List of Covered Drugs (Formulary) (Medicare Medicaid Plan)

Transcription

1 2017 List of Covered Drugs (Formulary) RiverSpring FIDA Plan (Medicare Medicaid Plan) To contact Participant Services, please call (TTY 711). We are available to take your call 7 days a week from 8 a.m. to 8 p.m. EST. PLEASE READ: This document contains information about the drugs we cover in this plan. We have made no changes to this comprehensive formulary since 07/28/2016. HPMS Approved Formulary File Submission ID , Version number 5. Effective 07/28/2016

2 RiverSpring FIDA Plan 2017 List of Covered Drugs (Formulary) This is a list of drugs that Participants can get in RiverSpring FIDA Plan. RiverSpring FIDA Plan is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check RiverSpring FIDA Plan s up-to-date List of Covered Drugs online at RiverSpringFIDA.org or by calling RiverSpring FIDA Plan Participant Services at Limitations and restrictions may apply. For more information, call RiverSpring FIDA Plan Participant Services or read the RiverSpring FIDA Plan Participant Handbook. This means that you need to follow certain rules to have RiverSpring FIDA Plan pay for your services. There are no copays for any covered drugs. H6435_2017Formulary_Pending You can get this information for free in other languages. Call (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. Ou ka jwenn enfòmasyon sa a gratis nan lòt lang. Rele nan ak nan TTY/TDD: 711 ant 8:00 am ak 8:00 pm., Lè Zòn Lès, 7 jou pa semèn. Koutfil la gratis. Vous pouvez obtenir ces informations gratuitement dans d autres langues. Appelez le ou notre numéro TTY/TDD: jours sur 7 de 8 a.m. à 8 p.m. EST. L appel est gratuit. Usted puede obtener esta informacion en otros idiomas de forma gratuita. Llame al y TTY/TDD: 711 8:00 am a 8:00 pm Hora del Este, los 7 días de la semana. La llamada es gratuita. 이정보는다른언어로도제공됩니다 ( 무료 ). 주 7 일 8:00 am 8:00 pm(est) 중 나 TTY/TDD: 711 으로전화주십시오. 통화료는무료입니다. 您可免費取得以其他語言撰寫的資訊 請於週一至週日美國東部標準時間上午 8 時至下午 8 時致電 : ,TTY/TDD 使用者 : 711 每週 7 天服務 此為免付費電話 Данная информация доступна бесплатно на других языках. Звоните по номеру или 711 (линия TTY/TDD) с 8:00 до 20:00 по восточному поясному времени 7 дней в неделю. Звонок бесплатный.? If you have questions, please call RiverSpring FIDA Plan at (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. For more information, visit RiverSpringFIDA.org I

3 È possibile ricevere queste informazioni in altre lingue gratuitamente. Contatta il e TTY/TDD: 711 dalle ore 8:00 alle ore 20:00 EST (ora standard orientale degli Stati Uniti), 7 giorni su 7. Il servizio è gratuito. You can get this information for free in other formats, such as large print, braille, or audio. Call (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. If you require any of the Plan materials, now or in the future, in your preferred language or alternative format, please call Participant Services at (TTY 711) we d be happy to help you. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by RiverSpring FIDA Plan. ICAN may be reached toll-free at or online at icannys.org. (TTY rs call 711, then follow the prompts to dial )? If you have questions, please call RiverSpring FIDA Plan at (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. For more information, visit RiverSpringFIDA.org II

4 Frequently Asked Questions (FAQ) Find answers here to questions you 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 1 are the drugs covered by RiverSpring FIDA Plan. 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 you services. We refer to these pharmacies as network pharmacies. RiverSpring FIDA Plan will cover all drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, the drug is medically necessary for your condition, and you fill the prescription at a RiverSpring FIDA Plan network pharmacy. RiverSpring FIDA Plan may have additional steps to access certain drugs (see question #5 below). In some cases, you may have to do something before you can get a drug, like try other drugs first. You can also see an up-to-date list of drugs that we cover on our website at RiverSpringFIDA.org or call Participant Services at Does the Drug List ever change? Yes. RiverSpring FIDA Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a new 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 RiverSpring FIDA Plan or your Interdisciplinary Team (IDT) before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ).? If you have questions, please call RiverSpring FIDA Plan at (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. For more information, visit RiverSpringFIDA.org III

5 Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page V.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you 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 RiverSpring FIDA Plan s up to date Drug List online at RiverSpringFIDA.org. You can also call Participant Services to check the current Drug List at What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If a cheaper drug becomes available that works as well as a drug on the Drug List now: Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now. RiverSpring FIDA Plan may decide to take the more expensive drug off of the Drug List. If you are taking a drug that we remove from the Drug List beca a cheaper drug that works just as well comes along, we will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. We will tell you when this happens by mailing you a letter. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter and call you to tell you that the unsafe drug was taken off the Drug List. After you receive this letter, you should contact the doctor who prescribed the drug for you.? If you have questions, please call RiverSpring FIDA Plan at (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. For more information, visit RiverSpringFIDA.org IV

6 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 you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from RiverSpring FIDA Plan or your Interdisciplinary Team (IDT) before you fill your prescription. If you don t get approval, RiverSpring FIDA Plan may not cover the drug. Quantity limits: Sometimes RiverSpring FIDA Plan limits the amount of a drug you can get. Step therapy: Sometimes RiverSpring FIDA Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables beginning on page 1. You can also get more information by visiting our web site at RiverSpringFIDA.org. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing facility or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new RiverSpring FIDA Plan Participant. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 1 has a column labeled.? If you have questions, please call RiverSpring FIDA Plan at (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. For more information, visit RiverSpringFIDA.org V

7 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 you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section on page 127. Then look for the name of your drug in the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 2. The drugs in this section are grouped into categories depending on the type of medical conditions they are d to treat. For example, if you have a heart condition, you should look in the category, Cardiac Drugs. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Participant Services at and ask about it. If you learn that RiverSpring FIDA Plan will not cover the drug, you can do one of these things: Ask Participant Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions.? If you have questions, please call RiverSpring FIDA Plan at (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. For more information, visit RiverSpringFIDA.org VI

