Blue Cross and Blue Shield of Minnesota FlexRx Drug Formulary

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1 October 07 Blue Cross and Blue Shield of Minnesota FlexRx Drug Formulary Please consider talking to your doctor about prescribing formulary medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The drug formulary is regularly updated. Please visit for the most up-to-date formulary. Contents Introduction... I Pharmacy and Therapeutics (P&T) Committee and Coverage Committee... I Formulary guidelines... II Formulary addition request... III Generic drugs... III Frequently asked questions about generics... III How to use the drug list... IV Benefit programs... V Managing drug usage... VIII Key... IX Therapeutic Class Drug List Anti-Infective Drugs... Immunizing Agents... 8 Cancer Drugs... 8 Hormones, Diabetes and Related Drugs... 8 Heart and Circulatory Drugs... 6 Respiratory Drugs Gastrointestinal Drugs Genitourinary Drugs... 4 Central Nervous System Drugs Pain Relief Drugs... 5 Neuromuscular Drugs Supplements Blood Modifying Drugs Topical Drugs Miscellaneous Categories... 7 Index To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search. 746-A MN Prime Therapeutics LLC 0/7

2 Introduction Blue Cross and Blue Shield of Minnesota and Blue Plus are pleased to present the FlexRx drug formulary (drug list). Our goal is to give members access to safe and effective prescription drugs at a reasonable cost. Brand name drugs are not included in this formulary unless they are listed. Blue Cross may choose to not add a drug to the formulary because of effectiveness or safety concerns, or because a similar, more cost-effective drug is already on the formulary. New drugs may be not covered or non-preferred (NP) until reviewed and approved for inclusion by the Pharmacy and Therapeutics (P&T) Committee and Coverage Committee. Blue Cross encourages providers to prescribe preferred drugs. Your drug benefit is presented in the Drug Formulary, and includes most prescription drugs, although some restrictions and exclusions do apply. For example, investigational drugs and drugs indicated for cosmetic purposes, e.g., Propecia, may not be eligible for coverage under your prescription drug benefit. Some drugs may only be available through your medical benefit. Coverage and copayment levels vary depending on the plan. This prescription drug benefit is multi-tiered, placing prescription drugs into one of four Copay/Coinsurance levels: Preferred Generic drugs (Tier ) Preferred Brand drugs (Tier ) Non-preferred Brand and Generic drugs (Tier 3) drugs (Tier 4) There are various types of pharmacy benefit programs. To understand which program you have, please refer to your Benefit Booklet, Certificate of Coverage, Contract, Member Handbook or prescription drug endorsement or call the number on your member ID card for more information. Pharmacy and Therapeutics (P&T) Committee and Coverage Committee The Blue Cross Coverage Committee selects drugs for this formulary based on recommendations of an independent Pharmacy and Therapeutics (P&T) Committee that includes practicing physicians and pharmacists. Decisions to add or remove drugs from the FlexRx formulary are based on the drug s safety, effectiveness, uniqueness and cost. The P&T Committee and Coverage Committee meet at least quarterly. All drugs are reviewed each year as required by the National Committee on Quality Assurance (NCQA) standards. You can find recent changes and the current version of the formulary at bluecrossmn.com. FlexRx Drug Formulary, October 07 I

3 Formulary guidelines The requirement of P&T and Coverage Committee review is a precondition of Blue Cross coverage and: Applies in addition to all other conditions and terms stated in Blue Cross contracts and stated herein; and Applies to medications and select medical devices when administered in any manner that is approved by the U. S. Food and Drug Administration (FDA); and Applies to approved medications legally prescribed and select medical devices legally used when administered in any manner that is not mentioned in the labeling approved by the FDA (referred to as an off-label use). Use of a medication or medical device for an indication, dosage form, dose regimen, population, or other use parameter not mentioned in the approved labeling is considered to be an off-label use. These guidelines in no way imply that members should not receive specific services based on the recommendation of the provider. These guidelines govern coverage and not clinical practices. Providers are responsible for giving medical advice and treating members. Members with specific health care needs should consult an appropriate health care provider. Members and providers have the right to appeal coverage decisions. These rights are explained in member and provider plan documents. Members with questions about appeal rights should call customer service at the number on the back of their member ID card. Providers can call provider services at or toll free at This information is not an offer of coverage, solicitation of coverage, summary of coverage or guarantee of coverage. All products and coverage guidelines are subject to applicable laws and regulations. Member or provider coverage is contingent on all the applicable terms, conditions, limitations and exclusions of member or provider plan documents. FlexRx Drug Formulary, October 07 II

4 Formulary addition request Any health care provider may request in writing that the Blue Cross Coverage Committee consider adding or deleting a drug from the formulary. All formulary requests are brought before the Coverage Committee. Generic drugs Blue Cross encourages use of generic drugs as a way to provide high-quality, cost-effective care. Generic drugs are safe, effective and they may cost less than brand name drugs. Members will likely pay a lower copayment or coinsurance for a generic drug. Frequently asked questions about generics Are generics as good as brand name drugs? Both brand name and generic drugs must be approved by the FDA. Generic drugs meet the same high standards as brand name drugs. Why should I take generics rather than brand name drugs? We must all do our part to make health care affordable. One way is to be wise consumers of drugs. Generics provide the same effectiveness and safety as their brand name counterparts, but are often lower in cost. This typically occurs when competition among several manufacturers who produce the generic drug, results in lower prices for it. Lower costs generally mean lower copayments for members. Generics also save money for your health plan, so it can help keep insurance premiums as low as possible. How can I take advantage of lower-cost generics? Ask your pharmacist for a generic whenever available. Also, talk with your doctor or other provider about prescribing generic drugs. Most drug classes include some generic drugs. FlexRx Drug Formulary, October 07 III

5 How to use this list The drug list is organized into broad categories (e.g., HORMONES, DIABETES AND RELATED DRUGS). The graphic below shows the information that is provided in each column of the medication list and is an example only. Please use the drug search function to find current information for drugs on the medication list. The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand. Brand prescription drugs are shown in capital letters followed by the generic name. The second column indicates the formulary tier level. Preferred Generic drugs (Tier ) Preferred Brand drugs (Tier ) The third column indicates if the drug is a specialty drug. Note: Additional information about specialty drugs can be found in this document under the topic Benefit Programs. A drug may be added to the specialty drug management list at any time. The remaining columns indicate the Utilization Management (UM) program(s) that may apply to the prescription drug (e.g.,, and ). If an indicator is present in the column(s), then the UM program noted is possibly applied to your benefit. Some plans may have UM on additional medications beyond those noted in this document. Compounded prescriptions Compounded prescriptions contain two or more drugs mixed together. The end product cannot be available in an equivalent commercial form. Plus, at least one ingredient must be an FDA-approved prescription drug. Compounded prescriptions are processed according to member benefits. Injectable drugs Self-administered injectable drugs are generally part of the pharmacy benefit and may be included on the formulary. Injectable drugs are processed according to member benefits. Some injectable drugs that need to be administered by a health care professional are covered only under the plan s medical benefit. FlexRx Drug Formulary, October 07 IV

