IMCare Classic (HMO SNP) 2018 List of Covered Drugs (Formulary)

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1 IMCare ITASCA MEDICAL CARE / IMCare Classic (HMO SNP) 1219 SE 2 nd Avenue Grand Rapids, MN Toll Free Number: Hearing Impaired Number TDD: IMCare Classic (HMO SNP) 2018 List of Covered Drugs (Formulary) Last Updated 11/01/2018 HPMS Formulary File Submission ID , Version Number #14 This is a list of drugs that members can get in IMCare Classic. IMCare Classic (HMO SNP) is a health plan that contracts with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in IMCare Classic (HMO SNP) depends on contract renewal. 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 and/or copays may change on January 1 of each year. You can always check IMCare Classic s up-to-date List of Covered Drugs online at Limitations, copays, and restrictions may apply. For more information, call IMCare Classic Member Services at the number listed at the bottom of this page or read the IMCare Classic Member Handbook. Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details. You can get this document for free in other formats, such as large print, braille, or audio. Call Member Services at the number listed at the bottom of this page. You can make a standing request get this information, now and in the future, in a language other than English or in an alternate format, by calling IMCare Member services at the number at the bottom of the page. American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral.? If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 1

2 Civil Rights Notice Discrimination is against the law. Itasca Medical Care does not discriminate on the basis of any of the following: Race Sex (including sex stereotypes and Color gender identity) National Origin Marital Status Creed Political Beliefs Religion Medical Condition Sexual Orientation Health Status Public Assistance Status Receipt of Health Care Services Age Claims Experience Disability (including physical or Medical History mental impairment) Genetic Information Auxiliary Aids and Services. Itasca Medical Care provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner, to ensure an equal opportunity to participate in our health care programs. Contact Itasca Medical Care at or toll-free for more information. Language Assistance Services. Itasca Medical Care provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact Itasca Medical Care at or toll-free for more information. Civil Rights Complaints You have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by a human service agency. You may contact any of the following three agencies directly to file a discrimination complaint. U.S. Department of Health and Human Services Office for Civil Rights (OCR) You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following: Race Disability Color Sex (including sex stereotypes and National Origin gender identity) Age Contact the OCR directly to file a complaint: Director U.S. Department of Health and Human Services Office for Civil Rights 200 Independence Avenue SW Room 509F HHH Building Washington, DC 20201? If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 2

3 (Voice) (TDD) Complaint Portal Minnesota Department of Human Rights (MDHR) In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following: Race Sex Color Sexual Orientation National Origin Marital Status Religion Public Assistance Status Creed Disability Contact the MDHR directly to file a complaint: Minnesota Department of Human Rights Freeman Building, 625 North Robert Street St. Paul, MN (voice) (toll free) 711 or (MN Relay) (Fax) ( ) Minnesota Department of Human Services (DHS) You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following: Race Color National Origin Creed Religion Sexual Orientation Public Assistance Status Age Disability (including physical or mental impairment) Sex (including sex stereotypes and gender identity) Marital Status Political Beliefs Medical Condition Health Status Receipt of Health Care Services Claims Experience Medical History Genetic Information Complaints must be in writing and filed within 180 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint. DHS will notify you in writing of the investigation s outcome. You have a right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome period. Be brief and state why you disagree with the decision. Include additional information you think is important.? If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 3

4 If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administration actions. Contact DHS directly to file a discrimination complaint: ATTN: Civil Rights Coordinator Minnesota Department of Human Services Equal Opportunity and Access Division P.O. Box St. Paul, MN (voice) or use your preferred relay service Itasca Medical Care You have the right to file a complaint with Itasca Medical Care (IMCare) if you believe you have been discriminated against in our health care programs because of any of the following: Race Sex (including sex stereotypes and Color gender identity) National Origin Marital Status Creed Medical Condition Religion Health Status Sexual Orientation Receipt of Health Care Services Public Assistance Status Claims Experience Age Medical History Disability (including physical or Genetic Information mental impairment) You have the right to file a complaint with IMCare or IMCare Classic if you believe you have been discriminated against because of any of the items listed above. You can file a complaint and ask for help in filing a complaint in person or by mail, phone, fax, or at: ATTN: Leah Huso, Performance Improvement Compliance Coordinator Itasca Medical Care (IMCare) 1219 SE 2nd Ave Grand Rapids, MN (voice) (toll free) ext or (MN Relay) (Fax) If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 4

5 ? If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 5

6 Frequently Asked Questions (FAQ) Find answers 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 Drug List that starts on page 13 are the drugs covered by IMCare Classic. 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. IMCare Classic will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a IMCare Classic network pharmacy. IMCare Classic may have additional steps to access certain drugs (see question 5 below). You can also see an up-to-date list of drugs we cover on our website at or call Member Services at the number listed at the bottom of this page. 2. Does the Drug List ever change? Yes. IMCare Classic may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior authorization for a drug. (Prior authorization is permission from IMCare Classic before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits). 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 questions 5, 6, and 7.) 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 have more information on what happens when the Drug List changes. You can always check IMCare Classic s current Drug List online at You can also call Member Services at the number listed at the bottom of this page to check the current Drug List.? If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 6

