CareFirst Exchange Formulary

Transcription

1 CareFirst Exchange Formulary 2019 PLEASE READ: This document contains information about the drugs we cover in this plan. This formulary is for: Individuals or families purchasing their own plan with an effective date of January 1, 2019 or after, and embers of an employer group with less than 51 employees purchasing a plan with an effective date of January 1, 2019 or after This formulary was updated 03/01/2019. For more recent information or other questions, please contact CareFirst Pharmacy Services at or visit carefirst.com/rx. Last updated 03/01/2019

2 Introduction A formulary is a list of covered prescription drugs. Our drug list is reviewed and approved by an independent national committee comprised of physicians, pharmacists and other health care professionals, known as the Pharmacy and Therapeutics Committee. This committee makes sure the drugs on the formulary are safe and clinically effective. Within the formulary, prescription drugs are divided into tiers as described below. Depending on your plan, prescription drugs fall into one of five drug tiers which determines the price you pay. Using Your Formulary The first column of the formulary lists drugs by name. If the drugs are shown in lowercase italics, they are generic drugs. If the drugs are bold and capitalized, they are BRAND-NAE DRUGS. If the brand drug has a generic drug option available, it is listed under the brand-name drug. You may search the formulary for a drug by pressing CTRL and F at the same time to prompt a search. The second column indicates the drug tier for a covered drug. The third column indicates any prescription guidelines a drug requires such as prior authorization (), step therapy (ST) or quantity limits (QL). Prior Authorization from CareFirst is required before you fill prescriptions for certain drugs. Your doctor may need to provide some of your medical history or laboratory tests to determine if these medications are appropriate. Without prior authorization from CareFirst, your drugs may not be covered. Step Therapy requires that you try lowercost, equally effective drugs that treat the same medical condition before trying a higher-cost alternative. Your doctor will need to provide information to CareFirst about your experience with these alternatives prior to dispensing a more expensive drug. Quantity Limits have been placed on the use of selected drugs for quality or safety reasons. Limits may be placed on the amount of the drug covered per prescription or for a defined period of time. embers can view specific cost-share (copay or coinsurance) information and prescription guidelines by logging in to y Account at carefirst.com/myaccount and clicking on Tools and Drug Pricing Tool or by reviewing their annual summary of benefits. Tier 0: $0 Drugs Tier 1: Generic Drugs $ Tier 2: Preferred Brand Drugs $$ Tier 3: Non-preferred Brand Drugs $$$ Tier 4: Preferred Specialty Drugs $$$$ Tier 5: Non-Preferred Specialty Drugs $$$$ Preventive drugs (e.g. statins, aspirin, folic acid, fluoride, iron supplements, smoking cessation products and FDA-approved contraceptives for women) are available at a zero-dollar cost share if prescribed under certain medical criteria by your doctor. Oral chemotherapy drugs and diabetic supplies (e.g. insulin syringes, pen needles, lancets, test strips, and alcohol swabs) are also available at a zero-dollar cost share. Generic drugs are the same as brand-name drugs in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. Generic drugs generally cost less than brand-name drugs. Preferred brand drugs are brand-name drugs that do not have a generic equivalent. They are chosen for their cost-effectiveness compared to alternatives. Your cost-share will be more than generic drugs but less than non-preferred brand drugs. If a generic drug becomes available, the preferred brand drug may be moved to the non-preferred brand tier. Non-preferred brand drugs often have a generic or preferred brand drug option where your cost-share will be lower. Preferred specialty drugs are generic and brand-name drugs that are used to treat chronic, complex, and/or rare health conditions. Preferred specialty drugs may have a lower cost-share than non-preferred specialty drugs. Non-preferred specialty drugs have a more cost-effective preferred generic or brand specialty drug alternative available.

3 CareFirst Exchange Formulary - 5-Tier eff 03/01/2019 ANALGESICS COX-2 INHIBITORS celecoxib cap 50 1 celecoxib cap celecoxib cap celecoxib cap GOUT allopurinol sodium for inj 500 allopurinol tab allopurinol tab colchicine tab colchicine w/ probenecid tab probenecid tab ULORIC TAB 40G 3 ST; ** ULORIC TAB 80G 3 ST; ** NON-OPIOID ANALGESICS butalbital-acetaminophen-caffeine cap 1 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine cap 1 QL (48 caps / 25 days) butalbital-acetaminophen-caffeine tab 1 QL (48 tabs / 25 days) butalbital-aspirin-caffeine cap QL (48 caps / 25 days) tencon tab QL (48 tabs / 25 days) NSAIDS, COBINATIONS diclofenac w/ misoprostol tab delayed 1 release diclofenac w/ misoprostol tab delayed 1 release NSAIDS diclofenac potassium tab 50 1 diclofenac sodium tab delayed release 25 1 diclofenac sodium tab delayed release 50 1 diclofenac sodium tab delayed release 75 1 diclofenac sodium tab er 24hr

4 etodolac cap etodolac cap etodolac tab etodolac tab etodolac tab er 24hr etodolac tab er 24hr etodolac tab er 24hr fenoprofen calcium cap fenoprofen calcium tab flurbiprofen tab 50 1 flurbiprofen tab ibuprofen susp 100 /5ml 1 ibuprofen tab ibuprofen tab ibuprofen tab indomethacin cap 25 1 indomethacin cap 50 1 ketoprofen cap er 24hr ketorolac tromethamine im inj 60 /2ml (30 /ml) ketorolac tromethamine inj 15 /ml ketorolac tromethamine inj 30 /ml ketorolac tromethamine tab 10 1 QL (20 tabs / 25 days) meclofenamate sodium cap 50 1 meclofenamate sodium cap mefenamic acid cap meloxicam tab meloxicam tab 15 1 nabumetone tab nabumetone tab naproxen dr tab naproxen dr tab naproxen tab naproxen tab naproxen tab oxaprozin tab piroxicam cap 10 1 piroxicam cap 20 1 sulindac tab sulindac tab tolmetin sodium cap

5 tolmetin sodium tab tolmetin sodium tab OPIOID AGONIST/ANTAGONIST buprenorphine hcl-naloxone hcl sl tab (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 (base equiv) 1 QL (90 tabs / 25 days); ust obtain approval after the initial fill 1 QL (90 tabs / 25 days); ust obtain approval after the initial fill SUBOXONE IS 2-0.5G 2 QL (90 units / 25 days) SUBOXONE IS 4-1G 2 QL (90 units / 25 days) SUBOXONE IS 8-2G 2 QL (90 units / 25 days) SUBOXONE IS 12-3G 2 QL (60 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (90 units / 25 days) ZUBSOLV SUB QL (60 units / 25 days) ZUBSOLV SUB QL (30 units / 25 days) OPIOID ANALGESICS acetaminophen w/ codeine soln /5ml acetaminophen w/ codeine tab acetaminophen w/ codeine tab acetaminophen w/ codeine tab QL (2700 ml / 25 days), ST; Subject to initial 7-day limit QL (400 tabs / 25 days), ST; Subject to initial 7-day limit QL (360 tabs / 25 days), ST; Subject to initial 7-day limit QL (180 tabs / 25 days), ST; Subject to initial 7-day limit 1 QL (48 caps / 25 days) butalbital-acetaminophen-caff w/ cod cap butorphanol tartrate inj 1 /ml butorphanol tartrate inj 2 /ml butorphanol tartrate nasal soln 10 /ml 1 QL (2 bottles / 25 days) CAPITAL/COD SUS /5 3 QL (2700 ml / 25 days), ST; Subject to initial 7-day limit 3