6 Benefit programs 90dayRx Blue Cross has an optional 90dayRx program. Members with this benefit may receive up to a 90-day supply of drugs at a reduced cost. In addition to being able to obtain up to a 90-day supply of drugs through our mail order pharmacy you may be able to receive up to a 90-day supply of drugs through a participating retail pharmacy. Please refer to your plan documents for complete coverage details. Retail Pharmacy Vaccine Program Blue Cross has an optional vaccine pharmacy program for flu, pneumonia, shingles, diphtheria tetanus combinations, human papillomavirus (HPV) and meningitis vaccines. Members with this benefit can simply present their health plan member ID card when visiting a participating pharmacy. The cost share will be based on their pharmacy coverage for this benefit. Members can go to MyPrime.com to locate network pharmacies that administer approved vaccines for Blue Cross Blue Shield of Minnesota members. Please note that age limitations, advance registration or other requirements may apply. The availability of each vaccine may vary by individual pharmacy or location. For your convenience, you may contact the pharmacy in advance if you have questions or to make sure these services are available at a particular location. drugs Blue Cross has an optional specialty pharmacy network. Members with this benefit must obtain their specialty drugs from an in-network specialty provider or they will pay 00 percent of the drug cost. The specialty drug vendors and drugs covered by this specialty drug benefit are listed at bluecrossmn.com. Over-the-counter (OTC) drugs Blue Cross has an OTC drug benefit. Members with this coverage may receive an eligible OTC product at their lowest cost. Covered OTC drugs require a prescription. Members can get a one-month supply with this benefit: The program limits coverage to formulary and OTC drugs in these classes. Drugs not on the formulary or included in the OTC benefit will not be covered. Drugs covered by this OTC drug benefit are listed at bluecrossmn.com. FlexRx Drug Formulary, October 07 V

7 Affordable Care Act Bowel Prep for Colonoscopy Starting July, 06, select bowel preparation drugs will be covered without cost share, in accordance with each member s specific benefit plan. The following select drugs will be available at $0 cost to eligible members with a prescription. Gavilyte-C Gavilyte-G Gavilyte-N peg KCl -na bicarb- NaCL -Na sulfate for solution 40 gm (generic of COLYTE 40 g) peg KCl -na bicarb- NaCL-Na sulfate for solution 36 gm (generic for GOLYTELY 36 g) peg 3350-KCl-sod bicarb-nacl for solution 40 gm (generic of NULYTELY) Trilyte Affordable Care Act Breast Cancer Preventive Drugs Select Breast Cancer drugs when prescribed for prevention of breast cancer for men and women at elevated risk will be covered without cost share in accordance with each member s specific benefit plan. The following select Breast Cancer drugs will be available at $0 cost to eligible members with a prescription. tamoxifen, for ages 35 and older raloxifene, for ages 35 and older Affordable Care Act Contraceptives Select contraceptives will be covered without cost share for women in accordance with each member s specific benefit plan. The following select contraceptive medications will be available at $0 cost to eligible members: Barrier Method Types > Cervical Caps > Diaphragms > Female Condom > Spermicide > Sponge Emergency Contraceptives: Aftera, Econtra EZ, ELLA, Fallback Solo, levonorgestrel.5, My Way, Next Choice One Dose, Opcicon One-Step, Option, PLAN B One-Step, React, Take Action Injectables > DEPO-PROVERA CONTRACEPTIVE > DEPO-SUBQ-PROVERA 04 > medroxyprogesterone acetate Hormonal Methods > NUVARING > Oral combination triphasic contraceptives include generic norgestimate/ethinyl estradiol (generic for Ortho Tri-Cyclen), Tri Femynor, Tri-Estarylla, Tri-Linyah, Trinessa, Tri-Previfem, and Tri- Sprintec. > Oral extended cycle/continuous use contraceptives include generic Introvale, Jolessa, levonorgestrel/ethinyl estradiol (9-day) tab , Quasense, and Setlakin. > Oral progestin contraceptives include generic Camila, Deblitane, Errin, Heather, Jencycla, Jolivette, Lyza, Nora-BE, norethindrone, Norlyroc, and Sharobel. > XULANE patch FlexRx Drug Formulary, October 07 VI

8 Affordable Care Act OTC Supplements Select OTC supplements will be covered without cost share in accordance with each member s specific benefit plan. The following select OTC supplement will be available at $0 cost to eligible members with a prescription. Aspirin 8 Folic acid- containing Fluoride- for preschool children ages 6 months-5 years Iron- children ages 6- months and women ages -64 Vitamin D- adults ages 65 and older Affordable Care Act Tobacco Cessation Select tobacco cessation will be covered without cost share in accordance with each member s specific benefit plan. The following select tobacco cessation will be available at $0 cost to eligible members with a prescription. bupropion ext-release (Zyban) CHANTIX nicotine gum, lozenge, kit, patch NICOTROL NS NICOTROL Inhaler FlexRx Drug Formulary, October 07 VII

9 Managing drug usage Exceptions Formulary Exceptions To request coverage of a non-preferred drug for a member with a closed formulary benefit plan Other Exceptions To request a brand name drug exception for a member with a mandatory generic plan for DAW prescriptions Steps on how a prescriber may request a Formulary Exception: A prescriber may obtain a Minnesota Uniform Form for Prescription Drug Request & Formulary Exceptions online at providers.bluecrossmn.com in the Forms section. The prescriber can also obtain the form by calling provider services at or If the request is for a brand name drug exception for a member with a mandatory generic plan, the prescriber must request this specifically on the request form. Submit the completed request form to the following address or fax: Prime Therapeutics Clinical Review Department 305 Corporate Center Drive Eagan, MN 55 Fax number: Some drugs require prior authorization because of their high potential for misuse or overuse. Coverage may be approved after certain criteria are met. Approval is required for claims to process at network pharmacies. Policies regarding the covered uses of drugs and drug classes requiring prior authorization can be found at bluecrossmn.com. For more information, call the number on the back of your member ID card. Providers can call provider services at or toll free at Steps on how a prescriber may request a : For an easy way to submit PA requests for your patients at no additional cost, consider using an electronic prior authorization tool, through CoverMyMeds. CoverMyMeds is an online submission method for doctors and pharmacists to submit PA requests to our pharmacy benefit manager. It eliminates traditional paper forms and faxes and greatly reduces follow-up calls. To get started, go to CoverMyMeds.com and click on the link to Create an Account. Alternatively, a prescriber may obtain a Minnesota Uniform Form for Prescription Drug Request & Formulary Exceptions online at providers.bluecrossmn.com in the Forms section. The prescriber can also obtain the form by calling provider services at or Submit the completed request form along with relevant medical records to the following address or fax: Blue Cross and Blue Shield of Minnesota Integrated Health Management, Route 47 P.O. Box 6465 St. Paul, MN Fax number: FlexRx Drug Formulary, October 07 VIII

