HAP Midwest MI Health Link (Medicare-Medicaid Plan) 2016 Formulary (List of Covered Drugs)

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1 H9712_001_2016_LOCD_Approved HAP Midwest MI Health Link (Medicare-Medicaid Plan) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID: v16 We have made no changes to this formulary since 10/25/2016. For more recent information or other questions, please contact HAP Midwest MI Health Link (Medicare-Medicaid Plan) Customer Service at (TTY 711) 7 days a week, 8 a.m. to 8 p.m. Eastern Time. The call is free. Or visit The Formulary may change at any time. You will receive notice when necessary. HAP Midwest MI Health Link is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. H9712_001_2016_LOCD_Approved 1

2 HAP Midwest MI Health Link 2016 List of Covered Drugs (Formulary) This is a list of drugs that members can get in HAP Midwest MI Health Link Plan. HAP Midwest MI Health Link is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send a notice before we make a change that affects. Benefits may change on January 1 of each year. You can always check HAP Midwest MI Health Link s up-to-date List of Covered Drugs online at Limitations, restrictions, and patient pay amounts may apply. This means that may have to pay for some services and that need to follow certain rules to have HAP Midwest MI Health Link pay for r services. For more information, call HAP Midwest MI Health Link Customer Services or read the HAP Midwest MI Health Link Member Handbook. You can get this information for free in other languages. Call HAP Midwest MI Health Link Customer Service (TTY 711) 7 Days a week, 8 a.m. to 8 p.m. Eastern Time. The call is free. Puedes hablar con alguien acerca de obtener esta información en otros idiomas. Llamar al حول ما خص ل ال ح ول ل وم ھذه ع ى أخرى ل غات ف ي ال م ع ات gratuita La llamadaes (888) ي ال م ال ك ك.مجان ة ت ح ي م ن ش مع ال دث ص You can also get this information for free in other formats, such as large print, braille, or audio. Call Customer Service at (TTY 711) 7 Days a week, 8 a.m. to 8 p.m. Eastern Time. The call is free.? If have questions, please call HAP Midwest MI Health Link at (TTY 711), 7 Days a Week, 8 a.m. to 8 p.m. Eastern time. The call is free. For more information, visit 2

3 Frequently Asked Questions (FAQ) Find answers here to questions have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 12 are the drugs covered by HAP Midwest MI Health Link. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide services. We refer to these pharmacies as network pharmacies. HAP Midwest MI Health Link will cover all medically necessary drugs on the Drug List if: r doctor or other prescriber says need them to get better or stay healthy, and fill the prescription at a <plan name> network pharmacy. HAP Midwest MI Health Link may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Customer Services at (TTY 711) 7 days a week, 8 a.m. to 8 p.m. Eastern Time. The call is free. 2. Does the Drug List ever change? Yes. HAP Midwest MI Health Link may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from HAP Midwest MI Health Link before can get a drug.) Add or change the amount of a drug can get (called quantity limits ).? If have questions, please call HAP Midwest MI Health Link at (TTY 711), 7 Days a Week, 8 a.m. to 8 p.m. Eastern time. The call is free. For more information, visit 3

4 Add or change step therapy restrictions on a drug. (Step therapy means must try one drug before we will cover another drug.) (For more information on these drug rules, see page 5.) We will tell when a drug are taking is removed from the Drug List. We will also tell when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check HAP Midwest MI Health Link s up to date Drug List online at You can also call Customer Services to check the current Drug List at (TTY 711) 7 days a week, 8 a.m. to 8 p.m. Eastern Time. 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If are taking a drug that is removed beca a cheaper drug that works just as well comes along, we will tell. We will tell at least 60 days before we remove it from the Drug List or when ask for a refill. Then can get a 60-day supply of the drug before the change to the Drug List is made. You will receive this notification in the mail and at the pharmacy when ask for a refill. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug are taking is not safe, we will take it off the Drug List right away. We will also send a letter telling that. You can call Customer Service for a list of similar drugs that are covered by HAP Midwest MI Health Link. When receive the list, show it to r doctor and ask him or her to prescribe a similar drug that is covered by HAP Midwest MI Health Link. Or, can ask HAP Midwest MI Health Link to make an exception and cover r drug. Please see question 11 for more information about exceptions. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount can get. In some cases must do something before can get the drug. For example:? If have questions, please call HAP Midwest MI Health Link at (TTY 711), 7 Days a Week, 8 a.m. to 8 p.m. Eastern time. The call is free. For more information, visit 4

5 Prior approval (or prior authorization): For some drugs, or r doctor or other prescriber must get approval from HAP Midwest MI Health Link before fill r prescription. If don t get approval, HAP Midwest MI Health Link may not cover the drug. Quantity limits: Sometimes HAP Midwest MI Health Link limits the amount of a drug can get. Step therapy: Sometimes HAP Midwest MI Health Link requires to do step therapy. This means will have to try drugs in a certain order for r medical condition. You might have to try one drug before we will cover another drug. If r prescriber thinks the first drug doesn t work for, then we will cover the second. You can find out if r drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send a copy. You can also ask for an exception from these limits. Please see question 11 for more information on exceptions. If are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if cannot easily get the drug need, we can help. We will cover a 31-day emergency supply of the drug need (unless have a prescription for fewer days), whether or not are a new HAP Midwest MI Health Link member. This will give time to talk to r doctor or other prescriber. He or she can help decide if there is a similar drug on the Drug List can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will know if the drug want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 12 has a column labeled restrictions, or limits on.? If have questions, please call HAP Midwest MI Health Link at (TTY 711), 7 Days a Week, 8 a.m. to 8 p.m. Eastern time. The call is free. For more information, visit 5

6 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell at least 60 days before the restriction is added or when next ask for a refill. Then, can get a 60-day supply of the drug before the change to the Drug List is made. This gives time to talk to r doctor or other prescriber about what to do next. 8. How can find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it starting on page 123. The section provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find r drug. Next to r drug, will see the page number where can find coverage information. Turn to the page listed in the Index and find the name of r drug in the first column of the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 12. The drugs in this section are grouped into categories depending on the type of medical conditions they are d to treat. For example, if have a heart condition, should look in the category, Cardiovascular Agents. That is where will find drugs that treat heart conditions. 9. What if the drug want to take is not on the Drug List? If don t see r drug on the Drug List, call Customer Services at (TTY 711) 7 days a week, 8 a.m. to 8 p.m. Eastern Time and ask about it. If learn that HAP Midwest MI Health Link will not cover the drug, can do one of these things: Ask Customer Services for a list of drugs like the one want to take. Then show the list to r doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one want to take. Or? If have questions, please call HAP Midwest MI Health Link at (TTY 711), 7 Days a Week, 8 a.m. to 8 p.m. Eastern time. The call is free. For more information, visit 6

