Upper Peninsula Health Plan Advantage HMO Formulary. List of Covered Drugs

Transcription

1 Upper Peninsula Health Plan Advantage HMO 015 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE S WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID: v13 This formulary was updated on 10/7/015. For more recent information or other questions, please contact Upper Peninsula Health Plan Advantage at or, for TTY users, 711, 8 am to 9 p.m. Eastern time, Monday through Friday, with weekend hours October 1 through February 14, or visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Upper Peninsula Health Plan. When it refers to plan or our plan, it means Upper Peninsula Health Plan Advantage HMO. This document includes a list of the drugs (formulary) for our plan which is current as of 10/7/015. For a complete, updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use H161_00_015_P1085 CMS Accepted Upper Peninsula Health Plan Advantage (HMO) is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula Health Plan Advantage (HMO) depends on contract renewal. H161_00_015_P1085_Accepted

2 your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 015, and from time to time during the year. What is the Upper Peninsula Health Plan Advantage HMO Formulary? A formulary is a list of covered drugs selected by Upper Peninsula Health Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Upper Peninsula Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Upper Peninsula Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 10/7/015. To get updated information about the drugs covered by Upper Peninsula Health Plan, please contact us. Our contact information appears on the front and back cover pages. In the event of mid-year non-maintenance formulary changes, all affected members will be notified via mail (at least 60 days before the change becomes effective). In addition, the printed formulary will be updated the first week of the effective month. The printed formulary will be posted on our Web site at How do I use the Formulary? There are two ways to find your drug within the formulary: H161_00_015_P1085 CMS Accepted Upper Peninsula Health Plan Advantage (HMO) is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula Health Plan Advantage (HMO) depends on contract renewal.

3 Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins below. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 83. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Upper Peninsula Health Plan Advantage HMO covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Upper Peninsula Health Plan Advantage HMO requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Upper Peninsula Health Plan Advantage HMO before you fill your prescriptions. If you don t get approval, Upper Peninsula Health Plan Advantage HMO may not cover the drug. Quantity Limits: For certain drugs, Upper Peninsula Health Plan Advantage HMO limits the amount of the drug that Upper Peninsula Health Plan Advantage HMO will cover. For example, Upper Peninsula Health Plan Advantage HMO provides 30 units per prescription for REVLIMID. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Upper Peninsula Health Plan Advantage HMO requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Upper Peninsula Health Plan H161_00_015_P1085 CMS Accepted Upper Peninsula Health Plan Advantage (HMO) is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula Health Plan Advantage (HMO) depends on contract renewal. 3

4 Advantage HMO may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Upper Peninsula Health Plan Advantage HMO will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Upper Peninsula Health Plan Advantage HMO to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Upper Peninsula Health Plan Advantage HMO s formulary? on page 5 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you learn that Upper Peninsula Health Plan Advantage HMO does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Upper Peninsula Health Plan Advantage HMO. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Upper Peninsula Health Plan Advantage HMO. You can ask Upper Peninsula Health Plan Advantage HMO to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Upper Peninsula Health Plan Advantage HMO Formulary? You can ask Upper Peninsula Health Plan Advantage HMO to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. H161_00_015_P1085 CMS Accepted Upper Peninsula Health Plan Advantage (HMO) is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula Health Plan Advantage (HMO) depends on contract renewal. 4

5 You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Upper Peninsula Health Plan Advantage HMO limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Upper Peninsula Health Plan Advantage HMO will only approve your request for an exception if the alternative drugs included on the plan s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than at least 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day H161_00_015_P1085 CMS Accepted Upper Peninsula Health Plan Advantage (HMO) is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula Health Plan Advantage (HMO) depends on contract renewal. 5

6 emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If you have a level of care change (for example discharged from the hospital to your home), we will cover a temporary 31-day supply (unless you have a prescription written for fewer days). If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Please note that our transition policy applies only to those drugs that are Part D drugs and bought at a network pharmacy. The transition policy cannot be used to buy a non-part D drug or a drug out of network, unless you qualify for out of network access. For more information For more detailed information about your Upper Peninsula Health Plan Advantage HMO prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Upper Peninsula Health Plan Advantage HMO, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call 711. Or, visit Upper Peninsula Health Plan Advantage HMO s Formulary The formulary below provides coverage information about the drugs covered by Upper Peninsula Health Plan Advantage HMO. If you have trouble finding your drug in the list, turn to the Index that begins on page 83. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics simvastatin. The information in the Requirements/Limits column tells you if Upper Peninsula Health Plan Advantage HMO has any special requirements for coverage of your drug. H161_00_015_P1085 CMS Accepted Upper Peninsula Health Plan Advantage (HMO) is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula Health Plan Advantage (HMO) depends on contract renewal. 6

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

8 Analgesics Nonsteroidal Anti-inflammatory Drugs CELEBREX (50 MG CAPSULE, 100 MG CAPSULE, 00 MG CAPSULE) 3 QL (60 CELEBREX 400 MG CAPSULE 3 QL (30 celecoxib (50 mg capsule, 100 mg capsule, 00 mg capsule) QL (60 celecoxib 400 mg capsule QL (30 COMFORT PAC-MELOXICAM 1 COMFORT PAC-NAPROXEN 1 diclofenac potassium diclofenac sodium (5 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er 4h) diclofenac sodium/misoprostol etodolac (00 mg capsule, 300 mg capsule, 400 mg tab er 4h, 400 mg tablet, 500 mg tablet, 500 mg tab er 4h, 600 mg tab er 4h) flurbiprofen (50 mg tablet, 100 mg tablet) 1 ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) ibuprofen 100 mg/5ml oral susp ibuprofen/irritants counter-irritants combination # ketoprofen (50 mg capsule, 75 mg capsule) ketorolac tromethamine 10 mg tablet 4 PA meloxicam (7.5 mg tablet, 15 mg tablet) 1 nabumetone (500 mg tablet, 750 mg tablet) naproxen (50 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg tablet) naproxen 15 mg/5ml oral susp naproxen sodium (75 mg tablet, 550 mg tablet)