10 Step therapy programs help manage the cost of expensive drugs by redirecting members to safe, effective and less expensive alternatives. Preferred and non-preferred drugs may be subject to step therapy. If a member does not meet the criteria in the automated review of the member s claims, their doctor can submit a request for review. Steps on how a prescriber may request a authorization: A prescriber may obtain a Authorization request form online at providers.bluecrossmn.com in the Forms section. The prescriber can also obtain the form by calling provider services at or Submit the completed request form to the following address or fax: Prime Therapeutics Clinical Review Department 305 Corporate Center Drive Eagan, MN 55 Fax number: Certain drugs have quantity limits to encourage appropriate drug usage, enhance drug therapy and reduce costs. The quantity limit is the maximum quantity that can be dispensed over a given period of time. Preferred and non-preferred drugs may have quantity limits. Steps on how a prescriber may request a Quantity Limit exception: A prescriber may obtain a Override request form online at providers.bluecrossmn.com in the Forms section. The prescriber can also obtain the form by calling provider services at or Submit the completed request form to the following address or fax: Key Prime Therapeutics Clinical Review Department 305 Corporate Center Drive Eagan, MN 55 Fax number: cap...capsules chew...chewable conc... concentrate cr... controlled release dr... delayed release ec... enteric coated effe... effervescent equiv... equivalent er... extended release inhal... inhalation inj...injection liq... liquid lotn... lotion nebu... nebulizer odt.... orally disintegrating tabs oint... ointment ophth...ophthalmic osm... osmotic release powd... powder sa... sustained action sl... sublingual soln...solution sr...sustained release suppos... suppositories susp... suspension tab... tablets td... transdermal FlexRx Drug Formulary, October 07 IX

11 NOTICE OF NONDISCRIMINATION PRACTICES Effective July 8, 06 Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or gender. Blue Cross does not exclude people or treat them differently because of race, color, national origin, age, disability, or gender. Blue Cross provides resources to access information in alternative formats and languages: Auxiliary aids and services, such as qualified interpreters and written information available in other formats, are available free of charge to people with disabilities to assist in communicating with us. Language services, such as qualified interpreters and information written in other languages, are available free of charge to people whose primary language is not English. If you need these services, contact us at or by using the telephone number on the back of your member identification card. TTY users call 7. If you believe that Blue Cross has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or gender, you can file a grievance with the Nondiscrimination Civil Rights Coordinator by at: Civil.Rights.Coord@bluecrossmn.com by mail at: Nondiscrimination Civil Rights Coordinator Blue Cross and Blue Shield of Minnesota and Blue Plus M495 PO Box Eagan, MN or by phone at: Grievance forms are available by contacting us at the contacts listed above, by calling or by using the telephone number on the back of your member identification card. TTY users call 7. If you need help filing a grievance, assistance is available by contacting us at the numbers listed above. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at: by phone at: or (TDD) or by mail at: U.S. Department of Health and Human Services 00 Independence Avenue SW Room 509F HHH Building Washington, DC 00 Complaint forms are available at image_0006_ndl_portrait (09/6) Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association. F0773R0 (/7)

12 This information is available in other languages. Free language assistance services are available by calling the toll free number below. For TTY, call 7. Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al Para TTY, llame al 7. Yog tias koj hais lus Hmoob, muaj kev pab txhais lus pub dawb rau koj. Hu rau Rau TTY, hu rau 7. Haddii aad ku hadasho Soomaali, adigu waxaad heli kartaa caawimo luqad lacag la'aan ah. Wac Markay tahay dad maqalku ku adag yahay (TTY), wac 7. erh>uwdrundusdm'd;< Aw>u[h.eRusdmw>rRpXRuvDwz.M.vDRIAud; vx ATTY t*d><aud; 7 wuh>i إذا كنت تتحدث العربية تتوفر لك خدمات المساعدة اللغوية المجانية. اتصل بالرقم للھاتف النصي اتصل بالرقم. 7 Nếu quý vị nói Tiếng Việt, có sẵn các dịch vụ hỗ trợ ngôn ngữ miễn phí cho quý vị. Gọi số Người dùng TTY xin gọi 7. Afaan Oromoo dubbattu yoo ta e, tajaajila gargaarsa afaan hiikuu kaffaltii malee. Argachuuf bilbilaa. TTY dhaaf, 7 bilbilaa. 如果您說中文, 我們可以為您提供免費的語言協助服務 請撥打 聽語障專 (TTY), 請撥打 7 Если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Звоните Для использования телефонного аппарата с текстовым выходом звоните 7. Si vous parlez français, des services d assistance linguistique sont disponibles gratuitement. Appelez le Pour les personnes malentendantes, appelez le 7. አማርኛ የሚናገሩ ከሆነ ነጻ የቋንቋ አገልግሎት እርዳ አለሎት በ ይደውሉ ለ TTY በ 7 한국어를사용하시는경우, 무료언어지원서비스가제공됩니다 으로전화하십시오. TTY 사용자는 7 로전화하십시오. ຖ າເຈ າເວ າພາສາລາວໄດ, ມການບລການຊວຍເຫ ອພາສາໃຫເຈ າຟຣ. ໃຫໂທຫາ ສາລ ບ. TTY, ໃຫ ໂທຫາ 7. Kung nagsasalita kayo ng Tagalog, mayroon kayong magagamit na libreng tulong na a serbisyo sa wika. Tumawag sa Para sa TTY, tumawag sa 7. Wenn Sie Deutsch sprechen, steht Ihnen fremdsprachliche Unterstützung zur Verfügung. Wählen Sie Für TTY wählen Sie 7. របស ន បអកនយ យភ ស ខរមន ន ម អកអ ចរកប ន សវ ជនយភ ស ឥតគត ថ ន ល ទរសពមក លខ ទ សរម ប TTY សមទរសពមក លខ ទ 7 Din4 k'ehj7 yn7[t'i'go saad bee yt'i' 47 t'j77k'e bee n7k'a'doowo[go 47 n'ahoot'i'. Koj8 47 b44sh bee hod77lnih TTY biniiy4go 47 7 j8 b44sh bee hod77lnih. image_000r0_general_portrait (0/7)

13 07 ANTI-INFECTIVE DRUGS PENICILLINS AMOXICILLIN amoxicillin (trihydrate) chew tab 5 AMOXICILLIN amoxicillin (trihydrate) chew tab 50 amoxicillin (trihydrate) cap 50 amoxicillin (trihydrate) cap 500 amoxicillin (trihydrate) for susp 5 /5ml amoxicillin (trihydrate) for susp 00 /5ml amoxicillin (trihydrate) for susp 50 /5ml amoxicillin (trihydrate) for susp 400 /5ml amoxicillin (trihydrate) tab 500 amoxicillin (trihydrate) tab 875 amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin) amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml (Augmentin es-600) amoxicillin & k clavulanate tab er hr (Augmentin xr) amoxicillin & k clavulanate tab 50-5 amoxicillin & k clavulanate tab (Augmentin) amoxicillin & k clavulanate tab (Augmentin) ampicillin cap 500 AUGMENTIN amoxicillin & k clavulanate for susp /5ml dicloxacillin sodium cap 50 dicloxacillin sodium cap 500 penicillin v potassium for soln 5 /5ml penicillin v potassium for soln 50 /5ml penicillin v potassium tab 50 penicillin v potassium tab 500 CEPHALOSPORINS cefadroxil cap 500 cefadroxil for susp 50 /5ml cefadroxil for susp 500 /5ml cefadroxil tab gm cefdinir cap 300 cefdinir for susp 5 /5ml cefdinir for susp 50 /5ml cefixime for susp 00 /5ml (Suprax) cefixime for susp 00 /5ml (Suprax) cefprozil for susp 5 /5ml cefprozil for susp 50 /5ml cefprozil tab 50 cefprozil tab 500 CEFTIN cefuroxime axetil for susp 5 /5ml ceftriaxone sodium for inj 50 ceftriaxone sodium for inj 500 FlexRx Drug Formulary, October 07

