 80MG/2ML 3 DOCETAXEL INJ 80MG/8ML 3 DOCETAXEL INJ 140/7ML 3 DOCETAXEL INJ 160/8ML 3 DOCETAXEL INJ 160/16ML 3 DOCETAXEL INJ 200MG/20 3 DOCETAXEL INJ NON-ALCO 3 docetaxel soln for iv infusion 20 /2ml 2 docetaxel soln for iv infusion 80 /8ml 2 docetaxel soln for iv infusion 160 /16ml 2 paclitaxel iv conc 30 /5ml (6 /ml) 2 paclitaxel iv conc 100 /16.7ml (6 2 /ml) paclitaxel iv conc 150 /25ml (6 /ml) 2 paclitaxel iv conc 300 /50ml (6 /ml) 2 ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate inj 1 /ml 2 vincasar pfs inj 1/ml 2 vincristine sulfate iv soln 1 /ml 2 vinorelbine tartrate inj 10 /ml (base 2 equiv) vinorelbine tartrate inj 50 /5ml (10 2 /ml) (base equiv) BIOLOGIC RESPONSE MODIFIERS ERBITUX INJ 100MG 5 PA ERBITUX INJ 200MG 5 PA ERIVEDGE CAP 150MG 5 QL (30 caps / 30 days), PA FARYDAK CAP 10MG 5 PA FARYDAK CAP 15MG 5 PA FARYDAK CAP 20MG 5 PA GAZYVA INJ 25MG/ML 5 PA IBRANCE CAP 75MG 5 QL (21 caps / 28 days), PA IBRANCE CAP 100MG 5 QL (21 caps / 28 days), PA IBRANCE CAP 125MG 5 QL (21 caps / 28 days), PA KADCYLA INJ 100MG 5 PA KADCYLA INJ 160MG 5 PA KEYTRUDA INJ 100MG/4M 5 PA KEYTRUDA SOL 50MG 5 PA LYNPARZA CAP 50MG 5 QL (480 caps / 30 days), PA LYNPARZA TAB 100MG 5 QL (180 tabs / 30 days), PA LYNPARZA TAB 150MG 5 QL (120 tabs / 30 days), PA RYDAPT CAP 25MG 6 QL (224 caps / 28 days), PA ZEJULA CAP 100MG 6 QL (90 caps / 30 days), PA ZOLINZA CAP 100MG 5 QL (120 caps / 30 days), PA 28

29 HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 2 bicalutamide tab 50 2 DEPO-PROVERA INJ 400/ML 4 ELIGARD INJ 7.5MG 5 PA ELIGARD INJ 22.5MG 5 PA ELIGARD INJ 30MG 5 PA ELIGARD INJ 45MG 5 PA exemestane tab 25 2 FARESTON TAB 60MG 3 FASLODEX INJ 250/5ML 3 flutamide cap letrozole tab leuprolide acetate inj kit 5 /ml 5 PA LUPR DEP-PED INJ 3M 30MG 5 PA LUPR DEP-PED INJ 7.5MG 5 PA LUPR DEP-PED INJ 11.25MG 5 PA LUPR DEP-PED INJ 15MG 5 PA LUPRON DEPOT INJ 3.75MG 5 PA LUPRON DEPOT INJ 7.5MG 5 PA LUPRON DEPOT INJ 11.25MG 5 PA LUPRON DEPOT INJ 22.5MG 5 PA LUPRON DEPOT INJ 30MG 5 PA LUPRON DEPOT INJ 45MG 5 PA LYSODREN TAB 500MG 3 megestrol acetate susp 40 /ml 2 megestrol acetate susp 625 /5ml 2 megestrol acetate tab 20 2 megestrol acetate tab 40 2 nilutamide tab tamoxifen citrate tab 10 (base equivalent) 2 $0 copay for women > 35 years for the primary prevention of breast cancer tamoxifen citrate tab 20 (base equivalent) 2 $0 copay for women > 35 years for the primary prevention of breast cancer XTANDI CAP 40MG 5 QL (120 caps / 30 days), PA ZYTIGA TAB 250MG 5 QL (120 tabs / 30 days), PA ZYTIGA TAB 500MG 5 QL (60 tabs / 30 days), PA KINASE INHIBITORS AFINITOR DIS TAB 2MG 5 QL (60 tabs / 30 days), PA AFINITOR DIS TAB 3MG 5 QL (90 tabs / 30 days), PA AFINITOR DIS TAB 5MG 5 QL (60 tabs / 30 days), PA AFINITOR TAB 2.5MG 5 QL (30 tabs / 30 days), PA AFINITOR TAB 5MG 5 QL (30 tabs / 30 days), PA AFINITOR TAB 7.5MG 5 QL (30 tabs / 30 days), PA 29