9 oxaprozin piroxicam (10 mg capsule, 0 mg capsule) sulindac (150 mg tablet, 00 mg tablet) 1 tolmetin sodium 400 mg capsule VOLTAREN 3 ST Opioid Analgesics, Long-acting fentanyl (1 mcg/hr, 5mcg/hr, 50mcg/hr, 75mcg/hr, 100 mcg/hr) QL (15 levorphanol tartrate mg tablet 4 QL (10 methadone hcl 10 mg tablet QL (360 methadone hcl 5 mg tablet QL (180 morphine sulfate (15 mg tablet er, 30 mg tablet er, 60 mg tablet er, 100 mg tablet er, 00 mg tablet er) QL (90 morphine sulfate 10 mg cap er pel QL (60 NUCYNTA ER 3 QL (60 OPANA ER 3 QL (60 OXYCONTIN (10 MG TABLET, 15 MG TABLET, 0 MG TABLET, 30 MG TABLET, 40 MG TABLET) 3 QL (60 OXYCONTIN (60 MG TABLET, 80 MG TABLET) 3 QL (10 tramadol hcl (100 mg tbmp 4hr, 100 mg tab er 4h, 00 mg tbmp 4hr, 00 mg tab er 4h) QL (30 ZOHYDRO ER 4 PA, QL (60 Opioid Analgesics, Short-acting acetaminophen with codeine 300mg-60mg tablet QL (180 acetaminophen with codeine phosphate (10-1mg/5, 300mg/1.5) acetaminophen with codeine phosphate (300mg- 30mg tablet, 300mg-15mg tablet) butorphanol tartrate (1 mg/ml vial, mg/ml vial, 10 mg/ml spray) codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg tablet) QL (700 QL (360 QL (180 9

10 DURAMORPH PA - Part B vs D Determination fentanyl citrate (00 mcg, 400 mcg, 600 mcg, 800 mcg, 100 mcg, 1600 mcg) hydrocodone bitartrate/acetaminophen (.5-108/5, 5-17mg/10, /15) hydrocodone bitartrate/acetaminophen (5 mg- 35mg tablet, 5mg-300mg tablet) hydrocodone bitartrate/acetaminophen (7.5-35mg tablet, mg tablet, 10mg-35mg tablet, 10mg-300mg tablet) hydrocodone/ibuprofen ( mg tablet, 10mg-00mg tablet) hydromorphone hcl ( mg tablet, 4 mg tablet, 8 mg tablet) 5 PA, QL (10 QL (3600 QL (360 QL (180 QL (150 QL (180 hydromorphone hcl 1 mg/ml liquid QL (1440 hydromorphone hcl/pf (10 mg/ml ampul, 10 mg/ml vial) PA - Part B vs D Determination LAZANDA 5 PA, QL (30 morphine sulfate 10 mg/5 ml solution QL (700 morphine sulfate 100 mg/5ml solution QL (70 morphine sulfate 15 mg tablet 4 QL (40 morphine sulfate 0 mg/5 ml solution QL (1350 morphine sulfate 30 mg tablet 4 QL (180 oxycodone hcl (10 mg tablet, 15 mg tablet, 0 mg tablet, 30 mg tablet) QL (180 oxycodone hcl 5 mg tablet QL (360 oxycodone hcl/acetaminophen (.5-35mg tablet, 5 mg-35mg tablet) oxycodone hcl/acetaminophen 10mg-35mg tablet QL (360 QL (180 oxycodone hcl/acetaminophen mg tablet QL (40 oxycodone hcl/aspirin QL (360 SUBSYS 5 PA, QL (10 10

11 tramadol hcl 50 mg tablet 1 QL (40 tramadol hcl/acetaminophen QL (40 Anesthetics Local Anesthetics ADV DNA MEDICATED COLLECT KIT lidocaine 5 % oint. (g) lidocaine 5%(700mg) adh. patch PA lidocaine hcl ( % solution, % jel/pf app, % jel (ml), 40 mg/ml solution) lidocaine/prilocaine (.5 cream (g),.5 kit) Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/ Anti-craving acamprosate calcium disulfiram (50 mg tablet, 500 mg tablet) Opioid Dependence Treatments buprenorphine hcl ( mg tab, 8 mg tab) PA buprenorphine hcl/naloxone hcl PA BUTRANS 3 QL (4 PER 8 DAYS) naltrexone hcl 50 mg tablet SUBOXONE ( MG-0.5 MG, 4 MG-1 MG, 8 MG- MG, 1 MG-3 MG) VIVITROL 5 Opioid Reversal Agents naloxone hcl 1 mg/ml syringe Smoking Cessation Agents 4 PA bupropion hcl 150 mg tablet er QL (60 CHANTIX 3 QL (336 PER 365 DAYS) 11

12 NICOTROL 4 NICOTROL NS 4 Antibacterials Aminoglycosides amikacin sulfate (500 mg/ml vial, 1000mg/4ml vial) gentamicin sulfate (0.1 % oint., 0.1 % cream) 4 gentamicin sulfate (0.3 % oint. (g), 0.3 % drops, 0 mg/ ml vial, 40 mg/ml vial) gentamicin sulfate in sodium chloride, iso-osmotic (gentamic60 mg/50ml, gentamic80 mg/50ml, gentamic80mg/100ml, gentamic100mg/0.1l, gentamic10mg/0.1l) gentamicin sulfate in sodium chloride, iso-osmotic (gentamic70 mg/50ml, gentamic90mg/100ml) gentamicin sulfate/pf neomycin sulfate 500 mg tablet paromomycin sulfate 50 mg capsule streptomycin sulfate 1 g vial 4 tobramycin 0.3 % drops tobramycin sulfate (1. g vial, 10 mg/ml vial, 40 mg/ml vial) tobramycin/sodium chloride 80mg/100ml piggyback Antibacterials, Other bacitracin 500 unit/g oint. (g) 4 bacitracin/polymyxin b sulfate chloramphenicol sod succ 4 clindamycin hcl (75 mg capsule, 150 mg capsule, 300 mg capsule) 4 4 1

13 clindamycin phosphate (1 % lotion, 1 % gel (gram), 1 % med. swab, 1 % solution, % cream/appl, 150 mg/ml vial, 300 mg/ml vial port, 600 mg/4ml vial port, 900mg/6ml vial port) clindamycin phosphate/dextrose 5 % in water colistin (colistimethate na) 150 mg vial CUBICIN 5 DALVANCE 5 linezolid 600 mg tablet 5 PA linezolid 600mg/300 iv soln 5 methenamine hippurate methenamine mandelate 1 g tablet METRO IV metronidazole (0.75 % gel (gram), 0.75 % cream (g), 0.75 % gel w/appl, 0.75 % lotion, 1 % gel w/pump, 1 % gel (gram), 50 mg tablet, 375 mg capsule, 500 mg tablet) metronidazole in sodium chloride mupirocin % oint. (g) neomycin sulfate/bacitracin/polymyxin b neomycin sulfate/polymyxin b sulfate neomycin sulfate/polymyxin b sulfate/gramicidin d nitrofurantoin 5 mg/5 ml oral susp 4 QL (700 PER 365 DAYS) nitrofurantoin macrocrystal (50 mg capsule, 100 mg capsule) 4 QL (360 PER 365 DAYS) nitrofurantoin monohydrate/macrocrystals 4 QL (180 PER 365 DAYS) polymyxin b sulfate/trimethoprim 1 SIVEXTRO 00 MG TABLET 5 PA SIVEXTRO 00 MG VIAL 5 SYNERCID 5 trimethoprim 100 mg tablet 1 13