14 07 ceftriaxone sodium for inj gm ceftriaxone sodium for inj gm ceftriaxone sodium for iv soln gm ceftriaxone sodium for iv soln gm cefuroxime axetil tab 50 cefuroxime axetil tab 500 cephalexin cap 50 (Keflex) cephalexin cap 500 (Keflex) cephalexin for susp 5 /5ml cephalexin for susp 50 /5ml SUPRAX cefixime cap 400 SUPRAX cefixime for susp 500 /5ml SUPRAX cefixime chew tab 00 SUPRAX cefixime chew tab 00 MACROLIDES AZITHROMYCIN azithromycin powd pack for susp gm azithromycin for susp 00 /5ml (Zithromax) azithromycin for susp 00 /5ml (Zithromax) azithromycin tab 50 (Zithromax) azithromycin tab 500 (Zithromax) azithromycin tab 600 (Zithromax) clarithromycin for susp 5 /5ml clarithromycin for susp 50 /5ml (Biaxin) clarithromycin tab 50 (Biaxin) clarithromycin tab 500 (Biaxin) DIFICID fidaxomicin tab 00 E.E.S. 400 erythromycin ethylsuccinate tab 400 ERYTHROCIN STEARATE erythromycin stearate tab 50 ERYTHROMYCIN ETHYLSUCCINATE erythromycin ethylsuccinate tab 400 TETRACYCLINES demeclocycline hcl tab 50 demeclocycline hcl tab 300 doxycycline hyclate cap 50 doxycycline hyclate cap 00 (Vibramycin) doxycycline hyclate tab delayed release 75 doxycycline hyclate tab delayed release 00 doxycycline hyclate tab delayed release 50 doxycycline hyclate tab 0 doxycycline hyclate tab 00 doxycycline monohydrate cap 50 doxycycline monohydrate cap 75 (Monodox) doxycycline monohydrate cap 00 (Monodox) doxycycline monohydrate cap 50 (Adoxa) doxycycline monohydrate tab 50 (Adoxa) doxycycline monohydrate tab 75 (Adoxa) doxycycline monohydrate tab 00 (Adoxa pak /00) FlexRx Drug Formulary, October 07

15 07 doxycycline monohydrate tab 50 (Adoxa pak /50) minocycline hcl cap 50 (Minocin) minocycline hcl cap 75 (Minocin) minocycline hcl cap 00 (Minocin) MINOCYCLINE HCL ER minocycline hcl tab er 4hr 45 minocycline hcl tab er 4hr 90 minocycline hcl tab er 4hr 35 minocycline hcl tab 50 minocycline hcl tab 75 minocycline hcl tab 00 FLUOROQUINOLONES ciprofloxacin for oral susp 50 /5ml (5%) (5 gm/00ml) (Cipro) ciprofloxacin for oral susp 500 /5ml (0%) (0 gm/00ml) (Cipro) ciprofloxacin hcl tab 50 (base equiv) (Cipro) ciprofloxacin hcl tab 500 (base equiv) (Cipro) ciprofloxacin hcl tab 750 (base equiv) LEVOFLOXACIN levofloxacin oral soln 5 /ml levofloxacin tab 50 (Levaquin) levofloxacin tab 500 (Levaquin) levofloxacin tab 750 (Levaquin) AMINOGLYCOSIDES neomycin sulfate tab 500 paromomycin sulfate cap 50 tobramycin nebu soln 300 /5ml (Tobi) SULFONAMIDES sulfamethoxazole-trimethoprim susp /5ml sulfamethoxazole-trimethoprim tab (Bactrim) sulfamethoxazole-trimethoprim tab (Bactrim ds) TUBERCULOSIS ethambutol hcl tab 00 (Myambutol) ethambutol hcl tab 400 (Myambutol) ISONIAZID isoniazid syrup 50 /5ml isoniazid tab 00 isoniazid tab 300 PRIFTIN rifapentine tab 50 pyrazinamide tab 500 rifabutin cap 50 (Mycobutin) rifampin cap 50 (Rifadin) rifampin cap 300 (Rifadin) FUNGAL INFECTIONS fluconazole for susp 0 /ml (Diflucan) fluconazole for susp 40 /ml (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) fluconazole tab 50 (Diflucan) fluconazole tab 00 (Diflucan) flucytosine cap 50 (Ancobon) FlexRx Drug Formulary, October 07 3

16 07 flucytosine cap 500 (Ancobon) griseofulvin microsize susp 5 /5ml griseofulvin microsize tab 500 itraconazole cap 00 (Sporanox) NOXAFIL posaconazole tab delayed release 00 NOXAFIL posaconazole susp 40 /ml nystatin oral powder terbinafine hcl tab 50 (Lamisil) voriconazole for susp 40 /ml (Vfend) voriconazole tab 50 (Vfend) voriconazole tab 00 (Vfend) VIRAL INFECTIONS Cytomegalovirus valganciclovir hcl for soln 50 /ml (base equiv) (Valcyte) valganciclovir hcl tab 450 (base equivalent) (Valcyte) Hepatitis BARACLUDE entecavir oral soln 0.05 /ml entecavir tab 0.5 (Baraclude) entecavir tab (Baraclude) EPCLUSA sofosbuvir-velpatasvir tab EPIVIR HBV lamivudine oral soln 5 /ml (hbv) HARVONI ledipasvir-sofosbuvir tab INTRON A interferon alfa-b inj unit/ml INTRON A interferon alfa-b inj unit/ml INTRON A interferon alfa-b for inj unit INTRON A interferon alfa-b for inj unit INTRON A interferon alfa-b for inj unit INTRON A W/DILUENT interferon alfa-b for inj unit INTRON A W/DILUENT interferon alfa-b for inj unit INTRON A W/DILUENT interferon alfa-b for inj unit PEGASYS peginterferon alfa-a inj 80 mcg/ml PEGASYS peginterferon alfa-a inj 80 mcg/0.5ml PEGASYS PROCLICK peginterferon alfa-a inj 35 mcg/0.5ml PEGASYS PROCLICK peginterferon alfa-a inj 80 mcg/0.5ml ribavirin cap 00 (Rebetol) SOVALDI sofosbuvir tab 400 Herpes acyclovir cap 00 (Zovirax) acyclovir susp 00 /5ml (Zovirax) acyclovir tab 400 (Zovirax) acyclovir tab 800 (Zovirax) famciclovir tab 5 famciclovir tab 50 famciclovir tab 500 valacyclovir hcl tab 500 (Valtrex) FlexRx Drug Formulary, October 07 4