6 codeine sulfate tab 15 1 QL (42 tabs / 25 days), ST; Subject to initial 7-day limit codeine sulfate tab 30 1 QL (42 tabs / 25 days), ST; Subject to initial 7-day limit codeine sulfate tab 60 1 QL (42 tabs / 25 days), ST; Subject to initial 7-day limit EBEDA CAP G 2 QL (60 caps / 25 days), ST EBEDA CAP G 2 QL (60 caps / 25 days), ST EBEDA CAP 50-2G 2 QL (30 caps / 25 days), ST EBEDA CAP G 2 QL (30 caps / 25 days), ST EBEDA CAP G 2 QL (30 caps / 25 days), ST EBEDA CAP 100-4G 2, ST; High Strength Requires endocet tab QL (360 tabs / 25 days), ST; Subject to initial 7-day limit endocet tab QL (360 tabs / 25 days), ST; Subject to initial 7-day limit endocet tab QL (240 tabs / 25 days), ST; Subject to initial 7-day limit endocet tab QL (180 tabs / 25 days), ST; Subject to initial 7-day limit fentanyl citrate lozenge on a handle 200 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 400 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 600 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 800 mcg 1 QL (120 lozenges / 25 days), fentanyl citrate lozenge on a handle 1200 mcg 1 QL (120 lozenges / 25 days), 4

7 fentanyl citrate lozenge on a handle 1600 mcg 1 QL (120 lozenges / 25 days), fentanyl td patch 72hr 12 mcg/hr 1 QL (10 patches / 25 days), ST fentanyl td patch 72hr 25 mcg/hr 1 QL (10 patches / 25 days), ST fentanyl td patch 72hr 50 mcg/hr 1, ST; High Strength Requires fentanyl td patch 72hr 75 mcg/hr 1, ST; High Strength Requires fentanyl td patch 72hr 100 mcg/hr 1, ST; High Strength Requires hydrocodone-acetaminophen soln /15ml hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab hydrocodone-acetaminophen tab QL (2700 ml / 25 days), ST; Subject to initial 7-day limit QL (240 tabs / 25 days), ST; Subject to initial 7-day limit 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit HYDROORPHON SUP 3G 3 QL (120 suppositories / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl inj 1 /ml hydromorphone hcl inj 2 /ml hydromorphone hcl inj 4 /ml hydromorphone hcl liqd 1 /ml 1 QL (600 ml / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl preservative free (pf) inj 10 /ml hydromorphone hcl tab 2 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl tab 4 1 QL (150 tabs / 25 days), ST; Subject to initial 7-day limit 5

8 hydromorphone hcl tab 8 1 QL (60 tabs / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl tab er 24hr deter 8 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 12 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 16 1 QL (30 tabs / 25 days), ST hydromorphone hcl tab er 24hr deter 32 1, ST; High Strength Requires HYSINGLA ER TAB 20 G 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 30 G 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 40 G 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 60 G 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 80 G 2 QL (30 tabs / 25 days), ST HYSINGLA ER TAB 100 G 2, ST; High Strength Requires HYSINGLA ER TAB 120 G 2, ST; High Strength Requires lortab tab QL (180 tabs / 25 days), ST; Subject to initial 7-day limit methadone con 10/ml 1 QL (60 ml / 25 days), ST; (generic of ethadone Intensol, indicated for pain) methadone hcl conc 10 /ml 1 QL (30 ml / 25 days); (indicated for opioid addiction) methadone hcl inj 10 /ml methadone hcl soln 5 /5ml 1 QL (450 ml / 25 days), ST methadone hcl soln 10 /5ml 1 QL (300 ml / 25 days), ST methadone hcl tab 5 1 QL (90 tabs / 25 days), ST 6

9 methadone hcl tab 10 1 QL (60 tabs / 25 days), ST methadone hcl tab for oral susp 40 1 QL (9 tabs / 25 days) methadose tab 40 1 QL (9 tabs / 25 days) ORPHINE SUL INJ 2G/L ORPHINE SUL INJ 4G/L ORPHINE SUL INJ 5G/L ORPHINE SUL INJ 150/30L morphine sulfate beads cap er 24hr 30 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 45 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 60 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 75 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 90 1 QL (30 caps / 25 days), ST morphine sulfate beads cap er 24hr 120 1, ST; High Strength Requires morphine sulfate cap er 24hr 10 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 20 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 30 1 QL (60 caps / 25 days), ST morphine sulfate cap er 24hr 50 1 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 60 1 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 80 1 QL (30 caps / 25 days), ST morphine sulfate cap er 24hr 100 1, ST; High Strength Requires morphine sulfate inj 8 /ml morphine sulfate inj 10 /ml morphine sulfate inj pf 0.5 /ml morphine sulfate inj pf 1 /ml morphine sulfate iv soln 1 /ml morphine sulfate iv soln pf 4 /ml morphine sulfate iv soln pf 8 /ml morphine sulfate iv soln pf 10 /ml 7

10 morphine sulfate iv soln pf 15 /ml morphine sulfate oral soln 10 /5ml 1 QL (900 ml / 25 days), ST; Subject to initial 7-day limit morphine sulfate oral soln 20 /5ml 1 QL (675 ml / 25 days), ST; Subject to initial 7-day limit morphine sulfate oral soln 100 /5ml (20 1 QL (135 ml / 25 days), /ml) ST; Subject to initial 7-day limit morphine sulfate suppos 5 1 QL (180 suppositories / 25 days), ST; Subject to initial 7-day limit morphine sulfate suppos 10 1 QL (180 suppositories / 25 days), ST; Subject to initial 7-day limit morphine sulfate suppos 20 1 QL (120 supp / 25 days), ST; Subject to initial 7-day limit ORPHINE SULFATE SUPPOS 30 G 1 QL (90 supp / 25 days), ST; Subject to initial 7-day limit morphine sulfate tab 15 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit morphine sulfate tab 30 1 QL (90 tabs / 25 days), ST; Subject to initial 7-day limit morphine sulfate tab er 15 1 QL (90 tabs / 25 days), ST morphine sulfate tab er 30 1 QL (90 tabs / 25 days), ST morphine sulfate tab er 60 1, ST; High Strength Requires morphine sulfate tab er 100 1, ST; High Strength Requires morphine sulfate tab er 200 1, ST; High Strength Requires nalbuphine hcl inj 10 /ml nalbuphine hcl inj 20 /ml NUCYNTA ER TAB 50G 2 QL (60 tabs / 25 days), ST 8

11 NUCYNTA ER TAB 100G 2 QL (60 tabs / 25 days), ST NUCYNTA ER TAB 150G 2, ST; High Strength Requires NUCYNTA ER TAB 200G 2, ST; High Strength Requires NUCYNTA ER TAB 250G 2, ST; High Strength Requires NUCYNTA TAB 50G 2 QL (120 tabs / 25 days), ST; Subject to initial 7-day limit NUCYNTA TAB 75G 2 QL (90 tabs / 25 days), ST; Subject to initial 7-day limit NUCYNTA TAB 100G 2 QL (60 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl cap 5 1 QL (180 caps / 25 days), ST; Subject to initial 7-day limit oxycodone hcl conc 100 /5ml (20 /ml) 1 QL (90 ml / 25 days), ST; Subject to initial 7-day limit oxycodone hcl soln 5 /5ml 1 QL (900 ml / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab 5 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab 10 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab 15 1 QL (120 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab 20 1 QL (90 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab 30 1 QL (60 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone hcl tab er 12hr deter 10 1 QL (60 tabs / 25 days), ST 9