7 You can ask the health plan to make an exception to cover r drug. Please see question 11 for more information about exceptions. 10. What if are a new HAP Midwest MI Health Link member and can t find r drug on the Drug List or have a problem getting r drug? We can help. We may cover a temporary 30-day supply of r drug during the first 90 days are a member of HAP Midwest MI Health Link. This will give time to talk to r doctor or other prescriber. He or she can help decide if there is a similar drug on the Drug List can take instead or whether to request an exception. We will cover a 30-day supply of r drug if: are taking a drug that is not on our Drug List, or health plan rules do not let get the amount ordered by r prescriber, or the drug requires prior approval by HAP Midwest MI Health Link, or are taking a drug that is part of a step therapy restriction. If live in a nursing home or other long-term care facility, may refill r prescription for as long as 91 days. You may refill the drug multiple times during r first 90 days in the plan. This gives r prescriber time to change r drugs to ones on the Drug List or ask for an exception. Exceptions are available in situations where experience a change in the level of care are receiving that also requires to transition from one facility or treatment center to another. In such circumstances, would be eligible for a temporary, one-time fill exception even if are outside of the first 90 days as a member of the plan. 11. Can ask for an exception to cover r drug? Yes. You can ask HAP Midwest MI Health Link to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on r drug. For example, HAP Midwest MI Health Link may limit the amount of a drug we will cover. If r drug has a limit, can ask us to change the limit and cover more.? If have questions, please call HAP Midwest MI Health Link at (TTY 711), 7 Days a Week, 8 a.m. to 8 p.m. Eastern time. The call is free. For more information, visit 7

8 Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from r prescriber supporting r request for an exception. After we receive the statement, we will give a decision on r exception request within 72 hours. If or r prescriber think r health may be harmed if have to wait 72 hours for a decision, can ask for an expedited exception. This is a faster decision. If r prescriber supports r request, we will give a decision within 24 hours of receiving r prescriber s supporting statement. 13. How can ask for an exception? To ask for an exception, call (TTY 711) 7 days a week, 8 a.m. to 8 p.m. Eastern Time. A Customer Services representative will work with and r provider to help ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). HAP Midwest MI Health Link covers both brand name drugs and generic drugs.? If have questions, please call HAP Midwest MI Health Link at (TTY 711), 7 Days a Week, 8 a.m. to 8 p.m. Eastern time. The call is free. For more information, visit 8

9 15. What are OTC drugs? OTC stands for over-the-counter. HAP Midwest MI Health Link covers some OTC drugs when they are written as prescriptions by r provider. You can read the HAP Midwest MI Health Link Drug List to see what OTC drugs are covered. 16. What is r copay? HAP Midwest MI Health Link members have no copays for prescription and OTC drugs. 17. What are drug tiers? This is a description of the HAP Midwest MI Health Link drug tiers, type of drug and copay amounts. Drug Tier Type of Drug Copay Amount 1 Generics ($0) 2 Brands ($0) There is no copay charged on drugs in either Tier 1 or Tier 2.? If have questions, please call HAP Midwest MI Health Link at (TTY 711), 7 Days a Week, 8 a.m. to 8 p.m. Eastern time. The call is free. For more information, visit 9

10 List of Covered Drugs The list of covered drugs that begins on the next page gives information about the drugs covered by HAP Midwest MI Health Link. If have trouble finding r drug in the list, turn to the Index that begins on page 123. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the necessary actions, column tells if HAP Midwest MI Health Link has any rules for covering r drug. Note: The * next to a drug means the drug is not a Part D drug. These drugs have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if think we made a mistake. For example, we might decide that a drug that want is not covered or is no longer covered by Medicare or Michigan Medicaid. If or r prescriber disagrees with our decision, can appeal. To ask for instructions on how to appeal, call Customer Services at (TTY 711) 7 days a week, 8 a.m. to 8 p.m. Eastern Time. The call is free. You can also read Chapter 9 in the Member Handbook to learn how to appeal a decision. List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are d to treat. For example, if have a heart condition, should look in the category, Cardiovascular Agents. That is where will find drugs that treat heart conditions.? If have questions, please call HAP Midwest MI Health Link at (TTY 711), 7 Days a Week, 8 a.m. to 8 p.m. Eastern time. The call is free. For more information, visit 10

11 Legend Tier Description 1 Generics ($0) 2 Brands ($0) Symbol QL PA ST Description Quantity limit, dispense limit for 30 days, unless otherwise noted You (or r physician) are required to get prior authorization before fill r prescription for this drug. Without prior approval, we may not cover this drug. Step therapy exception required LA Limited access, This prescription may be available only at certain pharmacies BD Covered under Medicare Part B or D * Non-Part D drugs or OTC items that are covered by Medicaid (g) Only the generic version of this drug is covered. The brand name version is not covered. M The brand name version of this drug is in Tier 2. The generic version is in Tier 1 If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at days a week, 8 a.m. to 8 p.m. Eastern Time. The call is free. 11

12 Analgesics Nonsteroidal Anti-inflammatory Drugs acetaminophen (160 mg/5ml oral susp, 325 mg tablet, 500 mg capsule, 500 mg tablet, 650 mg supp.rect, 650 mg tablet er) * aspirin 81 mg tablet dr * celecoxib (100 mg capsule, 200 mg capsule, 50 mg capsule) $0 (Tier 1) QL (60 PER 30 DAYS), (g) celecoxib 400 mg capsule diclofenac potassium 50 mg tablet diclofenac sodium (100 mg tab er 24h, 25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr) diclofenac sodium 1 % gel (gram) $0 (Tier 1) ST, (g) diclofenac sodium/misoprostol (50 mg-200 tab ir dr, 75 mg-200 tab ir dr) etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tab er 24h, 500 mg tablet, 600 mg tab er 24h) fenoprofen calcium 400 mg capsule FLECTOR 1.3% PATCH PA flurbiprofen (100 mg tablet, 50 mg ibuprofen (100 mg tab chew, 100 mg/5ml oral susp, 200 mg tablet, 50 mg/1.25 drops susp) * ibuprofen (400 mg tablet, 600 mg tablet, 800 mg ketoprofen (50 mg capsule, 75 mg capsule) meloxicam (15 mg tablet, 7.5 mg nabumetone (500 mg tablet, 750 mg If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-12