30 AFINITOR TAB 10MG 5 QL (30 tabs / 30 days), PA ALECENSA CAP 150MG 5 QL (240 caps / 30 days), PA BOSULIF TAB 100MG 5 QL (90 tabs / 30 days), PA BOSULIF TAB 400MG 5 QL (30 tabs / 30 days), PA BOSULIF TAB 500MG 5 QL (30 tabs / 30 days), PA CALQUENCE CAP 100MG 6 QL (60 caps / 30 days), PA CAPRELSA TAB 100MG 5 QL (60 tabs / 30 days), PA CAPRELSA TAB 300MG 5 QL (30 tabs / 30 days), PA COMETRIQ KIT 60MG 5 QL (1 kit / 28 days), PA COMETRIQ KIT 100MG 5 QL (1 kit / 28 days), PA COMETRIQ KIT 140MG 5 QL (1 kit / 28 days), PA ICLUSIG TAB 15MG 5 QL (60 tabs / 30 days), PA ICLUSIG TAB 45MG 5 QL (30 tabs / 30 days), PA IDHIFA TAB 50MG 5 QL (30 tabs / 30 days), PA IDHIFA TAB 100MG 5 QL (30 tabs / 30 days), PA imatinib mesylate tab 100 (base 5 QL (90 tabs / 30 days), PA equivalent) imatinib mesylate tab 400 (base 5 QL (60 tabs / 30 days), PA equivalent) IMBRUVICA CAP 70MG 5 QL (30 caps / 30 days), PA IMBRUVICA CAP 140MG 5 QL (120 caps / 30 days), PA IMBRUVICA TAB 140MG 5 QL (30 tabs / 30 days), PA IMBRUVICA TAB 280MG 5 QL (30 tabs / 30 days), PA IMBRUVICA TAB 420MG 5 QL (30 tabs / 30 days), PA IMBRUVICA TAB 560MG 5 QL (30 tabs / 30 days), PA INLYTA TAB 1MG 5 QL (180 tabs / 30 days), PA INLYTA TAB 5MG 5 QL (120 tabs / 30 days), PA JAKAFI TAB 5MG 5 QL (60 tabs / 30 days), PA JAKAFI TAB 10MG 5 QL (60 tabs / 30 days), PA JAKAFI TAB 15MG 5 QL (60 tabs / 30 days), PA JAKAFI TAB 20MG 5 QL (60 tabs / 30 days), PA JAKAFI TAB 25MG 5 QL (60 tabs / 30 days), PA LENVIMA CAP 8 MG 5 QL (60 caps / 30 days), PA LENVIMA CAP 10 MG 5 QL (30 caps / 30 days), PA LENVIMA CAP 14 MG 5 QL (60 caps / 30 days), PA LENVIMA CAP 18 MG 5 QL (90 caps / 30 days), PA LENVIMA CAP 20 MG 5 QL (60 caps / 30 days), PA LENVIMA CAP 24 MG 5 QL (90 caps / 30 days), PA MEKINIST TAB 0.5MG 5 QL (90 tabs / 30 days), PA MEKINIST TAB 2MG 5 QL (30 tabs / 30 days), PA NEXAVAR TAB 200MG 5 QL (120 tabs / 30 days), PA SPRYCEL TAB 20MG 5 QL (90 tabs / 30 days), PA SPRYCEL TAB 50MG 5 QL (30 tabs / 30 days), PA SPRYCEL TAB 70MG 5 QL (30 tabs / 30 days), PA SPRYCEL TAB 80MG 5 QL (30 tabs / 30 days), PA SPRYCEL TAB 100MG 5 QL (30 tabs / 30 days), PA 30