8 10. What if you are a new RiverSpring FIDA Plan Participant and can t find your drug on the Drug List or have a problem getting your drug? We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of RiverSpring FIDA Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. We will cover up to 90 days of temporary supplies of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by RiverSpring FIDA Plan or your Interdisciplinary Team (IDT), or you are taking a drug that is part of a step therapy restriction. If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 90 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. If you are a current participant being admitted to or discharged from a long-term care facility, you will be able to get an early refill on your medications, if needed. 11. Can you ask for an exception to cover your drug? Yes. You can ask RiverSpring FIDA Plan or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the Drug List. You can also ask RiverSpring FIDA Plan or your IDT to change the rules on your drug. For example, RiverSpring FIDA Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more. Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements.? If you have questions, please call RiverSpring FIDA Plan at (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. For more information, visit RiverSpringFIDA.org VII

9 12. How long does it take to get an exception? First, RiverSpring FIDA Plan or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we get the statement, you will get a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, you will get a decision within 24 hours of getting your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same 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). RiverSpring FIDA Plan covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. RiverSpring FIDA Plan covers some OTC drugs when they are written as prescriptions by your provider. You can read the RiverSpring FIDA Plan Drug List to see what OTC drugs are covered. 16. Does RiverSpring FIDA Plan cover OTC non-drug products? RiverSpring FIDA Plan covers some OTC non-drug products when they are written as prescriptions by your provider, such as Band-Aids. You can read the RiverSpring FIDA Plan Drug List to see what OTC non-drug products are covered.? If you have questions, please call RiverSpring FIDA Plan at (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. For more information, visit RiverSpringFIDA.org VIII

10 As a member of our plan, you are also covered for up to $25 a month for over-the-counter products. OTC items may only be purchased for the Participant. Please contact the plan for specific instructions on how to this benefit. You can also find additional information in Chapter 4 of your Participant Handbook. 17. What is your copay? You will not be charged a copay for drugs on the Drug List. 18. What are drug tiers? Tiers are groups of drugs on our Drug List. You pay nothing for drugs in any tier. The tiers of drugs are listed below. Tier 1 Generic drugs Tier 2 Brand drugs Tier 3 OTC Drugs and Products? If you have questions, please call RiverSpring FIDA Plan at (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. For more information, visit RiverSpringFIDA.org IX

11 List of Covered Drugs The list of covered drugs that begins on the next page gives you information about the drugs covered by RiverSpring FIDA Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 127. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., VYTORIN) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the necessary actions, column tells you if RiverSpring FIDA Plan has any rules for covering your 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 for a review of and change to a coverage decision if you think there was a mistake. For example, RiverSpring FIDA Plan or your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at (TTY 711) or the Independent Consumer Advocacy Network (ICAN) at (TTY rs call 711, then follow the prompts to dial ) You can also read the Participant 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 you have a heart condition, you should look in the category, Cardiac Drugs. That is where you will find drugs that treat heart conditions.? If you have questions, please call RiverSpring FIDA Plan at (TTY 711) 7 days a week from 8 a.m. to 8 p.m. EST. The call is free. For more information, visit RiverSpringFIDA.org X

12 Legend Tier Description 1 Generics ($0) 2 Brands ($0) 3 Non-Medicare Rx/OTC Drugs ($0) Symbol QL PA ST LA MO NDS BD Description Quantity limit, dispense limit for 30 days, unless otherwise noted 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. Step therapy exception required Limited access, This prescription may be available only at certain pharmacies This prescription may also be available via mail. Non-Extended Day Supply. These drugs are not available as an extended day supply. 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 1

13 Analgesics Nonsteroidal Anti-Inflammatory Drugs celecoxib (100 mg capsule, 200 mg capsule, 400 mg capsule, 50 mg capsule) $0 (Tier 1) QL (60 PER 30 DAYS), MO, (g) diclofenac potassium (tablet) diclofenac sodium (100 mg tab er 24h, 25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr) diclofenac sodium/misoprostol (tab ir dr) diflunisal (tablet) 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 600 mg tablet FIORINAL (CAPSULE) $0 (Tier 1) NDS flurbiprofen (100 mg tablet, 50 mg tablet) ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) indomethacin (25 mg capsule, 50 mg capsule, 75 mg capsule er) ketoprofen (200 mg cap24h pel, 50 mg capsule, 75 mg capsule) ketorolac tromethamine 10 mg tablet meclofenamate sodium (100 mg capsule, 50 mg capsule) mefenamic acid 250 mg capsule meloxicam (15 mg tablet, 7.5 mg tablet, 7.5 mg/5ml oral susp) nabumetone 500 mg tablet $0 (Tier 1) MO, NDS, (g) nabumetone 750 mg tablet 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, 375 mg tbmp 24hr, 500 mg tbmp 24hr, 550 mg tablet) 2

14 Analgesics oxaprozin (tablet) piroxicam (10 mg capsule, 20 mg capsule) sulindac (150 mg tablet, 200 mg tablet) tolmetin sodium (400 mg capsule, 600 mg tablet) Opioid Analgesics, Long-Acting fentanyl (100 mcg/hr patch td72, 12 mcg/hr patch td72, 25 mcg/hr patch td72, 25mcg/hr patch td72, 37.5mcg/hr patch td72, 50mcg/hr patch td72, 62.5mcg/hr patch td72, 75mcg/hr patch td72, 87.5mcg/hr patch td72) $0 (Tier 1) QL (10 PER 30 DAYS), NDS, (g) levorphanol tartrate 2 mg tablet methadone hcl (10 mg tablet, 5 mg tablet) $0 (Tier 1) QL (180 PER 30 DAYS), NDS, (g) methadone hcl (10 mg/5 ml solution, 5 mg/5 ml solution) morphine sulfate (10 mg cap er pel, 100 mg cap er pel, 100 mg tablet er, 120 mg cpmp 24hr, 20 mg cap er pel, 30 mg cap er pel, 30 mg cpmp 24hr, 30 mg tablet er, 45 mg cpmp 24hr, 50 mg cap er pel, 60 mg cap er pel, 60 mg cpmp 24hr, 60 mg tablet er, 75 mg cpmp 24hr, 80 mg cap er pel, 90 mg cpmp 24hr) oxycodone hcl (10 mg tab er 12h, 20 mg tab er 12h, 40 mg tab er 12h, 80 mg tab er 12h) $0 (Tier 1) QL (90 PER 30 DAYS), NDS, (g) $0 (Tier 1) QL (60 PER 30 DAYS), NDS, (g) OXYCONTIN (TAB ER 12H) $0 (Tier 2) QL (60 PER 30 DAYS), NDS oxymorphone hcl (10 mg tab er 12h, 15 mg tab er 12h, 20 mg tab er 12h, 30 mg tab er 12h, 40 mg tab er 12h, 5 mg tab er 12h, 7.5 mg tab er 12h) tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mg tab er 24h, 200 mg tbmp 24hr) $0 (Tier 1) QL (60 PER 30 DAYS), NDS, (g) $0 (Tier 1) QL (90 PER 30 DAYS), NDS, (g) tramadol hcl (300 mg tab er 24h, 300 mg tbmp 24hr) Opioid Analgesics, Short-Acting acetaminophen with codeine 300mg-30mg tablet $0 (Tier 1) QL (400 PER 30 DAYS), NDS, (g) acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg/12.5 solution) $0 (Tier 1) QL (4500 ML PER 30 DAYS), NDS, (g) 3