14 TYGACIL 4 vancomycin hcl (1 g vial, 1 g vial port, 5 g vial, 10 g vial, 500 mg vial, 500 mg vial port, 750 mg vial) vancomycin hcl (15 mg capsule, 50 mg capsule) 5 vancomycin hcl/dextrose 5 % in water (1g/00ml, 500mg/0.1l) vancomycin in dextrose, iso-osmotic VANDAZOLE ZYVOX (100 MG/5 ML SUSPENSION, 600 MG TABLET) ZYVOX (00 MG/100 ML SOLN, 600 MG/300 ML SOLN) 5 PA 5 Beta-lactam, Cephalosporins cefaclor (50 mg capsule, 500 mg capsule) cefadroxil (1 g tablet, 50 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon) cefazolin sodium (1 g vial, 10 g vial, 0 g vial, 100 g bulkbaginj, 300g bulkbaginj, 500 mg vial) cefdinir (15 mg/5ml susp recon, 50 mg/5ml susp recon, 300 mg capsule) cefepime hcl cefotaxime sodium (1 g vial, g vial, 500 mg vial) cefoxitin sodium cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 00 mg tablet) cefprozil (15 mg/5ml susp recon, 50 mg tablet, 50 mg/5ml susp recon, 500 mg tablet) ceftazidime (1 vial, vial, 6 vial) ceftriaxone sodium (1 g vial, 1 g vial port, 1 g pggybk btl, g vial port, g pggybk btl, g vial, 10 g vial, 100 g bulkbaginj, 50 mg vial, 500 mg vial) ceftriaxone sodium/dextrose, iso-osmotic (1 ml piggyback, 1 ml froz.piggy, ml froz.piggy, ml piggyback) 14

15 cefuroxime axetil cefuroxime sodium (1.5 g vial, 7.5g vial, 7.5 g vial, 750 mg vial) cephalexin (15, 50) cephalexin (50 mg capsule, 500 mg capsule, 750 mg capsule) SUPRAX (100 MG TABLET CHEWABLE, 00 MG TABLET CHEWABLE, 400 MG TABLET, 400 MG CAPSULE) 1 4 TEFLARO 4 Beta-lactam, Other AZACTAM-ISO-OSMOTIC DEXTROSE 4 aztreonam imipenem/cilastatin sodium INVANZ 1 GM VIAL 4 meropenem Beta-lactam, Penicillins amoxicillin (15 mg/5ml susp recon, 00 mg/5ml susp recon, 50 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 875 mg tablet) amoxicillin (50 mg capsule, 500 mg capsule) 1 amoxicillin/potassium clavulanate (00-8.5mg tab chew, /5 susp recon, mg tablet, mg tab chew, mg/5 susp recon, mg tablet, /5 susp recon, mg tablet) ampicillin sodium (1 g vial, 1 g vial port, g vial, 10 g vial, 50 mg vial, 500 mg vial) ampicillin sodium/sulbactam sodium (1.5 vial, 3 vial) ampicillin trihydrate (15, 50) 4 ampicillin trihydrate (50 mg capsule, 500 mg capsule) BICILLIN L-A

16 dicloxacillin sodium nafcillin sodium (1 vial, vial, 10 vial) penicillin g potassium penicillin g potassium/dextrose-water (mm/50ml froz.piy, 3mm/50ml froz.piy) 4 penicillin g sodium 4 penicillin v potassium (15 mg/5ml soln recon, 50 mg tablet, 50 mg/5ml soln recon, 500 mg tablet) piperacillin sodium/tazobactam sodium (.5 vial, vial, vial port, 4.5 vial, 4.5 vial port, 40.5 vial) ZOSYN (.5 GM/50 ML BAG, GM/50 ML, 4.5 GM/100 ML BAG) 4 Macrolides azithromycin (100 mg/5ml susp recon, 00 mg/5ml susp recon, 50 mg tablet, 500 mg vial port, 500 mg tablet, 500 mg vial, 600 mg tablet) azithromycin 1 g packet 4 clarithromycin (15 mg/5ml susp recon, 50 mg/5ml susp recon, 50 mg tablet, 500 mg tab er 4h, 500 mg tablet) DIFICID 5 E.E.S ERY-TAB 4 ERYPED 00 4 ERYPED ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500 MG ADDVNT VL) ERYTHROCIN STEARATE 4 erythromycin base (50 mg tablet, 500 mg tablet) 4 erythromycin base 5 mg/g oint. (g) erythromycin base/ethyl alcohol ( % med. swab, % solution) 4 16

17 ILOTYCIN Quinolones AVELOX IV 3 BESIVANCE 4 ciprofloxacin ciprofloxacin hcl (100 mg tablet, 50 mg tablet, 500 mg tablet, 750 mg tablet) ciprofloxacin hcl 0.3 % drops ciprofloxacin lactate ciprofloxacin lactate/dextrose 5 % in water ciprofloxacin/ciprofloxacin hcl levofloxacin (5 mg/ml vial, 50mg/10ml solution, 50 mg tablet, 500 mg tablet, 500mg/0ml solution, 750 mg tablet) levofloxacin/dextrose 5 % in water MOXEZA 4 moxifloxacin hcl 400 mg tablet ofloxacin (00 mg tablet, 300 mg tablet, 400 mg tablet) ofloxacin 0.3 % drops 1 VIGAMOX 3 Sulfonamides silver sulfadiazine 1 % cream (g) SSD sulfacetamide sodium (10 % drops, 10 % suspension) sulfadiazine 500 mg tablet 4 sulfamethoxazole/trimethoprim (00-40mg/5, /0) sulfamethoxazole/trimethoprim (400mg-80mg tablet, mg tablet)

18 sulfamethoxazole/trimethoprim 80-16mg/ml vial 4 Tetracyclines demeclocycline hcl doxycycline hyclate (0 mg tablet, 50 mg capsule, 100 mg capsule, 100 mg tablet, 100 mg vial) doxycycline monohydrate (50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 100 mg tablet, 100 mg capsule, 150 mg tablet, 150 mg capsule) minocycline hcl (50 mg capsule, 75 mg capsule, 100 mg capsule) minocycline hcl (50 mg tablet, 75 mg tablet, 100 mg tablet) tetracycline hcl (50 mg capsule, 500 mg capsule) 4 Anticonvulsants Anticonvulsants, Other levetiracetam (100 mg/ml solution, 50 mg tablet, 500 mg/5ml solution, 500 mg tablet, 500 mg/5ml vial, 750 mg tablet, 1000 mg tablet) levetiracetam in sodium chloride, iso-osmotic 4 POTIGA 4 Calcium Channel Modifying Agents CELONTIN 4 ethosuximide (50 mg/5ml solution, 50 mg capsule) LYRICA (0 MG/ML ORAL SOLUTION, 5 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 00 MG CAPSULE, 5 MG CAPSULE, 300 MG CAPSULE) zonisamide (5 mg capsule, 50 mg capsule, 100 mg capsule)