13 Analgesics naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet, 500 mg tablet dr) naproxen sodium (275 mg tablet, 550 mg naproxen sodium 220 mg tablet * oxaprozin 600 mg tablet PAIN & FEVER 500 MG TABLET * piroxicam (10 mg capsule, 20 mg capsule) sulindac (150 mg tablet, 200 mg tolmetin sodium 400 mg capsule VOLTAREN 1% GEL ST Opioid Analgesics, Long-acting EMBEDA (ER MG CAPSULE, ER MG CAPSULE) EMBEDA (ER MG CAPSULE, ER 50-2 MG CAPSULE) QL (120 PER 30 DAYS) QL (60 PER 30 DAYS) EMBEDA ER MG CAPSULE QL (90 PER 30 DAYS) EMBEDA ER MG CAPSULE QL (180 PER 30 DAYS) fentanyl (100 mcg/hr patch td72, 12 mcg/hr patch td72, 25 mcg/hr patch td72, 25mcg/hr patch td72, 50mcg/hr patch td72, 75mcg/hr patch td72) $0 (Tier 1) QL (15 PER 30 DAYS), (g) levorphanol tartrate 2 mg tablet QL (120 PER 30 DAYS), (g) methadone hcl 10 mg tablet $0 (Tier 1) QL (360 PER 30 DAYS), (g) methadone hcl 5 mg tablet $0 (Tier 1) QL (180 PER 30 DAYS), (g) morphine sulfate (100 mg tablet er, 15 mg tablet er, 200 mg tablet er, 30 mg tablet er, 60 mg tablet er) $0 (Tier 1) QL (90 PER 30 DAYS), (g) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-13

14 Analgesics morphine sulfate (120 mg cpmp 24hr, 30 mg cap er pel, 30 mg cpmp 24hr, 45 mg cpmp 24hr, 60 mg cap er pel, 60 mg cpmp 24hr, 75 mg cpmp 24hr, 90 mg cpmp 24hr) NUCYNTA ER (ER 100 MG TABLET, ER 150 MG TABLET, ER 200 MG TABLET, ER 250 MG TABLET, ER 50 MG TABLET) OPANA ER (ER 10 MG TABLET, ER 15 MG TABLET, ER 20 MG TABLET, ER 30 MG TABLET, ER 40 MG TABLET, ER 5 MG TABLET, ER 7.5 MG TABLET) OXYCONTIN (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40 MG TABLET) OXYCONTIN (60 MG TABLET, 80 MG TABLET) tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mg tab er 24h, 200 mg tbmp 24hr) ZOHYDRO ER (ER 10 MG CAPSULE, ER 15 MG CAPSULE, ER 20 MG CAPSULE, ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 50 MG CAPSULE) Opioid Analgesics, Short-acting ABSTRAL (100 MCG TAB SUBLINGUAL, 200 MCG TAB SUBLINGUAL, 300 MCG TAB SUBLINGUAL, 400 MCG TAB SUBLINGUAL, 600 MCG TAB SUBLINGUAL, 800 MCG TAB SUBLINGUAL) acetaminophen with codeine 300mg-60mg tablet acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg/12.5 solution) $0 (Tier 1) QL (30 PER 30 DAYS), (g) QL (60 PER 30 DAYS) QL (60 PER 30 DAYS) QL (60 PER 30 DAYS) QL (120 PER 30 DAYS) $0 (Tier 1) QL (30 PER 30 DAYS), (g) PA, QL (60 PER 30 DAYS) PA, QL (120 PER 30 DAYS) $0 (Tier 1) QL (180 PER 30 DAYS), (g) $0 (Tier 1) QL (2700 PER 30 DAYS), (g) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-14

15 Analgesics acetaminophen with codeine phosphate (300mg-15mg tablet, 300mg-30mg butorphanol tartrate (1 mg/ml vial, 10 mg/ml spray, 2 mg/ml vial) codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg DURAMORPH (10 MG/10 ML AMPUL, 5 MG/10 ML AMPUL) fentanyl citrate (1200 mcg lozenge hd, 1600 mcg lozenge hd, 200 mcg lozenge hd, 400 mcg lozenge hd, 600 mcg lozenge hd, 800 mcg lozenge hd) hydrocodone bitartrate/acetaminophen (10mg- 300mg tablet, 10mg-325mg tablet, mg tablet, mg hydrocodone bitartrate/acetaminophen ( /5 solution, 5-217mg/10 solution, /15 solution) hydrocodone bitartrate/acetaminophen (5 mg- 300mg tablet, 5 mg-325mg hydrocodone/ibuprofen (10mg- 200mg tablet, mg hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg $0 (Tier 1) QL (360 PER 30 DAYS), (g) $0 (Tier 1) QL (180 PER 30 DAYS), (g) $0 (Tier 1) PA $0 (Tier 1) PA, QL (120 PER 30 DAYS), (g) $0 (Tier 1) QL (180 PER 30 DAYS), (g) $0 (Tier 1) QL (3600 PER 30 DAYS), (g) $0 (Tier 1) QL (360 PER 30 DAYS), (g) $0 (Tier 1) QL (150 PER 30 DAYS), (g) $0 (Tier 1) QL (180 PER 30 DAYS), (g) hydromorphone hcl 1 mg/ml liquid $0 (Tier 1) QL (1440 PER 30 DAYS), (g) hydromorphone hcl 2 mg/ml syringe hydromorphone hcl/pf (10 mg/ml ampul, 10 mg/ml vial) LAZANDA (100 MCG NASAL SPRAY, 300 MCG NASAL SPRAY, 400 MCG NASAL SPRAY) $0 (Tier 1) PA, (g) PA, QL (30 PER 30 DAYS) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-15

16 Analgesics morphine sulfate 10 mg/5 ml solution morphine sulfate 100 mg/5ml solution $0 (Tier 1) QL (2700 PER 30 DAYS), (g) $0 (Tier 1) QL (270 PER 30 DAYS), (g) morphine sulfate 15 mg tablet QL (240 PER 30 DAYS), (g) morphine sulfate 20 mg/5 ml solution $0 (Tier 1) QL (1350 PER 30 DAYS), (g) morphine sulfate 30 mg tablet QL (180 PER 30 DAYS), (g) oxycodone hcl (10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg $0 (Tier 1) QL (180 PER 30 DAYS), (g) oxycodone hcl 5 mg tablet $0 (Tier 1) QL (360 PER 30 DAYS), (g) oxycodone hcl/acetaminophen ( mg tablet, 5 mg-325mg oxycodone hcl/acetaminophen 10mg-325mg tablet oxycodone hcl/acetaminophen 5-325/5 ml solution oxycodone hcl/acetaminophen mg tablet oxycodone hcl/aspirin tablet $0 (Tier 1) QL (360 PER 30 DAYS), (g) $0 (Tier 1) QL (180 PER 30 DAYS), (g) $0 (Tier 1) QL (1860 PER 30 DAYS), (g) $0 (Tier 1) QL (240 PER 30 DAYS), (g) $0 (Tier 1) QL (360 PER 30 DAYS), (g) tramadol hcl 50 mg tablet $0 (Tier 1) QL (240 PER 30 DAYS), (g) tramadol hcl/acetaminophen mg tablet $0 (Tier 1) QL (240 PER 30 DAYS), (g) Anesthetics Local Anesthetics lidocaine 5 % adh. patch $0 (Tier 1) PA, QL (90 PER 30 DAYS), (g) lidocaine 5 % oint. (g) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-16