7 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed from the Drug List because a cheaper drug that works just as well comes along, we will tell you. 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. You will get a letter from IMCare Classic telling you about the change in the drug list. Show the letter to your primary care provider and ask if there is another drug that will work for you. 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 telling you that. Show the letter to your primary care provider and ask if there is another drug that will work for you. 5. Are there any restrictions or limits on drug coverage? Or are there any actions required to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you, your doctor, or other prescriber must do something before you can get the drug. For example: Prior authorization: For some drugs, you, your doctor, or other prescriber must get authorization from IMCare Classic before you fill your prescription. If you don t get authorization, IMCare Classic may not cover the drug. Quantity limits: Sometimes IMCare Classic limits the amount of a drug you can get. Step therapy: Sometimes IMCare Classic 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 or other prescriber 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 on pages 12. You can also get more information by visiting our website at We have posted online a document that explains our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception to these limits. Please see questions 9-13 for more information on exceptions. If you are in a nursing home 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 IMCare Classic member. 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 questions 9-13 for more information about exceptions.? If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 7

8 6. How will you know if the drug you want has limitations or if there are any actions required to get the drug? The Drug List on page 13 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization, quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior authorization, 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 provider 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 drug type. To search alphabetically, go to the Index. You can find it page 165. The Index is an alphabetical list of all of the drugs included in the Drug List. Both brand name drugs and generic drugs are listed in the Index. To search by drug type, find the section labeled List of drugs by drug type on page 13. The drugs in this section are grouped into categories by type. For example, if you are taking a medicine for migraines, you should look in the Antimigraine Agents category. That is where you will find drugs that treat migraines. 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 Member Services at the number listed at the bottom of this page and ask about it. If you learn that IMCare Classic will not cover the drug, you can do one of these things: Ask Member 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 health plan to make an exception to cover your drug. Please see questions for more information about exceptions.? If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 8

9 10. What if you are a new IMCare Classic member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 31-day supply of your drug during the first 90 days you are a member of IMCare Classic. 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 a 31-day supply 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 authorization by IMCare Classic, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 days. You may refill the drug multiple times during your first 91 days. 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 member of our plan, you might have an unexpected change from one care setting to another. During this level-of-care change, you may be prescribed drugs that are not on the formulary. These drugs may or may not be covered based on your health condition. You will need to use the exception and appeals process if you want a drug that is not on the formulary. However, there is a way to stop a brief gap in care when you are discharged from a care facility to your home. You may have a full supply of a drug to continue taking once the temporary supply given to you at discharge is gone. You may get this supply before you are discharged from a Part A stay. When you are admitted to or leave a long-term care facility, you will not have access to existing prescriptions. A full refill will be given to you when you are admitted to or leave the facility. Normally, early refill checks are used to avoid overuse of a prescription. However, in this case, your refill request will not be denied due to early refill checks. You will be allowed to access a full refill upon admission or discharge. 11. Can you ask for an exception to cover your drug? Yes. You can ask IMCare Classic to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, IMCare Classic may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior authorization requirements.? If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 9

10 12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you 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, we will give you 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 IMCare Member Services. A Member Services representative 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 active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). IMCare Classic covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. IMCare Classic offers some OTC drugs through Medical Assistance (Medicaid) at no cost to you. You need a prescription for OTC drugs to be covered. These OTC drugs are listed in this Drug List starting on page Does IMCare Classic cover non-drug OTC products? IMCare Classic covers some non-drug OTC products through Medical Assistance (Medicaid). These non-drug OTC products are listed in this Drug List starting on page Can I get my drugs through Mail-Order/Long-Term Supply? Mail-Order Program. We offer a mail-order program that allows you to get up to a 31-day (1 month) or 93 day (3 months) supply of your prescription drugs sent directly to your home. A 93-day (3 months) supply has the same copay as a one month supply. Long-Term Supply. We offer a way to get a long-term supply of maintenance drugs on our plan s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.)? If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 10

11 For more information about getting drugs through mail-order or long-term supply, please call Member Services at the number listed at the bottom of this page. 18. What is your copay? You can read the IMCare Classic Drug List to learn about the copay for each drug. A copay is an amount you may be required to pay as your share of the cost of a prescription drug. A copay is usually a set amount, rather than a percentage. For example, you might pay $0.00 to $8.5 for a prescription drug. IMCare Classic members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays. The Drug List includes copay listed by tiers. Tier 1 Generic drugs have the lowest copay. The copay is from $0.00 to $3.35, depending on your income and level of Medical Assistance (Medicaid) eligibility. Tier 1 Brand drugs have a higher copay. The copay is from $0.00 to $8.35, depending on your income and level of Medical Assistance (Medicaid) eligibility. OTCs have a $0 copay. List of Covered Drugs The list of covered drugs below gives you information about the drugs covered by IMCare Classic. If you have trouble finding your drug in the list, turn to the Index that begins on page 165. The first column of the table lists the name of the drug. Generic drugs are listed in lower-case italics (e.g., citalopram), brand name drugs are capitalized (e.g., CELEBREX, and OTC drugs and products are listed in lower case (e.g., bayer). The information in the Necessary actions, restrictions, or limits on use column tells you if IMCare Classic has any rules for covering your drug.? If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 11

