List of Covered Drugs

Transcription

1 2013 MEDICARE ADVANTAGE List of Covered s (Formulary) Senior Blue H Forever Blue Medicare PPO If you have any questions, we re here to help! (TTY ) October 1-February 14 8 a.m. to 8 p.m., 7 days a week February 15-September 30 8 a.m. to 8 p.m., Monday-Friday During non-business hours, your call will be answered by our automated phone system. A representative will return your call the next business day. A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association. BlueCross BlueShield of Western New York is a health plan with a Medicare contract. 3500

2 BlueCross BlueShield of Western New York 2013 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Senior Blue H Forever Blue PPO 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. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, BlueCross BlueShield of Western New York is a Health plan with a Medicare contract. If you would like to receive this material in an alternate format or language, please call customer service at (TTY ). We re available: October 1-February 14 February 15-September 30 8 a.m. to 8 p.m., 7 days a week 8 a.m. to 8 p.m., Monday-Friday During non-business hours, your call will be answered by our automated phone system. A representative will return your call on the next business day. HPMS Approved Formulary File Submission ID , Version Number 7 Y0086_ PTD230 CMS Accepted I

3 What is the BlueCross BlueShield of Western New York Formulary? A formulary is a list of covered drugs selected by BlueCross BlueShield of Western New York 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. BlueCross BlueShield of Western New York will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BlueCross BlueShield of Western New York 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 change? Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 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 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 August 15, To get updated information about the drugs covered by BlueCross BlueShield of Western New York, please visit our website at or call customer service at (TTY ). If you are not yet a BlueCross BlueShield of Western New York member, please call (TTY ). We re available: October 1-February 14 February 15-September 30 8 a.m. to 8 p.m., 7 days a week 8 a.m. to 8 p.m., Monday-Friday During non-business hours, your call will be answered by our automated phone system. A representative will return your call the next business day. II

4 BlueCross BlueShield of Western New York inserts formulary update sheets into printed formularies to reflect any mid-year non-maintenance formulary changes. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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, Hypertension, and Lipids. If you know what your drug is used for, look for the category name in the list that begins on page 1. 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 39. 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? BlueCross BlueShield of Western New York 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: BlueCross BlueShield of Western New York requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from BlueCross BlueShield of Western New York before you fill your prescriptions. If you don t get approval, BlueCross BlueShield of Western New York may not cover the drug. Quantity Limits: For certain drugs, BlueCross BlueShield of Western New York limits the amount of the drug that BlueCross BlueShield of Western New York will cover. For example, BlueCross BlueShield of Western New York provides 30 tablets per prescription for Crestor. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, BlueCross BlueShield of Western New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, BlueCross BlueShield of Western New York may not cover B unless you try A first. If A does not work for you, BlueCross BlueShield of Western New York will then cover B. III

5 You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website at You can ask BlueCross BlueShield of Western New York to make an exception to these restrictions or limits. See the section, How do I request an exception to the BlueCross BlueShield of Western New York formulary? on page IV 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, you should first contact Member Services and confirm that your drug is not covered. If you learn that BlueCross BlueShield of Western New York does not cover your drug, you have two options: You can ask customer service for a list of similar drugs that are covered by BlueCross BlueShield of Western New York. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BlueCross BlueShield of Western New York. You can ask BlueCross BlueShield of Western New York 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 BlueCross BlueShield of Western New York Formulary? You can ask BlueCross BlueShield of Western New York to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on our formulary. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, BlueCross BlueShield of Western New York limit 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 more. You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred/highest tier subject to the tiering exceptions process tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred/lowest tier subject to the tiering exceptions process tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the 5th tier. Generally, BlueCross BlueShield of Western New York will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower-tiered drug 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, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s or prescribing physician 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 72 hours for a decision. If your request to IV

6 expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber s or prescribing physician s supporting statement. 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 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 the 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 emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Retail or Mail Pharmacy: For enrollees who obtain their drugs in a retail setting, home infusion setting, I/T/U, safety-net pharmacies, or at mail, a one-time, temporary day supply of at least 30 days (unless the prescription is written for less than 30 days in which case the enrollee will be allowed multiple fills to provide up to a total of 30 days of medication)is provided anytime during the first 90 days of enrollment. The transition period begins on the enrollee s effective date of coverage into the plan. Long-term Care Setting: For enrollees who obtain their drugs in a LTC setting, multiple fills of a temporary supply is provided during the 90 day Transition Period. The window for refills is defined by taking the allowed day supply and multiplying by 3. So, if the allowed day supply is 31, the refill window is a 93 day supply. The transition period begins on the enrollee s effective date of coverage into the plan. CMS indicates that in an LTC setting the day supply allowed for transition should be a 31 day supply (unless the prescription is written for a shorter duration). Transition supplies in LTC settings are able to be provided at the point of sale. Emergency Transition Supply is granted to LTC enrollees whose dates of service are outside of the 90- day transition period. BlueCross BlueShield of Western New York covers a onetime emergency Transition Supply of non- formulary Part D drugs (or drugs that have a step therapy edit or require a prior authorization) for 31 (or the defined amount for a one month supply by the plan in their bid) during this exception process (unless the enrollee presents with a prescription for less than 31 (or the defined amount for a one month supply by the plan in their bid), while an exception or prior authorization is requested. The decision pursuant to an exception request will not affect this emergency supply already in place. Emergency Supplies for Members Entering a LTC facility BlueCross BlueShield of Western New York also covers an emergency Transition Supply of 31 (or the defined amount for a one month V

7 supply by the plan in their bid) for current enrollees who are entering a LTC facility from other healthcare settings. BlueCross BlueShield of Western New York will not utilize early refill edits to limit appropriate access to the member s Part D benefit, and will allow access to refill upon admission or discharge. BlueCross BlueShield of Western New York will not require residents of long-term care facilities to request an exception or coverage determination in order to receive an emergency supply or first fill of a nonformulary drug (or drugs that have a step therapy edit or require a prior authorization) when the member is outside of the initial transition period.ltc pharmacies are permitted to use Emergency Boxes (E Box) when necessary. However the E Box should be replenished from the patient s monthly Rx claim. During the Transition Period, BlueCross BlueShield of Western New York assures a transition supply is provided. The enrollee is notified so that he or she can begin the exception process. Transition Population BlueCross BlueShield of Western New York s Transition Process applies to the following types of enrollees: New enrollees enrolled in an Express Scripts administered prescription drug plan following the Annual Election Period (AEP); Newly eligible Medicare beneficiaries. Individuals who change plans. Current enrollees affected by formulary change (including Part D drugs that are on the formulary but require prior authorization or step therapy) for an upcoming contract year if applicable. Existing LTC Residents who are outside their transition window but change therapy to a non formulary drug or a drug that has a step therapy edit or requires a prior authorization. This is known as an Emergency Supply. Level of Care Changes BlueCross BlueShield of Western New York covers a Transition Supply for enrollees who have a level of care change which is defined as when enrollees: Enter LTC facilities from hospitals or other settings; Leave LTC facilities and return to the community; Are discharged from a hospital to a home; End a skilled nursing facility (SNF) stay covered under Medicare Part A (where all pharmacy charges are covered), and must revert to coverage under their Part D plan formulary; Revert from hospice status to standard Medicare Part A and B benefits; and Are discharged from psychiatric hospitals with medication regimens that are highly individualized. While Part A does provide reimbursement for a limited supply to facilitate beneficiary discharge, beneficiaries must be permitted to have a full outpatient supply available to continue therapy once this limited supply is exhausted. Level of Care supplies will be available for prescriptions, when appropriate, that are received at a retail settings. VI