17 Anesthetics lidocaine hcl (2 % jel (ml), 2 % jel/pf app, 2 % jelly(ml), 2 % solution, 4 % solution, 40 mg/ml solution) lidocaine/prilocaine (2.5 %-2.5% cream (g), 2.5 %-2.5% kit) Anti-Addiction/ Substance Ab Treatment Agents Alcohol Deterrents/ Anti-craving acamprosate calcium 333 mg tablet dr disulfiram (250 mg tablet, 500 mg Opioid Dependence Treatments buprenorphine hcl (2 mg tab subl, 8 mg tab subl) buprenorphine hcl/naloxone hcl (/naloxone 2 mg-0.5mg tab subl, /naloxone 8 mg-2 mg tab subl) BUTRANS (10 MCG/HR PATCH, 15 MCG/HR PATCH, 20 MCG/HR PATCH, 5 MCG/HR PATCH, 7.5 MCG/HR PATCH) $0 (Tier 1) PA, (g) $0 (Tier 1) PA, (g) QL (4 PER 28 DAYS) naltrexone hcl 50 mg tablet SUBOXONE (12 MG-3 MG SL FILM, 2 MG-0.5 MG SL FILM, 4 MG-1 MG SL FILM, 8 MG-2 MG SL FILM) VIVITROL (380 MG VIAL, 380 MG VIAL + DILUENT) PA ZUBSOLV MG TABLET SL QL (30 PER 30 DAYS) ZUBSOLV MG TABLET SL QL (150 PER 30 DAYS) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-17

18 Anti-Addiction/ Substance Ab Treatment Agents Opioid Reversal Agents naloxone hcl 0.4 mg/ml vial naloxone hcl 1 mg/ml syringe (g) Smoking Cessation Agents bupropion hcl 150 mg tablet er CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG TABLET, STARTING MONTH BOX) nicotine (14mg/24hr patch td24, 21 mg/24hr patch td24, 7mg/24hr patch td24) * nicotine polacrilex (2 mg gum, 2 mg lozenge, 4 mg gum, 4 mg lozenge) * NICOTROL CARTRIDGE INHALER NICOTROL NS 10 MG/ML SPRAY Antibacterials Aminoglycosides amikacin sulfate (1000mg/4ml vial, 500 mg/2ml vial) gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g)) gentamicin sulfate (0.3 % drops, 0.3 % oint. (g), 40 mg/ml vial) gentamicin sulfate in sodium chloride, iso-osmotic (gentamic100mg/0.1l piggyback, gentamic120mg/0.1l piggyback, gentamic60 mg/50ml piggyback, gentamic80 mg/50ml piggyback, gentamic80mg/100ml piggyback) (g) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-18

19 Antibacterials gentamicin sulfate in sodium chloride, iso-osmotic (gentamic70 mg/50ml piggyback, gentamic90mg/100ml piggyback) gentamicin sulfate/pf (100mg/10ml vial port, 20 mg/2 ml vial, 60 mg/6 ml vial port, 80 mg/8 ml vial port) (g) neomycin sulfate 500 mg tablet paromomycin sulfate 250 mg capsule streptomycin sulfate 1 g vial (g) tobramycin 0.3 % drops tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial) tobramycin/sodium chloride 80mg/100ml piggyback (g) Antibacterials, Other bacitracin 500 unit/g oint. (g) (g) bacitracin/polymyxin b sulfate k/g oint. (g) chloramphenicol sod succ 1 g vial (g) clindamycin hcl (150 mg capsule, 300 mg capsule, 75 mg capsule) clindamycin phosphate (1 % gel (gram), 1 % lotion, 1 % med. swab, 1 % solution, 150 mg/ml vial, 2 % cream/appl, 300 mg/2ml vial port, 600 mg/4ml vial port, 900mg/6ml vial port) clindamycin phosphate/dextrose 5 % in water (300mg/50ml piggyback, 600mg/50ml piggyback, 900mg/50ml piggyback) CLINDESSE 2% VAGINAL CREAM colistin (colistimethate na) 150 mg vial If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-19

20 Antibacterials CUBICIN 500 MG VIAL DALVANCE 500 MG VIAL linezolid (100 mg/5ml susp recon, 600 mg $0 (Tier 1) PA, (g) linezolid 600mg/300 iv soln linezolid-0.9% sodium chloride 600mg/300 iv soln methenamine hippurate 1 g tablet metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % gel w/appl, 0.75 % lotion, 1 % gel (gram), 1 % gel w/pump, 250 mg tablet, 375 mg capsule, 500 mg metronidazole/sodium chloride 500mg/0.1l piggyback mupirocin 2 % oint. (g) neomycin su/bacitra/polymyxin 3.5mg-400 oint. (g) neomycin sulfate/polymyxin b sulfate (ampul, vial) neomycin/polymyxn b/gramicidin 1.75mg-10k drops nitrofurantoin 25 mg/5 ml oral susp $0 (Tier 1) PA, QL (7200 PER 365 DAYS), (g) nitrofurantoin macrocrystal (100 mg capsule, 50 mg capsule) nitrofurantoin macrocrystal 25 mg capsule nitrofurantoin monohyd/m-cryst 100 mg capsule polymyxin b sulf/trimethoprim /ml drops $0 (Tier 1) PA, QL (360 PER 365 DAYS), (g) $0 (Tier 1) QL (90 PER 365 OVER TIME), (g) $0 (Tier 1) QL (90 PER 365 OVER TIME), (g) SIVEXTRO 200 MG TABLET PA If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-20