31 SPRYCEL TAB 140MG 5 QL (30 tabs / 30 days), PA STIVARGA TAB 40MG 5 QL (84 tabs / 28 days), PA SUTENT CAP 12.5MG 5 QL (30 caps / 30 days), PA SUTENT CAP 25MG 5 QL (30 caps / 30 days), PA SUTENT CAP 37.5MG 5 QL (30 caps / 30 days), PA SUTENT CAP 50MG 5 QL (30 caps / 30 days), PA TAFINLAR CAP 50MG 5 QL (120 caps / 30 days), PA TAFINLAR CAP 75MG 5 QL (120 caps / 30 days), PA TARCEVA TAB 25MG 5 QL (60 tabs / 30 days), PA TARCEVA TAB 100MG 5 QL (30 tabs / 30 days), PA TARCEVA TAB 150MG 5 QL (30 tabs / 30 days), PA TYKERB TAB 250MG 5 QL (180 tabs / 30 days), PA VOTRIENT TAB 200MG 5 QL (120 tabs / 30 days), PA XALKORI CAP 200MG 5 QL (60 caps / 30 days), PA XALKORI CAP 250MG 5 QL (60 caps / 30 days), PA ZELBORAF TAB 240MG 5 QL (240 tabs / 30 days), PA ZYDELIG TAB 100MG 5 QL (60 tabs / 30 days), PA ZYDELIG TAB 150MG 5 QL (60 tabs / 30 days), PA ZYKADIA CAP 150MG 5 QL (150 caps / 30 days), PA MISCELLANEOUS bexarotene cap 75 5 PA DROXIA CAP 200MG 3 DROXIA CAP 300MG 3 DROXIA CAP 400MG 3 hydroxyurea cap MATULANE CAP 50MG 3 mitoxantrone hcl inj conc 20 /10ml (2 5 PA /ml) mitoxantrone hcl inj conc 25 /12.5ml 5 PA (2 /ml) mitoxantrone hcl inj conc 30 /15ml (2 5 PA /ml) ONCASPAR INJ 750/ML 5 PA PHOTOFRIN INJ 75MG 3 QUADRAMET INJ 3 THERACYS INJ 3 TICE BCG INJ 3 tretinoin cap 10 2 TRISENOX INJ 12MG/6ML 3 TRISENOX SOL 10MG/10M 3 UVADEX INJ 20MCG/ML 3 VISTOGARD PAK 10GM 3 PLATINUM-BASED AGENTS carboplatin iv soln 50 /5ml 2 carboplatin iv soln 150 /15ml 2 carboplatin iv soln 450 /45ml 2 31

32 carboplatin iv soln 600 /60ml 2 cisplatin inj 50 /50ml (1 /ml) 2 cisplatin inj 100 /100ml (1 /ml) 2 cisplatin inj 200 /200ml (1 /ml) 2 oxaliplatin for iv inj 50 2 oxaliplatin for iv inj oxaliplatin iv soln 50 /10ml 2 oxaliplatin iv soln 100 /20ml 2 PROTECTIVE AGENTS amifostine for inj dexrazoxane for inj dexrazoxane for inj leucovorin calcium for inj 50 2 leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium for inj leucovorin calcium tab 5 2 leucovorin calcium tab 10 2 leucovorin calcium tab 15 2 leucovorin calcium tab 25 2 mesna inj 100 /ml 2 MESNEX TAB 400MG 3 TOPOISOMERASE INHIBITORS CAMPTOSAR INJ 300/15ML 3 etoposide cap 50 2 etoposide inj 100 /5ml (20 /ml) 2 irinotecan hcl inj 40 /2ml (20 /ml) 2 irinotecan hcl inj 100 /5ml (20 /ml) 2 irinotecan hcl inj 500 /25ml (20 /ml) 2 TENIPOSIDE INJ 50MG/5ML 3 toposar inj 20/ml 2 toposar inj 100/5ml 2 topotecan hcl for inj 4 2 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC, BCL-2 INHIBITORS VENCLEXTA TAB 10MG 5 PA VENCLEXTA TAB 50MG 5 PA VENCLEXTA TAB 100MG 5 PA VENCLEXTA TAB START PK 5 PA CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap

33 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 captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide 1 tab enalapril maleate & hydrochlorothiazide 1 tab fosinopril sodium & hydrochlorothiazide 1 tab fosinopril sodium & hydrochlorothiazide 1 tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab

34 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 10 1 benazepril hcl tab 20 1 benazepril hcl tab 40 1 captopril tab captopril tab 25 1 captopril tab 50 1 captopril tab enalapril maleate tab enalapril maleate tab 5 1 enalapril maleate tab 10 1 enalapril maleate tab 20 1 fosinopril sodium tab 10 1 fosinopril sodium tab 20 1 fosinopril sodium tab 40 1 lisinopril tab lisinopril tab 5 1 lisinopril tab 10 1 lisinopril tab 20 1 lisinopril tab 30 1 lisinopril tab 40 1 moexipril hcl tab moexipril hcl tab 15 1 perindopril erbumine tab 2 1 perindopril erbumine tab 4 1 perindopril erbumine tab 8 1 quinapril hcl tab 5 1 quinapril hcl tab 10 1 quinapril hcl tab 20 1 quinapril hcl tab 40 1 ramipril cap ramipril cap ramipril cap 5 1 ramipril cap 10 1 trandolapril tab 1 1 trandolapril tab 2 1 trandolapril tab

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