8 For more information For more detailed information about your BlueCross BlueShield of Western New York prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about BlueCross BlueShield of Western New York please call customer service at (TTY ). If you are not yet a BlueCross BlueShield of Western New York member, please call (TTY ). We re available: October 1-February 14 February 15-September 30 8 a.m. to 8 p.m., 7 days a week 8 a.m. to 8 p.m., Monday-Friday During non-business hours, your call will be answered by our automated phone system. A representative will return your call the next business day. Or visit If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY/TDD users should call Or, visit BlueCross BlueShield of Western New York Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by BlueCross BlueShield of Western New York. If you have trouble finding your drug in the list, turn to the Index that begins on page 39. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Requirements/Limits column tells you if BlueCross BlueShield of Western New York has any special requirements for coverage of your drug. Below is a list of abbreviations that may appear on the following pages in the Notes column that tells you if there are any special requirements for coverage of your drug. VII

9 List of Abbreviations B/D: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. If it is determined that coverage for this drug falls under Medicare Part B, your cost will not be the tier co-pay in this drug list. Please refer to Chapter 4 of your evidence of coverage for the cost of Part B drugs or contact customer service. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call customer service. : Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. VIII

10 Commonly Prescribed Therapeutic Categories ANTI - INFECTIVES ANTIFUNGAL AGENTS amphotericin b 2 B/D PA clotrimazole troc 2 ERAXIS INJ 100MG 3 fluconazole in dextrose inj 2 56mg/ml; 400mg/200ml fluconazole susr 1 fluconazole tabs 1 flucytosine 2 GRIS-PEG 4 griseofulvin microsize 2 itraconazole 2 ketoconazole 2 NOXAFIL 3 nystatin susp 1 nystatin tabs 1 SPORANOX ORAL SOLN 3 terbinafine tabs 1 VFEND IV 3 VFEND SUSR 3 voriconazole tabs 2 ANTIVIRALS acyclovir caps 1 acyclovir inj 500mg 1 acyclovir susp 1 acyclovir tabs 1 amantadine 2 APTIVUS CAPS 5 QL(360 per APTIVUS ORAL SOLN 5 QL(950 per ATRIPLA 5 QL(90 per BARACLUDE ORAL SOLN 3 QL(1890 per BARACLUDE TABS 3 QL(90 per COMPLERA 5 QL(90 per CRIXIVAN 3 didanosine 2 QL(90 per EDURANT 5 QL(90 per EMTRIVA CAPS 3 QL(90 per EMTRIVA ORAL SOLN 3 QL(2210 per EPIVIR HBV 3 EPIVIR ORAL SOLN 3 QL(2880 per EPZICOM 5 QL(90 per famciclovir 2 foscarnet sodium 2 B/D PA FUZEON 5 QL(180 per ganciclovir caps 2 HEPSERA 5 QL(90 per INCIVEK 5 PA QL(504 per 84 days) INTELENCE TABS 200MG 5 QL(180 per INTELENCE TABS 100MG 5 QL(360 per INVIRASE CAPS 4 QL(900 per 2

11 INVIRASE TABS 5 QL(360 per ISENTRESS 5 QL(360 per KALETRA ORAL SOLN 5 QL(1280 per KALETRA TABS 200MG; 50MG 5 QL(360 per KALETRA TABS 100MG; 25MG 3 QL(900 per lamivudine tabs 300mg 2 QL(90 per lamivudine tabs 150mg 2 QL(180 per lamivudine/zidovudine 2 QL(180 per LEXIVA SUSP 3 QL(5175 per LEXIVA TABS 5 QL(360 per nevirapine tabs 2 QL(180 per NORVIR CAPS 3 QL(1080 per NORVIR ORAL SOLN 3 QL(1440 per NORVIR TABS 3 QL(1080 per PREZISTA TABS 150MG 3 QL(540 per PREZISTA TABS 75MG 3 QL(900 per PREZISTA TABS 400MG, 600MG Tier Notes 5 QL(180 per REBETOL ORAL SOLN 3 PA RELENZA DISKHALER 3 QL(300 per 365 days) RESCRIPTOR TABS 200MG 4 QL(540 per RESCRIPTOR TABS 100MG 4 QL(1080 per RETROVIR IV INFUSION 3 REYATAZ CAPS 300MG 3 QL(90 per REYATAZ CAPS 150MG, 200MG 3 QL(180 per REYATAZ CAPS 100MG 3 QL(360 per ribapak tabs 5 PA ribasphere caps 2 PA ribasphere tabs 400mg 2 PA ribasphere tabs 200mg 2 PA ribasphere tabs 600mg 5 PA ribavirin 2 PA rimantadine hcl 2 SELZENTRY TABS 150MG 5 QL(180 per SELZENTRY TABS 300MG 5 QL(360 per stavudine caps 2 QL(180 per SUSTIVA CAPS 200MG 3 QL(360 per SUSTIVA CAPS 50MG 3 QL(630 per 3

12 SUSTIVA TABS 3 QL(90 per TAMIFLU CAPS 45MG, 75MG 3 QL(60 per 365 days) TAMIFLU CAPS 30MG 3 QL(120 per 365 days) TAMIFLU SUSR 3 QL(720 per 365 days) TRIZIVIR 5 QL(180 per TRUVADA 5 QL(90 per TYZEKA 5 valacyclovir hcl tabs 1000mg 2 QL(100 per valacyclovir hcl tabs 500mg 2 QL(200 per VALCYTE ORAL SOLN 5 VALCYTE TABS 5 VICTRELIS 5 PA QL(1008 per 84 days) VIDEX PEDIATRIC ORAL SOLN 2GM 3 QL(3600 per VIRACEPT TABS 625MG 5 QL(360 per VIRACEPT TABS 250MG 5 QL(900 per VIRAMUNE SUSP 3 QL(3600 per VIREAD POWD 3 QL(720 per VIREAD TABS 3 QL(90 per ZERIT ORAL SOLN 4 QL(7200 per ZIAGEN ORAL SOLN 3 QL(2880 per ZIAGEN TABS 3 QL(180 per zidovudine caps 2 QL(540 per zidovudine syrp 2 QL(5520 per zidovudine tabs 2 QL(180 per CEPHALOSPORINS cefaclor 2 cefadroxil 2 cefazolin inj 10gm, 1gm; 5%, 2 500mg cefazolin inj 1gm 2 cefdinir 2 cefepime inj 2gm 2 cefepime inj 1gm 2 cefotaxime sodium inj 10gm, 1gm 2 cefotaxime sodium inj 2gm 2 cefoxitin sodium inj 10gm, 2gm 2 cefoxitin sodium inj 1gm 2 cefpodoxime proxetil 2 ceftazidime inj 1gm, 6gm 2 ceftazidime inj 2gm 2 ceftriaxone sodium inj 10gm 2 ceftriaxone sodium inj 1gm, 2 250mg, 2gm, 500mg cefuroxime axetil tabs 2 cefuroxime sodium inj 7.5gm 2 cefuroxime sodium inj 1.5gm, 2 750mg cephalexin 1 4