12 Key act actuation mcg microgram aer, aero aerosol meq milliequivalent cap capsules mg milligram chew tab chewable tablets ml milliliter conc concentrate nebu nebules conj conjugate NF non-formulary CR controlled-release odt, orally disintegrating orally disintegrating tablets tab crys crystals oint ointment DR delayed-release op, ophth ophthalmic deter deterrent pow, powd powder ec enteric coated pf preservative-free ER, extended, extended-release sl sublingual extended rel, XL, XR g, gm gram soln solution hr hour suppos suppositories IR immediate-release susp suspension inh, inhal inhalation sr sustained-release inj injection tab tablets im intramuscular td transdermal iv intravenous tl translingual liqd liquid unt unit LA long acting vac vaccine Here are the meanings of the codes used in the Necessary actions, restrictions, or limits on use column: (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 3. The generic version is in Tier 1. PA = Prior authorization (approval): you must have approval from the plan before you can get this drug. ST = Step therapy: you must try another drug before you can get this one.? If you have questions, IMCare Classic (HMO SNP) at or toll free at , TTY/TDD , Monday through Friday from 8:00 a.m. to 8:00 p.m. (Central Time Zone). The call is free. For more information, visit 12

13 IMCare 2T Stnd eff 11/01/2018 ANALGESICS GOUT allopurinol tab colchicine w/ probenecid COLCRYS $0/$3.70/$8.35 (TIER 1 BRAND) QL (120 tabs / 30 days), NM MITIGARE $0/$3.70/$8.35 (TIER 1 BRAND) QL (60 caps / 30 days), NM probenecid ULORIC $0/$3.70/$8.35 (TIER 1 BRAND) ST NSAIDS celecoxib CAPS 50mg QL (240 caps / 30 days) celecoxib CAPS 100mg QL (120 caps / 30 days) celecoxib CAPS 200mg QL (60 caps / 30 days) celecoxib CAPS 400mg QL (30 caps / 30 days) diclofenac potassium QL (120 tabs / 30 days) diclofenac sodium TB24; TBEC diflunisal etodolac etodolac er flurbiprofen TABS ibu tabs 600mg ibu tabs 800mg ibuprofen SUSP NM 13

14 ibuprofen TABS 400mg, 600mg, 800mg ketoprofen CAPS 50mg, 75mg meloxicam TABS nabumetone TABS naproxen SUSP; TABS naproxen dr naproxen sodium TABS 275mg, 550mg piroxicam CAPS sulindac TABS OPIOID ANALGESICS acetaminophen w/ codeine SOLN QL (5000 ml / 30 days), NM acetaminophen w/ codeine TABS QL (400 tabs / 30 days), NM butorphanol tartrate SOLN 1mg/ml, 2mg/ml NM nalbuphine hcl SOLN NM tramadol hcl TABS QL (240 tabs / 30 days), NM tramadol-acetaminophen QL (240 tabs / 30 days), NM OPIOID ANALGESICS, CII endocet QL (360 tabs / 30 days), NM fentanyl citrate LPOP QL (120 lozenges / 30 days), NM, PA 14

15 fentanyl patch 12 mcg/hr QL (10 patches / 30 days), NM fentanyl patch 25 mcg/hr QL (10 patches / 30 days), NM fentanyl patch 50 mcg/hr QL (10 patches / 30 days), NM, PA fentanyl patch 75 mcg/hr QL (10 patches / 30 days), NM, PA fentanyl patch 100 mcg/hr QL (10 patches / 30 days), NM, PA FENTORA $0/$3.70/$8.35 (TIER 1 BRAND) QL (120 tabs / 30 days), NM, PA hydroco/apap tab 5-325mg QL (360 tabs / 30 days), NM hydroco/apap tab QL (360 tabs / 30 days), NM hydroco/apap tab mg QL (360 tabs / 30 days), NM hydrocodone-acetaminophen mg/15ml hydrocodone-ibuprofen tab mg QL (5400 ml / 30 days), NM QL (150 tabs / 30 days), NM hydromorphone hcl LIQD NM hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml B/D, NM hydromorphone hcl TABS QL (270 tabs / 30 days), NM HYSINGLA ER 20mg, 30mg, 40mg, 60mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (60 tabs / 30 days), NM 15

16 HYSINGLA ER 80mg, 100mg, 120mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (30 tabs / 30 days), NM lorcet hd tab mg QL (360 tabs / 30 days), NM lorcet plus tab QL (360 tabs / 30 days), NM methadone hcl SOLN 5mg/5ml, 10mg/5ml QL (450 ml / 30 days), NM methadone hcl 5mg QL (180 tabs / 30 days), NM methadone hcl 10mg QL (180 tabs / 30 days), NM methadone hcl intensol QL (120 ml / 30 days), NM morphine ext-rel tab 15mg, 30mg, 60mg, 100mg QL (90 tabs / 30 days), NM morphine ext-rel tab 200mg QL (60 tabs / 30 days), NM morphine sul inj 1mg/ml B/D, NM MORPHINE SUL INJ 4MG/ML $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM morphine sul inj 10mg/ml B/D, NM MORPHINE SULFATE SOLN $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml, 150mg/30ml morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml B/D, NM morphine sulfate TABS QL (180 tabs / 30 days), NM morphine sulfate oral sol NM 16