12 oxycodone hcl tab er 12hr deter 15 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 20 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 30 1 QL (60 tabs / 25 days), ST oxycodone hcl tab er 12hr deter 40 1, ST; High Strength Requires oxycodone hcl tab er 12hr deter 60 1, ST; High Strength Requires oxycodone hcl tab er 12hr deter 80 1, ST; High Strength Requires oxycodone w/ acetaminophen soln /5ml 1 QL (1800 ml / 25 days), ST; Subject to initial 7-day limit oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab oxycodone w/ acetaminophen tab QL (360 tabs / 25 days), ST; Subject to initial 7-day limit 1 QL (360 tabs / 25 days), ST; Subject to initial 7-day limit 1 QL (240 tabs / 25 days), ST; Subject to initial 7-day limit 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone-aspirin tab QL (360 tabs / 25 days), ST; Subject to initial 7-day limit oxycodone-ibuprofen tab QL (28 tabs / 25 days), ST; Subject to initial 7-day limit OXYCONTIN TAB 10G CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 15G CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 20G CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 30G CR 2 QL (60 tabs / 25 days), ST OXYCONTIN TAB 40G CR 2, ST; High Strength Requires 10

13 OXYCONTIN TAB 60G CR 2, ST; High Strength Requires OXYCONTIN TAB 80G CR 2, ST; High Strength Requires oxymorphone hcl tab 5 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit oxymorphone hcl tab 10 1 QL (90 tabs / 25 days), ST; Subject to initial 7-day limit oxymorphone hcl tab er 12hr 5 1 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 10 1 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 15 1 QL (60 tabs / 25 days), ST oxymorphone hcl tab er 12hr 20 1, ST; High Strength Requires oxymorphone hcl tab er 12hr 30 1, ST; High Strength Requires oxymorphone hcl tab er 12hr 40 1, ST; High Strength Requires tramadol hcl tab 50 1 QL (180 tabs / 25 days), ST; Subject to initial 7-day limit tramadol hcl tab er 24hr QL (30 tabs / 25 days), ST tramadol hcl tab er 24hr 200 1, ST; High Strength Requires tramadol hcl tab er 24hr 300 1, ST; High Strength Requires XARTEIS XR TAB QL (120 tabs / 25 days) xylon tab QL (50 tabs / 25 days), ST; Subject to initial 7-day limit OPIOID RTIAL AGONISTS BELBUCA IS 75CG 2 QL (60 films / 25 days), ST BELBUCA IS 150CG 2 QL (60 films / 25 days), ST 11

14 BELBUCA IS 300CG 2 QL (60 films / 25 days), ST BELBUCA IS 450CG 2 QL (60 films / 25 days), ST BELBUCA IS 600CG 2, ST; High Strength Requires Prior Auth BELBUCA IS 750CG 2, ST; High Strength Requires Prior Auth BELBUCA IS 900CG 2, ST; High Strength Requires Prior Auth buprenorphine hcl inj 0.3 /ml (base equiv) buprenorphine hcl sl tab 2 (base equiv) 1 QL (90 tabs / 25 days); ust obtain approval after the initial fill buprenorphine hcl sl tab 8 (base equiv) 1 QL (90 tabs / 25 days); ust obtain approval after the initial fill SALICYLATES aspirin chw 81 0 QL (100 tabs / 30 days); $0 copay for members age or members at risk for preeclampsia aspirin low tab 81 ec 0 QL (100 tabs / 30 days); $0 copay for members age or members at risk for preeclampsia diflunisal tab ANESTHETICS LOCAL ANESTHETICS LIDO/DEXTROS INJ 5-7.5% lidocaine hcl local inj 0.5% lidocaine hcl local inj 1% lidocaine hcl local inj 2% lidocaine hcl local preservative free (pf) inj 0.5% lidocaine hcl local preservative free (pf) inj 1% lidocaine hcl local preservative free (pf) inj 1.5% lidocaine hcl local preservative free (pf) inj 2% 12

15 lidocaine hcl local preservative free (pf) inj 4% ANTI-INFECTIVES ANTI-BACTERIALS - ISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 /ml) amikacin sulfate inj 500 /2ml (250 /ml) chloramphenicol sodium succinate for iv inj 1 gm GENTA/NACL INJ 0.9G/L GENTA/NACL INJ 1.4G/L gentamicin in saline inj 0.8 /ml gentamicin in saline inj 1 /ml gentamicin in saline inj 1.2 /ml gentamicin in saline inj 1.6 /ml gentamicin in saline inj 2 /ml gentamicin sulfate inj 10 /ml gentamicin sulfate inj 40 /ml ONUROL K GRANULES 3 neomycin sulfate tab paromomycin sulfate cap streptomycin sulfate for inj 1 gm SULFADIAZINE TAB 500G 3 tinidazole tab tinidazole tab tobramycin nebu soln 300 /5ml 4 QL (280 ml / 28 days), tobramycin sulfate for inj 1.2 gm tobramycin sulfate inj 1.2 gm/30ml (40 /ml) (base equiv) tobramycin sulfate inj 2 gm/50ml (40 /ml) (base equiv) tobramycin sulfate inj 10 /ml (base equivalent) tobramycin sulfate inj 80 /2ml (40 /ml) (base equiv) ANTI-INFECTIVES - ISCELLANEOUS ALINIA SUS 100/5L 2 ALINIA TAB 500G 2 atovaquone susp 750 /5ml 1 AZACTA/DEX INJ 1G 13

16 AZACTA/DEX INJ 2G aztreonam for inj 1 gm aztreonam for inj 2 gm CAYSTON INH 75G 4 QL (84 vials / 28 days), clindamycin hcl cap 75 1 clindamycin hcl cap clindamycin hcl cap clindamycin palmitate hcl for soln 75 1 /5ml (base equiv) clindamycin phosphate inj 9 gm/60ml clindamycin phosphate inj 300 /2ml clindamycin phosphate inj 600 /4ml clindamycin phosphate inj 900 /6ml clindamycin phosphate iv soln 300 /2ml clindamycin phosphate iv soln 900 /6ml dapsone tab 25 1 dapsone tab daptomycin for iv soln 500 DARAPRI TAB 25G 3 doripenem for iv infusion 250 doripenem for iv infusion 500 EVER CHW 100G 3 QL (12 tabs / 365 days) ertapenem sodium for inj 1 gm (base equivalent) imipenem-cilastatin intravenous for soln 250 imipenem-cilastatin intravenous for soln 500 INVANZ INJ 1G ivermectin tab 3 1 linezolid for susp 100 /5ml 1 linezolid in sodium chloride iv soln 600 /300ml-0.9% linezolid iv soln 600 /300ml (2 /ml) linezolid tab meropenem iv for soln 1 gm meropenem iv for soln 500 methenamine hippurate tab 1 gm 1 metronidazole cap