17 07 valacyclovir hcl tab gm (Valtrex) HIV/AIDS abacavir sulfate tab 300 (base equiv) (Ziagen) abacavir sulfate-lamivudine tab (Epzicom) abacavir sulfate-lamivudinezidovudine tab (Trizivir) APTIVUS tipranavir cap 50 APTIVUS tipranavir oral soln 00 /ml ATRIPLA efavirenz-emtricitabinetenofovir df tab COMPLERA emtricitabinerilpivirine-tenofovir df tab CRIXIVAN indinavir sulfate cap 00 CRIXIVAN indinavir sulfate cap 400 DESCOVY emtricitabinetenofovir alafenamide fumarate tab 00-5 didanosine delayed release capsule 5 (Videx ec) didanosine delayed release capsule 00 (Videx ec) didanosine delayed release capsule 50 (Videx ec) didanosine delayed release capsule 400 (Videx ec) EDURANT rilpivirine hcl tab 5 (base equivalent) EMTRIVA emtricitabine caps 00 EMTRIVA emtricitabine soln 0 /ml EVOTAZ atazanavir sulfatecobicistat tab (base equiv) FUZEON enfuvirtide for inj 90 GENVOYA elvitegrav-cobicemtricitab-tenofov af tab INTELENCE etravirine tab 5 INTELENCE etravirine tab 00 INTELENCE etravirine tab 00 INVIRASE saquinavir mesylate cap 00 INVIRASE saquinavir mesylate tab 500 ISENTRESS raltegravir potassium packet for susp 00 (base equiv) ISENTRESS raltegravir potassium tab 400 (base equiv) ISENTRESS raltegravir potassium chew tab 5 (base equiv) ISENTRESS raltegravir potassium chew tab 00 (base equiv) ISENTRESS HD raltegravir potassium tab 600 (base equiv) KALETRA lopinavir-ritonavir tab 00-5 KALETRA lopinavir-ritonavir tab lamivudine oral soln 0 /ml (Epivir) lamivudine tab 50 (Epivir) lamivudine tab 300 (Epivir) lamivudine-zidovudine tab (Combivir) FlexRx Drug Formulary, October 07 5

18 07 LEXIVA fosamprenavir calcium tab 700 (base equiv) LEXIVA fosamprenavir calcium susp 50 /ml (base equiv) lopinavir-ritonavir soln /5ml (80-0 /ml) (Kaletra) nevirapine tab er 4hr 00 (Viramune xr) nevirapine tab er 4hr 400 (Viramune xr) nevirapine tab 00 (Viramune) NORVIR ritonavir cap 00 NORVIR ritonavir tab 00 NORVIR ritonavir oral soln 80 /ml ODEFSEY emtricitabinerilpivirine-tenofovir af tab PREZCOBIX darunavir-cobicistat tab PREZISTA darunavir ethanolate susp 00 /ml (base equiv) PREZISTA darunavir ethanolate tab 75 (base equiv) PREZISTA darunavir ethanolate tab 50 (base equiv) PREZISTA darunavir ethanolate tab 600 (base equiv) PREZISTA darunavir ethanolate tab 800 (base equiv) RESCRIPTOR delavirdine mesylate tab 00 RESCRIPTOR delavirdine mesylate tab 00 REYATAZ atazanavir sulfate oral powder packet 50 (base equiv) REYATAZ atazanavir sulfate cap 50 (base equiv) REYATAZ atazanavir sulfate cap 00 (base equiv) REYATAZ atazanavir sulfate cap 300 (base equiv) SELZENTRY maraviroc oral soln 0 /ml SELZENTRY maraviroc tab 5 SELZENTRY maraviroc tab 75 SELZENTRY maraviroc tab 50 SELZENTRY maraviroc tab 300 stavudine cap 5 (Zerit) stavudine cap 0 (Zerit) stavudine cap 30 (Zerit) stavudine cap 40 (Zerit) STRIBILD elvitegrav-cobicemtricitab-tenofovdf tab SUSTIVA efavirenz tab 600 SUSTIVA efavirenz cap 50 SUSTIVA efavirenz cap 00 TIVICAY dolutegravir sodium tab 0 (base equiv) TIVICAY dolutegravir sodium tab 5 (base equiv) TIVICAY dolutegravir sodium tab 50 (base equiv) TRIUMEQ abacavir-dolutegravirlamivudine tab TRUVADA emtricitabine-tenofovir disoproxil fumarate tab TRUVADA emtricitabine-tenofovir disoproxil fumarate tab FlexRx Drug Formulary, October 07 6

19 07 TRUVADA emtricitabine-tenofovir disoproxil fumarate tab TRUVADA emtricitabine-tenofovir disoproxil fumarate tab TYBOST cobicistat tab 50 VIDEX didanosine for soln gm VIDEX didanosine for soln 4 gm VIRACEPT nelfinavir mesylate tab 50 VIRACEPT nelfinavir mesylate tab 65 VIRAMUNE nevirapine susp 50 /5ml VIREAD tenofovir disoproxil fumarate oral powder 40 /gm VIREAD tenofovir disoproxil fumarate tab 50 VIREAD tenofovir disoproxil fumarate tab 00 VIREAD tenofovir disoproxil fumarate tab 50 VIREAD tenofovir disoproxil fumarate tab 300 ZERIT stavudine for oral soln /ml ZIAGEN abacavir sulfate soln 0 /ml (base equiv) zidovudine cap 00 (Retrovir) zidovudine syrup 0 /ml (Retrovir) zidovudine tab 300 Influenza oseltamivir phosphate cap 30 (base equiv) (Tamiflu) oseltamivir phosphate cap 45 (base equiv) (Tamiflu) oseltamivir phosphate cap 75 (base equiv) (Tamiflu) TAMIFLU oseltamivir phosphate for susp 6 /ml (base equiv) MALARIA atovaquone-proguanil hcl tab (Malarone) atovaquone-proguanil hcl tab (Malarone) CHLOROQUINE PHOSPHATE chloroquine phosphate tab 50 chloroquine phosphate tab 500 DARAPRIM pyrimethamine tab 5 hydroxychloroquine sulfate tab 00 (Plaquenil) mefloquine hcl tab 50 PRIMAQUINE PHOSPHATE primaquine phosphate tab 6.3 (5 base) WORM INFECTIONS ALBENZA albendazole tab 00 BILTRICIDE praziquantel tab 600 ivermectin tab 3 (Stromectol) OTHER ANTI-INFECTIVES clindamycin hcl cap 75 (Cleocin) clindamycin hcl cap 50 (Cleocin) clindamycin hcl cap 300 (Cleocin) clindamycin palmitate hcl for soln 75 /5ml (base equiv) (Cleocin pediatric gr) dapsone tab 5 dapsone tab 00 IMPAVIDO miltefosine cap 50 FlexRx Drug Formulary, October 07 7