19 Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT 4 QL (5 DIASTAT ACUDIAL MG 4 QL (40 DIASTAT ACUDIAL MG KT 4 QL (0 diazepam kit 4 QL (40 diazepam.5 mg kit 4 QL (5 diazepam mg kit 4 QL (0 divalproex sodium gabapentin (100 mg capsule, 300 mg capsule, 400 mg capsule) gabapentin (50 mg/5ml solution, 300 mg/6ml solution, 600 mg tablet, 800 mg tablet) GABITRIL (1 MG TABLET, 16 MG TABLET) 4 ONFI (10 MG TABLET, 0 MG TABLET) 4 PA - FOR NEW STARTS ONLY, QL (60 ONFI.5 MG/ML SUSPENSION 4 PA - FOR NEW STARTS ONLY, QL (480 phenobarbital (15 mg tablet, 16. mg tablet, 0 mg/5 ml elixir, 30 mg tablet, 3.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.mg tablet, 100 mg tablet) primidone (50 mg tablet, 50 mg tablet) 1 SABRIL 4 tiagabine hcl valproic acid (as sodium salt) (valproate sodium) (50 mg/5ml solution, 500 mg/5ml vial, 500mg/10ml solution) valproic acid 50 mg capsule 1 4 PA - FOR NEW STARTS ONLY Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) FYCOMPA ( MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 1 MG TABLET) 4 19

20 LAMICTAL ODT 4 lamotrigine (5 mg tablet, 100 mg tablet, 150 mg tablet, 00 mg tablet) lamotrigine (5 mg tb chw dsp, 5 mg tab rapdis, 5 mg tb chw dsp, 50 mg tab rapdis, 100 mg tab rapdis, 00 mg tab rapdis) 1 topiramate (15 mg cap, 5 mg cap) topiramate (5 mg tablet, 50 mg tablet, 100 mg tablet, 00 mg tablet) 1 Sodium Channel Agents APTIOM 4 BANZEL (40 MG/ML SUSPENSION, 400 MG TABLET) BANZEL 00 MG TABLET 4 carbamazepine (100 mg cpmp 1hr, 100 mg/5ml oral susp, 00 mg tab er 1h, 00 mg cpmp 1hr, 300 mg cpmp 1hr, 400 mg tab er 1h) carbamazepine (100 mg tab chew, 00 mg tablet) 1 DILANTIN 30 MG CAPSULE 4 fosphenytoin sodium oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) PEGANONE 4 phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 15 mg/5ml oral susp) phenytoin sodium extended TEGRETOL XR 100 MG TABLET 4 VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 00 MG/0 ML VIAL, 00 MG TABLET) 5 3 0

21 Antidementia Agents Antidementia Agents, Other ergoloid mesylates 1 mg tablet 3 PA - FOR NEW STARTS ONLY Cholinesterase Inhibitors donepezil hcl (5 mg tab rapdis, 10 mg tab rapdis) donepezil hcl (5 mg tablet, 10 mg tablet, 3 mg tablet) EXELON (4.6, 9.5, 13.3) 3 galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap4h pel, 8 mg tablet, 1 mg tablet, 16 mg cap4h pel, 4 mg cap4h pel) rivastigmine tartrate N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (5 mg-10 mg tab ds pk, 5 mg tablet, 10 mg tablet) NAMENDA ( MG/ML SOLUTION, 5-10 MG TITRATION PK, 5 MG TABLET, 10 MG TABLET) NAMENDA XR 3 Antidepressants Antidepressants, Other bupropion hcl (150 mg tab er, 300 mg tab er) QL (30 bupropion hcl (75 mg tablet, 100 mg tablet er, 00 mg tablet er) 1 3 QL (60 bupropion hcl 100 mg tablet QL (10 mirtazapine (15 mg tab rapdis, 30 mg tab rapdis, 45 mg tab rapdis) mirtazapine (7.5 mg tablet, 15 mg tablet, 30 mg tablet, 45 mg tablet) QL (30 1 QL (30 1

22 Monoamine Oxidase Inhibitors EMSAM 5 MARPLAN 4 phenelzine sulfate 15 mg tablet tranylcypromine sulfate SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibito BRINTELLIX 4 QL (30 citalopram hydrobromide (10 mg tablet, 0 mg tablet, 40 mg tablet) 1 QL (30 citalopram hydrobromide 10 mg/5 ml solution QL (600 duloxetine hcl (0 mg capsule dr, 30 mg capsule dr, 60 mg capsule dr) escitalopram oxalate (5 mg tablet, 10 mg tablet, 0 mg tablet) QL (60 1 QL (30 escitalopram oxalate 5 mg/5 ml solution QL (600 FETZIMA (ER 0 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 10 MG CAPSULE) 4 QL (30 FETZIMA 0-40 MG TITRATION PAK 4 QL (8 PER 8 DAYS) fluoxetine hcl 10 mg capsule 1 QL (30 fluoxetine hcl 10 mg tablet QL (30 fluoxetine hcl 0 mg capsule 1 QL (10 fluoxetine hcl 0 mg tablet QL (10 fluoxetine hcl 0 mg/5 ml solution QL (600 fluoxetine hcl 40 mg capsule 1 QL (60 fluoxetine hcl 90 mg capsule dr QL (4 PER 8 DAYS) fluvoxamine maleate (5 mg tablet, 50 mg tablet) QL (30 fluvoxamine maleate 100 mg tablet QL (90 maprotiline hcl 4 QL (90 nefazodone hcl (50 mg tablet, 100 mg tablet, 150 mg tablet, 00 mg tablet) 4