17 NUCYNTA ER 50mg, 100mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (120 tabs / 30 days), NM NUCYNTA ER 150mg, 200mg, 250mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (60 tabs / 30 days), NM oxycodone hcl CAPS QL (180 caps / 30 days), NM oxycodone hcl CONC; SOLN NM oxycodone hcl TABS QL (180 tabs / 30 days), NM oxycodone w/ acetaminophen mg oxycodone w/ acetaminophen 5-325mg oxycodone w/ acetaminophen mg oxycodone w/ acetaminophen mg QL (360 tabs / 30 days), NM QL (360 tabs / 30 days), NM QL (360 tabs / 30 days), NM QL (360 tabs / 30 days), NM ANESTHETICS LOCAL ANESTHETICS lidocaine inj 0.5% B/D, NM lidocaine inj 0.5% preservative free (pf) B/D, NM lidocaine inj 1% B/D, NM lidocaine inj 1% preservative free (pf) lidocaine inj 1.5% preservative free (pf) B/D, NM B/D, NM lidocaine inj 2% B/D, NM ANTI-INFECTIVES 17

18 ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN NM gentamicin in saline NM gentamicin sulfate SOLN NM neomycin sulfate TABS NM paromomycin sulfate CAPS NM streptomycin sulfate SOLR NM SULFADIAZINE TABS $0/$3.70/$8.35 (TIER 1 BRAND) NM tobramycin NEBU NM, PA tobramycin inj 1.2 gm/30ml NM tobramycin inj 1.2gm NM tobramycin inj 10mg/ml NM tobramycin inj 40mg/ml NM tobramycin inj 80mg/2ml NM ANTI-INFECTIVES - MISCELLANEOUS ALBENZA $0/$3.70/$8.35 (TIER 1 BRAND) NM ALINIA $0/$3.70/$8.35 (TIER 1 BRAND) NM atovaquone SUSP NM AZACTAM IN ISO-OSMOTIC DE $0/$3.70/$8.35 (TIER 1 BRAND) NM AZACTAM/DEX INJ $0/$3.70/$8.35 (TIER 1 BRAND) NM aztreonam NM BILTRICIDE $0/$3.70/$8.35 (TIER 1 BRAND) NM CAYSTON $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA 18

19 clindamycin cap 75mg NM clindamycin cap 300mg NM clindamycin hcl cap 150 mg NM clindamycin phosphate in d5w NM CLINDAMYCIN PHOSPHATE IN NACL $0/$3.70/$8.35 (TIER 1 BRAND) NM clindamycin phosphate inj NM clindamycin soln 75mg/5ml NM colistimethate sodium SOLR NM dapsone TABS daptomycin 500mg NM EMVERM $0/$3.70/$8.35 (TIER 1 BRAND) NM ertapenem sodium NM imipenem-cilastatin NM INVANZ $0/$3.70/$8.35 (TIER 1 BRAND) NM ivermectin TABS NM linezolid NM linezolid in sodium chloride NM meropenem NM methenamine hippurate NM metronidazole TABS NM metronidazole in nacl NM NEBUPENT $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM 19

20 nitrofurantoin macrocrystal 50mg, 100mg NM, PA; PA applies if 65 years and older after a 90 day supply in a calendar year nitrofurantoin monohyd macro NM, PA; PA applies if 65 years and older after a 90 day supply in a calendar year PENTAM 300 $0/$3.70/$8.35 (TIER 1 BRAND) NM praziquantel TABS NM SIVEXTRO $0/$3.70/$8.35 (TIER 1 BRAND) NM sulfamethoxazole-trimethop ds NM sulfamethoxazole-trimethoprim NM sulfamethoxazole-trimethoprim inj NM SYNERCID $0/$3.70/$8.35 (TIER 1 BRAND) NM TIGECYCLINE 50mg NM TIGECYCLINE 50mg $0/$3.70/$8.35 (TIER 1 BRAND) NM trimethoprim TABS NM vancomycin hcl CAPS NM vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg NM VANCOMYCIN IN NACL $0/$3.70/$8.35 (TIER 1 BRAND) NM ANTIFUNGALS ABELCET $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM AMBISOME $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM amphotericin b SOLR B/D, NM CANCIDAS $0/$3.70/$8.35 (TIER 1 BRAND) NM 20

21 CASPOFUNGIN ACETATE 50mg, 70mg CASPOFUNGIN ACETATE 50mg, 70mg NM $0/$3.70/$8.35 (TIER 1 BRAND) NM fluconazole SUSR; TABS NM fluconazole in dextrose NM FLUCONAZOLE INJ NACL 100 $0/$3.70/$8.35 (TIER 1 BRAND) NM fluconazole inj nacl 200 NM fluconazole inj nacl 400 NM flucytosine CAPS NM griseofulvin microsize NM griseofulvin ultramicrosize NM itraconazole CAPS NM, PA ketoconazole TABS NM, PA MYCAMINE $0/$3.70/$8.35 (TIER 1 BRAND) NM NOXAFIL SUSP $0/$3.70/$8.35 (TIER 1 BRAND) QL (630 ml / 30 days) NOXAFIL TBEC $0/$3.70/$8.35 (TIER 1 BRAND) QL (93 tabs / 30 days) nystatin TABS NM terbinafine hcl TABS QL (90 tabs / 365 days), NM voriconazole SOLR; SUSR; TABS NM ANTIMALARIALS atovaquone-proguanil hcl NM chloroquine phosphate TABS COARTEM $0/$3.70/$8.35 (TIER 1 BRAND) NM 21