13 FORTAZ INJ 1GM/50ML; 5%, 3 2GM/50ML; 5%, 6GM SUPRAX SUSR 4 SUPRAX TABS 4 TEFLARO 3 ZINACEF IN ISO-OSTIC 3 DEXTROSE ZINACEF IN ISO-OSTIC DILUENT 3 ERYTHROMYCINS / OTHER MACROLIDES azithromycin inj 500mg 2 azithromycin susr 2 azithromycin tabs 2 clarithromycin 2 clarithromycin er 2 DIFICID 3 QL(60 per e.e.s E.E.S. GRANULES 3 ERY-TAB TBEC 500MG 3 ery-tab tbec 250mg, 333mg 2 ERYTHROCIN 3 LACTOBIONATE INJ 500MG erythrocin stearate 1 ERYTHROMYCIN BASE 3 erythromycin ethylsuccinate 2 ZMAX 3 MISCELLANEOUS ANTIINFECTIVES ALBENZA 3 ALINIA 3 amikacin sulfate inj 500mg/2ml, 2 50mg/ml atovaquone/proguanil hcl tabs 2 250mg; 100mg AZACTAM IN ISO-OSTIC 3 DEXTROSE AZACTAM INJ 2GM 3 aztreonam inj 1gm 2 BILTRICIDE 3 CAPASTAT SULFATE 4 CAYSTON 5 LA chloroquine 2 CLEOCIN GALAXY 3 CLEOCIN IN D5W 3 clindamycin hcl caps 150mg, 2 300mg clindamycin phosphate addvantage 2 COARTEM 3 colistimethate sodium 2 CUBICIN 3 B/D PA DAPSONE 3 DARAPRIM 3 ethambutol tabs 400mg 2 ethambutol tabs 100mg 2 gentamicin sulfate inj 10mg/ml 2 gentamicin sulfate inj 40mg/ml 2 gentamicin sulfate/0.9% sodium 2 chloride gentamicin sulfate/sodium 2 chloride inj 1.2mg/ml; 0.9% hydroxychloroquine 2 imipenem/cilastatin 2 ISONIAZID SYRP 3 isoniazid tabs 1 isotonic gentamicin inj 0.8mg/ml; 2 0.9% KETEK 3 QL(20 per 30 days) mefloquine hcl 2 MEPRON 5 meropenem inj 500mg 2 metronidazole 1 metronidazole in nacl 0.79% 2 MYCOBUTIN 3 NEBUPENT 3 B/D PA neomycin sulfate 2 paromomycin 2 PASER 3 PRIMAQUINE 3 QUALAQUIN 3 rifampin 2 SEROMYCIN 3 STREPTOMYCIN SULFATE 3 STROMECTOL 3 5

14 TOBI 5 B/D PA tobramycin inj 10mg/ml, 1 80mg/2ml TOBRAMYCIN SULFATE / 3 SODIUM CHLORIDE TRECATOR 3 TYGACIL 3 XIFAXAN TABS 200MG 3 QL(9 per 30 days) XIFAXAN TABS 550MG 3 QL(180 per ZYVOX INJ 3 ZYVOX SUSR 3 QL(1800 per 30 days) ZYVOX TABS 3 QL(56 per 30 days) PENICILLINS amoxicillin 1 amoxicillin/clavulanate potassium 2 amoxicillin/clavulanate potassium 2 er amoxicillin/potassium clavulanate 2 tabs ampicillin caps 2 ampicillin inj 125mg, 1gm 2 ampicillin inj 10gm 2 ampicillin susr 2 ampicillin-sulbactam inj 10gm; 2 5gm ampicillin-sulbactam inj 2gm; 2 1gm BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin sodium 2 nafcillin sodium inj 10gm 2 nafcillin sodium inj 1gm 2 NALLPEN/DEXTROSE INJ 0; 3 1GM/50ML PENICILLIN G POTASSIUM IN 3 ISO-OSTIC DEXTROSE penicillin g potassium inj 5mu 2 PENICILLIN G PROCAINE 3 PENICILLIN G SODIUM 3 6 penicillin v potassium 1 pfizerpen-g inj 20mu 2 piperacillin sodium/tazobactam 2 sodium inj 4gm; 0.5gm piperacillin sodium/tazobactam 2 sodium inj 3gm; 0.375gm ZOSYN INJ 5%; 2GM/50ML; GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML QUINOLONES CIPRO I.V.-IN D5W INJ 3 200MG/100ML; 5% ciprofloxacin inj 400mg/40ml 1 ciprofloxacin tabs 1 levofloxacin 2 levofloxacin in d5w inj 5%; 2 500mg/100ml NOROXIN 4 ofloxacin 2 SULFA'S / RELATED AGENTS sulfadiazine 2 sulfamethoxazole/trimethoprim 1 sulfamethoxazole/trimethoprim ds 1 TETRACYCLINES demeclocycline hcl 2 doxycycline caps 75mg 2 doxycycline hyclate caps 1 doxycycline hyclate inj 1 doxycycline hyclate tabs 1 doxycycline hyclate tbec 1 doxycycline monohydrate tabs 2 150mg, 50mg, 75mg minocycline hcl 2 minocycline hcl er 2 tetracycline hcl 1 VIBRAMYCIN SUSR 3 VIBRAMYCIN SYRP 3 URINARY TRACT AGENTS MACRODANTIN CAPS 25MG 3 methenamine hippurate 2 nitrofurantoin 2 nitrofurantoin macrocrystalline 2 caps 50mg nitrofurantoin monohydrate 2