15 Analgesics acetaminophen with codeine phosphate (300mg- 15mg tablet, 300mg-60mg tablet) $0 (Tier 1) QL (240 PER 30 DAYS), NDS, (g) ASCOMP WITH CODEINE (CAPSULE) $0 (Tier 1) NDS butalbit/acetamin/caff/codeine capsule $0 (Tier 1) QL (180 PER 30 DAYS), NDS, (g) butorphanol tartrate (1 mg/ml vial, 2 mg/ml vial) butorphanol tartrate 10 mg/ml spray $0 (Tier 1) QL (2.5 ML PER 14 DAYS), NDS, (g) codeine phosphate/carisoprodol/aspirin (tablet) $0 (Tier 1) QL (120 PER 30 DAYS), NDS, (g) codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg tablet) DURAMORPH 10 MG/10 ML AMPUL $0 (Tier 1) NDS ENDOCET (5-325 TABLET, MG TABLET) $0 (Tier 1) QL (360 PER 30 DAYS), NDS 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- 325mg tablet, mg tablet, 5 mg-325mg tablet, mg tablet) hydrocodone/ibuprofen (10mg-200mg tablet, 5mg- 200mg tablet, mg tablet) hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 4 mg tablet, 8 mg tablet) hydromorphone hcl/pf (10 mg/ml ampul, 10 mg/ml vial) $0 (Tier 1) PA, NDS, (g) $0 (Tier 1) QL (240 PER 30 DAYS), NDS, (g) $0 (Tier 1) QL (150 PER 30 DAYS), NDS, (g) ibuprofen/oxycodone hcl (tablet) $0 (Tier 1) QL (300 PER 30 DAYS), NDS, (g) LAZANDA (100 MCG NASAL SPRAY, 400 MCG NASAL SPRAY) $0 (Tier 2) PA, NDS LORCET (TABLET) $0 (Tier 1) QL (240 PER 30 DAYS), NDS LORCET PLUS (TABLET) $0 (Tier 1) QL (240 PER 30 DAYS), NDS meperidine hcl (100 mg tablet, 50 mg tablet) 4

16 Analgesics morphine sulfate (10 mg/5 ml solution, 100 mg/5ml solution, 2 mg/ml syringe, 20 mg/5 ml solution, 8 mg/ml syringe) morphine sulfate (15 mg tablet, 30 mg tablet) $0 (Tier 1) QL (120 PER 30 DAYS), NDS, (g) nalbuphine hcl (10 mg/ml ampul, 10 mg/ml vial, 20 mg/ml ampul, 20 mg/ml vial) oxycodone hcl (10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet, 5 mg tablet) $0 (Tier 1) BD, NDS, (g) $0 (Tier 1) QL (180 PER 30 DAYS), NDS, (g) oxycodone hcl 5 mg/5 ml solution $0 (Tier 1) QL (2400 ML PER 30 DAYS), NDS, (g) oxycodone hcl/acetaminophen 5 mg-325mg tablet $0 (Tier 1) QL (360 PER 30 DAYS), NDS, (g) tramadol hcl 50 mg tablet $0 (Tier 1) QL (240 PER 30 DAYS), NDS, (g) tramadol hcl/acetaminophen (tablet) $0 (Tier 1) QL (240 PER 30 DAYS), NDS, (g) Anesthetics Local Anesthetics lidocaine 5 % adh. patch $0 (Tier 1) PA, NDS, (g) lidocaine 5 % oint. (g) lidocaine hcl (2 % jel (ml), 2 % jel/pf app, 20 mg/ml vial, 40 mg/ml solution, 5 mg/ml vial) lidocaine hcl/pf (20 mg/ml vial, 5 mg/ml vial) lidocaine/prilocaine (2.5 %-2.5% cream (g), 2.5 %-2.5% kit) 5

17 Anti-Addiction/Substance Ab Treatment Agents Alcohol Deterrents/Anti-Craving acamprosate calcium (tablet dr) disulfiram (250 mg tablet, 500 mg tablet) naltrexone hcl 50 mg tablet Opioid Dependence Treatments buprenorphine hcl (2 mg tab subl, 8 mg tab subl) buprenorphine hcl/naloxone hcl 2 mg-0.5mg tab subl $0 (Tier 1) QL (120 PER 30 DAYS), MO, (g) buprenorphine hcl/naloxone hcl 8 mg-2 mg tab subl $0 (Tier 1) QL (90 PER 30 DAYS), MO, (g) Opioid Reversal Agents NARCAN (SPRAY) $0 (Tier 2) NDS Smoking Cessation Agents BUPROBAN (TABLET ER) $0 (Tier 1) NDS CHANTIX (0.5 MG TABLET, 1 MG TABLET) $0 (Tier 2) ST, NDS CHANTIX (1 MG CONT MONTH BOX, STARTING MONTH BOX) $0 (Tier 2) NDS NICOTROL (CARTRIDGE) $0 (Tier 2) NDS NICOTROL NS (SPRAY) $0 (Tier 2) ST, NDS Antibacterials Aminoglycosides amikacin sulfate 500 mg/2ml vial $0 (Tier 1) BD, NDS, (g) GENTAK (OINT. (G)) $0 (Tier 1) NDS gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g), 0.3 % drops, 0.3 % oint. (g), 40 mg/ml vial) 6