22 mefloquine hcl PRIMAQUINE PHOSPHATE $0/$3.70/$8.35 (TIER 1 BRAND) NM quinine sulfate CAPS NM, PA ANTIRETROVIRAL AGENTS abacavir sulfate NM APTIVUS $0/$3.70/$8.35 (TIER 1 BRAND) NM atazanavir sulfate NM CRIXIVAN $0/$3.70/$8.35 (TIER 1 BRAND) NM didanosine NM EDURANT $0/$3.70/$8.35 (TIER 1 BRAND) NM efavirenz NM EMTRIVA $0/$3.70/$8.35 (TIER 1 BRAND) NM fosamprenavir tab 700 mg NM FUZEON $0/$3.70/$8.35 (TIER 1 BRAND) NM INTELENCE $0/$3.70/$8.35 (TIER 1 BRAND) NM INVIRASE $0/$3.70/$8.35 (TIER 1 BRAND) NM ISENTRESS $0/$3.70/$8.35 (TIER 1 BRAND) NM ISENTRESS HD $0/$3.70/$8.35 (TIER 1 BRAND) NM lamivudine NM LEXIVA $0/$3.70/$8.35 (TIER 1 BRAND) NM nevirapine susp 50 mg/5ml NM nevirapine tab 100mg NM nevirapine tab 200mg NM nevirapine tab 400mg er NM 22

23 NORVIR $0/$3.70/$8.35 (TIER 1 BRAND) NM PREZISTA SUSP $0/$3.70/$8.35 (TIER 1 BRAND) QL (400 ml / 30 days), NM PREZISTA TABS 75mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (480 tabs / 30 days), NM PREZISTA TABS 150mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (240 tabs / 30 days), NM PREZISTA TABS 600mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (60 tabs / 30 days), NM PREZISTA TABS 800mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (30 tabs / 30 days), NM RESCRIPTOR $0/$3.70/$8.35 (TIER 1 BRAND) NM RETROVIR IV INFUSION $0/$3.70/$8.35 (TIER 1 BRAND) NM REYATAZ PACK $0/$3.70/$8.35 (TIER 1 BRAND) NM ritonavir NM SELZENTRY $0/$3.70/$8.35 (TIER 1 BRAND) NM stavudine NM SUSTIVA TABS $0/$3.70/$8.35 (TIER 1 BRAND) NM tenofovir disoproxil fumarate NM TIVICAY $0/$3.70/$8.35 (TIER 1 BRAND) NM TROGARZO $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA TYBOST $0/$3.70/$8.35 (TIER 1 BRAND) NM VIDEX EC 125mg $0/$3.70/$8.35 (TIER 1 BRAND) NM VIDEX PEDIATRIC $0/$3.70/$8.35 (TIER 1 BRAND) NM VIRACEPT $0/$3.70/$8.35 (TIER 1 BRAND) NM VIRAMUNE SUSP $0/$3.70/$8.35 (TIER 1 BRAND) NM 23

24 VIREAD $0/$3.70/$8.35 (TIER 1 BRAND) NM ZERIT SOLR $0/$3.70/$8.35 (TIER 1 BRAND) NM zidovudine cap 100mg NM zidovudine syp 50mg/5ml NM zidovudine tab 300mg NM ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine NM abacavir sulfate-lamivudinezidovudine NM ATRIPLA $0/$3.70/$8.35 (TIER 1 BRAND) NM BIKTARVY $0/$3.70/$8.35 (TIER 1 BRAND) NM CIMDUO $0/$3.70/$8.35 (TIER 1 BRAND) NM COMPLERA $0/$3.70/$8.35 (TIER 1 BRAND) NM DESCOVY $0/$3.70/$8.35 (TIER 1 BRAND) NM EVOTAZ $0/$3.70/$8.35 (TIER 1 BRAND) NM GENVOYA $0/$3.70/$8.35 (TIER 1 BRAND) NM JULUCA $0/$3.70/$8.35 (TIER 1 BRAND) NM KALETRA TAB MG $0/$3.70/$8.35 (TIER 1 BRAND) NM KALETRA TAB MG $0/$3.70/$8.35 (TIER 1 BRAND) NM lamivudine-zidovudine NM lopinavir-ritonavir NM ODEFSEY $0/$3.70/$8.35 (TIER 1 BRAND) NM PREZCOBIX $0/$3.70/$8.35 (TIER 1 BRAND) NM STRIBILD $0/$3.70/$8.35 (TIER 1 BRAND) NM 24

25 SYMFI $0/$3.70/$8.35 (TIER 1 BRAND) NM SYMFI LO $0/$3.70/$8.35 (TIER 1 BRAND) NM SYMTUZA $0/$3.70/$8.35 (TIER 1 BRAND) NM TRIUMEQ $0/$3.70/$8.35 (TIER 1 BRAND) NM TRUVADA TAB $0/$3.70/$8.35 (TIER 1 BRAND) QL (60 tabs / 30 days), NM TRUVADA TAB $0/$3.70/$8.35 (TIER 1 BRAND) QL (30 tabs / 30 days), NM TRUVADA TAB $0/$3.70/$8.35 (TIER 1 BRAND) QL (30 tabs / 30 days), NM TRUVADA TAB $0/$3.70/$8.35 (TIER 1 BRAND) QL (30 tabs / 30 days), NM ANTITUBERCULAR AGENTS CAPASTAT SULFATE $0/$3.70/$8.35 (TIER 1 BRAND) NM cycloserine CAPS NM ethambutol hcl TABS NM isoniazid TABS isoniazid inj 100 mg/ml NM isoniazid syp 50mg/5ml PASER D/R $0/$3.70/$8.35 (TIER 1 BRAND) NM PRIFTIN $0/$3.70/$8.35 (TIER 1 BRAND) NM pyrazinamide TABS NM rifabutin NM rifampin CAPS; SOLR NM RIFATER $0/$3.70/$8.35 (TIER 1 BRAND) NM SIRTURO $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA 25