15 Tier Notes PRIMSOL 4 trimethoprim 2 VANCOMYCIN vancomycin caps 2 vancomycin inj 10gm, 500mg 2 B/D PA vancomycin inj 1000mg 2 B/D PA VIBATIV INJ 250MG 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine 5 dexrazoxane inj 500mg 2 ELITEK INJ 1.5MG 5 FUSILEV 5 leucovorin calcium inj 100mg, 2 350mg leucovorin calcium tabs 25mg, 2 5mg LEUCOVORIN CALCIUM 3 TABS 10MG, 15MG mesna 2 MESNEX TABS 3 XGEVA 5 PA QL(5.1 per ZINECARD INJ 250MG 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 4 adriamycin inj 2mg/ml 2 AFINITOR TABS 10MG, 7.5MG 5 PA QL(180 per AFINITOR TABS 2.5MG, 5MG 5 PA QL(270 per ALIMTA INJ 500MG 4 ALKERAN INJ 4 anastrozole 2 ARRANON 4 ARZERRA 3 AVASTIN INJ 100MG/4ML 4 azathioprine 2 B/D PA azathioprine sodium 2 7 bicalutamide 2 BICNU 4 bleomycin sulfate inj 30unit 2 BUSULFEX 3 CAMPATH 4 CAPRELSA TABS 300MG 5 QL(90 per CAPRELSA TABS 100MG 5 QL(180 per carboplatin inj 150mg/15ml 2 CEENU 3 CELLCEPT INTRAVENOUS 3 CELLCEPT SUSR 3 B/D PA cisplatin inj 100mg/100ml 2 cladribine 2 CLOLAR 4 COSMEGEN 4 cyclophosphamide tabs 2 B/D PA cyclosporine caps 100mg, 25mg 2 B/D PA CYCLOSPORINE CAPS 50MG 3 B/D PA cyclosporine inj 2 cyclosporine oral soln 2 B/D PA CYTARABINE AQUEOUS INJ 3 100MG/ML cytarabine aqueous inj 20mg/ml 2 cytarabine inj 500mg 2 dacarbazine inj 200mg 2 DACOGEN 3 daunorubicin hcl inj 5mg/ml 2 DOCEFREZ 5 docetaxel inj 80mg/4ml 2 DOCETAXEL INJ 80MG/8ML 3 DOXIL 3 doxorubicin hcl inj 2mg/ml 2 DROXIA 3 ELLENCE INJ 200MG/100ML 4 ELOXATIN INJ 100MG/20ML 4 ELSPAR 4 EMCYT 3 epirubicin hcl inj 50mg/25ml 2 ERBITUX INJ 100MG/50ML 4 ERIVEDGE 5 PA ETOPOPHOS 4

16 etoposide inj 2 exemestane 2 FARESTON 4 FASLODEX 5 FIRMAGON INJ 120MG 5 QL(240 per 84 days) FIRMAGON INJ 80MG 3 QL(240 per 84 days) fludarabine phosphate inj 50mg 2 fluorouracil inj 500mg/10ml 2 flutamide 2 gemcitabine hcl inj 1gm 5 gengraf 2 B/D PA GLEEVEC 5 HALAVEN 5 HERCEPTIN 4 HEXALEN 5 hydroxyurea 2 idarubicin hcl inj 10mg/10ml 2 IFEX INJ 3GM 4 ifosfamide inj 1gm 2 INLYTA 5 PA irinotecan inj 100mg/5ml 5 ISTODAX 3 IXEMPRA KIT INJ 45MG 5 JAKAFI 5 PA QL(180 per JEVTANA 5 letrozole 2 LEUKERAN 3 leuprolide acetate 2 LUPRON DEPOT INJ 3.75MG 3 LUPRON DEPOT INJ 22.5MG, 5 30MG, 45MG, 7.5MG LUPRON DEPOT-PED INJ MG, 15MG LYSODREN 3 MATULANE 5 MEGACE ES 3 QL(150 per 30 days) 8 megestrol acetate 1 melphalan hydrochloride 2 mercaptopurine 2 methotrexate 2 B/D PA methotrexate sodium inj 25mg/ml 2 METHOTREXATE SODIUM 4 INJ 1GM mitomycin inj 20mg 2 mitoxantrone hcl 2 MUSTARGEN 4 mycophenolate mofetil 2 B/D PA MYFORTIC 3 B/D PA NEORAL 3 B/D PA NEXAVAR 5 LA PA QL(360 per NILANDRON 4 QL(120 per NIPENT 4 NULOJIX 5 octreotide inj 1000mcg/ml, 5 500mcg/ml octreotide inj 100mcg/ml, 2 200mcg/ml, 50mcg/ml ONTAK 4 oxaliplatin inj 100mg/20ml 5 paclitaxel inj 300mg/50ml 2 pentostatin 2 PROGRAF INJ 3 RAPAMUNE 3 B/D PA REVLIMID CAPS 15MG, 25MG 5 LA QL(21 per 28 days) REVLIMID CAPS 10MG, 5MG 5 LA QL(30 per 30 days) RHEUMATREX 4 B/D PA RITUXAN 3 PA SANDIMMUNE CAPS 3 B/D PA SANDIMMUNE INJ 3 SANDIMMUNE ORAL SOLN 3 B/D PA SANDOSTATIN LAR DEPOT 4 SIMULECT INJ 20MG 3

17 SOMATULINE DEPOT 5 SPRYCEL TABS 100MG, 140MG, 50MG, 70MG, 80MG 5 QL(90 per SPRYCEL TABS 20MG 5 QL(180 per SUTENT 5 PA QL(90 per TABLOID 3 tacrolimus 2 B/D PA tamoxifen citrate 2 TARCEVA TABS 100MG, 150MG 5 PA QL(90 per TARCEVA TABS 25MG 5 PA QL(180 per TARGRETIN 3 TASIGNA 5 QL(336 per 84 days) TAXOTERE INJ 80MG/4ML 5 THALOMID 5 PA thiotepa 2 toposar 2 topotecan hcl inj 4mg 2 TORISEL 5 PA TREANDA INJ 100MG 5 TRELSTAR DEPOT MIXJECT 4 TRELSTAR LA MIXJECT 4 TRELSTAR MIXJECT 4 tretinoin 2 TRISENOX 3 TYKERB 5 LA QL(540 per VECTIBIX INJ 100MG/5ML 5 VELCADE 4 VIDAZA 5 QL(4200 per vinblastine sulfate inj 10mg 2 vincasar pfs 2 vincristine sulfate 2 vinorelbine tartrate inj 50mg/5ml 2 VOTRIENT 5 QL(360 per XALKORI 5 PA QL(180 per YERVOY INJ 50MG/10ML 5 PA ZANOSAR 4 ZELBORAF 5 PA QL(720 per ZOLINZA 5 QL(360 per ZORTRESS TABS 0.5MG, 0.75MG 5 B/D PA ZORTRESS TABS 0.25MG 3 B/D PA ZYTIGA 5 PA QL(360 per AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS BANZEL 3 carbamazepine 1 carbamazepine er cp12 1 CELONTIN 3 clonazepam 2 clonazepam odt 2 diazepam gel 2 DILANTIN CAPS 30MG 3 DILANTIN INFATABS 3 divalproex sodium 2 divalproex sodium dr 2 divalproex sodium er 2 epitol 1 ethosuximide 2 felbamate 2 fosphenytoin sodium inj 100mg 2 pe/2ml gabapentin 2 GABITRIL 3 9