18 Antibacterials gentamicin sulfate in sodium chloride, iso-osmotic (gentamic100mg/0.1l piggyback, gentamic80 mg/50ml 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) neomycin sulfate 500 mg tablet paromomycin sulfate 250 mg capsule streptomycin sulfate 1 g vial tobramycin 0.3 % drops tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial) TOBREX (DROPS, OINTMENT) $0 (Tier 2) NDS Antibacterials, Other ALTABAX (OINT. (G)) $0 (Tier 2) NDS BACIIM (VIAL) $0 (Tier 1) NDS bacitracin (500 unit/g oint. (g), unit vial) BACTROBAN NASAL (OINT. (G)) $0 (Tier 2) NDS chloramphenicol sod succ (vial) clindamycin hcl (150 mg capsule, 300 mg capsule, 75 mg capsule) clindamycin palmitate hcl (soln recon) clindamycin phosphate (1 % gel (gram), 1 % lotion, 1 % solution, 2 % cream/appl) clindamycin phosphate/dextrose 5 % in water (piggyback) colistin (colistimethate na) 150 mg vial CUBICIN (VIAL) $0 (Tier 2) PA, NDS erythromycin base/benzoyl peroxide (gel (gram)) KETEK (TABLET) $0 (Tier 2) PA, NDS linezolid 100 mg/5ml susp recon $0 (Tier 1) QL (840 ML PER 14 DAYS), NDS, (g) 7

19 Antibacterials linezolid 600 mg tablet $0 (Tier 1) QL (28 PER 14 DAYS), NDS, (g) linezolid 600mg/300 iv soln methenamine hippurate (tablet) metronidazole (0.75 % gel w/appl, 250 mg tablet, 375 mg capsule, 500 mg tablet) metronidazole in sodium chloride (piggyback) mupirocin 2 % oint. (g) mupirocin calcium (cream (g)) neomycin sulfate/polymyxin b sulfate (ampul, vial) nitrofurantoin 25 mg/5 ml oral susp nitrofurantoin macrocrystal 100 mg capsule $0 (Tier 1) QL (180 PER 365 DAYS), NDS, (g) nitrofurantoin macrocrystal 25 mg capsule nitrofurantoin macrocrystal 50 mg capsule $0 (Tier 1) QL (720 PER 365 DAYS), NDS, (g) nitrofurantoin monohydrate/macrocrystals (capsule) $0 (Tier 1) QL (180 PER 365 DAYS), NDS, (g) SYNERCID (VIAL) $0 (Tier 2) NDS tinidazole (250 mg tablet, 500 mg tablet) trimethoprim 100 mg tablet TYGACIL (VIAL) $0 (Tier 2) vancomycin hcl (1 g vial, 1 g vial port, 10 g vial, 5 g vial, 500 mg vial, 500 mg vial port, 750 mg vial) vancomycin hcl (125 mg capsule, 250 mg capsule) $0 (Tier 1) QL (112 PER 4 DAYS), NDS, (g) ZERBAXA (VIAL) $0 (Tier 2) NDS ZYVOX 100 MG/5 ML SUSPENSION $0 (Tier 2) PA, QL (840 ML PER 14 DAYS), NDS 8

20 Antibacterials Beta-Lactam, Cephalosporins cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375 mg/5ml susp recon, 500 mg capsule, 500 mg tab er 12h) cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon) cefazolin sodium (1 g vial, 1 g vial port, 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 (vial) $0 (Tier 1) (g) cefixime (susp recon) cefotaxime sodium (1 g vial, 2 g vial, 500 mg vial) cefotetan disodium (1 g vial, 2 g vial) cefoxitin sodium (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 tablet) ceftazidime (1 g vial, 2 g vial, 6 g vial) 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) cefuroxime axetil (tablet) cefuroxime sodium (1.5 g vial, 7.5 g vial, 7.5g vial, 75 g bulkbaginj, 750 mg vial) cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 750 mg capsule) SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE) TAZICEF (1 GM ADD-VANTAGE VIAL, 1 GRAM VIAL, 2 GM ADD-VANTAGE, 2 GRAM VIAL, 6 GRAM VIAL) $0 (Tier 2) NDS $0 (Tier 1) NDS TEFLARO (VIAL) $0 (Tier 2) NDS 9

21 Antibacterials Beta-Lactam, Other AZACTAM-ISO-OSMOTIC DEXTROSE (FROZ.PIGGY) $0 (Tier 2) NDS aztreonam 1 g vial DORIBAX 500 MG VIAL $0 (Tier 2) PA, NDS imipenem/cilastatin sodium (vial) $0 (Tier 1) PA, NDS, (g) INVANZ 1 GM VIAL $0 (Tier 2) NDS meropenem 500 mg vial Beta-Lactam, Penicillins amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 875 mg tablet) amoxicillin/potassium clavulanate ( tab er 12h, /5 susp recon, mg tab chew, mg tablet, /5 susp recon, mg tab chew, mg/5 susp recon, mg tablet, /5 susp recon, mg tablet) ampicillin sodium (1 g vial, 1 g vial port, 10 g vial, 125 mg vial) ampicillin sodium/sulbactam sodium (1.5 g vial, 1.5 g vial port, 15 g vial, 3 g vial, 3 g vial port) ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule) BICILLIN L-A (SYRINGE) $0 (Tier 2) NDS dicloxacillin sodium (capsule) nafcillin sodium (1 g vial, 1 g vial port, 10 g vial) oxacillin sodium (1 g vial, 10 g vial, 2 g vial, 2 g vial port) penicillin g sodium (vial) penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) piperacillin sodium/tazobactam 40.5 g vial piperacillin sodium/tazobactam sodium (3.375 g vial, g vial port, 4.5 g vial, 4.5 g vial port) $0 (Tier 1) PA, NDS, (g) 10

22 Antibacterials Macrolides AZASITE (DROPS) $0 (Tier 2) NDS azithromycin (1 g packet, 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 tablet) clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tab er 24h, 500 mg tablet) E.E.S. 200 (SUSP RECON) $0 (Tier 1) NDS E.E.S. 400 (TABLET) $0 (Tier 1) NDS ERY (MED. SWAB) $0 (Tier 1) NDS ERYTHROCIN LACTOBIONATE (500 MG ADDVNT VL, 500 MG VIAL) $0 (Tier 2) NDS ERYTHROCIN STEARATE (TABLET) $0 (Tier 1) NDS erythromycin base 5 mg/g oint. (g) erythromycin base/ethyl alcohol (2 % gel (gram), 2 % solution) erythromycin ethylsuccinate 400 mg tablet ILOTYCIN (OINT. (G)) $0 (Tier 1) NDS PCE (TAB PART) $0 (Tier 2) NDS ZITHROMAX 250 MG TABLET $0 (Tier 1) NDS ZMAX (SUS ER REC) $0 (Tier 2) NDS Quinolones ciprofloxacin (sus mc rec) ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet) ciprofloxacin lactate 400mg/40ml vial ciprofloxacin lactate/d5w 200mg/0.1l piggyback ciprofloxacin/ciprofloxacin hcl (tbmp 24hr) gatifloxacin (drops) 11