26 TRECATOR $0/$3.70/$8.35 (TIER 1 BRAND) NM ANTIVIRALS acyclovir CAPS; SUSP; TABS NM acyclovir sodium B/D, NM adefovir dipivoxil NM BARACLUDE SOLN $0/$3.70/$8.35 (TIER 1 BRAND) NM DAKLINZA $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA entecavir NM EPCLUSA $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA EPIVIR HBV SOLN $0/$3.70/$8.35 (TIER 1 BRAND) NM famciclovir TABS NM ganciclovir inj 500mg B/D, NM GANCICLOVIR INJ 500MG/10ML $0/$3.70/$8.35 (TIER 1 BRAND) B/D HARVONI $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA lamivudine (hbv) NM MAVYRET $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA moderiba tab 200mg NM oseltamivir phosphate CAPS 30mg oseltamivir phosphate CAPS 45mg, 75mg QL (168 caps / year), NM QL (84 caps / year), NM oseltamivir phosphate SUSR QL (1080 ml / year), NM PEGASYS $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA PEGASYS PROCLICK $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA 26

27 REBETOL SOLN $0/$3.70/$8.35 (TIER 1 BRAND) NM RELENZA DISKHALER $0/$3.70/$8.35 (TIER 1 BRAND) QL (6 inhalers / year), NM ribasphere NM ribavirin 200mg NM rimantadine hydrochloride NM SOVALDI $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA valacyclovir hcl TABS NM valganciclovir hcl VEMLIDY $0/$3.70/$8.35 (TIER 1 BRAND) NM VOSEVI $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA ZEPATIER $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA CEPHALOSPORINS cefaclor NM CEFACLOR MONOHYDRATE ER $0/$3.70/$8.35 (TIER 1 BRAND) NM cefadroxil NM CEFAZOLIN IN DEXTROSE 2GM/100ML-4% $0/$3.70/$8.35 (TIER 1 BRAND) NM cefazolin inj NM cefazolin sodium SOLR 1gm, 20gm CEFAZOLIN SODIUM 1 GM/50ML NM $0/$3.70/$8.35 (TIER 1 BRAND) NM cefdinir NM cefepime hcl NM 27

28 cefixime NM cefotaxime sodium NM cefoxitin sodium NM cefpodoxime proxetil NM cefprozil NM ceftazidime SOLR NM CEFTAZIDIME/DEXTROSE $0/$3.70/$8.35 (TIER 1 BRAND) NM ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg NM cefuroxime axetil NM cefuroxime sodium NM cephalexin CAPS 250mg, 500mg NM cephalexin SUSR NM SUPRAX CAPS $0/$3.70/$8.35 (TIER 1 BRAND) NM SUPRAX CHEW $0/$3.70/$8.35 (TIER 1 BRAND) NM SUPRAX SUSR 500mg/5ml $0/$3.70/$8.35 (TIER 1 BRAND) NM tazicef SOLR NM TEFLARO $0/$3.70/$8.35 (TIER 1 BRAND) NM ERYTHROMYCINS/MACROLIDES azithromycin PACK; SOLR; SUSR; TABS NM clarithromycin TABS NM clarithromycin er NM clarithromycin for susp NM DIFICID $0/$3.70/$8.35 (TIER 1 BRAND) NM 28

29 e.e.s 400 NM ery-tab NM ERYTHROCIN LACTOBIONATE $0/$3.70/$8.35 (TIER 1 BRAND) NM erythrocin stearate NM erythromycin base NM erythromycin cap 250mg ec NM erythromycin ethylsuccinate TABS NM FLUOROQUINOLONES ciprofloxacin SUSR NM ciprofloxacin hcl tab NM ciprofloxacin in d5w NM levofloxacin TABS NM levofloxacin in d5w NM levofloxacin inj 25mg/ml NM levofloxacin oral soln 25 mg/ml NM PENICILLINS amoxicillin NM amoxicillin & pot clavulanate NM ampicillin & sulbactam sodium NM ampicillin cap 250mg NM ampicillin cap 500mg NM ampicillin inj NM ampicillin sodium NM 29

30 ampicillin susp NM BICILLIN L-A $0/$3.70/$8.35 (TIER 1 BRAND) NM dicloxacillin sodium NM nafcillin sodium NM oxacillin sodium NM PENICILLIN G POT IN DEXTROSE 2MU PENICILLIN G POT IN DEXTROSE 3MU $0/$3.70/$8.35 (TIER 1 BRAND) NM $0/$3.70/$8.35 (TIER 1 BRAND) NM PENICILLIN G PROCAINE $0/$3.70/$8.35 (TIER 1 BRAND) NM penicillin g sodium NM penicillin v potassium NM penicilln gk inj 5mu NM penicilln gk inj 20mu NM pfizerpen-g inj 5mu NM pfizerpen-g inj 20mu NM piper/tazoba inj gm NM piper/tazoba inj gm NM piper/tazoba inj 4-0.5gm NM PIPER/TAZOBA INJ GM $0/$3.70/$8.35 (TIER 1 BRAND) NM piper/tazoba inj gm NM TETRACYCLINES doxy 100 NM doxycycline (monohydrate) CAPS 50mg, 100mg NM 30