18 LAMICTAL ODT TBDP 3 LAMICTAL STARTER/NOT 3 TAKING CARBAMAZEPINE LAMICTAL 3 STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE LAMICTAL 3 STARTER/TAKING VALPROATE LAMICTAL XR KIT 3 LAMICTAL XR TB24 100MG, 3 200MG, 250MG, 25MG, 50MG lamotrigine 2 levetiracetam er 2 levetiracetam inj 500mg/5ml 2 levetiracetam oral soln 2 levetiracetam tabs 2 LYRICA CAPS 225MG, 300MG 3 QL(180 per LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG 3 QL(270 per ONFI 3 oxcarbazepine 2 PEGANONE 3 phenobarbital elix 2 PA phenobarbital tabs 16.2mg, 30mg, 2 PA 32.4mg, 64.8mg, 97.2mg phenytoin 2 PHENYTOIN SODIUM 3 phenytoin sodium extended 2 POTIGA 4 primidone 2 SABRIL 3 TEGRETOL-XR TB12 100MG 3 topiramate 2 TRILEPTAL SUSP 4 valproate sodium 2 valproic acid 2 VIMPAT INJ 3 VIMPAT ORAL SOLN 3 VIMPAT TABS 3 zonisamide 2 10 ANTIPARKINSONISM AGENTS APOKYN 3 LA AZILECT 3 benztropine mesylate inj 1 benztropine mesylate tabs 1 bromocriptine mesylate 2 carbidopa / levodopa 2 carbidopa / levodopa er 2 carbidopa/levodopa odt 2 COMTAN 3 LODOSYN 3 MIRAPEX ER 3 pramipexole dihydrochloride 2 ropinirole 2 ropinirole er 2 selegiline 2 STALEVO STALEVO STALEVO STALEVO STALEVO 50 3 STALEVO 75 3 trihexyphenidyl 1 ZELAPAR 3 MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine mesylate 2 ergotamine tartrate / caffeine 2 migergot 2 MIGRANAL 4 QL(24 per naratriptan hcl tabs 2.5mg 2 QL(24 per naratriptan hcl tabs 1mg 2 QL(36 per RELPAX 3 QL(36 per sumatriptan succinate inj 6mg/0.5ml 2 QL(12 per

19 sumatriptan succinate tabs 100mg 2 QL(27 per sumatriptan succinate tabs 25mg, 50mg 2 QL(54 per MISCELLANEOUS NEUROLOGICAL THERAPY ARICEPT TABS 23MG 3 QL(90 per COPAXONE 5 PA QL(90 per donepezil hcl 2 QL(90 per EXELON ORAL SOLN 3 EXELON PT24 3 QL(90 per galantamine hydrobromide cp24 2 QL(90 per galantamine hydrobromide oral 2 soln galantamine hydrobromide tabs 2 QL(180 per GILENYA 5 PA QL(28 per 28 days) MYTELASE 3 NAMENDA ORAL SOLN 3 NAMENDA TABS 10MG 3 QL(180 per NAMENDA TABS 5MG 3 QL(270 per NAMENDA TITRATION PAK 3 NUEDEXTA 3 QL(180 per rivastigmine tartrate 2 QL(180 per XENAZINE 5 LA 11 MUSCLE RELAXANTS / ANTISPASDIC THERAPY baclofen 1 cyclobenzaprine hcl tabs 10mg, 1 5mg dantrolene sodium caps 2 LIORESAL INTRATHECAL INJ 3 B/D PA 0.05MG/ML LIORESAL INTRATHECAL INJ 3 B/D PA 10MG/20ML, 10MG/5ML MESTINON SYRP 3 MESTINON TIMESPAN 3 pyridostigmine bromide 2 regonol 2 tizanidine hcl 2 NARCOTIC ANALGESICS acetaminophen / codeine 2 acetaminophen/codeine #3 2 ascomp/codeine 2 BUPRENEX 3 buprenorphine hcl inj 2 buprenorphine hcl subl 2 codeine sulfate tabs 2 DILAUDID INJ 3 DILAUDID-5 3 DILAUDID-HP INJ 10MG/ML 3 duramorph 2 endocet tabs 650mg; 10mg 2 QL(540 per endocet tabs 500mg; 7.5mg 2 QL(720 per endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 2 QL(1080 per EXALGO 3 fentanyl citrate oral transmucosal lpop 200mcg fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 400mcg, 600mcg, 800mcg 2 PA QL(360 per 5 PA QL(360 per

20 fentanyl patches 2 QL(30 per hydrocodone bitartrate/acetaminophen oral soln 2 QL(5550 per 30 days) hydrocodone bitartrate/acetaminophen tabs 750mg; 10mg hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg hydrocodone/acetaminophen oral soln hydrocodone/acetaminophen tabs 750mg; 7.5mg hydrocodone/acetaminophen tabs 650mg; 10mg, 650mg; 7.5mg, 660mg; 10mg hydrocodone/acetaminophen tabs 500mg; 10mg, 500mg; 2.5mg, 500mg; 5mg, 500mg; 7.5mg hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg 2 QL(450 per 2 QL(1080 per 2 QL(3600 per 30 days) 2 QL(450 per 2 QL(540 per 2 QL(720 per 2 QL(1080 per hydrocodone/ibuprofen 2 hydromorphone hcl inj 2 500mg/50ml hydromorphone hcl tabs 2 levorphanol tartrate 2 methadone hcl conc 2 methadone hcl inj 2 methadone hcl oral soln 2 methadone hcl tabs 2 methadose tabs 2 morphine sulfate er 2 morphine sulfate oral soln 2 morphine sulfate tabs 2 ONSOLIS FILM 1200MCG, 400MCG, 600MCG, 800MCG 3 PA QL(360 per ONSOLIS FILM 200MCG 3 PA QL(720 per OPANA ER (CRUSH RESISTANT) Tier Notes 3 QL(540 per oxycodone / acetaminophen caps 2 QL(720 per oxycodone / acetaminophen tabs 650mg; 10mg oxycodone / acetaminophen tabs 500mg; 7.5mg oxycodone / acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg 2 QL(540 per 2 QL(720 per 2 QL(1080 per oxycodone hcl caps 2 QL(1080 per oxycodone hcl conc 2 QL(1800 per oxycodone hcl tabs 15mg, 30mg 2 QL(540 per oxycodone hcl tabs 5mg 2 QL(1080 per oxycodone/aspirin 2 OXYCONTIN 4 QL(540 per oxymorphone hydrochloride 2 oxymorphone hydrochloride er 2 reprexain tabs 10mg; 200mg 2 ROXICET ORAL SOLN 3 QL(5580 per stagesic 2 QL(720 per NON-NARCOTIC ANALGESICS ARTHROTEC 50 4 ARTHROTEC 75 4 butorphanol tartrate nasal soln 2 PA QL(30 per 12