23 Antibacterials levofloxacin (0.5 % drops, 250 mg tablet, 250mg/10ml solution, 500 mg tablet, 500mg/20ml solution, 750 mg tablet) levofloxacin/dextrose 5 % in water (500mg/0.1l piggyback, 750mg/.15l piggyback) moxifloxacin hcl 400 mg tablet $0 (Tier 1) QL (14 PER 14 DAYS), NDS, (g) moxifloxacin hcl in sodium acetate and sulfate,water,iso-osm (piggyback) ofloxacin 400 mg tablet VIGAMOX (DROPS) $0 (Tier 2) NDS Sulfonamides silver sulfadiazine 1 % cream (g) SSD (CREAM (G)) $0 (Tier 1) NDS sulfacetamide sodium (10 % drops, 10 % oint. (g), 10 % suspension) sulfadiazine 500 mg tablet sulfamethoxazole/trimethoprim (200-40mg/5 oral susp, 400mg-80mg tablet, 80-16mg/ml vial, mg tablet, /20 oral susp) Tetracyclines demeclocycline hcl (tablet) DOXY 100 (VIAL) $0 (Tier 1) NDS doxycycline hyclate (100 mg capsule, 100 mg tablet, 100 mg vial, 20 mg tablet, 50 mg capsule) doxycycline monohydrate (100 mg capsule, 150 mg tablet, 50 mg capsule, 50 mg tablet) minocycline hcl (100 mg capsule, 100 mg tablet, 135 mg tab er 24h, 45 mg tab er 24h, 50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 90 mg tab er 24h) tetracycline hcl (250 mg capsule, 500 mg capsule) 12

24 Anticonvulsants Anticonvulsants, Other BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 100 MG TABLET, 25 MG TABLET, 50 MG TABLET, 75 MG TABLET) FYCOMPA (10 MG TABLET, 12 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET) $0 (Tier 2) $0 (Tier 2) MO FYCOMPA 0.5 MG/ML ORAL SUSP $0 (Tier 2) KEPPRA (1,000 MG TABLET, 100 MG/ML ORAL SOLN, 250 MG TABLET, 500 MG TABLET, 750 MG TABLET) $0 (Tier 2) MO KEPPRA XR (TAB ER 24H) $0 (Tier 2) MO levetiracetam (100 mg/ml solution, 1000 mg tablet, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet, 500 mg/5ml solution, 750 mg tab er 24h, 750 mg tablet) levetiracetam 500 mg/5ml vial $0 (Tier 1) (g) levetiracetam in sodium chloride, iso-osmotic (piggyback) POTIGA (TABLET) $0 (Tier 2) MO ROWEEPRA (TABLET) $0 (Tier 2) MO SPRITAM (TAB SUSP) $0 (Tier 2) MO Calcium Channel Modifying Agents CELONTIN (CAPSULE) $0 (Tier 2) MO ethosuximide (250 mg capsule, 250 mg/5ml solution) ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) $0 (Tier 2) MO ZONEGRAN (CAPSULE) $0 (Tier 2) MO zonisamide (100 mg capsule, 25 mg capsule, 50 mg capsule) Gamma-Aminobutyric Acid (Gaba) Augmenting Agents DEPACON (VIAL) $0 (Tier 2) DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) $0 (Tier 2) MO DEPAKOTE (TABLET DR) $0 (Tier 2) MO 13

25 Anticonvulsants DEPAKOTE ER (TAB ER 24H) $0 (Tier 2) MO DEPAKOTE SPRINKLE (CAP SPRINK) $0 (Tier 2) MO DIASTAT (KIT) $0 (Tier 2) DIASTAT ACUDIAL (KIT) $0 (Tier 2) diazepam ( kit, 2.5 mg kit, mg kit) $0 (Tier 1) PA, NDS, (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 tablet) GABITRIL (TABLET) $0 (Tier 2) MO MYSOLINE 250 MG TABLET $0 (Tier 2) MO MYSOLINE 50 MG TABLET $0 (Tier 1) MO NEURONTIN (100 MG CAPSULE, 250 MG/5 ML SOLN, 300 MG CAPSULE, 400 MG CAPSULE, 600 MG TABLET, 800 MG TABLET) ONFI (10 MG TABLET, 2.5 MG/ML SUSPENSION, 20 MG TABLET) phenobarbital (100 mg tablet, 15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet) $0 (Tier 2) MO $0 (Tier 2) MO primidone (250 mg tablet, 50 mg tablet) SABRIL (500 MG POWDER PACKET, 500 MG TABLET) $0 (Tier 2) PA, LA, NDS tiagabine hcl (tablet) valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution, 500mg/10ml solution) valproic acid (as sodium salt) 500 mg/5ml vial valproic acid 250 mg capsule Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 ML SUSP) $0 (Tier 2) MO 14

26 Anticonvulsants LAMICTAL (100 MG TABLET, 150 MG TABLET, 200 MG TABLET, 25 MG DISPER TABLET, 25 MG TABLET, 5 MG DISPER TABLET) $0 (Tier 2) MO LAMICTAL ODT (TAB RAPDIS) $0 (Tier 2) MO LAMICTAL XR (250 MG TABLET, 300 MG TABLET) $0 (Tier 2) MO lamotrigine (100 mg tab er 24, 100 mg tab rapdis, 100 mg tablet, 150 mg tablet, 200 mg tab er 24, 200 mg tab rapdis, 200 mg tablet, 25 mg tab er 24, 25 mg tab rapdis, 25 mg tablet, 25 mg tb chw dsp, 250 mg tab er 24, 300 mg tab er 24, 5 mg tb chw dsp, 50 mg tab er 24, 50 mg tab rapdis) topiramate (100 mg tablet, 15 mg cap sprink, 200 mg tablet, 25 mg cap sprink, 25 mg tablet, 50 mg tablet) Sodium Channel Agents APTIOM (TABLET) $0 (Tier 2) MO BANZEL (200 MG TABLET, 40 MG/ML SUSPENSION, 400 MG TABLET) carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 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) $0 (Tier 2) MO CEREBYX 500 MG PE/10 ML VIAL $0 (Tier 2) NDS DILANTIN 30 MG CAPSULE $0 (Tier 2) MO EPITOL (TABLET) $0 (Tier 1) MO fosphenytoin sodium 100mg pe/2 vial oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) PEGANONE (TABLET) $0 (Tier 2) MO phenytoin (100 mg/4ml oral susp, 125 mg/5ml oral susp, 50 mg tab chew) phenytoin sodium (50 mg/ml ampul, 50 mg/ml vial) $0 (Tier 1) (g) phenytoin sodium extended (capsule) TEGRETOL XR 100 MG TABLET $0 (Tier 2) MO VIMPAT (100 MG TABLET, 150 MG TABLET, 200 MG TABLET, 50 MG TABLET) $0 (Tier 2) QL (60 PER 30 DAYS), MO 15