31 doxycycline (monohydrate) TABS NM doxycycline hyclate CAPS NM doxycycline hyclate SOLR NM doxycycline hyclate TABS 20mg, 100mg NM minocycline hcl CAPS NM morgidox cap 1x50mg NM ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM busulfan B/D, NM CYCLOPHOSPHAMIDE CAPS 25mg, 50mg CYCLOPHOSPHAMIDE CAPS 25mg, 50mg B/D, NM $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM cyclophosphamide SOLR B/D, NM dacarbazine B/D, NM EMCYT $0/$3.70/$8.35 (TIER 1 BRAND) NM GLEOSTINE $0/$3.70/$8.35 (TIER 1 BRAND) NM HEXALEN $0/$3.70/$8.35 (TIER 1 BRAND) NM IFEX INJ 3GM $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM ifosfamide inj 1gm B/D, NM ifosfamide inj 1gm/20ml B/D, NM IFOSFAMIDE INJ 3GM $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM ifosfamide inj 3gm/60ml B/D, NM 31

32 LEUKERAN $0/$3.70/$8.35 (TIER 1 BRAND) NM melphalan hcl B/D, NM MUSTARGEN $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM ANTHRACYCLINES adriamycin B/D, NM doxorubicin hcl B/D, NM doxorubicin hcl liposomal inj 2mg/ml B/D, NM doxorubicin hcl soln 2mg/ml B/D, NM epirubicin hcl B/D, NM ANTIBIOTICS bleomycin sulfate B/D, NM mitomycin SOLR B/D, NM ANTIMETABOLITES adrucil B/D, NM ALIMTA $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM azacitidine B/D, NM cladribine B/D, NM cytarabine 20mg/ml B/D, NM fludarabine phosphate B/D, NM fluorouracil SOLN B/D, NM gemcitabine inj soln B/D, NM gemcitabine inj solr B/D, NM mercaptopurine TABS NM 32

33 methotrexate sodium inj B/D, NM NIPENT $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM PURIXAN $0/$3.70/$8.35 (TIER 1 BRAND) NM TABLOID $0/$3.70/$8.35 (TIER 1 BRAND) NM ANTIMITOTIC, TAXOIDS ABRAXANE $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM docetaxel CONC 20mg/ml, 80mg/4ml DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml docetaxel SOLN 20mg/2ml, 80mg/8ml DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml DOCETAXEL SOLN 160mg/16ml B/D, NM $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM B/D, NM $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM B/D, NM paclitaxel B/D, NM TAXOTERE 80mg/4ml $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate B/D, NM vincasar pfs B/D, NM vincristine sulfate B/D, NM vinorelbine tartrate B/D, NM BIOLOGIC RESPONSE MODIFIERS AVASTIN $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA BELEODAQ $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA 33

34 BORTEZOMIB $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA ERIVEDGE $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA FARYDAK $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA HERCEPTIN $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA IBRANCE $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA IDHIFA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA KADCYLA $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM KEYTRUDA $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA KISQALI $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA KISQALI FEMARA 200 DOSE $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA KISQALI FEMARA 400 DOSE $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA KISQALI FEMARA 600 DOSE $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA LYNPARZA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA MYLOTARG $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA NINLARO $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA ODOMZO $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA RITUXAN $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA RITUXAN HYCELA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA RUBRACA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA TECENTRIQ $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA TIBSOVO $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA VELCADE $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA VENCLEXTA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA VENCLEXTA STARTING PACK $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA 34

35 VERZENIO $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA YERVOY $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA ZEJULA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA ZOLINZA $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS bicalutamide NM DEPO-PROVERA INJ 400/ML $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM ERLEADA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA exemestane FARESTON $0/$3.70/$8.35 (TIER 1 BRAND) FASLODEX $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM flutamide NM hydroxyprogesterone caproate (antineoplastic) letrozole TABS B/D, NM leuprolide inj 1mg/0.2 NM, PA LUPRON DEPOT (1-MONTH) 3.75mg LUPRON DEPOT INJ 11.25MG (3-MONTH) $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA LYSODREN $0/$3.70/$8.35 (TIER 1 BRAND) NM megestrol ac sus 40mg/ml NM, PA; PA if 65 years and older megestrol ac tab 20mg NM, PA; PA if 65 years and older 35

36 megestrol ac tab 40mg NM, PA; PA if 65 years and older megestrol sus 625mg/5ml PA nilutamide NM SOLTAMOX tamoxifen citrate TABS $0/$3.70/$8.35 (TIER 1 BRAND) TRELSTAR DEP INJ 3.75MG $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA TRELSTAR LA INJ 11.25MG $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA XTANDI $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA ZYTIGA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA IMMUNOMODULATORS POMALYST CAP 1MG $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA POMALYST CAP 2MG $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA POMALYST CAP 3MG $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA POMALYST CAP 4MG $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA REVLIMID $0/$3.70/$8.35 (TIER 1 BRAND) QL (28 caps / 28 days), NM, LA, PA THALOMID 50mg, 100mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (30 caps / 30 days), NM, PA THALOMID 150mg, 200mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (60 caps / 30 days), NM, PA KINASE INHIBITORS AFINITOR $0/$3.70/$8.35 (TIER 1 BRAND) QL (30 tabs / 30 days), NM, PA AFINITOR DISPERZ 2mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (150 tabs / 30 days), NM, PA 36