21 Antibacterials SIVEXTRO 200 MG VIAL SYNERCID 500 MG VIAL trimethoprim 100 mg tablet TYGACIL 50 MG VIAL vancomycin hcl (1 g vial, 1 g vial port, 10 g vial, 125 mg capsule, 250 mg capsule, 5 g vial, 500 mg vial, 500 mg vial port, 750 mg vial) VANDAZOLE VAGINAL 0.75% GEL $0 (Tier 1) ZYVOX 100 MG/5 ML SUSPENSION PA Beta-lactam, Cephalosporins cefaclor (250 mg capsule, 500 mg capsule) cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon) cefazolin sodium (1 g vial, 10 g vial, 100 g bulkbaginj, 20 g vial, 300g bulkbaginj, 500 mg vial) cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) cefepime hcl (1 g vial, 2 g vial) cefotaxime sodium (1 g vial, 2 g vial, 500 mg vial) cefoxitin sodium (1 g vial, 10 g vial, 2 g vial) cefpodoxime proxetil (100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet, 50 mg/5 ml susp recon) cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg ceftazidime (1 g vial, 2 g vial, 6 g vial) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-21

22 Antibacterials ceftriaxone sodium (1 g vial, 1 g vial port, 10 g vial, 100 g bulkbaginj, 2 g vial, 2 g vial port, 250 mg vial, 500 mg vial) ceftriaxone sodium/dextrose, isoosmotic (1 g/50 ml froz.piggy, 2 g/50 ml froz.piggy) cefuroxime axetil (250 mg tablet, 500 mg cefuroxime sodium (1.5 g vial, 7.5 g vial, 7.5g vial, 750 mg vial) cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule, 750 mg capsule) SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPSULE) TEFLARO (400 MG VIAL, 600 MG VIAL) Beta-lactam, Other AZACTAM-ISO-OSMOTIC DEXTROSE (1 GM/50 ML, 2 GM/50 ML) aztreonam (1 g vial, 2 g vial) imipenem/cilastatin sodium (250 mg vial, 500 mg vial) INVANZ 1 GM VIAL meropenem (1 g vial, 500 mg vial) Beta-lactam, Penicillins amoxicillin (125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 875 mg If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-22

23 Antibacterials amoxicillin/potassium clavulanate ( /5 susp recon, mg tab chew, mg tablet, mg tab chew, mg/5 susp recon, mg tablet, /5 susp recon, mg ampicillin sodium (1 g vial, 1 g vial port, 10 g vial, 2 g vial, 250 mg vial, 500 mg vial) ampicillin sodium/sulbactam sodium (1.5 g vial, 1.5 g vial port, 3 g vial, 3 g vial port) ampicillin trihydrate (125 mg/5ml susp recon, 250 mg/5ml susp recon) ampicillin trihydrate (250 mg capsule, 500 mg capsule) BICILLIN L-A (1,200,000 UNITS, 2,400,000 UNITS, 600,000 UNIT/ML) dicloxacillin sodium (250 mg capsule, 500 mg capsule) nafcillin sodium (1 g vial, 10 g vial, 2 g vial) penicillin g potassium (20mm unit vial, 5mm unit vial) penicillin g potassium/dextrosewater (2mm/50ml froz.piy, 3mm/50ml froz.piy) (g) (g) penicillin g sodium 5mm unit vial (g) penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg piperacillin sodium/tazobactam sodium (2.25 g vial, g vial, g vial port, 4.5 g vial, 4.5 g vial port, 40.5 g vial) ZOSYN (2.25 GM/50 ML GALAXY BAG, GM/50 ML GALAXY, 4.5 GM/100 ML GALAXY BAG) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-23

24 Antibacterials Macrolides azithromycin (100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 500 mg vial, 500 mg vial port, 600 mg azithromycin 1 g packet (g) clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tab er 24h, 500 mg DIFICID 200 MG TABLET E.E.S. 200 MG/5 ML GRANULES ERY-TAB (EC 250 MG TABLET, EC 333 MG TABLET, EC 500 MG TABLET) ERYPED 200 MG/5 ML SUSPENSION ERYPED 400 MG/5 ML SUSPENSION ERYTHROCIN 250 MG FILMTAB ERYTHROCIN LACTOBIONATE (500 MG ADDVNT VL, 500 MG VIAL) erythromycin base (250 mg capsule dr, 5 mg/g oint. (g)) erythromycin base (250 mg tablet, 500 mg erythromycin base/ethyl alcohol (2 % med. swab, 2 % solution) ILOTYCIN 0.5% EYE OINTMENT $0 (Tier 1) Quinolones AVELOX IV 400 MG/250 ML BESIVANCE 0.6% SUSP ciprofloxacin (250 mg/5ml sus mc rec, 500 mg/5ml sus mc rec) (g) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-24

25 Antibacterials ciprofloxacin hcl (0.3 % drops, 250 mg tablet, 500 mg tablet, 750 mg ciprofloxacin hcl 100 mg tablet (g) ciprofloxacin lactate (200mg/20ml vial, 400mg/40ml vial) ciprofloxacin lactate/dextrose 5 % in water (200mg/0.1l piggyback, 400mg/0.2l piggyback) ciprofloxacin/ciprofloxacin hcl (1000 mg tbmp 24hr, 500 mg tbmp 24hr) levofloxacin (25 mg/ml vial, 250 mg tablet, 250mg/10ml solution, 500 mg tablet, 500mg/20ml solution, 750 mg levofloxacin/dextrose 5 % in water (250mg/50ml piggyback, 500mg/0.1l piggyback, 750mg/.15l piggyback) MOXEZA 0.5% EYE DROPS moxifloxacin hcl 400 mg tablet moxifloxacin/sod.ace,sul/water 400mg/.25l piggyback (g) ofloxacin 0.3 % drops ofloxacin 400 mg tablet (g) VIGAMOX 0.5% EYE DROPS Sulfonamides silver sulfadiazine 1 % cream (g) SSD 1% CREAM $0 (Tier 1) sulfacetamide sodium (10 % drops, 10 % suspension) sulfadiazine 500 mg tablet (g) sulfamethoxazole/trimethoprim (200-40mg/5 oral susp, 400mg- 80mg tablet, mg tablet, /20 oral susp) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-25

26 Antibacterials sulfamethoxazole/trimethoprim 80-16mg/ml vial Tetracyclines demeclocycline hcl (150 mg tablet, 300 mg doxycycline hyclate (100 mg capsule, 100 mg tablet, 100 mg vial, 20 mg tablet, 50 mg capsule) doxycycline monohydrate (100 mg capsule, 100 mg tablet, 150 mg capsule, 150 mg tablet, 50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg minocycline hcl (100 mg capsule, 100 mg tablet, 50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tetracycline hcl (250 mg capsule, 500 mg capsule) (g) (g) Anticonvulsants Anticonvulsants, Other BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 100 MG TABLET, 25 MG TABLET, 50 MG TABLET, 50 MG/5 ML VIAL, 75 MG TABLET) FYCOMPA 0.5 MG/ML ORAL SUSP levetiracetam (100 mg/ml solution, 1000 mg tablet, 250 mg tablet, 500 mg tablet, 500 mg/5ml solution, 500 mg/5ml vial, 750 mg If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-26