20 07 linezolid for susp 00 /5ml (Zyvox) linezolid iv soln 600 /300ml ( /ml) (Zyvox) linezolid tab 600 (Zyvox) metronidazole cap 375 (Flagyl) metronidazole tab 50 (Flagyl) metronidazole tab 500 (Flagyl) NEBUPENT pentamidine isethionate for nebulization soln 300 SIVEXTRO tedizolid phosphate tab 00 SULFADIAZINE sulfadiazine tab 500 trimethoprim tab 00 vancomycin hcl cap 5 (Vancocin hcl) vancomycin hcl cap 50 (Vancocin hcl) XIFAXAN rifaximin tab 550 IMMUNIZING AGENTS BCG VACCINE bcg vaccine inj CANCER DRUGS ABRAXANE paclitaxel proteinbound particles for iv susp 00 ACTIMMUNE interferon gamma-b inj 00 mcg/0.5ml ( unit/0.5ml) ADCETRIS brentuximab vedotin for iv soln 50 AFINITOR everolimus tab.5 AFINITOR everolimus tab 5 AFINITOR everolimus tab 7.5 AFINITOR everolimus tab 0 AFINITOR DISPERZ everolimus tab for oral susp AFINITOR DISPERZ everolimus tab for oral susp 3 AFINITOR DISPERZ everolimus tab for oral susp 5 ALECENSA alectinib hcl cap 50 (base equivalent) ALFERON N interferon alfa-n3 inj unit/ml ALIMTA pemetrexed disodium for iv soln 00 (base equiv) ALIMTA pemetrexed disodium for iv soln 500 (base equiv) ALKERAN melphalan tab ALUNBRIG brigatinib tab 30 anastrozole tab (Arimidex) ARRANON nelarabine iv soln 5 /ml ARZERRA ofatumumab conc for iv infusion 00 /5ml ARZERRA ofatumumab conc for iv infusion 000 /50ml AVASTIN bevacizumab iv soln 00 /4ml (for infusion) AVASTIN bevacizumab iv soln 400 /6ml (for infusion) azacitidine for inj 00 (Vidaza) BAVENCIO avelumab soln for iv infusion 00 /0ml (0 /ml) BELEODAQ belinostat for iv inj 500 BENDEKA bendamustine hcl iv soln 00 /4ml (5 /ml) BESPONSA inotuzumab ozogamicin for iv soln 0.9 bexarotene cap 75 (Targretin) bicalutamide tab 50 (Casodex) FlexRx Drug Formulary, October 07 8

21 07 BICNU carmustine for inj 00 bleomycin sulfate for inj 5 unit bleomycin sulfate for inj 30 unit BLINCYTO blinatumomab for iv infusion 35 mcg BOSULIF bosutinib tab 00 BOSULIF bosutinib tab 500 busulfan inj 6 /ml (Busulfex) CABOMETYX cabozantinib s-malate tab 0 (base equivalent) CABOMETYX cabozantinib s-malate tab 40 (base equivalent) CABOMETYX cabozantinib s-malate tab 60 (base equivalent) CAMPTOSAR irinotecan hcl inj 300 /5ml (0 /ml) capecitabine tab 50 (Xeloda) capecitabine tab 500 (Xeloda) CAPRELSA vandetanib tab 00 CAPRELSA vandetanib tab 300 carboplatin iv soln 50 /5ml carboplatin iv soln 50 /5ml carboplatin iv soln 450 /45ml carboplatin iv soln 600 /60ml CISPLATIN cisplatin inj 00 /00ml ( /ml) cisplatin inj 50 /50ml ( / ml) cisplatin inj 00 /00ml ( / ml) cladribine iv soln 0 /0ml ( /ml) clofarabine iv soln /ml (Clolar) CLOLAR clofarabine iv soln /ml COMETRIQ cabozantinib s- malate cap 3 x 0 (60 dose) kit COMETRIQ cabozantinib s-mal cap x 80 & x 0 (00 dose) kit COMETRIQ cabozantinib s-mal cap x 80 & 3 x 0 (40 dose) kit COTELLIC cobimetinib fumarate tab 0 (base equivalent) CYCLOPHOSPHAMIDE cyclophosphamide cap 5 CYCLOPHOSPHAMIDE cyclophosphamide cap 50 cyclophosphamide for inj 500 cyclophosphamide for inj gm cyclophosphamide for inj gm CYRAMZA ramucirumab iv soln 00 /0ml (for infusion) CYRAMZA ramucirumab iv soln 500 /50ml (for infusion) CYTARABINE cytarabine inj 0 /ml cytarabine inj pf 0 /ml cytarabine inj pf 00 /ml DACARBAZINE dacarbazine for inj 00 dacarbazine for inj 00 DARZALEX daratumumab iv soln 00 /5ml DARZALEX daratumumab iv soln 400 /0ml daunorubicin hcl inj 5 /ml (base equiv) decitabine for inj 50 (Dacogen) FlexRx Drug Formulary, October 07 9

22 07 DEPO-PROVERA medroxyprogesterone acetate im susp 400 /ml dexrazoxane for inj 50 (Zinecard) dexrazoxane for inj 500 (Zinecard) DOCETAXEL docetaxel for inj conc 0 /ml DOCETAXEL docetaxel for inj conc 80 /4ml (0 /ml) DOCETAXEL docetaxel for inj conc 60 /8ml (0 /ml) DOCETAXEL docetaxel for inj conc 00 /0ml (0 /ml) DOCETAXEL docetaxel for inj conc 0 /0.5ml (40 /ml) DOCETAXEL docetaxel for inj conc 80 /ml (40 /ml) DOCETAXEL docetaxel soln for iv infusion 0 /ml DOCETAXEL docetaxel soln for iv infusion 80 /8ml DOCETAXEL docetaxel soln for iv infusion 60 /6ml DOCETAXEL (NON-ALCOHOL FO docetaxel (non-alcohol formula) iv soln 0 /ml DOCETAXEL (NON-ALCOHOL FO docetaxel (non-alcohol formula) iv soln 80 /4ml DOCETAXEL (NON-ALCOHOL FO docetaxel (non-alcohol formula) iv soln 60 /8ml docetaxel for inj conc 0 /ml (Taxotere) docetaxel for inj conc 80 /4ml (0 /ml) (Taxotere) DOXORUBICIN HCL doxorubicin hcl for inj 0 DOXORUBICIN HCL doxorubicin hcl for inj 50 doxorubicin hcl inj /ml doxorubicin hcl liposomal inj (for iv infusion) /ml (Doxil) ELITEK rasburicase for iv soln.5 ELITEK rasburicase for iv soln 7.5 EMCYT estramustine phosphate sodium cap 40 EMPLICITI elotuzumab for iv soln 300 EMPLICITI elotuzumab for iv soln 400 epirubicin hcl iv soln 50 /5ml ( /ml) (Ellence) epirubicin hcl iv soln 00 /00ml ( /ml) (Ellence) ERBITUX cetuximab iv soln 00 /50ml ( /ml) ERBITUX cetuximab iv soln 00 /00ml ( /ml) ERIVEDGE vismodegib cap 50 ERWINAZE asparaginase erwinia chrysanthemi for inj 0000 unit ETOPOPHOS etoposide phosphate iv for inj 00 (base equivalent) ETOPOSIDE etoposide cap 50 etoposide inj 00 /5ml (0 / ml) etoposide inj 500 /5ml (0 /ml) etoposide inj gm/50ml (0 / ml) FlexRx Drug Formulary, October 07 0