37 AFINITOR DISPERZ 3mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (90 tabs / 30 days), NM, PA AFINITOR DISPERZ 5mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (60 tabs / 30 days), NM, PA ALECENSA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA ALUNBRIG $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA BOSULIF $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA BRAFTOVI $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA CABOMETYX $0/$3.70/$8.35 (TIER 1 BRAND) QL (30 tabs / 30 days), NM, LA, PA CALQUENCE $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA CAPRELSA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA COMETRIQ $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA COTELLIC $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA GILOTRIF TAB 20MG $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA GILOTRIF TAB 30MG $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA GILOTRIF TAB 40MG $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA ICLUSIG $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA imatinib mesylate 100mg QL (90 tabs / 30 days), NM, PA imatinib mesylate 400mg QL (60 tabs / 30 days), NM, PA IMBRUVICA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA INLYTA 1mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (180 tabs / 30 days), NM, LA, PA INLYTA 5mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (120 tabs / 30 days), NM, LA, PA 37

38 IRESSA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA JAKAFI $0/$3.70/$8.35 (TIER 1 BRAND) QL (60 tabs / 30 days), NM, LA, PA LENVIMA 4 MG DAILY DOSE $0/$3.70/$8.35 (TIER 1 BRAND) LENVIMA 8 MG DAILY DOSE $0/$3.70/$8.35 (TIER 1 BRAND) LENVIMA 10 MG DAILY DOSE $0/$3.70/$8.35 (TIER 1 BRAND) LENVIMA 12MG DAILY DOSE $0/$3.70/$8.35 (TIER 1 BRAND) LENVIMA 14 MG DAILY DOSE $0/$3.70/$8.35 (TIER 1 BRAND) LENVIMA 18 MG DAILY DOSE $0/$3.70/$8.35 (TIER 1 BRAND) LENVIMA 20 MG DAILY DOSE $0/$3.70/$8.35 (TIER 1 BRAND) LENVIMA 24 MG DAILY DOSE $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA MEKINIST $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA MEKTOVI $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA NERLYNX $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA NEXAVAR $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA RYDAPT $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA SPRYCEL $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA STIVARGA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA SUTENT $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA TAFINLAR $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA TAGRISSO $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA TARCEVA 25mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (90 tabs / 30 days), NM, LA, PA TARCEVA 100mg, 150mg $0/$3.70/$8.35 (TIER 1 BRAND) QL (30 tabs / 30 days), NM, LA, PA 38

39 TASIGNA $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA TYKERB $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA VOTRIENT $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA XALKORI $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA ZELBORAF $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA ZYDELIG $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA ZYKADIA $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA, PA MISCELLANEOUS bexarotene NM, PA DROXIA $0/$3.70/$8.35 (TIER 1 BRAND) hydroxyurea CAPS NM LONSURF $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA MATULANE $0/$3.70/$8.35 (TIER 1 BRAND) NM, LA mitoxantrone hcl B/D, NM SYLATRON KIT 200MCG $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA SYLATRON KIT 300MCG $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA SYLATRON KIT 600MCG $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA SYNRIBO $0/$3.70/$8.35 (TIER 1 BRAND) NM, PA tretinoin (chemotherapy) NM TRISENOX $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM PLATINUM-BASED AGENTS carboplatin B/D, NM cisplatin B/D, NM oxaliplatin inj 50mg B/D, NM 39

40 oxaliplatin inj 50mg/10ml B/D, NM oxaliplatin inj 100mg B/D, NM oxaliplatin inj 100mg/20ml B/D, NM PROTECTIVE AGENTS dexrazoxane B/D, NM ELITEK $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM leucovorin calcium SOLR B/D, NM leucovorin calcium TABS NM levoleucovorin calcium 175mg/17.5ml, 250mg/25ml B/D, NM LEVOLEUCOVORIN CALCIUM 250mg/25ml $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM levoleucovorin calcium 50mg B/D, NM LEVOLEUCOVORIN CALCIUM 175MG $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM mesna B/D, NM MESNEX TABS $0/$3.70/$8.35 (TIER 1 BRAND) NM TOPOISOMERASE INHIBITORS etoposide SOLN B/D, NM irinotecan hcl B/D, NM toposar B/D, NM topotecan inj 4mg B/D, NM TOPOTECAN INJ 4MG/4ML $0/$3.70/$8.35 (TIER 1 BRAND) B/D, NM CARDIOVASCULAR ACE INHIBITOR COMBINATIONS 40

41 amlodipine--benazepril hcl cap mg amlodipine-benazepril hcl cap mg amlodipine-benazepril hcl cap 5-10 mg amlodipine-benazepril hcl cap 5-20 mg amlodipine-benazepril hcl cap 5-40 mg amlodipine-benazepril hcl cap 10-40mg benazepril & hydrochlorothiazide captopril & hydrochlorothiazide enalapril maleate & hydrochlorothiazide fosinopril sodium & hydrochlorothiazide lisinopril & hydrochlorothiazide moexipril-hydrochlorothiazide quinapril-hydrochlorothiazide ACE INHIBITORS benazepril hcl TABS captopril TABS enalapril maleate TABS fosinopril sodium lisinopril TABS 41

42 moexipril hcl perindopril erbumine quinapril hcl ramipril trandolapril ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone spironolactone TABS ALPHA BLOCKERS doxazosin mesylate TABS 1mg, 2mg, 4mg doxazosin mesylate TABS 8mg prazosin hcl terazosin hcl QL (30 tabs / 30 days) ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine-valsartanhydrochlorothiazide mg 42

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