21 CELEBREX 4 PA QL(180 per diclofenac potassium 2 diclofenac sodium dr 1 diclofenac sodium er 1 diflunisal 2 etodolac caps 200mg 2 etodolac tabs 2 etodolac tb24 2 fenoprofen calcium 2 FLECTOR 4 flurbiprofen 2 ibuprofen susp 1 ibuprofen tabs 400mg, 600mg, 1 800mg indomethacin caps 1 indomethacin er 1 ketoprofen 2 ketoprofen er 2 meclofenamate sodium 2 mefenamic acid 2 meloxicam 1 nabumetone 2 naloxone inj 1mg/ml 2 naltrexone 2 naproxen 1 naproxen sodium tabs 275mg, 2 550mg NUCYNTA 3 QL(541 per NUCYNTA ER 3 QL(180 per oxaprozin 2 PENNSAID 3 piroxicam 1 SUBOXONE 3 sulindac 2 tolmetin sodium 2 tramadol 2 QL(720 per tramadol hcl er tb24 100mg, 200mg Tier Notes 2 QL(90 per tramadol hcl er tb24 300mg 3 QL(90 per VIVO 3 QL(180 per VOLTAREN GEL 3 PSYCHOTHERAPEUTIC DRUGS ABILIFY DISCMELT TBDP 15MG ABILIFY DISCMELT TBDP 10MG 3 QL(180 per 3 QL(270 per ABILIFY INJ 3 ABILIFY ORAL SOLN 3 ABILIFY TABS 20MG, 2MG, 30MG, 5MG 3 QL(90 per ABILIFY TABS 15MG 3 QL(180 per ABILIFY TABS 10MG 3 QL(270 per amitriptyline 1 amoxapine 2 budeprion sr 2 QL(180 per budeprion xl tb24 300mg 2 QL(90 per budeprion xl tb24 150mg 2 QL(270 per bupropion hcl 2 bupropion hcl sr 2 QL(180 per buspirone hcl 2 chlordiazepoxide/amitriptyline 2 chlorpromazine 2 citalopram oral soln 1 13

22 citalopram tabs 40mg 1 QL(90 per citalopram tabs 10mg 1 QL(180 per citalopram tabs 20mg 1 QL(270 per clomipramine 2 clorazepate dipotassium 2 clozapine tabs 100mg, 25mg, 2 50mg CLOZAPINE TABS 200MG 3 CYMBALTA CPEP 60MG 3 QL(180 per CYMBALTA CPEP 30MG 3 QL(360 per CYMBALTA CPEP 20MG 3 QL(540 per desipramine 2 dextroamphetamine sulfate 2 PA dextroamphetamine sulfate er 2 PA diazepam intensol 2 diazepam oral soln 2 diazepam tabs 2 doxepin 1 EMSAM 4 QL(90 per escitalopram oxalate oral soln 2 QL(1920 per escitalopram oxalate tabs 2 QL(90 per FANAPT TABS 1MG, 2MG, 4MG 4 QL(90 per FANAPT TABS 10MG, 12MG, 6MG, 8MG 4 QL(180 per FANAPT TITRATION PACK 4 FAZACLO 4 14 fluoxetine caps 40mg 1 QL(180 per fluoxetine caps 20mg 1 QL(360 per fluoxetine caps 10mg 1 QL(720 per fluoxetine dr 1 QL(12 per fluoxetine oral soln 1 fluoxetine tabs 20mg 1 QL(360 per fluoxetine tabs 10mg 1 QL(720 per fluphenazine conc 1 fluphenazine decanoate inj 1 fluphenazine elix 1 fluphenazine inj 1 fluphenazine tabs 1 fluvoxamine 2 QL(270 per FOCALIN XR 3 PA GEODON INJ 4 HALDOL 3 HALDOL DECANOATE HALDOL DECANOATE 50 3 haloperidol conc 2 haloperidol decanoate inj 2 haloperidol lactate inj 2 haloperidol tabs 1 imipramine 2 imipramine pamoate 2 INTUNIV 4 INVEGA SUSTENNA INJ 39MG/0.25ML 3 QL(0.75 per INVEGA SUSTENNA INJ 78MG/0.5ML 3 QL(1.5 per

23 INVEGA SUSTENNA INJ 117MG/0.75ML INVEGA SUSTENNA INJ 156MG/ML INVEGA SUSTENNA INJ 234MG/1.5ML INVEGA TB24 1.5MG, 3MG, 9MG 3 QL(2.25 per 3 QL(3 per 90 days) 3 QL(4.5 per 4 QL(90 per INVEGA TB24 6MG 4 QL(180 per LATUDA TABS 80MG 3 QL(90 per LATUDA TABS 40MG 3 QL(180 per LATUDA TABS 20MG 3 QL(360 per lithium carbonate 1 lithium carbonate er 1 lithium citrate 2 lorazepam intensol 2 lorazepam tabs 2 loxapine 2 LUNESTA 4 QL(90 per maprotiline 2 MARPLAN 3 METADATE CD CPCR 20MG, 4 PA 30MG, 40MG, 50MG, 60MG methylphenidate hcl 2 PA methylphenidate hcl er cp24 2 PA methylphenidate hydrochloride 2 PA mirtazapine 2 QL(90 per mirtazapine odt tbdp 30mg, 45mg 2 QL(90 per nefazodone 2 QL(180 per nortriptyline 1 olanzapine inj 2 olanzapine odt 2 QL(90 per olanzapine tabs 2 QL(90 per ORAP 3 paroxetine er tb mg, 37.5mg 1 QL(180 per paroxetine er tb24 25mg 1 QL(270 per paroxetine tabs 20mg, 40mg 1 QL(90 per paroxetine tabs 10mg, 30mg 1 QL(180 per PAXIL SUSP 3 perphenazine 2 phenelzine sulfate 2 PRISTIQ 3 QL(90 per protriptyline hcl 2 PROVIGIL 3 PA QL(90 per quetiapine fumarate tabs 25mg, 300mg, 400mg quetiapine fumarate tabs 100mg, 200mg, 50mg 2 QL(180 per 2 QL(270 per RISPERDAL CONSTA 3 QL(12 per 84 days) risperidone odt 2 QL(180 per risperidone oral soln 2 15

24 risperidone tabs 2 QL(180 per SAPHRIS 3 QL(180 per SEROQUEL XR TB24 150MG, 300MG, 400MG 3 QL(180 per SEROQUEL XR TB24 200MG, 50MG 3 QL(270 per sertraline conc 2 sertraline tabs 100mg, 25mg 2 QL(180 per sertraline tabs 50mg 2 QL(270 per SILENOR 4 QL(90 per STRATTERA 3 SYMBYAX 4 QL(90 per temazepam 2 thioridazine 2 thiothixene 1 tranylcypromine 2 trazodone 1 trifluoperazine 2 trimipramine maleate 2 venlafaxine hcl er cp24 150mg, 37.5mg 2 QL(90 per venlafaxine hcl er cp24 75mg 2 QL(270 per venlafaxine hcl tabs 100mg, 25mg, 37.5mg 2 QL(270 per venlafaxine hcl tabs 75mg 2 QL(450 per Tier Notes venlafaxine hcl tabs 50mg 2 QL(675 per VIIBRYD KIT 3 QL(30 per 365 days) VIIBRYD TABS 3 QL(90 per XYREM 5 PA zaleplon caps 5mg 2 QL(90 per zaleplon caps 10mg 2 QL(180 per ziprasidone hcl 2 QL(180 per zolpidem 2 QL(90 per zolpidem tartrate er 2 QL(90 per CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj 50mg/ml 2 amiodarone tabs 2 disopyramide phosphate 2 flecainide acetate 2 mexiletine 2 MULTAQ 3 NORPACE CR 3 PACERONE TABS 100MG 3 pacerone tabs 200mg 2 procainamide 2 propafenone hcl 2 propafenone hcl er 2 quinidine gluconate er 2 quinidine sulfate 2 quinidine sulfate er 2 sorine tabs 240mg 1 sorine tabs 120mg, 160mg, 80mg 1 16