27 Anticonvulsants levetiracetam in sodium chloride, iso-osmotic (1000mg/100 piggyback, 1500mg/100 piggyback, 500mg/0.1l piggyback) POTIGA (200 MG TABLET, 300 MG TABLET, 400 MG TABLET, 50 MG TABLET) (g) Calcium Channel Modifying Agents CELONTIN 300 MG KAPSEAL ethosuximide (250 mg capsule, 250 mg/5ml solution) LYRICA (100 MG CAPSULE, 150 MG CAPSULE, 20 MG/ML ORAL SOLUTION, 200 MG CAPSULE, 225 MG CAPSULE, 25 MG CAPSULE, 300 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE) zonisamide (100 mg capsule, 25 mg capsule, 50 mg capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT 2.5 MG PEDI SYSTEM QL (5 PER 30 DAYS) DIASTAT ACUDIAL MG QL (40 PER 30 DAYS) DIASTAT ACUDIAL MG KT QL (20 PER 30 DAYS) diazepam kit QL (40 PER 30 DAYS), (g) diazepam 2.5 mg kit QL (5 PER 30 DAYS), (g) diazepam mg kit QL (20 PER 30 DAYS), (g) divalproex sodium (125 mg cap sprink, 125 mg tablet dr, 250 mg tab er 24h, 250 mg tablet dr, 500 mg tab er 24h, 500 mg tablet dr) gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300 mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-27

28 Anticonvulsants GABITRIL (12 MG TABLET, 16 MG TABLET) ONFI (10 MG TABLET, 20 MG TABLET) PA, QL (60 PER 30 DAYS) ONFI 2.5 MG/ML SUSPENSION PA, QL (480 PER 30 DAYS) phenobarbital (100 mg tablet, 15 mg tablet, 30 mg tablet, 60 mg phenobarbital (16.2 mg tablet, 20 mg/5 ml elixir, 32.4 mg tablet, 64.8 mg tablet, 97.2mg primidone (250 mg tablet, 50 mg SABRIL (500 MG POWDER PACKET, 500 MG TABLET) tiagabine hcl (2 mg tablet, 4 mg valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution, 500 mg/5ml vial, 500mg/10ml solution) PA, (g) $0 (Tier 1) PA, (g) valproic acid 250 mg capsule Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) FYCOMPA (10 MG TABLET, 12 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET) lamotrigine (100 mg tab rapdis, 100 mg tablet, 150 mg tablet, 200 mg tab rapdis, 200 mg tablet, 25 mg tab rapdis, 25 mg tablet, 25 mg tb chw dsp, 5 mg tb chw dsp, 50 mg tab rapdis) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-28

29 Anticonvulsants topiramate (100 mg tablet, 15 mg cap sprink, 200 mg tablet, 25 mg cap sprink, 25 mg tablet, 50 mg Sodium Channel Agents APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) BANZEL (200 MG TABLET, 40 MG/ML SUSPENSION, 400 MG TABLET) carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg tab er 12h, 100 mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 300 mg cpmp 12hr, 400 mg tab er 12h) DILANTIN 30 MG CAPSULE fosphenytoin sodium (100mg pe/2 vial, 500 pe/10 vial) oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg PEGANONE 250 MG TABLET phenytoin (100 mg/4ml oral susp, 125 mg/5ml oral susp, 50 mg tab chew) phenytoin sodium extended (100 mg capsule, 200 mg capsule, 300 mg capsule) TEGRETOL XR 100 MG TABLET VIMPAT (10 MG/ML SOLUTION, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET, 200 MG/20 ML VIAL, 50 MG TABLET) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-29

30 Antidementia Agents Antidementia Agents, Other ergoloid mesylates 1 mg tablet $0 (Tier 1) PA, (g) Cholinesterase Inhibitors donepezil hcl (10 mg tab rapdis, 10 mg tablet, 23 mg tablet, 5 mg tab rapdis, 5 mg EXELON (13.3 MG/24HR PATCH, 4.6 MG/24HR PATCH, 9.5 MG/24HR PATCH) galantamine hbr (12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel, 4 mg tablet, 8 mg cap24h pel, 8 mg galantamine hbr 4 mg/ml solution (g) rivastigmine (13.3mg/24h patch td24, 4.6mg/24hr patch td24, 9.5mg/24hr patch td24) rivastigmine tartrate (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 6 mg capsule) N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (10 mg tablet, 2 mg/ml solution, 5 mg tablet, 5 mg- 10 mg tab ds pk) NAMENDA (10 MG TABLET, 2 MG/ML SOLUTION, 5 MG TABLET, 5-10 MG TITRATION PK) NAMENDA XR (14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE, 7 MG CAPSULE, TITRATION PACK) Antidepressants $0 (Tier 1) PA, (g) PA PA Antidepressants, Other If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-30

31 bupropion hcl (100 mg tablet er, 150 mg tablet er, 200 mg tablet er, 75 mg $0 (Tier 1) QL (60 PER 30 DAYS), (g) Antidepressants bupropion hcl (150 mg tab er 24h, 300 mg tab er 24h) $0 (Tier 1) QL (30 PER 30 DAYS), (g) bupropion hcl 100 mg tablet $0 (Tier 1) QL (120 PER 30 DAYS), (g) mirtazapine (15 mg tab rapdis, 15 mg tablet, 30 mg tab rapdis, 30 mg tablet, 45 mg tab rapdis, 45 mg tablet, 7.5 mg $0 (Tier 1) QL (30 PER 30 DAYS), (g) Monoamine Oxidase Inhibitors EMSAM (12 MG/24 HOURS PATCH, 6 MG/24 HOURS PATCH, 9 MG/24 HOURS PATCH) MARPLAN 10 MG TABLET phenelzine sulfate 15 mg tablet tranylcypromine sulfate 10 mg tablet SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibito BRINTELLIX (10 MG TABLET, 20 MG TABLET, 5 MG TABLET) citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mg citalopram hydrobromide 10 mg/5 ml solution duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 60 mg capsule dr) escitalopram oxalate (10 mg tablet, 20 mg tablet, 5 mg escitalopram oxalate 5 mg/5 ml solution FETZIMA (ER 120 MG CAPSULE, ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE) QL (30 PER 30 DAYS) $0 (Tier 1) QL (30 PER 30 DAYS), (g) $0 (Tier 1) QL (600 PER 30 DAYS), (g) $0 (Tier 1) QL (60 PER 30 DAYS), (g) $0 (Tier 1) QL (30 PER 30 DAYS), (g) $0 (Tier 1) QL (600 PER 30 DAYS), (g) QL (30 PER 30 DAYS) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-31