23 07 EVOMELA melphalan hcl for inj 50 (propylene glycol (pg) free) exemestane tab 5 (Aromasin) FARESTON toremifene citrate tab 60 (base equivalent) FARYDAK panobinostat lactate cap 0 (base equivalent) FARYDAK panobinostat lactate cap 5 (base equivalent) FARYDAK panobinostat lactate cap 0 (base equivalent) FASLODEX fulvestrant inj 50 /5ml FIRMAGON degarelix acetate for inj 80 (base equiv) FIRMAGON degarelix acetate for inj 0 (base equiv) FLOXURIDINE floxuridine for inj 0.5 gm fludarabine phosphate for inj 50 fludarabine phosphate inj 5 / ml fluorouracil inj 500 /0ml (50 /ml) fluorouracil inj gm/0ml (50 /ml) fluorouracil inj.5 gm/50ml (50 /ml) fluorouracil inj 5 gm/00ml (50 /ml) flutamide cap 5 FOLOTYN pralatrexate iv inj 0 /ml FOLOTYN pralatrexate iv inj 40 /ml GAZYVA obinutuzumab soln for iv infusion 000 /40ml (5 / ml) gemcitabine hcl for inj 00 (Gemzar) gemcitabine hcl for inj gm (Gemzar) gemcitabine hcl for inj gm gemcitabine hcl inj 00 /5.6ml (38 /ml) (base equiv) gemcitabine hcl inj gm/6.3ml (38 /ml) (base equiv) gemcitabine hcl inj gm/5.6ml (38 /ml) (base equiv) GILOTRIF afatinib dimaleate tab 0 (base equivalent) GILOTRIF afatinib dimaleate tab 30 (base equivalent) GILOTRIF afatinib dimaleate tab 40 (base equivalent) GLEOSTINE lomustine cap 5 GLEOSTINE lomustine cap 0 GLEOSTINE lomustine cap 40 GLEOSTINE lomustine cap 00 GLIADEL WAFER carmustine in polifeprosan intracranial implant wafer 7.7 HALAVEN eribulin mesylate inj /ml (0.5 /ml) HERCEPTIN trastuzumab for iv soln 50 HERCEPTIN trastuzumab for iv soln 440 HEXALEN altretamine cap 50 HYCAMTIN topotecan hcl cap 0.5 (base equiv) FlexRx Drug Formulary, October 07

24 07 HYCAMTIN topotecan hcl cap (base equiv) HYDROXYPROGESTERONE CAPRO hydroxyprogesterone caproate im in oil.5 gm/5ml hydroxyurea cap 500 (Hydrea) IBRANCE palbociclib cap 75 IBRANCE palbociclib cap 00 IBRANCE palbociclib cap 5 ICLUSIG ponatinib hcl tab 5 (base equiv) ICLUSIG ponatinib hcl tab 45 (base equiv) idarubicin hcl iv inj 5 /5ml ( /ml) (Idamycin pfs) idarubicin hcl iv inj 0 /0ml ( /ml) (Idamycin pfs) idarubicin hcl iv inj 0 /0ml ( /ml) (Idamycin pfs) IDHIFA enasidenib mesylate tab 50 (base equivalent) IDHIFA enasidenib mesylate tab 00 (base equivalent) IFEX ifosfamide for inj gm IFEX ifosfamide for inj 3 gm IFOSFAMIDE ifosfamide for inj 3 gm ifosfamide for inj gm (Ifex) ifosfamide iv inj gm/0ml (50 /ml) ifosfamide iv inj 3 gm/60ml (50 /ml) imatinib mesylate tab 00 (base equivalent) (Gleevec) imatinib mesylate tab 400 (base equivalent) (Gleevec) IMBRUVICA ibrutinib cap 40 IMFINZI durvalumab soln for iv infusion 0 /.4ml (50 /ml) IMFINZI durvalumab soln for iv infusion 500 /0ml (50 /ml) IMLYGIC talimogene laherparepvec intralesional inj unit/ml IMLYGIC talimogene laherparepvec intralesional inj unit/ml INLYTA axitinib tab INLYTA axitinib tab 5 INTRON A interferon alfa-b inj unit/ml INTRON A interferon alfa-b inj unit/ml INTRON A interferon alfa-b for inj unit INTRON A interferon alfa-b for inj unit INTRON A interferon alfa-b for inj unit INTRON A W/DILUENT interferon alfa-b for inj unit INTRON A W/DILUENT interferon alfa-b for inj unit INTRON A W/DILUENT interferon alfa-b for inj unit IRESSA gefitinib tab 50 IRINOTECAN irinotecan hcl inj 500 /5ml (0 /ml) irinotecan hcl inj 40 /ml (0 /ml) (Camptosar) irinotecan hcl inj 00 /5ml (0 /ml) (Camptosar) ISTODAX (OVERFILL) romidepsin for iv inj 0 FlexRx Drug Formulary, October 07

25 07 IXEMPRA KIT ixabepilone for iv infusion 5 IXEMPRA KIT ixabepilone for iv infusion 45 JAKAFI ruxolitinib phosphate tab 5 (base equivalent) JAKAFI ruxolitinib phosphate tab 0 (base equivalent) JAKAFI ruxolitinib phosphate tab 5 (base equivalent) JAKAFI ruxolitinib phosphate tab 0 (base equivalent) JAKAFI ruxolitinib phosphate tab 5 (base equivalent) JEVTANA cabazitaxel inj 60 /.5ml (for iv infusion) KADCYLA ado-trastuzumab emtansine for iv soln 00 KADCYLA ado-trastuzumab emtansine for iv soln 60 KEPIVANCE palifermin for iv inj 6.5 KEYTRUDA pembrolizumab iv soln 00 /4ml (5 /ml) KEYTRUDA pembrolizumab for iv soln 50 KISQALI ribociclib succinate tab 00 (base equiv) KISQALI FEMARA 00 DOSE ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 400 DOSE ribociclib tab 00 & letrozole tab.5 therapy pack KISQALI FEMARA 600 DOSE ribociclib tab 00 & letrozole tab.5 therapy pack KYMRIAH tisagenlecleucel-t suspension for iv infusion KYPROLIS carfilzomib for inj 30 KYPROLIS carfilzomib for inj 60 LARTRUVO olaratumab soln for iv infusion 90 /9ml (0 / ml) LARTRUVO olaratumab soln for iv infusion 500 /50ml (0 / ml) LENVIMA 0 MG DAILY DOSE lenvatinib cap therapy pack 0 (0 daily dose) LENVIMA 4 MG DAILY DOSE lenvatinib cap therapy pack 0 & 4 (4 daily dose) LENVIMA 8 MG DAILY DOSE lenvatinib cap therapy pack 0 & 4 () (8 daily dose) LENVIMA 0 MG DAILY DOSE lenvatinib cap therapy pack 0 () (0 daily dose) LENVIMA 4 MG DAILY DOSE lenvatinib cap therapy pack 0 () & 4 (4 daily dose) LENVIMA 8 MG DAILY DOSE lenvatinib cap therapy pack 4 () (8 daily dose) letrozole tab.5 (Femara) LEUCOVORIN CALCIUM leucovorin calcium for inj 500 LEUCOVORIN CALCIUM leucovorin calcium tab 0 LEUCOVORIN CALCIUM leucovorin calcium tab 5 leucovorin calcium for inj 50 leucovorin calcium for inj 00 leucovorin calcium for inj 00 leucovorin calcium for inj 350 leucovorin calcium tab 5 FlexRx Drug Formulary, October 07 3