17 metronidazole in nacl 0.79% iv soln 500 /100ml metronidazole tab metronidazole tab NEBUPENT INH 300G 3 nitrofurantoin macrocrystalline cap 25 1 ; High Risk edications require for members age 70 and nitrofurantoin macrocrystalline cap 50 1 ; High Risk edications require for members age 70 and nitrofurantoin macrocrystalline cap ; High Risk edications require for members age 70 and nitrofurantoin monohydrate macrocrystalline cap ; High Risk edications require for members age 70 and nitrofurantoin susp 25 /5ml 1 ; High Risk edications require for members age 70 and PENTA 300 INJ 300G polymyxin b sulfate for inj unit praziquantel tab QL (24 tabs / 365 days) PRISOL SOL 50G/5L 2 SIVEXTRO INJ 200G SIVEXTRO TAB 200G 3 sulfamethoxazole-trimethoprim iv soln /5ml sulfamethoxazole-trimethoprim susp /5ml 1 sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim tab trimethoprim tab vancomycin hcl cap 125 (base equivalent) 1 QL (80 caps / 10 days) 15

18 vancomycin hcl cap 250 (base 1 QL (80 caps / 10 days) equivalent) vancomycin hcl for iv soln 1 gm (base 1 equivalent) vancomycin hcl for iv soln 5 gm (base 1 equivalent) vancomycin hcl for iv soln 10 gm (base 1 equivalent) vancomycin hcl for iv soln 500 (base 1 equivalent) vancomycin hcl for iv soln 750 (base 1 equivalent) XIFAXAN TAB 200G 2 XIFAXAN TAB 550G 2 ANTIFUNGALS amphotericin b for inj 50 BIO-STATIN CAP BIO-STATIN CAP bio-statin pow 1 CRESEBA CAP 186 G 3 fluconazole for susp 10 /ml 1 fluconazole for susp 40 /ml 1 fluconazole in dextrose inj 200 /100ml fluconazole in dextrose inj 400 /200ml fluconazole in nacl 0.9% inj 200 /100ml fluconazole in nacl 0.9% inj 400 /200ml fluconazole tab 50 1 fluconazole tab fluconazole tab fluconazole tab FLUCONAZOLE/ INJ NACL 100 griseofulvin microsize susp 125 /5ml 1 griseofulvin microsize tab griseofulvin ultramicrosize tab griseofulvin ultramicrosize tab itraconazole cap itraconazole oral soln 10 /ml 1 NOXAFIL SUS 40G/L 2 NOXAFIL TAB 100G 2 nystatin tab unit 1 SPORANOX SOL 10G/L 2 16

19 terbinafine hcl tab voriconazole for susp 40 /ml 3 voriconazole tab 50 3 voriconazole tab ANTIALARIALS atovaquone-proguanil hcl tab atovaquone-proguanil hcl tab chloroquine phosphate tab chloroquine phosphate tab COARTE TAB G 3 mefloquine hcl tab PRIAQUINE TAB 26.3G 3 quinine sulfate cap ANTIRETROVIRAL AGENTS abacavir sulfate soln 20 /ml (base 1 QL (900 ml / 30 days) equiv) abacavir sulfate tab 300 (base equiv) 1 QL (60 tabs / 30 days) APTIVUS CAP 250G 2 QL (120 caps / 30 days) APTIVUS SOL 2 QL (285 ml / 28 days) atazanavir sulfate cap 150 (base equiv) 1 QL (30 caps / 30 days) atazanavir sulfate cap 200 (base equiv) 1 QL (60 caps / 30 days) atazanavir sulfate cap 300 (base equiv) 1 QL (30 caps / 30 days) CRIXIVAN CAP 200G 2 QL (450 caps / 30 days) CRIXIVAN CAP 400G 2 QL (180 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) didanosine delayed release capsule QL (30 caps / 30 days) EDURANT TAB 25G 2 QL (60 tabs / 30 days) efavirenz cap 50 1 QL (90 caps / 30 days) efavirenz cap QL (90 caps / 30 days) efavirenz tab QL (30 tabs / 30 days) ETRIVA CAP 200G 2 QL (30 caps / 30 days) ETRIVA SOL 10G/L 2 QL (680 ml / 28 days) fosamprenavir calcium tab 700 (base 1 QL (120 tabs / 30 days) equiv) FUZEON INJ 90G 4 QL (60 vials / 30 days) INTELENCE TAB 25G 2 QL (120 tabs / 30 days) INTELENCE TAB 100G 2 QL (120 tabs / 30 days) INTELENCE TAB 200G 2 QL (60 tabs / 30 days) INVIRASE CAP 200G 2 QL (300 caps / 30 days) INVIRASE TAB 500G 2 QL (120 tabs / 30 days) 17

20 ISENTRESS CHW 25G 2 QL (180 tabs / 30 days) ISENTRESS CHW 100G 2 QL (180 tabs / 30 days) ISENTRESS HD TAB 600G 2 QL (60 tabs / 30 days) ISENTRESS POW 100G 2 QL (60 packets / 30 days) ISENTRESS TAB 400G 2 QL (120 tabs / 30 days) lamivudine oral soln 10 /ml 1 QL (900 ml / 30 days) lamivudine tab QL (60 tabs / 30 days) lamivudine tab QL (30 tabs / 30 days) LEXIVA SUS 50G/L 2 QL (1575 ml / 28 days) nevirapine susp 50 /5ml 1 QL (1200 ml / 30 days) nevirapine tab QL (60 tabs / 30 days) nevirapine tab er 24hr QL (90 tabs / 30 days) nevirapine tab er 24hr QL (30 tabs / 30 days) NORVIR CAP 100G 2 QL (360 caps / 30 days) NORVIR POW 100G 2 QL (360 packets / 30 days) NORVIR SOL 80G/L 2 QL (480 ml / 30 days) PREZISTA SUS 100G/L 2 QL (400 ml / 30 days) PREZISTA TAB 75G 2 QL (300 tabs / 30 days) PREZISTA TAB 150G 2 QL (180 tabs / 30 days) PREZISTA TAB 600G 2 QL (60 tabs / 30 days) PREZISTA TAB 800G 2 QL (30 tabs / 30 days) RESCRIPTOR TAB 100 G 3 QL (900 tabs / 30 days) RESCRIPTOR TAB 200G 3 QL (450 tabs / 30 days) RETROVIR INJ 10G/L REYATAZ POW 50G 2 QL (180 packets / 30 days) ritonavir tab QL (360 tabs / 30 days) SELZENTRY SOL 20G/L 2 QL (1840 ml / 30 days) SELZENTRY TAB 25G 2 QL (240 tabs / 30 days) SELZENTRY TAB 75G 2 QL (60 tabs / 30 days) SELZENTRY TAB 150G 2 QL (60 tabs / 30 days) SELZENTRY TAB 300G 2 QL (120 tabs / 30 days) stavudine cap 15 1 QL (60 caps / 30 days) stavudine cap 20 1 QL (60 caps / 30 days) stavudine cap 30 1 QL (60 caps / 30 days) stavudine cap 40 1 QL (60 caps / 30 days) tenofovir disoproxil fumarate tab QL (30 tabs / 30 days) TIVICAY TAB 10G 2 QL (60 tabs / 30 days) TIVICAY TAB 25G 2 QL (60 tabs / 30 days) 18