32 Antidepressants FETZIMA MG TITRATION PAK QL (28 PER 28 DAYS) fluoxetine hcl (10 mg capsule, 10 mg fluoxetine hcl (20 mg capsule, 20 mg $0 (Tier 1) QL (30 PER 30 DAYS), (g) $0 (Tier 1) QL (120 PER 30 DAYS), (g) fluoxetine hcl 20 mg/5 ml solution $0 (Tier 1) QL (600 PER 30 DAYS), (g) fluoxetine hcl 40 mg capsule $0 (Tier 1) QL (60 PER 30 DAYS), (g) fluoxetine hcl 90 mg capsule dr $0 (Tier 1) QL (4 PER 28 DAYS), (g) fluvoxamine maleate (25 mg tablet, 50 mg $0 (Tier 1) QL (30 PER 30 DAYS), (g) fluvoxamine maleate 100 mg tablet $0 (Tier 1) QL (90 PER 30 DAYS), (g) maprotiline hcl (25 mg tablet, 50 mg tablet, 75 mg nefazodone hcl (100 mg tablet, 150 mg tablet, 200 mg tablet, 50 mg QL (90 PER 30 DAYS), (g) (g) nefazodone hcl 250 mg tablet paroxetine hcl (10 mg tablet, 12.5 mg tab er 24h, 20 mg tablet, 40 mg paroxetine hcl (25 mg tab er 24h, 30 mg tablet, 37.5 mg tab er 24h) $0 (Tier 1) QL (30 PER 30 DAYS), (g) $0 (Tier 1) QL (60 PER 30 DAYS), (g) PAXIL 10 MG/5 ML SUSPENSION QL (900 PER 30 DAYS) PRISTIQ (ER 100 MG TABLET, ER 25 MG TABLET, ER 50 MG TABLET) sertraline hcl (25 mg tablet, 50 mg QL (30 PER 30 DAYS) $0 (Tier 1) QL (30 PER 30 DAYS), (g) sertraline hcl 100 mg tablet $0 (Tier 1) QL (60 PER 30 DAYS), (g) sertraline hcl 20 mg/ml oral conc $0 (Tier 1) QL (300 PER 30 DAYS), (g) trazodone hcl (100 mg tablet, 150 mg tablet, 300 mg tablet, 50 mg TRINTELLIX (10 MG TABLET, 20 MG TABLET, 5 MG TABLET) QL (30 PER 30 DAYS) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-32

33 Antidepressants venlafaxine hcl (100 mg tablet, 25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 24h, 75 mg tab er 24, 75 mg venlafaxine hcl (150 mg cap er 24h, 150 mg tab er 24, 37.5 mg cap er 24h, 37.5 mg tab er 24) VENLAFAXINE HCL ER (ER 150 MG TAB, ER 37.5 MG TAB) $0 (Tier 1) QL (90 PER 30 DAYS), (g) $0 (Tier 1) QL (30 PER 30 DAYS), (g) $0 (Tier 1) QL (30 PER 30 DAYS) VENLAFAXINE HCL ER 75 MG TAB $0 (Tier 1) QL (90 PER 30 DAYS) VIIBRYD (10 MG TABLET, MG STARTER PACK, MG STARTER PK, 20 MG TABLET, 40 MG TABLET) QL (30 PER 30 DAYS) Tricyclics amitriptyline hcl (10 mg tablet, 100 mg tablet, 150 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg amoxapine (100 mg tablet, 150 mg tablet, 25 mg tablet, 50 mg clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) desipramine hcl (10 mg tablet, 100 mg tablet, 150 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 100 mg capsule, 150 mg capsule, 25 mg capsule, 50 mg capsule) $0 (Tier 1) PA, (g) (g) $0 (Tier 1) PA, (g) $0 (Tier 1) PA, (g) doxepin hcl 75 mg capsule PA, (g) imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg nortriptyline hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) nortriptyline hcl 10 mg/5 ml solution $0 (Tier 1) PA, (g) (g) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-33

34 Antidepressants protriptyline hcl (10 mg tablet, 5 mg SURMONTIL (100 MG CAPSULE, 25 MG CAPSULE, 50 MG CAPSULE) trimipramine maleate (100 mg capsule, 25 mg capsule, 50 mg capsule) PA $0 (Tier 1) PA, (g) Antiemetics Antiemetics, Other chlorpromazine hcl (10 mg tablet, 100 mg tablet, 200 mg tablet, 25 mg tablet, 50 mg $0 (Tier 1) PA, (g) chlorpromazine hcl 25 mg/ml ampul PA, (g) hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet, 50 mg/25ml solution) meclizine hcl (12.5 mg tablet, 25 mg metoclopramide hcl (10 mg tab rapdis, 10 mg tablet, 10 mg/10ml solution, 5 mg tablet, 5 mg/5 ml solution, 5 mg/ml vial) perphenazine (16 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg PHENERGAN (12.5 MG SUPPOSITORY, 25 MG SUPPOSITORY) $0 (Tier 1) PA, (g) $0 (Tier 1) PA, (g) $0 (Tier 1) PA prochlorperazine 25 mg supp.rect prochlorperazine edisylate (10 mg/2 ml vial, 5 mg/ml vial) prochlorperazine maleate (10 mg tablet, 5 mg If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-34

35 Antiemetics promethazine hcl (12.5 mg supp.rect, 12.5 mg tablet, 25 mg supp.rect, 25 mg tablet, 50 mg tablet, 6.25mg/5ml syrup) $0 (Tier 1) PA, (g) Emetogenic Therapy Adjuncts ALOXI 0.25 MG/5 ML VIAL dronabinol (10 mg capsule, 2.5 mg capsule, 5 mg capsule) EMEND (125 MG CAPSULE, 40 MG CAPSULE, 80 MG CAPSULE, TRIPACK) $0 (Tier 1) PA, (g) PA granisetron hcl 1 mg tablet $0 (Tier 1) PA, (g) ondansetron (4 mg tab rapdis, 8 mg tab rapdis) ondansetron hcl (24 mg tablet, 4 mg tablet, 4 mg/5 ml solution, 8 mg ondansetron hcl/pf (4 mg/2 ml ampul, 4 mg/2 ml syringe, 4 mg/2 ml vial) Antifungals $0 (Tier 1) PA, (g) $0 (Tier 1) PA, (g) Antifungals AMBISOME 50 MG VIAL PA amphotericin b 50 mg vial PA, (g) CANCIDAS (50 MG VIAL, 70 MG VIAL) ciclopirox (0.77 % gel (gram), 1 % shampoo, 8 % solution) ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-35