23 nefazodone hcl 50 mg tablet paroxetine hcl (10 mg tablet, 0 mg tablet, 40 mg tablet) 1 QL (30 paroxetine hcl (5 mg tab er, 37.5 mg tab er) QL (60 paroxetine hcl 1.5 mg tab er 4h QL (30 paroxetine hcl 30 mg tablet 1 QL (60 PAXIL 10 MG/5 ML SUSPENSION 4 QL (900 PRISTIQ ER 4 QL (30 sertraline hcl (5 mg tablet, 50 mg tablet) 1 QL (30 sertraline hcl 100 mg tablet 1 QL (60 sertraline hcl 0 mg/ml oral conc QL (300 trazodone hcl (50 mg tablet, 100 mg tablet, 150 mg tablet, 300 mg tablet) venlafaxine hcl (5 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 4h, 75 mg tab er 4, 75 mg tablet, 100 mg tablet) venlafaxine hcl (37.5 mg cap er 4h, 37.5 mg tab er 4, 150 mg cap er 4h, 150 mg tab er 4) VENLAFAXINE HCL ER (ER 37.5 MG TAB, ER 150 MG TAB) 1 QL (90 QL (30 QL (30 VENLAFAXINE HCL ER 75 MG TAB QL (90 VIIBRYD 4 QL (30 Tricyclics amitriptyline hcl (10 mg tablet, 5 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) amoxapine 4 clomipramine hcl (5 mg capsule, 50 mg capsule, 75 mg capsule) desipramine hcl (10 mg tablet, 5 mg tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet, 150 mg tablet) 4 PA - FOR NEW STARTS ONLY 4 PA - FOR NEW STARTS ONLY 3

24 doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 5 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule) imipramine hcl (10 mg tablet, 5 mg tablet, 50 mg tablet) nortriptyline hcl (10 mg capsule, 5 mg capsule, 50 mg capsule, 75 mg capsule) 4 PA - FOR NEW STARTS ONLY 4 PA - FOR NEW STARTS ONLY 1 nortriptyline hcl 10 mg/5 ml solution 4 protriptyline hcl SURMONTIL 4 PA - FOR NEW STARTS ONLY Antiemetics Antiemetics, Other chlorpromazine hcl (10 mg tablet, 5 mg tablet, 50 mg tablet, 100 mg tablet, 00 mg tablet) chlorpromazine hcl 5 mg/ml ampul 4 hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 5 mg tablet, 50 mg tablet) hydroxyzine hcl 50 mg/5ml solution 4 meclizine hcl (1.5 mg tablet, 5 mg tablet) metoclopramide hcl (5 mg tablet, 10 mg tablet) 1 metoclopramide hcl (5 mg/5 ml, 10 mg/10ml) perphenazine ( mg tablet, 4 mg tablet, 8 mg tablet, 16 mg tablet) 4 PA - FOR NEW STARTS ONLY PHENERGAN (1.5 MG, 5 MG) 4 PA - FOR NEW STARTS ONLY prochlorperazine prochlorperazine edisylate (5 mg/ml vial, 10 mg/ ml vial) prochlorperazine maleate (5 mg tablet, 10 mg tablet) promethazine hcl (6.5mg/5ml syrup, 1.5 mg supp.rect, 1.5 mg tablet, 5 mg tablet, 5 mg supp.rect, 50 mg tablet) 1 4 PA - FOR NEW STARTS ONLY 4

25 Emetogenic Therapy Adjuncts ALOXI 4 dronabinol PA - Part B vs D Determination EMEND (40 MG CAPSULE, 80 MG CAPSULE, 15 MG CAPSULE, TRIFOLD PACK) 3 PA - Part B vs D Determination granisetron hcl 1 mg tablet PA - Part B vs D Determination ondansetron PA - Part B vs D Determination ondansetron hcl (4 mg/5 ml solution, 4 mg tablet, 8 mg tablet, 4 mg tablet) ondansetron hcl mg/ml vial ondansetron hcl/pf PA - Part B vs D Determination SANCUSO 4 QL (4 PER 8 DAYS) Antifungals AMBISOME 5 PA - Part B vs D Determination amphotericin b 50 mg vial 4 PA - Part B vs D Determination CANCIDAS 5 ciclopirox (0.77 % gel (gram), 1 % shampoo, 8 % solution) ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) ciclopirox/urea/camphor/menthol/eucalyptol ciclopirox/vitamin e mixed/nail lacquer remover, non-acet clotrimazole (1 % cream (g), 10 mg troche) CRESEMBA 5 PA econazole nitrate 1 % cream (g) fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 00 mg tablet) fluconazole in dextrose, iso-osmotic 5

26 fluconazole in sodium chloride, iso-osmotic (100mg/50ml pggybk btl, 00mg/0.1l pggybk btl, 00mg/0.1l piggyback, 400mg/0.l pggybk btl, 400mg/0.l piggyback) flucytosine (50 mg capsule, 500 mg capsule) 5 griseofulvin ultramicrosize griseofulvin, microsize 15 mg/5ml oral susp itraconazole 100 mg capsule ketoconazole ( % cream (g), % shampoo, 00 mg tablet) MYCAMINE 100 MG VIAL 5 MYCAMINE 50 MG VIAL 4 NATACYN 4 NOXAFIL 40 MG/ML SUSPENSION 5 PA nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, /ml oral susp, /g powder, /g cream (g), /g oint. (g)) terbinafine hcl 50 mg tablet 1 terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) voriconazole (50 mg tablet, 00 mg tablet, 00 mg/5ml susp recon) 5 PA voriconazole 00 mg vial PA Antigout Agents allopurinol (100 mg tablet, 300 mg tablet) 1 ALOPRIM 4 colchicine/probenecid COLCRYS 3 probenecid ULORIC 3 6

27 Antimigraine Agents butalbital/acetaminophen/caffeine/codeine phosphate 4 PA - FOR NEW STARTS ONLY, QL (180 codeine phosphate/butalbital/aspirin/caffeine 4 PA - FOR NEW STARTS ONLY, QL (180 ergotamine tartrate/caffeine -100mg supp.rect 4 MIGRANAL 3 Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl QL (18 rizatriptan benzoate QL (18 sumatriptan (5 mg, 0 mg) 4 QL (1 sumatriptan succinate (5 mg tablet, 50 mg tablet, 100 mg tablet) sumatriptan succinate (6 pen injctr, 6 syringe, 6 cartridge, 6 vial) Antimyasthenic Agents Parasympathomimetics guanidine hcl 4 MESTINON 180 MG TIMESPAN 3 MESTINON 60 MG/5 ML SYRUP 4 pyridostigmine bromide (60 mg tablet, 180 mg tablet er) Antimycobacterials Antimycobacterials, Other dapsone (5 mg tablet, 100 mg tablet) rifabutin Antituberculars CAPASTAT SULFATE 4 QL (18 7

28 ethambutol hcl isoniazid (100 mg tablet, 300 mg tablet) 1 isoniazid 100 mg/ml vial 4 PASER 4 PRIFTIN 4 pyrazinamide rifampin (150 mg capsule, 300 mg capsule, 600 mg vial) TRECATOR 4 Antineoplastics Alkylating Agents BUSULFEX 5 cyclophosphamide (5 mg capsule, 50 mg capsule) GLEOSTINE 4 4 PA - Part B vs D Determination HEXALEN 5 PA - FOR NEW STARTS ONLY LEUKERAN 3 LOMUSTINE 4 MATULANE 5 PA - FOR NEW STARTS ONLY melphalan hcl 5 MUSTARGEN 4 VALCHLOR 5 Antiandrogens bicalutamide flutamide NILANDRON 4 XTANDI 5 PA - FOR NEW STARTS ONLY, QL (10 ZYTIGA 5 PA - FOR NEW STARTS ONLY, QL (10 8