27 Anticonvulsants VIMPAT 10 MG/ML SOLUTION $0 (Tier 2) MO VIMPAT 200 MG/20 ML VIAL $0 (Tier 2) NDS Antidementia Agents Antidementia Agents, Other ergoloid mesylates 1 mg tablet Cholinesterase Inhibitors donepezil hcl (10 mg tab rapdis, 10 mg tablet, 23 mg tablet, 5 mg tab rapdis, 5 mg tablet) 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, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet) $0 (Tier 2) MO rivastigmine (patch td24) rivastigmine tartrate (capsule) $0 (Tier 1) QL (60 PER 30 DAYS), MO, (g) N-Methyl-D-Aspartate (Nmda) Receptor Antagonist memantine hcl (10 mg tablet, 2 mg/ml solution, 5 mg tablet) memantine hcl 5 mg-10 mg tab ds pk NAMENDA (10 MG TABLET, 2 MG/ML SOLUTION, 5 MG TABLET) $0 (Tier 2) MO NAMENDA 5-10 MG TITRATION PK $0 (Tier 2) NDS 16

28 Antidepressants Antidepressants, Other amitriptyline hcl/chlordiazepoxide (tablet) APLENZIN (TAB ER 24H) $0 (Tier 2) MO bupropion hcl (100 mg tablet, 100 mg tablet er, 150 mg tab er 24h, 200 mg tablet er, 300 mg tab er 24h, 75 mg tablet) bupropion hcl 150 mg tablet er $0 (Tier 1) MO, NDS, (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 tablet) olanzapine/fluoxetine hcl (12mg-25mg capsule, 12mg-50mg capsule, 3 mg-25 mg capsule, 6mg- 50mg capsule) $0 (Tier 1) QL (30 PER 30 DAYS), MO, (g) perphenazine/amitriptyline hcl (tablet) Monoamine Oxidase Inhibitors EMSAM (PATCH TD24) $0 (Tier 2) MO MARPLAN (TABLET) $0 (Tier 2) MO phenelzine sulfate 15 mg tablet tranylcypromine sulfate (tablet) Ssris/Snris (Selective Serotonin Reuptake Inhibitors/Serotonin And Norepinephrine Reuptake Inhibitor BRINTELLIX (TABLET) $0 (Tier 2) MO citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mg tablet) escitalopram oxalate (10 mg tablet, 20 mg tablet, 5 mg tablet) $0 (Tier 1) QL (30 PER 30 DAYS), MO, (g) escitalopram oxalate 5 mg/5 ml solution FETZIMA (ER 120 MG CAPSULE, ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE) $0 (Tier 2) MO FETZIMA MG TITRATION PAK $0 (Tier 2) NDS 17

29 Antidepressants fluoxetine hcl (10 mg capsule, 10 mg tablet, 20 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 40 mg capsule, 60 mg tablet, 90 mg capsule dr) fluvoxamine maleate (100 mg cap er 24h, 100 mg tablet, 150 mg cap er 24h, 25 mg tablet, 50 mg tablet) KHEDEZLA (TAB ER 24) $0 (Tier 2) MO maprotiline hcl (tablet) nefazodone hcl (tablet) paroxetine hcl (10 mg tablet, 12.5 mg tab er 24h, 20 mg tablet, 25 mg tab er 24h, 30 mg tablet, 37.5 mg tab er 24h, 40 mg tablet) PAXIL 10 MG/5 ML SUSPENSION $0 (Tier 2) MO PEXEVA (TABLET) $0 (Tier 2) MO PRISTIQ ER (TAB ER 24H) $0 (Tier 2) sertraline hcl (100 mg tablet, 20 mg/ml oral conc, 25 mg tablet, 50 mg tablet) trazodone hcl (100 mg tablet, 150 mg tablet, 300 mg tablet, 50 mg tablet) TRINTELLIX (TABLET) $0 (Tier 2) venlafaxine hcl (100 mg tablet, 150 mg cap er 24h, 25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 24h, 75 mg tablet) VIIBRYD (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) $0 (Tier 2) MO VIIBRYD MG STARTER PACK $0 (Tier 2) NDS Tricyclics amitriptyline hcl (10 mg tablet, 100 mg tablet, 150 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet) amoxapine (tablet) 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 tablet) 18

30 Antidepressants doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 100 mg capsule, 150 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) imipramine pamoate (capsule) nortriptyline hcl (10 mg capsule, 10 mg/5 ml solution, 25 mg capsule, 50 mg capsule, 75 mg capsule) protriptyline hcl (tablet) SURMONTIL (CAPSULE) $0 (Tier 2) MO trimipramine maleate (capsule) Antiemetics Antiemetics, Other COMPRO (SUPP.RECT) $0 (Tier 1) NDS meclizine hcl (12.5 mg tablet, 25 mg tablet) metoclopramide hcl (10 mg tablet, 10 mg/10ml solution, 5 mg tablet, 5 mg/5 ml solution) perphenazine (16 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet) PHENADOZ 12.5 MG SUPPOSITORY $0 (Tier 1) NDS PHENERGAN (12.5 MG SUPPOSITORY, 25 MG SUPPOSITORY, 50 MG SUPPOSITORY) $0 (Tier 1) NDS prochlorperazine (supp.rect) prochlorperazine edisylate (10 mg/2 ml vial, 5 mg/ml vial) prochlorperazine maleate (10 mg tablet, 5 mg tablet) promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect) $0 (Tier 1) PA, NDS, (g) 19