21 TIVICAY TAB 50G 2 QL (60 tabs / 30 days) TROGARZO INJ 150G/L TYBOST TAB 150G 2 QL (30 tabs / 30 days) VIDEX EC CAP 125G 2 QL (30 caps / 30 days) VIDEX SOL 2G 2 QL (1200 ml / 30 days) VIDEX SOL 4G 2 QL (1200 ml / 30 days) VIRACEPT TAB 250G 2 QL (300 tabs / 30 days) VIRACEPT TAB 625G 2 QL (120 tabs / 30 days) VIRAUNE SUS 50G/5L 2 QL (1200 ml / 30 days) VIREAD POW 40G/G 2 QL (240 gm / 30 days) VIREAD TAB 150G 2 QL (30 tabs / 30 days) VIREAD TAB 200G 2 QL (30 tabs / 30 days) VIREAD TAB 250G 2 QL (30 tabs / 30 days) ZERIT SOL 1G/L 2 QL (2400 ml / 30 days) zidovudine cap QL (180 caps / 30 days) zidovudine syrup 10 /ml 1 QL (1800 ml / 30 days) zidovudine tab QL (60 tabs / 30 days) ANTIRETROVIRAL COBINATION AGENTS abacavir sulfate-lamivudine tab QL (30 tabs / 30 days) abacavir sulfate-lamivudine-zidovudine tab 1 QL (60 tabs / 30 days) BIKTARVY TAB 2 QL (30 tabs / 30 days) CIDUO TAB QL (30 tabs / 30 days) COPLERA TAB 2 QL (30 tabs / 30 days) DESCOVY TAB 200/25 2 QL (30 tabs / 30 days) EVOTAZ TAB QL (30 tabs / 30 days) GENVOYA TAB 2 QL (30 tabs / 30 days) KALETRA TAB G 2 QL (240 tabs / 30 days) KALETRA TAB G 2 QL (120 tabs / 30 days) lamivudine-zidovudine tab QL (60 tabs / 30 days) lopinavir-ritonavir soln /5ml 1 QL (390 ml / 30 days) (80-20 /ml) ODEFSEY TAB 2 QL (30 tabs / 30 days) PREZCOBIX TAB QL (30 tabs / 30 days) STRIBILD TAB 2 QL (30 tabs / 30 days) SYFI LO TAB 2 QL (30 tabs / 30 days) SYFI TAB 2 QL (30 tabs / 30 days) TRIUEQ TAB 2 QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days) 19

22 TRUVADA TAB QL (30 tabs / 30 days) TRUVADA TAB QL (30 tabs / 30 days), ST; **; (coverage for pre and post-exposure prophylaxis only) ANTITUBERCULAR AGENTS cycloserine cap ethambutol hcl tab ethambutol hcl tab isoniazid inj 100 /ml isoniazid syrup 50 /5ml 1 isoniazid tab isoniazid tab SER GRA 4G 3 PRIFTIN TAB 150G 2 pyrazinamide tab rifabutin cap RIFAATE CAP 2 rifampin cap rifampin cap rifampin for inj 600 RIFATER TAB 2 SIRTURO TAB 100G 3 TRECATOR TAB 250G 2 ANTIVIRALS acyclovir cap acyclovir sodium for inj 500 acyclovir sodium iv soln 50 /ml acyclovir susp 200 /5ml 1 acyclovir tab acyclovir tab adefovir dipivoxil tab 10 4 BARACLUDE SOL.05G/L 3 cidofovir iv inj 75 /ml entecavir tab entecavir tab 1 4 EPIVIR HBV SOL 5G/L 2 famciclovir tab famciclovir tab famciclovir tab lamivudine tab 100 (hbv) 1 20

23 oseltamivir phosphate cap 30 (base 1 QL (40 caps / 90 days) equiv) oseltamivir phosphate cap 45 (base 1 QL (20 caps / 90 days) equiv) oseltamivir phosphate cap 75 (base 1 QL (20 caps / 90 days) equiv) oseltamivir phosphate for susp 6 /ml 1 QL (300 ml / 90 days) (base equiv) RELENZA IS DISKHALE 2 QL (2 inhalers / 90 days) ribavirin for inhal soln 6 gm 1 rimantadine hydrochloride tab valacyclovir hcl tab 1 gm 1 valacyclovir hcl tab valganciclovir hcl for soln 50 /ml (base 1 equiv) valganciclovir hcl tab 450 (base 1 equivalent) VELIDY TAB 25G 3 CEPHALOSPORINS cefaclor cap cefaclor cap CEFACLOR ER TAB 500G 2 cefaclor for susp 125 /5ml 1 cefaclor for susp 250 /5ml 1 cefaclor for susp 375 /5ml 1 cefadroxil cap cefadroxil for susp 250 /5ml 1 cefadroxil for susp 500 /5ml 1 cefadroxil tab 1 gm 1 cefazolin sodium for inj 1 gm cefazolin sodium for inj 10 gm cefazolin sodium for inj 20 gm cefazolin sodium for inj 500 cefazolin sodium for iv soln 1 gm cefdinir cap cefdinir for susp 125 /5ml 1 cefdinir for susp 250 /5ml 1 cefditoren pivoxil tab 200 (base 1 equivalent) cefditoren pivoxil tab 400 (base 1 equivalent) 21

24 cefepime hcl for inj 1 gm cefepime hcl for inj 2 gm cefixime for susp 100 /5ml 1 cefixime for susp 200 /5ml 1 cefotaxime sodium for inj 1 gm cefotaxime sodium for inj 2 gm cefotaxime sodium for inj 10 gm cefotaxime sodium for inj 500 cefotetan disodium for inj 1 gm cefotetan disodium for inj 2 gm cefotetan disodium for inj 10 gm cefoxitin sodium for inj 10 gm cefoxitin sodium for iv soln 1 gm cefoxitin sodium for iv soln 2 gm cefpodoxime proxetil for susp 50 /5ml 1 cefpodoxime proxetil for susp 100 /5ml 1 cefpodoxime proxetil tab cefpodoxime proxetil tab cefprozil for susp 125 /5ml 1 cefprozil for susp 250 /5ml 1 cefprozil tab cefprozil tab ceftazidime for inj 2 gm ceftibuten cap ceftibuten for susp 180 /5ml 1 CEFTIN SUS 125/5L 2 CEFTIN SUS 250/5L 2 ceftriaxone sodium for inj 1 gm ceftriaxone sodium for inj 2 gm ceftriaxone sodium for inj 10 gm ceftriaxone sodium for inj 250 ceftriaxone sodium for inj 500 ceftriaxone sodium for iv soln 1 gm ceftriaxone sodium for iv soln 2 gm cefuroxime axetil tab cefuroxime axetil tab cefuroxime sodium for inj 7.5 gm cefuroxime sodium for inj 750 cefuroxime sodium for iv soln 1.5 gm cephalexin cap cephalexin cap

25 cephalexin cap cephalexin for susp 125 /5ml 1 cephalexin for susp 250 /5ml 1 cephalexin tab cephalexin tab SUPRAX CAP 400G 2 SUPRAX CHW 100G 2 SUPRAX CHW 200G 2 SUPRAX SUS 500/5L 2 tazicef inj 1gm tazicef inj 2gm tazicef inj 6gm ZINACEF INJ 750G ZINACEF/H20 INJ 1.5G PB ERYTHROYCINS/ACROLIDES azithromycin for susp 100 /5ml 1 azithromycin for susp 200 /5ml 1 azithromycin iv for soln 500 azithromycin powd pack for susp 1 gm 1 azithromycin tab azithromycin tab azithromycin tab clarithromycin for susp 125 /5ml 1 clarithromycin for susp 250 /5ml 1 clarithromycin tab clarithromycin tab clarithromycin tab er 24hr DIFICID TAB 200G 2 e.e.s. 400 tab ery-tab tab 250 ec 1 ery-tab tab 333 ec 1 ery-tab tab 500 ec 1 ERYPED SUS 400/5L 2 ERYTHROCIN INJ 500G erythrocin tab erythromycin ethylsuccinate for susp /5ml erythromycin ethylsuccinate tab erythromycin tab erythromycin tab