29 Antiangiogenic Agents POMALYST 5 PA - FOR NEW STARTS ONLY, QL (1 PER 8 DAYS) REVLIMID (15 MG CAPSULE, 0 MG CAPSULE, 5 MG CAPSULE) REVLIMID (.5 MG CAPSULE, 5 MG CAPSULE, 10 MG CAPSULE) 5 PA - FOR NEW STARTS ONLY, QL (1 PER 8 DAYS) 5 PA - FOR NEW STARTS ONLY, QL (30 THALOMID (150 MG CAPSULE, 00 MG CAPSULE) 5 PA - FOR NEW STARTS ONLY, QL (60 THALOMID (50 MG CAPSULE, 100 MG CAPSULE) 5 PA - FOR NEW STARTS ONLY, QL (30 ZALTRAP 5 Antiestrogens/Modifiers EMCYT 4 FARESTON 5 SOLTAMOX 4 tamoxifen citrate (10 mg tablet, 0 mg tablet) 1 Antimetabolites fluorouracil (1 g/0 ml vial,.5 g/50ml vial, 5 g/100 ml vial, 500mg/10ml vial) FOLOTYN 5 hydroxyurea 500 mg capsule mercaptopurine 50 mg tablet PURIXAN 5 TABLOID 4 DAUNOXOME 5 Antineoplastics, Other ABRAXANE 5 ALIMTA 5 amifostine crystalline 5 ARRANON 5 PA - Part B vs D Determination 9

30 azacitidine 5 BELEODAQ 5 BICNU 4 bleomycin sulfate PA - Part B vs D Determination carboplatin (10 mg/ml vial, 150 mg vial) cisplatin cladribine 5 PA - Part B vs D Determination CLOLAR 5 COSMEGEN 5 cytarabine PA - Part B vs D Determination cytarabine/pf (1 g vial, g/0 ml vial, 0 mg/ml vial, 100 mg vial, 100 mg/5ml vial) dacarbazine daunorubicin hcl (5 mg/ml vial, 0 mg vial) decitabine 5 dexrazoxane hcl 5 DOCEFREZ 0 MG VIAL 5 docetaxel (0 mg/ ml vial, 0mg/ml(1) vial, 80 mg/4 ml vial, 80 mg/8 ml vial, 140 mg/7ml vial, 160 mg/8ml vial, 160mg/16ml vial, 00mg/0ml vial) PA - Part B vs D Determination DOXIL 4 PA - Part B vs D Determination doxorubicin hcl ( mg/ml vial, 10 mg vial, 10 mg/5 ml vial, 0 mg/10ml vial, 50 mg vial, 50 mg/5ml vial) ELITEK 5 epirubicin hcl (50 mg vial, 50 mg/5ml vial, 00 mg vial, 00mg/0.1l vial) ERWINAZE 5 5 PA - Part B vs D Determination FARYDAK 5 PA - FOR NEW STARTS ONLY, QL (6 PER 1 DAYS) FASLODEX 5 30

31 fludarabine phosphate (50 mg vial, 50 mg/ ml vial) gemcitabine hcl (1 g vial, 1 g/6.3ml vial, g vial, g/5.6ml vial, 00 mg vial, 00mg/5.6 vial) HALAVEN 5 idarubicin hcl 5 ifosfamide (1 g/0 ml vial, 1 g vial, 3g/60ml vial, 3 g vial) ISTODAX 5 IXEMPRA 5 JEVTANA 5 leucovorin calcium (10 mg tablet, 15 mg tablet) 4 leucovorin calcium (5 mg tablet, 10 mg/ml vial, 5 mg tablet, 50 mg vial, 100 mg vial, 00 mg vial, 350 mg vial, 500mg/50ml vial, 500 mg vial) mesna MESNEX 400 MG TABLET 4 mitomycin (5 mg vial, 0 mg vial, 40 mg vial) mitoxantrone hcl NIPENT 5 ONCASPAR 5 oxaliplatin (50 mg vial, 50 mg/10ml vial, 100 mg vial, 100mg/0ml vial) paclitaxel PROLEUKIN 5 SYNRIBO 5 TAXOTERE 5 TORISEL 5 TREANDA (5 MG VIAL, 45 MG/0.5 ML VIAL, 100 MG VIAL, 180 MG/ ML VIAL) TRISENOX vinblastine sulfate (1 mg/ml vial, 10 mg vial) 4 PA - Part B vs D Determination 31

32 vincristine sulfate vinorelbine tartrate ZANOSAR 4 ZOLINZA 5 PA - FOR NEW STARTS ONLY, QL (10 Aromatase Inhibitors, 3rd Generation anastrozole 1 mg tablet 1 exemestane letrozole.5 mg tablet 1 Enzyme Inhibitors ETOPOPHOS 4 etoposide 0 mg/ml vial irinotecan hcl topotecan hcl (4 mg/4 ml vial, 4 mg vial) 5 Molecular Target Inhibitors AFINITOR 5 PA - FOR NEW STARTS ONLY, QL (30 AFINITOR DISPERZ ( MG TABLET, 5 MG TABLET) 5 PA - FOR NEW STARTS ONLY, QL (60 AFINITOR DISPERZ 3 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (90 BOSULIF 100 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (10 BOSULIF 500 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (30 CAPRELSA 100 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (60 CAPRELSA 300 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (30 COMETRIQ 100 MG DAILY-DOSE PK 5 PA - FOR NEW STARTS ONLY, QL (56 PER 8 DAYS) COMETRIQ 140 MG DAILY-DOSE PK 5 PA - FOR NEW STARTS ONLY, QL (11 PER 8 DAYS) 3

33 COMETRIQ 60 MG DAILY-DOSE PACK 5 PA - FOR NEW STARTS ONLY, QL (84 PER 8 DAYS) ERIVEDGE 5 PA - FOR NEW STARTS ONLY, QL (30 GILOTRIF 5 PA - FOR NEW STARTS ONLY, QL (30 GLEEVEC 100 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (90 GLEEVEC 400 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (60 IBRANCE 5 PA - FOR NEW STARTS ONLY, QL (1 PER 8 DAYS) ICLUSIG 15 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (60 IMBRUVICA 5 PA - FOR NEW STARTS ONLY, QL (10 INLYTA 1 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (180 INLYTA 5 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (10 JAKAFI 5 PA - FOR NEW STARTS ONLY, QL (60 LENVIMA (14 MG, 0 MG) 5 PA - FOR NEW STARTS ONLY, QL (60 LENVIMA 10 MG DAILY DOSE 5 PA - FOR NEW STARTS ONLY, QL (30 LENVIMA 4 MG DAILY DOSE 5 PA - FOR NEW STARTS ONLY, QL (90 LYNPARZA 5 QL (480 MEKINIST 0.5 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (90 MEKINIST MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (30 NEXAVAR 5 PA - FOR NEW STARTS ONLY, QL (10 SPRYCEL (50 MG TABLET, 70 MG TABLET, 80 MG TABLET, 100 MG TABLET, 140 MG TABLET) 5 PA - FOR NEW STARTS ONLY, QL (30 33