31 Antiemetics promethazine hcl 50 mg supp.rect PROMETHEGAN (25 MG SUPPOSITORY, 50 MG SUPPOSITORY) $0 (Tier 1) NDS TRANSDERM-SCOP (PATCH TD 3) $0 (Tier 2) NDS Emetogenic Therapy Adjuncts ANZEMET (100 MG TABLET, 50 MG TABLET) $0 (Tier 2) BD, QL (3 PER 21 DAYS), NDS ANZEMET 20 MG/ML VIAL $0 (Tier 2) BD, NDS dronabinol (capsule) $0 (Tier 1) BD, NDS, (g) EMEND (125 MG CAPSULE, 40 MG CAPSULE, 80 MG CAPSULE) $0 (Tier 2) BD, QL (6 PER 30 DAYS), NDS granisetron hcl (1 mg tablet, 1 mg/ml(1) vial) $0 (Tier 1) BD, NDS, (g) granisetron hcl 1 mg/ml vial granisetron hcl/pf (vial) $0 (Tier 1) BD, NDS, (g) ondansetron (tab rapdis) $0 (Tier 1) BD, NDS, (g) ondansetron hcl (24 mg tablet, 4 mg tablet, 4 mg/5 ml solution, 8 mg tablet) $0 (Tier 1) BD, NDS, (g) ondansetron hcl/pf (4 mg/2 ml ampul, 4 mg/2 ml vial) $0 (Tier 1) BD, NDS, (g) ondansetron hcl/pf 4 mg/2 ml syringe Antifungals Antifungals ABELCET (VIAL) $0 (Tier 2) NDS AMBISOME (VIAL) $0 (Tier 2) NDS amphotericin b 50 mg vial $0 (Tier 1) BD, NDS, (g) CANCIDAS (VIAL) $0 (Tier 2) NDS 20

32 Antifungals ciclopirox (0.77 % gel (gram), 1 % shampoo, 8 % solution) ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) clotrimazole (1 % cream (g), 1 % solution, 10 mg troche) econazole nitrate 1 % cream (g) ERAXIS (WATER DILUENT) (VIAL) $0 (Tier 2) NDS EXELDERM (CREAM, SOLUTION) $0 (Tier 2) NDS fluconazole (10 mg/ml susp recon, 100 mg tablet, 150 mg tablet, 200 mg tablet, 40 mg/ml susp recon, 50 mg tablet) fluconazole in sodium chloride, iso-osmotic (pggybk btl, piggyback) flucytosine (250 mg capsule, 500 mg capsule) griseofulvin ultramicrosize (tablet) griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) itraconazole 100 mg capsule KERYDIN (SOL W/APPL) $0 (Tier 2) NDS ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo, 200 mg tablet) MENTAX (CREAM (G)) $0 (Tier 2) NDS miconazole nitrate 200 mg supp.vag MYCAMINE (VIAL) $0 (Tier 2) NDS naftifine hcl 1 % cream (g) NAFTIN (1% GEL, 2% CREAM, 2% GEL) $0 (Tier 2) NDS NATACYN (DROPS SUSP) $0 (Tier 2) NDS NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) $0 (Tier 2) NDS NYAMYC (POWDER) $0 (Tier 1) NDS 21

33 Antifungals 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)) nystatin/triamcinolone acetonide (cream (g), oint. (g)) NYSTOP (POWDER) $0 (Tier 1) NDS OXISTAT (CREAM, LOTION) $0 (Tier 2) NDS terbinafine hcl 250 mg tablet terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) voriconazole (200 mg tablet, 200 mg vial, 200 mg/5ml susp recon, 50 mg tablet) Antigout Agents Antigout Agents allopurinol (100 mg tablet, 300 mg tablet) ALOPRIM (VIAL) $0 (Tier 1) NDS colchicine 0.6 mg tablet colchicine/probenecid (tablet) probenecid (tablet) ULORIC (TABLET) $0 (Tier 2) MO Antimigraine Agents Ergot Alkaloids dihydroergotamine mesylate (0.5mg/spry spray/pump, 1 mg/ml ampul, 1 mg/ml vial) 22

34 Antimigraine Agents ERGOMAR (TAB SUBL) $0 (Tier 2) NDS MIGERGOT (SUPP.RECT) $0 (Tier 1) NDS Serotonin (5-Ht) 1B/1D Receptor Agonists naratriptan hcl (tablet) $0 (Tier 1) QL (18 PER 30 DAYS), NDS, (g) rizatriptan benzoate (10 mg tab rapdis, 10 mg tablet) $0 (Tier 1) QL (18 PER 30 DAYS), NDS, (g) rizatriptan benzoate 5 mg tablet $0 (Tier 1) QL (180 PER 30 DAYS), NDS, (g) sumatriptan (20 mg spray, 5 mg spray) $0 (Tier 1) QL (12 PER 30 DAYS), NDS, (g) sumatriptan succinate (100 mg tablet, 25 mg tablet, 50 mg tablet) sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen injctr, 6 mg/0.5ml cartridge, 6 mg/0.5ml pen injctr) $0 (Tier 1) QL (18 PER 30 DAYS), NDS, (g) $0 (Tier 1) QL (9 ML PER 30 DAYS), NDS, (g) Antimyasthenic Agents Parasympathomimetics guanidine hcl (tablet) MESTINON (180 MG TIMESPAN, 60 MG/5 ML SYRUP) $0 (Tier 2) MO pyridostigmine bromide (180 mg tablet er, 60 mg tablet) 23

35 Antimycobacterials Antimycobacterials, Other dapsone (100 mg tablet, 25 mg tablet) rifabutin (capsule) Antituberculars CAPASTAT SULFATE (VIAL) $0 (Tier 2) NDS ethambutol hcl (tablet) isoniazid (100 mg tablet, 100 mg/ml vial, 300 mg tablet, 50 mg/5 ml solution) PASER (GRANPKT DR) $0 (Tier 2) NDS PRIFTIN (TABLET) $0 (Tier 2) NDS pyrazinamide 500 mg tablet rifampin (150 mg capsule, 300 mg capsule, 600 mg vial) RIFATER (TABLET) $0 (Tier 2) NDS SIRTURO (TABLET) $0 (Tier 2) PA, NDS TRECATOR (TABLET) $0 (Tier 2) NDS Antineoplastics Alkylating Agents BICNU (VIAL) $0 (Tier 2) PA, NDS BUSULFEX (VIAL) $0 (Tier 2) PA, NDS cyclophosphamide (25 mg capsule, 50 mg capsule) $0 (Tier 1) PA, NDS, (g) GLEOSTINE (CAPSULE) $0 (Tier 2) NDS HEXALEN (CAPSULE) $0 (Tier 2) PA, NDS ifosfamide (1 g vial, 1 g/20 ml vial, 3 g vial, 3g/60ml vial) $0 (Tier 1) PA, NDS, (g) 24