26 erythromycin w/ delayed release particles 1 cap 250 PCE TAB 333G EC 3 PCE TAB 500G EC 3 ZAX SUS 2G 3 FLUOROQUINOLONES ciprofloxacin 200 /100ml in d5w ciprofloxacin 400 /200ml in d5w ciprofloxacin for oral susp 250 /5ml 1 (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 /5ml (10%) (10 gm/100ml) 1 ciprofloxacin hcl tab 100 (base equiv) 1 ciprofloxacin hcl tab 250 (base equiv) 1 ciprofloxacin hcl tab 500 (base equiv) 1 ciprofloxacin hcl tab 750 (base equiv) 1 ciprofloxacin iv soln 200 /20ml (1%) ciprofloxacin iv soln 400 /40ml (1%) ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr (base eq) FACTIVE TAB 320G 3 levofloxacin in d5w iv soln 250 /50ml levofloxacin in d5w iv soln 500 /100ml levofloxacin in d5w iv soln 750 /150ml levofloxacin iv soln 25 /ml levofloxacin oral soln 25 /ml 1 levofloxacin tab levofloxacin tab levofloxacin tab moxifloxacin hcl 400 /250ml in sodium chloride 0.8% inj moxifloxacin hcl tab 400 (base equiv) 1 ofloxacin tab ofloxacin tab HETITIS C EPCLUSA TAB QL (28 tabs / 28 days), HARVONI TAB G 4 QL (28 tabs / 28 days), 24

27 PEGASYS INJ 4 QL (4 injections / 28 days), PEGASYS INJ 180CG/ 4 QL (4 injections / 28 days), PEGASYS INJ PROCLICK 4 QL (4 injections / 28 days), REBETOL SOL 40G/L 4 ribasphere cap ribasphere tab ribasphere tab ribasphere tab ribavirin cap ribavirin tab SOVALDI TAB 400G 5 QL (28 tabs / 28 days),, ST TECHNIVIE TAB 5 QL (56 tabs / 28 days),, ST VOSEVI TAB 4 QL (28 tabs / 28 days), ZETIER TAB G 5 QL (28 tabs / 28 days),, ST PENICILLINS amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml 1 amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab er 12hr amoxicillin (trihydrate) cap amoxicillin (trihydrate) cap amoxicillin (trihydrate) chew tab

28 amoxicillin (trihydrate) chew tab amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) for susp /5ml amoxicillin (trihydrate) tab amoxicillin (trihydrate) tab ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm ampicillin & sulbactam sodium for inj 3 (2-1) gm ampicillin & sulbactam sodium for inj 15 (10-5) gm ampicillin & sulbactam sodium for iv soln 15 (10-5) gm ampicillin cap ampicillin cap ampicillin for susp 125 /5ml 1 ampicillin for susp 250 /5ml 1 ampicillin sodium for inj 1 gm ampicillin sodium for inj 2 gm ampicillin sodium for inj 10 gm ampicillin sodium for inj 125 ampicillin sodium for inj 250 ampicillin sodium for inj 500 ampicillin sodium for iv soln 1 gm ampicillin sodium for iv soln 2 gm ampicillin sodium for iv soln 10 gm AUGENTIN SUS 125/5L 2 dicloxacillin sodium cap dicloxacillin sodium cap nafcillin sodium for inj 1 gm nafcillin sodium for inj 2 gm nafcillin sodium for iv soln 1 gm nafcillin sodium for iv soln 2 gm nafcillin sodium for iv soln 10 gm oxacillin sodium for inj 1 gm (base equivalent) 26

29 oxacillin sodium for inj 2 gm (base equivalent) oxacillin sodium for inj 10 gm (base equivalent) penicillin g potassium for inj unit penicillin g potassium for inj unit penicillin g sodium for inj unit penicillin v potassium for soln 125 /5ml 1 penicillin v potassium for soln 250 /5ml 1 penicillin v potassium tab penicillin v potassium tab pfizerpen inj 20mu piperacillin sod-tazobactam na for inj gm ( gm) piperacillin sod-tazobactam sod for inj 2.25 gm ( gm) piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 gm ( gm) TETRACYCLINES avidoxy tab demeclocycline hcl tab demeclocycline hcl tab doxy 100 inj 100 doxycycline hyclate cap 50 1 doxycycline hyclate cap doxycycline hyclate for inj 100 doxycycline hyclate tab 20 1 doxycycline hyclate tab doxycycline hyclate tab delayed release 75 1 doxycycline hyclate tab delayed release doxycycline hyclate tab delayed release doxycycline monohydrate cap 50 1 doxycycline monohydrate cap 75 1 doxycycline monohydrate cap doxycycline monohydrate cap doxycycline monohydrate for susp 25 1 /5ml 27

30 doxycycline monohydrate tab 50 1 doxycycline monohydrate tab 75 1 doxycycline monohydrate tab minocycline hcl cap 50 1 minocycline hcl cap 75 1 minocycline hcl cap minocycline hcl tab 50 1 minocycline hcl tab 75 1 minocycline hcl tab morgidox cap 1x100 1 tetracycline hcl cap tetracycline hcl cap VIBRAYCIN SYP 50G/5L 3 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU INJ 100G busulfan inj 6 /ml carmustine for inj 100 cyclophosphamide cap 25 0 cyclophosphamide cap 50 0 cyclophosphamide for inj 1 gm cyclophosphamide for inj 2 gm cyclophosphamide for inj 500 dacarbazine for inj 100 dacarbazine for inj 200 ECYT CAP 140G 0 GLEOSTINE CAP 5G 0 GLEOSTINE CAP 10G 0 GLEOSTINE CAP 40G 0 GLEOSTINE CAP 100G 0 GLIADEL WAF 7.7G HEXALEN CAP 50G 0 ifosfamide for inj 1 gm ifosfamide iv inj 1 gm/20ml (50 /ml) ifosfamide iv inj 3 gm/60ml (50 /ml) LEUKERAN TAB 2G 0 melphalan hcl for inj 50 (base equiv) melphalan tab 2 0 TEODAR INJ 100G temozolomide cap

31 temozolomide cap 20 0 temozolomide cap temozolomide cap temozolomide cap temozolomide cap ANTHRACYCLINES daunorubicin hcl iv soln 20 /4ml (base 1 equiv) doxorubicin hcl for inj 10 doxorubicin hcl for inj 50 doxorubicin hcl inj 2 /ml doxorubicin hcl liposomal inj (for iv infusion) 2 /ml epirubicin hcl iv soln 50 /25ml (2 /ml) epirubicin hcl iv soln 200 /100ml (2 /ml) idarubicin hcl iv inj 5 /5ml (1 /ml) idarubicin hcl iv inj 10 /10ml (1 /ml) idarubicin hcl iv inj 20 /20ml (1 /ml) ANTIBIOTICS bleomycin sulfate for inj 15 unit bleomycin sulfate for inj 30 unit mitomycin for iv soln 5 mitomycin for iv soln 20 mitomycin for iv soln 40 ANTIETABOLITES adrucil inj 500/10ml ALITA INJ 100G ALITA INJ 500G ARRANON INJ 5G/L azacitidine for inj 100 capecitabine tab QL (120 tabs / 30 days), capecitabine tab QL (300 tabs / 30 days), cladribine iv soln 10 /10ml (1 /ml) clofarabine iv soln 1 /ml cytarabine inj 20 /ml cytarabine inj pf 20 /ml cytarabine inj pf 100 /ml 29