26 07 leucovorin calcium tab 5 LEUKERAN chlorambucil tab leuprolide acetate inj kit 5 /ml LEVOLEUCOVORIN levoleucovorin calcium iv soln pf 50 /5ml (base equiv) LEVOLEUCOVORIN levoleucovorin calcium for iv inj 75 (base equiv) levoleucovorin calcium for iv inj 50 (base equiv) (Fusilev) levoleucovorin calcium inj 75 /7.5ml (base equiv) LONSURF trifluridine-tipiracil tab LONSURF trifluridine-tipiracil tab LUPRON DEPOT (-MONTH) leuprolide acetate for inj kit 3.75 LUPRON DEPOT (-MONTH) leuprolide acetate for inj kit 7.5 LUPRON DEPOT (3-MONTH) leuprolide acetate (3 month) for inj kit.5 LUPRON DEPOT (3-MONTH) leuprolide acetate (3 month) for inj kit.5 LUPRON DEPOT (4-MONTH) leuprolide acetate (4 month) for inj kit 30 LUPRON DEPOT (6-MONTH) leuprolide acetate (6 month) for inj kit 45 LYNPARZA olaparib cap 50 LYNPARZA olaparib tab 00 LYNPARZA olaparib tab 50 LYSODREN mitotane tab 500 MARQIBO vincristine sulfate liposome iv susp 5 /3ml (0.6 /ml) MATULANE procarbazine hcl cap 50 megestrol acetate susp 40 /ml (Megace oral) megestrol acetate tab 0 megestrol acetate tab 40 MEKINIST trametinib dimethyl sulfoxide tab 0.5 (base equivalent) MEKINIST trametinib dimethyl sulfoxide tab (base equivalent) melphalan hcl for inj 50 (base equiv) (Alkeran) melphalan tab (Alkeran) mercaptopurine tab 50 mesna inj 00 /ml (Mesnex) MESNEX mesna tab 400 METASTRON strontium-89 chloride inj mci/ml METHOTREXATE SODIUM methotrexate sodium inj 50 /0ml (5 /ml) methotrexate sodium for inj gm methotrexate sodium inj pf 50 /ml (5 /ml) methotrexate sodium inj pf 00 /4ml (5 /ml) methotrexate sodium inj pf 00 /8ml (5 /ml) methotrexate sodium inj pf 50 /0ml (5 /ml) methotrexate sodium inj pf 000 /40ml (5 /ml) methotrexate sodium inj 50 /ml (5 /ml) FlexRx Drug Formulary, October 07 4

27 07 methotrexate sodium tab.5 (base equiv) MITOMYCIN mitomycin for iv soln 5 mitomycin for iv soln 0 mitomycin for iv soln 40 mitoxantrone hcl inj conc 0 /0ml ( /ml) mitoxantrone hcl inj conc 5 /.5ml ( /ml) mitoxantrone hcl inj conc 30 /5ml ( /ml) MUSTARGEN mechlorethamine hcl for inj 0 MYLERAN busulfan tab NERLYNX neratinib maleate tab 40 (base equivalent) NEXAVAR sorafenib tosylate tab 00 (base equivalent) nilutamide tab 50 (Nilandron) NINLARO ixazomib citrate cap.3 (base equivalent) NINLARO ixazomib citrate cap 3 (base equivalent) NINLARO ixazomib citrate cap 4 (base equivalent) ODOMZO sonidegib phosphate cap 00 (base equivalent) ONCASPAR pegaspargase inj 750 unit/ml ONIVYDE irinotecan hcl liposome iv inj 43 /0ml (4.3 /ml) OPDIVO nivolumab iv soln 40 /4ml OPDIVO nivolumab iv soln 00 /0ml oxaliplatin for iv inj 50 oxaliplatin for iv inj 00 oxaliplatin iv soln 50 /0ml oxaliplatin iv soln 00 /0ml PACLITAXEL paclitaxel iv conc 50 /5ml (6 /ml) paclitaxel iv conc 30 /5ml (6 /ml) paclitaxel iv conc 00 /6.7ml (6 /ml) paclitaxel iv conc 300 /50ml (6 /ml) PERJETA pertuzumab soln for iv infusion 40 /4ml (30 /ml) PHOTOFRIN porfimer sodium for inj 75 POMALYST pomalidomide cap POMALYST pomalidomide cap POMALYST pomalidomide cap 3 POMALYST pomalidomide cap 4 PORTRAZZA necitumumab iv soln 800 /50ml (6 /ml) PROLEUKIN aldesleukin for iv soln unit PROVENGE sipuleucel-t suspension for iv infusion PURIXAN mercaptopurine susp 000 /00ml (0 /ml) QUADRAMET samarium sm 53 lexidronam inj 850 mbq/ml (50 mci/ml) RITUXAN rituximab iv soln 00 /0ml RITUXAN rituximab iv soln 500 /50ml RUBRACA rucaparib camsylate tab 00 (base equivalent) FlexRx Drug Formulary, October 07 5

28 07 RUBRACA rucaparib camsylate tab 50 (base equivalent) RUBRACA rucaparib camsylate tab 300 (base equivalent) RYDAPT midostaurin cap 5 SOLTAMOX tamoxifen citrate oral soln 0 /5ml (base equivalent) SPRYCEL dasatinib tab 0 SPRYCEL dasatinib tab 50 SPRYCEL dasatinib tab 70 SPRYCEL dasatinib tab 80 SPRYCEL dasatinib tab 00 SPRYCEL dasatinib tab 40 STIVARGA regorafenib tab 40 SUTENT sunitinib malate cap.5 (base equivalent) SUTENT sunitinib malate cap 5 (base equivalent) SUTENT sunitinib malate cap 37.5 (base equivalent) SUTENT sunitinib malate cap 50 (base equivalent) SYLATRON peginterferon alfa-b for inj kit 00 mcg SYLATRON peginterferon alfa-b for inj kit 300 mcg SYLATRON peginterferon alfa-b for inj kit 600 mcg SYNRIBO omacetaxine mepesuccinate for inj 3.5 TABLOID thioguanine tab 40 TAFINLAR dabrafenib mesylate cap 50 (base equivalent) TAFINLAR dabrafenib mesylate cap 75 (base equivalent) TAGRISSO osimertinib mesylate tab 40 (base equivalent) TAGRISSO osimertinib mesylate tab 80 (base equivalent) tamoxifen citrate tab 0 (base equivalent) tamoxifen citrate tab 0 (base equivalent) TARCEVA erlotinib hcl tab 5 (base equivalent) TARCEVA erlotinib hcl tab 00 (base equivalent) TARCEVA erlotinib hcl tab 50 (base equivalent) TASIGNA nilotinib hcl cap 50 (base equivalent) TASIGNA nilotinib hcl cap 00 (base equivalent) TECENTRIQ atezolizumab iv soln 00 /0ml TEMODAR temozolomide for iv soln 00 temozolomide cap 5 (Temodar) temozolomide cap 0 (Temodar) temozolomide cap 00 (Temodar) temozolomide cap 40 (Temodar) temozolomide cap 80 (Temodar) temozolomide cap 50 (Temodar) TENIPOSIDE teniposide iv soln 0 /ml TEPADINA thiotepa for inj 00 THERACYS bcg live intravesical for susp 8 /vial thiotepa for inj 5 (Tepadina) FlexRx Drug Formulary, October 07 6

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