34 SPRYCEL 0 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (60 STIVARGA 5 PA - FOR NEW STARTS ONLY, QL (84 PER 8 DAYS) SUTENT (5 MG CAPSULE, 37.5 MG CAPSULE, 50 MG CAPSULE) 5 PA - FOR NEW STARTS ONLY, QL (30 SUTENT 1.5 MG CAPSULE 5 PA - FOR NEW STARTS ONLY, QL (90 TAFINLAR 5 PA - FOR NEW STARTS ONLY, QL (10 TARCEVA (100 MG TABLET, 150 MG TABLET) 5 PA - FOR NEW STARTS ONLY, QL (30 TARCEVA 5 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (60 TASIGNA 5 PA - FOR NEW STARTS ONLY, QL (10 TYKERB 5 PA - FOR NEW STARTS ONLY, QL (180 VELCADE 5 VOTRIENT 5 PA - FOR NEW STARTS ONLY, QL (10 XALKORI 5 PA - FOR NEW STARTS ONLY, QL (60 ZELBORAF 5 PA - FOR NEW STARTS ONLY, QL (40 ZYDELIG 5 PA - FOR NEW STARTS ONLY, QL (60 ZYKADIA 5 PA - FOR NEW STARTS ONLY, QL (150 Monoclonal Antibodies ARZERRA 5 AVASTIN 5 ERBITUX 5 HERCEPTIN 5 34

35 KADCYLA 5 KEYTRUDA (50 MG VIAL, 100 MG/4 ML VIAL) 5 OPDIVO 5 PERJETA 5 RITUXAN 5 PA - FOR NEW STARTS ONLY SYLVANT 5 VECTIBIX 5 YERVOY 5 Retinoids bexarotene 5 PANRETIN 5 TARGRETIN (75 MG SOFTGEL, 75 MG CAPSULE) 5 PA - FOR NEW STARTS ONLY TARGRETIN 1% GEL 5 tretinoin 10 mg capsule 5 PA - FOR NEW STARTS ONLY Antiparasitics Anthelmintics ALBENZA 4 BILTRICIDE 4 ivermectin 3 mg tablet STROMECTOL 3 Antiprotozoals ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) atovaquone 5 atovaquone/proguanil hcl chloroquine phosphate (50 mg tablet, 500 mg tablet) COARTEM

36 DARAPRIM 4 hydroxychloroquine sulfate 00 mg tablet 1 mefloquine hcl NEBUPENT 4 PA - Part B vs D Determination PENTAM PA - Part B vs D Determination primaquine phosphate 4 Pediculicides/Scabicides lindane malathion permethrin 5 % cream (g) ULESFIA 4 Antiparkinson Agents Antiparkinson Agents, Other amantadine hcl (50 mg/5 ml solution, 100 mg capsule) amantadine hcl 100 mg tablet 4 benztropine mesylate (0.5 mg tablet, 1 mg tablet, mg tablet) carbidopa/levodopa/entacapone entacapone TASMAR 5 tolcapone 5 Dopamine Agonists APOKYN 5 bromocriptine mesylate (.5 mg tablet, 5 mg capsule) NEUPRO 3 pramipexole di-hcl (0.5 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet) 4 PA - FOR NEW STARTS ONLY 1 36

37 pramipexole di-hcl 0.15 mg tablet 1 PA - FOR NEW STARTS ONLY ropinirole hcl (0.5 mg tablet, 0.5 mg tablet, 1 mg tablet, mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet) Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa 5 mg tablet carbidopa/levodopa Monoamine Oxidase B (MAO-B) Inhibitors AZILECT 3 selegiline hcl (5 mg tablet, 5 mg capsule) Antipsychotics 1st Generation/Typical fluphenazine decanoate 5 mg/ml vial fluphenazine hcl (1 mg tablet,.5 mg tablet, 5 mg tablet, 10 mg tablet) fluphenazine hcl (.5 mg/5ml elixir,.5 mg/ml vial, 5 mg/ml oral conc) haloperidol (0.5 mg tablet, 1 mg tablet, mg tablet, 5 mg tablet, 10 mg tablet, 0 mg tablet) haloperidol decanoate (50 mg/ml vial, 50 mg/ml ampul, 100 mg/ml ampul, 100 mg/ml vial) haloperidol lactate loxapine succinate ORAP 4 thioridazine hcl (10 mg tablet, 5 mg tablet, 50 mg tablet, 100 mg tablet) thiothixene trifluoperazine hcl 4 4 PA - FOR NEW STARTS ONLY nd Generation/Atypical ABILIFY ( MG TABLET, 5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 0 MG TABLET, 30 MG TABLET) 5 QL (30 37

38 ABILIFY 1 MG/ML SOLUTION 5 QL (750 ABILIFY 9.7 MG/1.3 ML VIAL 4 QL (117 ABILIFY DISCMELT 5 QL (60 ABILIFY MAINTENA 5 QL (1 aripiprazole ( mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 0 mg tablet, 30 mg tablet) FANAPT (1 MG TABLET, MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 1 MG TABLET) 5 QL (30 4 QL (60 FANAPT TITRATION PACK 4 QL (56 PER 8 DAYS) GEODON 0 MG/ML VIAL 4 QL (60 INVEGA (ER 1.5 MG TABLET, ER 3 MG TABLET) 4 QL (30 INVEGA ER 6 MG TABLET 4 QL (60 INVEGA ER 9 MG TABLET 5 QL (30 INVEGA SUSTENNA 117 MG PREF SY 5 QL (0.75 INVEGA SUSTENNA 156 MG PREF SY 5 QL (1 INVEGA SUSTENNA 34 MG PREF SY 5 QL (1.5 INVEGA SUSTENNA 39 MG PREF SYR 4 QL (0.5 INVEGA SUSTENNA 78 MG PREF SYR 4 QL (0.5 LATUDA (0 MG TABLET, 40 MG TABLET, 60 MG TABLET, 10 MG TABLET) 4 QL (30 LATUDA 80 MG TABLET 4 QL (60 olanzapine (.5 mg tablet, 5 mg tablet, 5 mg tab rapdis, 7.5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 0 mg tablet, 0 mg tab rapdis) QL (30 olanzapine 10 mg vial QL (90 quetiapine fumarate (5 mg tablet, 50 mg tablet, 100 mg tablet, 00 mg tablet) quetiapine fumarate (300 mg tablet, 400 mg tablet) QL (90 QL (60 RISPERDAL CONSTA (1.5 MG, 5 MG) 4 QL ( PER 8 DAYS) RISPERDAL CONSTA (37.5 MG, 50 MG) 5 QL ( PER 8 DAYS) 38