32 decitabine for inj 50 floxuridine for inj 0.5 gm fludarabine phosphate for inj 50 fludarabine phosphate inj 25 /ml fluorouracil iv soln 1 gm/20ml (50 /ml) fluorouracil iv soln 2.5 gm/50ml (50 /ml) fluorouracil iv soln 5 gm/100ml (50 /ml) fluorouracil iv soln 500 /10ml (50 /ml) gemcitabine hcl for inj 1 gm gemcitabine hcl for inj 2 gm gemcitabine hcl for inj 200 gemcitabine hcl inj 1 gm/26.3ml (38 /ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 /ml) (base equiv) gemcitabine hcl inj 200 /5.26ml (38 /ml) (base equiv) mercaptopurine tab 50 0 methotrexate sodium for inj 1 gm methotrexate sodium inj 50 /2ml (25 /ml) methotrexate sodium inj 250 /10ml (25 /ml) methotrexate sodium inj pf 50 /2ml (25 /ml) methotrexate sodium inj pf 250 /10ml (25 /ml) methotrexate sodium inj pf 1000 /40ml (25 /ml) NIPENT INJ 10G TABLOID TAB 40G 0 ANTIITOTIC, TAXOIDS ABRAXANE INJ 100G DOCEFREZ INJ 20G docetaxel for inj conc 20 /ml docetaxel for inj conc 80 /4ml (20 /ml) DOCETAXEL INJ 20/0.5L DOCETAXEL INJ 80G/2L DOCETAXEL INJ 140/7L 30

33 DOCETAXEL INJ 160/8L DOCETAXEL INJ NON-ALCO docetaxel soln for iv infusion 20 /2ml docetaxel soln for iv infusion 80 /8ml docetaxel soln for iv infusion 160 /16ml paclitaxel iv conc 30 /5ml (6 /ml) paclitaxel iv conc 100 /16.7ml (6 /ml) paclitaxel iv conc 150 /25ml (6 /ml) paclitaxel iv conc 300 /50ml (6 /ml) ANTIITOTIC, VINCA ALKALOIDS vinblastine sulfate inj 1 /ml vincasar pfs inj 1/ml vincristine sulfate iv soln 1 /ml vinorelbine tartrate inj 10 /ml (base equiv) vinorelbine tartrate inj 50 /5ml (10 /ml) (base equiv) BIOLOGIC RESPONSE ODIFIERS ERBITUX INJ 100G ERBITUX INJ 200G ERIVEDGE CAP 150G 0 QL (30 caps / 30 days), FARYDAK CAP 10G 0 FARYDAK CAP 15G 0 FARYDAK CAP 20G 0 GAZYVA INJ 25G/L IBRANCE CAP 75G 0 QL (21 caps / 28 days), IBRANCE CAP 100G 0 QL (21 caps / 28 days), IBRANCE CAP 125G 0 QL (21 caps / 28 days), KADCYLA INJ 100G KADCYLA INJ 160G KEYTRUDA INJ 100G/4 KISQALI TAB 200DOSE 4 QL (63 tabs / 28 days), KISQALI TAB 400DOSE 4 QL (63 tabs / 28 days), KISQALI TAB 600DOSE 4 QL (63 tabs / 28 days), 31

34 LYNRZA CAP 50G 0 QL (480 caps / 30 days), LYNRZA TAB 100G 0 QL (180 tabs / 30 days), LYNRZA TAB 150G 0 QL (120 tabs / 30 days), RYDAPT CAP 25G 0 QL (224 caps / 28 days), ZEJULA CAP 100G 0 QL (90 caps / 30 days), ZOLINZA CAP 100G 0 QL (120 caps / 30 days), HORONAL ANTINEOPLASTIC AGENTS abiraterone acetate tab QL (120 tabs / 30 days), anastrozole tab 1 0 bicalutamide tab 50 0 DEPO-PROVERA INJ 400/L ELIGARD INJ 7.5G ELIGARD INJ 22.5G ELIGARD INJ 30G ELIGARD INJ 45G exemestane tab 25 0 FARESTON TAB 60G 0 FASLODEX INJ 250/5L flutamide cap letrozole tab leuprolide acetate inj kit 5 /ml 4 LUPR DEP-PED INJ 3 30G LUPR DEP-PED INJ 7.5G LUPR DEP-PED INJ 11.25G LUPR DEP-PED INJ 15G LYSODREN TAB 500G 0 megestrol acetate susp 40 /ml 0 megestrol acetate susp 625 /5ml 0 megestrol acetate tab 20 0 megestrol acetate tab 40 0 nilutamide tab tamoxifen citrate tab 10 (base equivalent) 0 $0 copay for women ages 35 and for the primary prevention of breast cancer 32

35 tamoxifen citrate tab 20 (base equivalent) 0 $0 copay for women ages 35 and for the primary prevention of breast cancer XTANDI CAP 40G 0 QL (120 caps / 30 days), ZYTIGA TAB 250G 0 QL (120 tabs / 30 days), ZYTIGA TAB 500G 0 QL (60 tabs / 30 days), KINASE INHIBITORS AFINITOR DIS TAB 2G 0 QL (60 tabs / 30 days), AFINITOR DIS TAB 3G 0 QL (90 tabs / 30 days), AFINITOR DIS TAB 5G 0 QL (60 tabs / 30 days), AFINITOR TAB 2.5G 0 QL (30 tabs / 30 days), AFINITOR TAB 5G 0 QL (30 tabs / 30 days), AFINITOR TAB 7.5G 0 QL (30 tabs / 30 days), AFINITOR TAB 10G 0 QL (30 tabs / 30 days), ALECENSA CAP 150G 0 QL (240 caps / 30 days), BOSULIF TAB 100G 0 QL (90 tabs / 30 days), BOSULIF TAB 400G 0 QL (30 tabs / 30 days), BOSULIF TAB 500G 0 QL (30 tabs / 30 days), CALQUENCE CAP 100G 0 QL (60 caps / 30 days), CAPRELSA TAB 100G 0 QL (60 tabs / 30 days), CAPRELSA TAB 300G 0 QL (30 tabs / 30 days), COETRIQ KIT 60G 0 QL (1 kit / 28 days), COETRIQ KIT 100G 0 QL (1 kit / 28 days), COETRIQ KIT 140G 0 QL (1 kit / 28 days), 33

36 ICLUSIG TAB 15G 0 QL (60 tabs / 30 days), ICLUSIG TAB 45G 0 QL (30 tabs / 30 days), IDHIFA TAB 50G 0 QL (30 tabs / 30 days), IDHIFA TAB 100G 0 QL (30 tabs / 30 days), imatinib mesylate tab 100 (base equivalent) 0 QL (90 tabs / 30 days), imatinib mesylate tab 400 (base equivalent) 0 QL (60 tabs / 30 days), IBRUVICA CAP 70G 0 QL (30 caps / 30 days), IBRUVICA CAP 140G 0 QL (90 caps / 30 days), IBRUVICA TAB 140G 0 QL (30 tabs / 30 days), IBRUVICA TAB 280G 0 QL (30 tabs / 30 days), IBRUVICA TAB 420G 0 QL (30 tabs / 30 days), IBRUVICA TAB 560G 0 QL (30 tabs / 30 days), INLYTA TAB 1G 0 QL (180 tabs / 30 days), INLYTA TAB 5G 0 QL (120 tabs / 30 days), JAKAFI TAB 5G 0 QL (60 tabs / 30 days), JAKAFI TAB 10G 0 QL (60 tabs / 30 days), JAKAFI TAB 15G 0 QL (60 tabs / 30 days), JAKAFI TAB 20G 0 QL (60 tabs / 30 days), JAKAFI TAB 25G 0 QL (60 tabs / 30 days), LENVIA CAP 4G 0 QL (30 caps / 30 days), LENVIA CAP 8 G 0 QL (60 caps / 30 days), 34