25 sotalol 1 TIKOSYN 4 ANTIHYPERTENSIVE THERAPY acebutolol 2 afeditab cr 2 amiloride 2 amiloride/hydrochlorothiazide 1 amlodipine 2 amlodipine / benazepril 2 QL(90 per AMTURNIDE 3 QL(90 per atenolol 1 atenolol / chlorthalidone 1 benazepril 1 benazepril / hydrochlorothiazide tabs 20mg; 12.5mg, 20mg; 25mg 2 QL(360 per benazepril / hydrochlorothiazide tabs 10mg; 12.5mg benazepril / hydrochlorothiazide tabs 5mg; 6.25mg 2 QL(720 per 2 QL(1440 per BENICAR HCT 3 QL(90 per BENICAR TABS 20MG, 40MG 3 QL(90 per BENICAR TABS 5MG 3 QL(180 per betaxolol hcl tabs 20mg 2 bisoprolol fumarate 2 bisoprolol fumarate / 1 hydrochlorothiazide bumetanide 1 BYSTOLIC 3 captopril 1 captopril/hydrochlorothiazide tabs 25mg; 15mg, 25mg; 25mg, 50mg; 15mg 2 QL(90 per captopril/hydrochlorothiazide tabs 50mg; 25mg Tier Notes 2 QL(270 per cartia xt 2 carvedilol 2 chlorothiazide 1 chlorothiazide sodium 2 chlorthalidone tabs 25mg, 50mg 1 clonidine ptwk 2 clonidine tabs 1 COREG CR 3 DEMSER 3 DIBENZYLINE 4 dilt-cd cp24 120mg, 300mg 2 dilt-xr cp24 180mg, 240mg 2 diltiazem cd cp24 120mg, 240mg, 2 300mg diltiazem hcl er cp12 2 diltiazem hcl er cp24 180mg, 2 360mg diltiazem hcl inj 50mg/10ml 2 DILTIAZEM HCL INJ 100MG 3 diltiazem hcl tabs 2 doxazosin 1 QL(180 per EDECRIN 3 enalapril 1 enalapril / hydrochlorothiazide tabs 5mg; 12.5mg 1 QL(90 per enalapril / hydrochlorothiazide tabs 10mg; 25mg 1 QL(180 per eplerenone 2 eprosartan mesylate 2 QL(90 per EXFORGE 3 QL(90 per EXFORGE HCT 3 QL(90 per felodipine er 2 17

26 fosinopril 2 fosinopril / hydrochlorothiazide tabs 10mg; 12.5mg 2 QL(90 per fosinopril / hydrochlorothiazide tabs 20mg; 12.5mg 2 QL(360 per furosemide inj 1 furosemide oral soln 10mg/ml 1 FUROSEMIDE ORAL SOLN 3 8MG/ML furosemide tabs 1 guanfacine hcl 1 hydralazine 1 hydrochlorothiazide 1 indapamide 1 irbesartan 2 QL(90 per irbesartan/hydrochlorothiazide 2 QL(90 per isradipine 2 labetalol inj 2 labetalol tabs 2 lisinopril 1 lisinopril/hydrochlorothiazide tabs 12.5mg; 10mg, 12.5mg; 20mg lisinopril/hydrochlorothiazide tabs 25mg; 20mg 1 QL(90 per 1 QL(360 per losartan potassium tabs 100mg 2 QL(90 per losartan potassium tabs 25mg, 50mg losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg losartan potassium/hydrochlorothiazide 2 QL(180 per 2 QL(90 per 2 QL(180 per tabs 12.5mg; 50mg matzim la 2 methyclothiazide 2 18 metolazone 2 metoprolol succinate er 2 metoprolol tartrate inj 1 metoprolol tartrate tabs 1 metoprolol/hydrochlorothiazide 2 MICARDIS HCT 3 QL(90 per MICARDIS TABS 20MG, 40MG 3 QL(90 per MICARDIS TABS 80MG 3 QL(180 per minoxidil tabs 2 moexipril 2 moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 12.5mg; 7.5mg 2 QL(90 per moexipril/hydrochlorothiazide tabs 25mg; 15mg 2 QL(180 per nadolol 1 nadolol/bendroflumethiazide 2 nicardipine caps 2 nifediac cc tb24 90mg 2 nifedical xl 2 nifedipine 2 nifedipine er tb24 30mg, 60mg 2 nifedipine er tb24 90mg 2 nimodipine 2 nisoldipine 2 nisoldipine er 2 perindopril erbumine 2 pindolol 1 prazosin 1 QL(360 per propranolol hcl er 1 propranolol hcl inj 1 propranolol hcl oral soln 1 propranolol hcl tabs 1 propranolol/hydrochlorothiazide 2 quinapril 2

27 quinapril/hydrochlorothiazide 2 QL(90 per ramipril 2 REDULIN 5 PA reserpine 2 spironolactone 1 spironolactone/hydrochlorothiazi 2 de taztia xt 2 TEKAMLO 3 QL(90 per TEKTURNA 3 QL(90 per TEKTURNA HCT 3 QL(90 per terazosin hcl 1 QL(180 per timolol maleate 1 torsemide tabs 2 trandolapril 2 triamterene/hydrochlorothiazide 1 TWYNSTA 3 QL(90 per verapamil er 1 verapamil inj 1 verapamil tabs 1 CARDIAC GLYCOSIDES digoxin inj 1 digoxin oral soln 1 digoxin tabs 1 LANOXIN INJ 3 LANOXIN TABS 3 COAGULATION THERAPY AGGRENOX 3 BRILINTA 3 cilostazol 2 clopidogrel 1 CYKLOKAPRON 3 enoxaparin sodium inj 2 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml enoxaparin sodium inj 100mg/ml, 5 120mg/0.8ml, 150mg/ml fondaparinux sodium 2 FRAGMIN 3 heparin sodium inj 10000unit/ml, unit/ml, 20000unit/ml, 5000unit/ml heparin sodium/d5w inj 5%; 2 40unit/ml HEPARIN SODIUM/NACL % heparin sodium/sodium chloride 2 0.9% premix jantoven 1 LOVENOX INJ 300MG/3ML 3 pentoxifylline er 2 PRADAXA 3 PROMACTA 5 LA PA QL(90 per ticlopidine hcl 2 warfarin 1 XARELTO 4 LIPID/CHOLESTEROL LOWERING AGENTS atorvastatin calcium 1 QL(90 per cholestyramine light pack 2 colestipol 2 CRESTOR 3 QL(90 per fenofibrate 2 fenofibrate micronized 2 fluvastatin 2 QL(90 per gemfibrozil 2 LIPOFEN 3 19