39 risperidone (0.5 mg tablet, 0.5 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg tablet, mg tablet, mg tab rapdis, 3 mg tab rapdis, 3 mg tablet) QL (60 risperidone (4 mg tab rapdis, 4 mg tablet) QL (10 risperidone 1 mg/ml solution QL (480 SAPHRIS 4 QL (60 SEROQUEL XR (150 MG TABLET, 00 MG TABLET) 3 QL (30 SEROQUEL XR (50 MG TABLET, 300 MG TABLET, 400 MG TABLET) 3 QL (60 ziprasidone hcl QL (60 ZYPREXA RELPREVV 5 QL ( PER 8 DAYS) Treatment-Resistant clozapine (5 mg tablet, 50 mg tablet) QL (90 clozapine 100 mg tablet QL (70 clozapine 00 mg tablet QL (10 FAZACLO (1.5 MG ODT, 100 MG ODT) 4 QL (90 FAZACLO 150 MG ODT 4 QL (180 FAZACLO 00 MG ODT 4 QL (10 FAZACLO 5 MG ODT 4 QL (70 VERSACLOZ 5 QL (540 Antispasticity Agents baclofen (10 mg tablet, 0 mg tablet) 1 COMFORT PAC-TIZANIDINE dantrolene sodium (5 mg capsule, 50 mg capsule, 100 mg capsule) tizanidine hcl ( mg capsule, mg tablet, 4 mg tablet, 4 mg capsule, 6 mg capsule) 39

40 Antivirals Anti-HIV Agents, Integrase Inhibitors (INSTI) ATRIPLA 5 QL (30 ISENTRESS (5 MG TABLET, 100 MG TABLET) 3 QL (180 ISENTRESS 100 MG POWDER PACKET 4 QL (60 ISENTRESS 400 MG TABLET 5 QL (60 STRIBILD 5 QL (30 TIVICAY 5 QL (60 TRIUMEQ 5 QL (30 VITEKTA 5 QL (30 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) COMPLERA 5 QL (30 EDURANT 5 QL (30 INTELENCE (100 MG TABLET, 00 MG TABLET) 5 QL (60 INTELENCE 5 MG TABLET 4 QL (10 nevirapine 00 mg tablet QL (60 nevirapine 400 mg tab er 4h QL (30 nevirapine 50 mg/5 ml oral susp 4 QL (100 RESCRIPTOR 100 MG TABLET 4 QL (360 RESCRIPTOR 00 MG TABLET 4 QL (180 SUSTIVA 00 MG CAPSULE 3 QL (60 SUSTIVA 50 MG CAPSULE 3 QL (90 SUSTIVA 600 MG TABLET 3 QL (30 VIRAMUNE 50 MG/5 ML SUSP 4 QL (100 VIRAMUNE XR 100 MG TABLET 4 QL (10 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir sulfate QL (60 abacavir sulfate/lamivudine/zidovudine 5 QL (60 40

41 didanosine QL (30 EMTRIVA 10 MG/ML SOLUTION 4 QL (850 EMTRIVA 00 MG CAPSULE 4 QL (30 EPIVIR 10 MG/ML ORAL SOLN 3 QL (960 EPZICOM 5 QL (30 lamivudine 10 mg/ml solution QL (960 lamivudine 150 mg tablet QL (60 lamivudine 300 mg tablet QL (30 lamivudine/zidovudine 5 QL (60 RETROVIR 00 MG/0 ML VIAL 4 stavudine (15 mg capsule, 0 mg capsule, 30 mg capsule, 40 mg capsule) QL (60 stavudine 1 mg/ml soln recon QL (400 TRUVADA 5 QL (30 VIDEX 4 QL (100 VIREAD (150 MG TABLET, 00 MG TABLET, 50 MG TABLET, 300 MG TABLET) 5 QL (30 VIREAD POWDER 5 QL (40 ZIAGEN 0 MG/ML SOLUTION 4 QL (960 zidovudine 10 mg/ml syrup 1 QL (190 zidovudine 100 mg capsule QL (180 zidovudine 300 mg tablet QL (60 Anti-HIV Agents, Other FUZEON 5 QL (60 SELZENTRY 150 MG TABLET 5 QL (60 SELZENTRY 300 MG TABLET 5 QL (10 TYBOST 4 QL (30 Anti-HIV Agents, Protease Inhibitors APTIVUS 100 MG/ML SOLUTION 5 QL (380 41

42 APTIVUS 50 MG CAPSULE 5 QL (10 CRIXIVAN 00 MG CAPSULE 3 QL (70 CRIXIVAN 400 MG CAPSULE 3 QL (180 EVOTAZ 5 QL (30 INVIRASE 00 MG CAPSULE 5 QL (300 INVIRASE 500 MG TABLET 5 QL (10 KALETRA MG TABLET 4 QL (300 KALETRA MG TABLET 5 QL (10 KALETRA /5 ML ORAL SOLU 5 QL (30 LEXIVA 50 MG/ML SUSPENSION 4 QL (1800 LEXIVA 700 MG TABLET 5 QL (10 NORVIR (100 MG TABLET, 100 MG SOFTGEL CAP) 4 QL (360 NORVIR 80 MG/ML SOLUTION 4 QL (480 PREZCOBIX 5 QL (30 PREZISTA 100 MG/ML SUSPENSION 5 QL (400 PREZISTA 150 MG TABLET 4 QL (180 PREZISTA 600 MG TABLET 5 QL (60 PREZISTA 75 MG TABLET 4 QL (300 PREZISTA 800 MG TABLET 5 QL (30 REYATAZ (150 MG CAPSULE, 300 MG CAPSULE) 5 QL (30 REYATAZ 00 MG CAPSULE 5 QL (60 REYATAZ 50 MG POWDER PACKET 5 QL (150 VIRACEPT 50 MG TABLET 5 QL (70 VIRACEPT 65 MG TABLET 5 QL (10 Anti-cytomegalovirus (CMV) Agents cidofovir 75 mg/ml vial foscarnet sodium 4 PA - Part B vs D Determination ganciclovir sodium PA - Part B vs D Determination VALCYTE (50 MG/ML SOLUTION, 450 MG TABLET) 5 4