37 LENVIA CAP 10 G 0 QL (30 caps / 30 days), LENVIA CAP 12G 0 QL (90 caps / 30 days), LENVIA CAP 14 G 0 QL (60 caps / 30 days), LENVIA CAP 18 G 0 QL (90 caps / 30 days), LENVIA CAP 20 G 0 QL (60 caps / 30 days), LENVIA CAP 24 G 0 QL (90 caps / 30 days), EKINIST TAB 0.5G 0 QL (90 tabs / 30 days), EKINIST TAB 2G 0 QL (30 tabs / 30 days), NEXAVAR TAB 200G 0 QL (120 tabs / 30 days), SPRYCEL TAB 20G 0 QL (90 tabs / 30 days), SPRYCEL TAB 50G 0 QL (30 tabs / 30 days), SPRYCEL TAB 70G 0 QL (30 tabs / 30 days), SPRYCEL TAB 80G 0 QL (30 tabs / 30 days), SPRYCEL TAB 100G 0 QL (30 tabs / 30 days), SPRYCEL TAB 140G 0 QL (30 tabs / 30 days), STIVARGA TAB 40G 0 QL (84 tabs / 28 days), SUTENT CAP 12.5G 0 QL (30 caps / 30 days), SUTENT CAP 25G 0 QL (30 caps / 30 days), SUTENT CAP 37.5G 0 QL (30 caps / 30 days), SUTENT CAP 50G 0 QL (30 caps / 30 days), TAFINLAR CAP 50G 0 QL (120 caps / 30 days), 35

38 TAFINLAR CAP 75G 0 QL (120 caps / 30 days), TARCEVA TAB 25G 0 QL (60 tabs / 30 days), TARCEVA TAB 100G 0 QL (30 tabs / 30 days), TARCEVA TAB 150G 0 QL (30 tabs / 30 days), TYKERB TAB 250G 0 QL (180 tabs / 30 days), VOTRIENT TAB 200G 0 QL (120 tabs / 30 days), XALKORI CAP 200G 0 QL (60 caps / 30 days), XALKORI CAP 250G 0 QL (60 caps / 30 days), ZELBORAF TAB 240G 0 QL (240 tabs / 30 days), ZYDELIG TAB 100G 0 QL (60 tabs / 30 days), ZYDELIG TAB 150G 0 QL (60 tabs / 30 days), ZYKADIA CAP 150G 0 QL (90 caps / 30 days), ISCELLANEOUS ARSENIC TRIOXIDE INJ 10 G/10L (1 G/L) bexarotene cap 75 0 DROXIA CAP 200G 0 DROXIA CAP 300G 0 DROXIA CAP 400G 0 hydroxyurea cap ATULANE CAP 50G 0 mitoxantrone hcl inj conc 20 /10ml (2 /ml) mitoxantrone hcl inj conc 25 /12.5ml (2 /ml) mitoxantrone hcl inj conc 30 /15ml (2 /ml) ODOZO CAP 200G 0 QL (30 caps / 30 days), ONCASR INJ 750/L 36

39 PHOTOFRIN INJ 75G QUADRAET INJ THERACYS INJ TICE BCG INJ tretinoin cap 10 0 TRISENOX INJ 12G/6L UVADEX INJ 20CG/L VISTOGARD K 10G 2 PLATINU-BASED AGENTS carboplatin iv soln 50 /5ml carboplatin iv soln 150 /15ml carboplatin iv soln 450 /45ml carboplatin iv soln 600 /60ml cisplatin inj 50 /50ml (1 /ml) cisplatin inj 100 /100ml (1 /ml) cisplatin inj 200 /200ml (1 /ml) oxaliplatin for iv inj 50 oxaliplatin for iv inj 100 oxaliplatin iv soln 50 /10ml oxaliplatin iv soln 100 /20ml PROTECTIVE AGENTS amifostine for inj 500 dexrazoxane for inj 250 dexrazoxane for inj 500 leucovorin calcium for inj 50 leucovorin calcium for inj 100 leucovorin calcium for inj 200 leucovorin calcium for inj 350 leucovorin calcium for inj 500 leucovorin calcium tab 5 0 leucovorin calcium tab 10 0 leucovorin calcium tab 15 0 leucovorin calcium tab 25 0 mesna inj 100 /ml ESNEX TAB 400G 0 TOPOISOERASE INHIBITORS CAPTOSAR INJ 300/15L etoposide cap 50 0 etoposide inj 100 /5ml (20 /ml) irinotecan hcl inj 40 /2ml (20 /ml) 37

40 irinotecan hcl inj 100 /5ml (20 /ml) irinotecan hcl inj 500 /25ml (20 /ml) TENIPOSIDE INJ 50G/5L toposar inj 20/ml toposar inj 100/5ml topotecan hcl for inj 4 (base equiv) ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC, BCL-2 INHIBITORS VENCLEXTA TAB 10G 0 VENCLEXTA TAB 50G 0 VENCLEXTA TAB 100G 0 VENCLEXTA TAB START PK 0 CARDIOVASCULAR ACE INHIBITOR COBINATIONS amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab

41 enalapril maleate & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er trandolapril-verapamil hcl tab er ACE INHIBITORS benazepril hcl tab 5 1 benazepril hcl tab 10 1 benazepril hcl tab 20 1 benazepril hcl tab 40 1 captopril tab captopril tab 25 1 captopril tab 50 1 captopril tab enalapril maleate tab enalapril maleate tab 5 1 enalapril maleate tab 10 1 enalapril maleate tab

42 fosinopril sodium tab 10 1 fosinopril sodium tab 20 1 fosinopril sodium tab 40 1 lisinopril tab lisinopril tab 5 1 lisinopril tab 10 1 lisinopril tab 20 1 lisinopril tab 30 1 lisinopril tab 40 1 moexipril hcl tab moexipril hcl tab 15 1 perindopril erbumine tab 2 1 perindopril erbumine tab 4 1 perindopril erbumine tab 8 1 quinapril hcl tab 5 1 quinapril hcl tab 10 1 quinapril hcl tab 20 1 quinapril hcl tab 40 1 ramipril cap ramipril cap ramipril cap 5 1 ramipril cap 10 1 trandolapril tab 1 1 trandolapril tab 2 1 trandolapril tab 4 1 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 1 eplerenone tab 50 1 ALPHA BLOCKERS doxazosin mesylate tab 1 1 doxazosin mesylate tab 2 1 doxazosin mesylate tab 4 1 doxazosin mesylate tab 8 1 prazosin hcl cap 1 1 prazosin hcl cap 2 1 prazosin hcl cap 5 1 terazosin hcl cap 1 (base equivalent) 1 terazosin hcl cap 2 (base equivalent) 1 terazosin hcl cap 5 (base equivalent) 1 terazosin hcl cap 10 (base equivalent) 1 40