28 lovastatin tabs 10mg 1 QL(90 per lovastatin tabs 20mg, 40mg 1 QL(180 per LOVAZA 3 NIASPAN 3 pravastatin tabs 10mg, 20mg, 80mg 2 QL(90 per pravastatin tabs 40mg 2 QL(180 per prevalite powd 2 simvastatin 1 QL(90 per TRILIPIX 3 WELCHOL 3 ZETIA 3 QL(90 per MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 NITRATES isosorbide dinitrate 1 isosorbide dinitrate er 1 isosorbide mononitrate er 1 isosorbide mononitrate tabs 20mg 2 nitro-bid 2 nitroglycerin inj 2 B/D PA nitroglycerin pt24 2 nitroglycerin transdermal pt24 0.1mg/hr 2 NITROLINGUAL PUMPSPRAY 3 NITROSTAT 3 DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC calcipotriene 2 selenium sulfide lotn 1 SORIATANE 3 BURN THERAPY silver sulfadiazine 2 ssd 2 thermazene 2 MISCELLANEOUS DERMATOLOGICALS 8-P 3 ammonium lactate 2 CARAC 3 CARL-HC 3 CONDYLOX GEL 3 ELIDEL 4 FLUOROPLEX 3 fluorouracil crea 2 imiquimod 2 laclotion 2 OXSORALEN ULTRA 5 PANRETIN 3 podofilox 2 PROTOPIC 4 REGRANEX 3 PA SOLARAZE 4 UVADEX 4 VEREGEN 4 THERAPY FOR ACNE adapalene 2 amnesteem 2 avita crea 2 AZELEX 3 claravis caps 10mg, 20mg, 40mg 2 claravis caps 30mg 5 clindamycin phosphate external 2 soln clindamycin phosphate foam 2 clindamycin phosphate gel 2 clindamycin phosphate lotn 2 clindamycin phosphate swab 2 clindamycin/benzoyl peroxide gel 2 5%; 1% DIFFERIN GEL 0.3% 3 DIFFERIN LOTN 3 ery 1 erythromycin / benzoyl peroxide 2 20

29 erythromycin external soln 1 erythromycin gel 1 FINACEA 3 METROGEL 3 metronidazole 1 TAZORAC 3 tretinoin 2 TOPICAL ANESTHETICS lidocaine / prilocaine crea 2 lidocaine external soln 2 lidocaine gel 2 lidocaine inj 0.5%, 1% 2 lidocaine oint 2 lidocaine viscous 2 LIDODERM 3 PA TOPICAL ANTIBACTERIALS ALTABAX 3 BACTROBAN CREA 3 gentamicin sulfate crea 1 gentamicin sulfate oint 0.1% 1 mupirocin 2 PHISOHEX 3 sulfacetamide sodium susp 2 SULFAMYLON 3 TOPICAL ANTIFUNGALS ciclopirox 2 ciclopirox nail lacquer 2 ciclopirox olamine 2 clotrimazole / betamethasone 2 clotrimazole external crea 2 clotrimazole external soln 2 econazole nitrate 2 ketoconazole 2 NAFTIN CREA 1% 3 NAFTIN GEL 3 nyamyc 1 nystatin / triamcinolone 1 nystatin crea 1 nystatin external powd 1 nystatin oint 1 nystop 1 pedi-dri 1 21 TOPICAL ANTIVIRALS DENAVIR 3 ZOVIRAX CREA 4 ZOVIRAX OINT 4 TOPICAL CORTICOSTEROIDS ala-cort 1 alclometasone dipropionate 2 amcinonide 2 augmented betamethasone 1 dipropionate crea augmented betamethasone 2 dipropionate lotn augmented betamethasone 1 dipropionate oint betamethasone dipropionate 2 betamethasone valerate 1 CAPEX 3 clobetasol propionate crea 2 clobetasol propionate external 2 soln clobetasol propionate foam 2 clobetasol propionate gel 2 clobetasol propionate lotn 2 clobetasol propionate oint 2 clobetasol propionate sham 2 CORDRAN TAPE 3 DERMA-SOTHE / FS BODY 3 OIL desonide 2 desoximetasone crea 2 desoximetasone gel 2 desoximetasone oint 0.25% 2 diflorasone diacetate 2 fluocinolone acetonide body 1 fluocinolone acetonide crea 1 fluocinolone acetonide external 1 soln fluocinolone acetonide oint 1 fluocinonide external soln 2 fluocinonide gel 2 fluocinonide oint 2 fluocinonide-e 2 fluticasone propionate 2 halobetasol propionate 2

30 hydrocortisone crea 1%, 2.5% 1 hydrocortisone lotn 2.5% 1 hydrocortisone oint 1%, 2.5% 1 hydrocortisone valerate 2 LOCOID LOTN 3 LUXIQ 3 mometasone furoate crea 2 mometasone furoate external soln 2 0.1% mometasone furoate external soln 0.1% 2 mometasone furoate oint 2 PANDEL 3 prednicarbate 2 triamcinolone acetonide crea 1 triamcinolone acetonide lotn 1 triamcinolone acetonide oint 1 triderm 1 TOPICAL ENZYMES SANTYL 3 TOPICAL SCABICIDES / PEDICULICIDES EURAX 3 lindane 2 QL(1800 per 365 days) malathion 2 permethrin crea 2 ULESFIA 4 DIAGNOSTICS / MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS ACTONEL TABS 30MG 4 PA QL(60 per 120 days) ADAGEN 5 LA alendronate sodium tabs 40mg 2 QL(180 per 365 days) anagrelide hydrochloride 2 ARALAST NP INJ 400MG 5 LA BUPHENYL 3 CAMPRAL 3 QL(540 per 22 CARBAGLU 5 LA CHEMET 3 CLINIMIX 4.25%/DEXTROSE 3 5% DEXTROSE 10%/NACL 0.45% 3 dextrose 10% flex container 2 DEXTROSE 10%/NACL 0.2% 3 dextrose 2.5%/sodium chloride % dextrose 5% 2 dextrose 5%/lactated ringers 2 dextrose 5%/nacl 0.2% 2 dextrose 5%/nacl 0.225% 2 DEXTROSE 5%/NACL 0.33% 3 dextrose 5%/nacl 0.45% 2 dextrose 5%/nacl 0.9% 2 disulfiram 2 etidronate disodium 2 EVOXAC 3 EXJADE TBSO 125MG 3 LA EXJADE TBSO 250MG, 500MG 5 LA FOSRENOL 3 INCRELEX 5 LA PA kionex powd 2 levocarnitine oral soln 2 B/D PA levocarnitine tabs 2 B/D PA midodrine 2 ORFADIN 5 LA pilocarpine hcl tabs 2 PROLASTIN-C 5 LA RECLAST 4 RENVELA 3 RILUTEK 5 SKELID 4 PA QL(180 per sodium chloride 0.9% 2 sodium chloride inj 0.9% 2 sodium polystyrene sulfonate susp 2 SYPRINE 3 SKING DETERRENTS