36 Antineoplastics LEUKERAN (TABLET) $0 (Tier 2) NDS MATULANE (CAPSULE) $0 (Tier 2) PA, LA, NDS melphalan hcl (vial) $0 (Tier 1) PA, NDS, (g) MUSTARGEN (VIAL) $0 (Tier 2) PA, NDS TREANDA (100 MG VIAL, 25 MG VIAL) $0 (Tier 2) PA, NDS VALCHLOR (GEL (GRAM)) $0 (Tier 2) MO Antiandrogens bicalutamide (tablet) flutamide (capsule) NILANDRON (TABLET) $0 (Tier 2) MO XTANDI (CAPSULE) $0 (Tier 2) PA, LA, QL (120 PER 30 DAYS), MO ZYTIGA (TABLET) $0 (Tier 2) PA, LA, QL (120 PER 30 DAYS), MO Antiangiogenic Agents POMALYST (CAPSULE) $0 (Tier 2) PA, LA, MO REVLIMID (10 MG CAPSULE, 15 MG CAPSULE, 2.5 MG CAPSULE, 25 MG CAPSULE, 5 MG CAPSULE) $0 (Tier 2) PA, LA, MO REVLIMID 20 MG CAPSULE $0 (Tier 2) MO THALOMID (CAPSULE) $0 (Tier 2) PA, MO Antiestrogens/Modifiers EMCYT (CAPSULE) $0 (Tier 2) PA, NDS FARESTON (TABLET) $0 (Tier 2) PA, MO FASLODEX (SYRINGE) $0 (Tier 2) PA, MO SOLTAMOX (SOLUTION) $0 (Tier 2) PA, MO tamoxifen citrate (10 mg tablet, 20 mg tablet) Antimetabolites ADRUCIL (VIAL) $0 (Tier 1) BD, NDS ALIMTA 500 MG VIAL $0 (Tier 2) PA, NDS 25

37 Antineoplastics cladribine (vial) $0 (Tier 1) PA, NDS, (g) CLOLAR (VIAL) $0 (Tier 2) PA, NDS cytarabine (vial) $0 (Tier 1) PA, NDS, (g) cytarabine/pf (100 mg/5ml vial, 20 mg/ml vial) $0 (Tier 1) PA, NDS, (g) DROXIA (CAPSULE) $0 (Tier 2) MO ELITEK 1.5 MG VIAL $0 (Tier 2) BD, NDS fluorouracil (1 g/20 ml vial, 2.5 g/50ml vial, 5 g/100 ml vial, 500mg/10ml vial) $0 (Tier 1) BD, NDS, (g) fluorouracil (2 % solution, 5 % cream (g), 5 % solution) FOLOTYN (VIAL) $0 (Tier 2) PA, NDS gemcitabine hcl 1 g vial $0 (Tier 1) PA, NDS, (g) hydroxyurea 500 mg capsule LONSURF (TABLET) $0 (Tier 2) NDS mercaptopurine 50 mg tablet NIPENT (VIAL) $0 (Tier 2) PURIXAN (ORAL SUSP) $0 (Tier 2) NDS TABLOID (TABLET) $0 (Tier 2) PA, NDS Antineoplastics, Other ABRAXANE (VIAL) $0 (Tier 2) PA, NDS amifostine crystalline (vial) ARRANON (VIAL) $0 (Tier 2) azacitidine (vial) $0 (Tier 1) PA, NDS, (g) BELEODAQ (VIAL) $0 (Tier 2) MO bleomycin sulfate 30 unit vial $0 (Tier 1) PA, NDS, (g) carboplatin (10 mg/ml vial, 150 mg vial) $0 (Tier 1) PA, NDS, (g) cisplatin (vial) $0 (Tier 1) PA, NDS, (g) COSMEGEN (VIAL) $0 (Tier 2) CYRAMZA (VIAL) $0 (Tier 2) MO 26

38 Antineoplastics dacarbazine 200 mg vial $0 (Tier 1) PA, NDS, (g) daunorubicin hcl (20 mg vial, 5 mg/ml vial) $0 (Tier 1) (g) decitabine (vial) $0 (Tier 1) PA, NDS, (g) dexrazoxane hcl 250 mg vial $0 (Tier 1) PA, NDS, (g) DOCEFREZ 20 MG VIAL $0 (Tier 2) PA, NDS docetaxel (vial) $0 (Tier 1) PA, NDS, (g) DOXIL (VIAL) $0 (Tier 2) doxorubicin hcl (10 mg vial, 10 mg/5 ml vial, 2 mg/ml vial, 20 mg/10ml vial, 50 mg vial, 50 mg/25ml vial) $0 (Tier 1) PA, NDS, (g) doxorubicin hcl pegylated liposomal (vial) $0 (Tier 1) (g) ELLENCE (VIAL) $0 (Tier 2) ERWINAZE (VIAL) $0 (Tier 2) PA, NDS FARYDAK (CAPSULE) $0 (Tier 2) PA, NDS fludarabine phosphate (50 mg vial, 50 mg/2 ml vial) $0 (Tier 1) PA, NDS, (g) FUSILEV (VIAL) $0 (Tier 2) NDS HALAVEN (VIAL) $0 (Tier 2) PA, NDS idarubicin hcl (vial) $0 (Tier 1) PA, NDS, (g) irinotecan hcl 100 mg/5ml vial $0 (Tier 1) PA, NDS, (g) ISTODAX (VIAL) $0 (Tier 2) PA, NDS JEVTANA (VIAL) $0 (Tier 2) PA, NDS leucovorin calcium (10 mg tablet, 15 mg tablet, 25 mg tablet, 5 mg tablet) leucovorin calcium (10 mg/ml vial, 100 mg vial, 200 mg vial, 350 mg vial, 50 mg vial, 500 mg vial, 500mg/50ml vial) $0 (Tier 1) BD, NDS, (g) levoleucovorin calcium 10 mg/ml vial LYNPARZA (CAPSULE) $0 (Tier 2) MO, NDS LYSODREN (TABLET) $0 (Tier 2) MO, NDS mesna (vial) MESNEX 400 MG TABLET $0 (Tier 2) NDS 27