36 Antifungals clotrimazole (1 % cream (g), 1 % cream/appl) * clotrimazole 10 mg troche CRESEMBA (186 MG CAPSULE, 372 MG VIAL) PA econazole nitrate 1 % cream (g) fluconazole (10 mg/ml susp recon, 100 mg tablet, 150 mg tablet, 200 mg tablet, 40 mg/ml susp recon, 50 mg fluconazole in dextrose, iso-osmotic (200mg/0.1l piggyback, 400mg/0.2l piggyback) flucytosine (250 mg capsule, 500 mg capsule) griseofulvin ultramicrosize (125 mg tablet, 250 mg griseofulvin, microsize 125 mg/5ml oral susp itraconazole 100 mg capsule ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo, 200 mg miconazole nitrate (100 mg supp.vag, 2 % cream/appl, 200 mg- 2 % kit, 4 % cream/appl) * MYCAMINE (100 MG VIAL, 50 MG VIAL) NATACYN EYE DROPS NOXAFIL 40 MG/ML SUSPENSION PA nystatin (100000/g cream (g), /g oint. (g), /g powder, /ml oral susp, 150mm unit powder(ea), 500k unit tablet, 500mm unit powder(ea), 50mm unit powder(ea)) terbinafine hcl 250 mg tablet If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-36

37 Antifungals terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) tioconazole 6.5 % oin/pf app * voriconazole (200 mg tablet, 200 mg vial, 200 mg/5ml susp recon, 50 mg $0 (Tier 1) PA, (g) Antigout Agents Antigout Agents allopurinol (100 mg tablet, 300 mg ALOPRIM 500 MG VIAL colchicine 0.6 mg tablet QL (120 PER 30 DAYS), (g) COLCRYS 0.6 MG TABLET probenecid 500 mg tablet probenecid/colchicine mg tablet ULORIC (40 MG TABLET, 80 MG TABLET) Antimigraine Agents Antimigraine Agents butalbital/acetaminophen/caffeine/ codeine phosphate ( capsule, capsule) codeine/butalbital/asa/caffein capsule $0 (Tier 1) PA, QL (180 PER 30 DAYS), (g) $0 (Tier 1) PA, QL (180 PER 30 DAYS), (g) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-37

38 Antimigraine Agents ergotamine tartrate/caffeine 2-100mg supp.rect (g) MIGRANAL NASAL SPRAY Serotonin (5-HT) 1b/1d Receptor Agonists almotriptan malate (12.5 mg tablet, 6.25 mg naratriptan hcl (1 mg tablet, 2.5 mg rizatriptan benzoate (10 mg tab rapdis, 10 mg tablet, 5 mg tab rapdis, 5 mg sumatriptan (20 mg spray, 5 mg spray) sumatriptan succinate (100 mg tablet, 25 mg tablet, 50 mg sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen injctr, 6 mg/0.5ml cartridge, 6 mg/0.5ml pen injctr) sumatriptan succinate (6 mg/0.5ml syringe, 6 mg/0.5ml vial) Antimyasthenic Agents $0 (Tier 1) QL (12 PER 30 DAYS), (g) $0 (Tier 1) QL (18 PER 30 DAYS), (g) $0 (Tier 1) QL (18 PER 30 DAYS), (g) QL (12 PER 30 DAYS), (g) $0 (Tier 1) QL (18 PER 30 DAYS), (g) $0 (Tier 1) QL (4 PER 30 DAYS), (g) Parasympathomimetics guanidine hcl 125 mg tablet (g) MESTINON (180 MG TIMESPAN, 60 MG/5 ML SYRUP) pyridostigmine bromide (180 mg tablet er, 60 mg If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-38

39 Antimycobacterials Antimycobacterials, Other dapsone (100 mg tablet, 25 mg rifabutin 150 mg capsule Antituberculars CAPASTAT SULFATE 1 GM VIAL ethambutol hcl (100 mg tablet, 400 mg isoniazid (100 mg tablet, 300 mg isoniazid 100 mg/ml vial (g) PASER GRANULES 4 GM PACKET PRIFTIN 150 MG TABLET pyrazinamide 500 mg tablet rifampin (150 mg capsule, 300 mg capsule, 600 mg vial) SIRTURO 100 MG TABLET TRECATOR 250 MG TABLET Antineoplastic Antineoplastics other hydroxyprogesterone caproate 250 mg/ml vial $0 (Tier 1) PA, (g) Antineoplastics Alkylating Agents If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-39

40 BUSULFEX 60 MG/10 ML VIAL Antineoplastics cyclophosphamide (25 mg capsule, 50 mg capsule) GLEOSTINE (10 MG CAPSULE, 100 MG CAPSULE, 40 MG CAPSULE, 5 MG CAPSULE) PA, (g) HEXALEN 50 MG CAPSULE PA LEUKERAN 2 MG TABLET LOMUSTINE (10 MG CAPSULE, 100 MG CAPSULE, 40 MG CAPSULE) MATULANE 50 MG CAPSULE PA melphalan hcl 50 mg vial MUSTARGEN 10 MG VIAL thiotepa 15 mg vial VALCHLOR 0.016% GEL Antiandrogens bicalutamide 50 mg tablet flutamide 125 mg capsule NILANDRON 150 MG TABLET nilutamide 150 mg tablet XTANDI 40 MG CAPSULE PA, QL (120 PER 30 DAYS) ZYTIGA 250 MG TABLET PA, QL (120 PER 30 DAYS) Antiangiogenic Agents POMALYST (1 MG CAPSULE, 2 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE) REVLIMID (10 MG CAPSULE, 2.5 MG CAPSULE, 5 MG CAPSULE) REVLIMID (15 MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE) THALOMID (100 MG CAPSULE, 50 MG CAPSULE) PA, QL (21 PER 28 DAYS) PA, QL (30 PER 30 DAYS) PA, QL (21 PER 28 DAYS) PA, QL (30 PER 30 DAYS) If have questions, please call HAP/Midwest Health Advantage MI Health Link (MMP) at 1-40

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