Upper Peninsula Health Plan (UPHP) UPHP Advantage (HMO) and UPHP Choice (HMO) 2018 Formulary. List of Covered Drugs

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1 Upper Peninsula Health Plan (UPHP) UPHP Advantage (HMO) and UPHP Choice (HMO) 08 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE S WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID, 0008v9 We have made no changes to this formulary since 5//08. For more recent information or other questions, please contact Upper Peninsula Health Plan (HMO) Customer Services at or, for TTY users, 7, 7 days a week, 8 am to 9 pm Eastern Time. The call is free. Or visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Upper Peninsula Health Plan (HMO). When it refers to plan or our plan, it means Upper Peninsula Health Plan Advantage (HMO) or Upper Peninsula Health Plan Choice (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 05//08 For an updated formulary, please contact us. Our contact information, along with the date we last updated the H6_08_P085 CMS Accepted 09/5/07 Upper Peninsula Health Plan is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula depends on contract renewal. mean by going to page 7. H6_08_P085

2 formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 08, and from time to time during the year. What is the Upper Peninsula Health Plan Advantage (HMO) and Upper Peninsula Health Plan Choice (HMO) Formulary? A formulary is a list of covered drugs selected by Upper Peninsula Health Plan (HMO) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Upper Peninsula Health Plan (HMO) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Upper Peninsula Health Plan (HMO) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 08 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 08 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of //08. To get updated information about the drugs covered by Upper Peninsula Health Plan (HMO), please contact us. Our contact information appears on the front and back cover pages. In the event of mid-year non-maintenance formulary changes, all affected members will be notified via mail (at least 60 days before the change becomes effective). In addition, the printed formulary will be updated the first week of the effected month. The printed formulary will be posted on our website at H6_08_P085 CMS Accepted 09/5/07 Upper Peninsula Health Plan is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula depends on contract renewal. mean by going to page 7.

3 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 6. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Upper Peninsula Health Plan (HMO) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Upper Peninsula Health Plan (HMO) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Upper Peninsula Health Plan (HMO) before you fill your prescriptions. If you don t get approval, Upper Peninsula Health Plan (HMO) may not cover the drug. Quantity Limits: For certain drugs, Upper Peninsula Health Plan (HMO) limits the amount of the drug that Upper Peninsula Health Plan (HMO) will cover. For example, Upper Peninsula Health Plan (HMO) provides 30 units per prescription for REVLIMID. This may be in addition to a standard one-month or three-month supply. H6_08_P085 CMS Accepted 09/5/07 Upper Peninsula Health Plan is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula depends on contract renewal. mean by going to page

4 Step Therapy: In some cases, Upper Peninsula Health Plan (HMO) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Upper Peninsula Health Plan (HMO) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Upper Peninsula Health Plan (HMO) will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Upper Peninsula Health Plan (HMO) to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Upper Peninsula Health Plan (HMO) s formulary? on page for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you learn that Upper Peninsula Health Plan (HMO) does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Upper Peninsula Health Plan (HMO). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Upper Peninsula Health Plan (HMO). You can ask Upper Peninsula Health Plan (HMO) to make an exception and cover your drug. See below for information about how to request an exception. H6_08_P085 CMS Accepted 09/5/07 Upper Peninsula Health Plan is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula depends on contract renewal. mean by going to page 7.

5 How do I request an exception to the Upper Peninsula Health Plan Advantage (HMO) s or Upper Peninsula Health Plan Choice (HMO) s Formulary? You can ask Upper Peninsula Health Plan (HMO) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level, if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Upper Peninsula Health Plan (HMO) limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Upper Peninsula Health Plan (HMO) will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. H6_08_P085 CMS Accepted 09/5/07 Upper Peninsula Health Plan is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula depends on contract renewal. mean by going to page

6 For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 9-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Please note that our transition policy applies to those drugs that are Part D drugs and bought at a Network Pharmacy. The transition policy cannot be used to buy a non-part D drug or a drug out of network unless you qualify for out of network access. For more information For more detailed information about your Upper Peninsula Health Plan (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Upper Peninsula Health Plan (HMO), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day/7 days a week. TTY users should call Or, visit Upper Peninsula Health Plan (HMO) s Formulary The formulary below provides coverage information about the drugs covered by Upper Peninsula Health Plan (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on page 6. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if Upper Peninsula Health Plan (HMO) has any special requirements for coverage of your drug. H6_08_P085 CMS Accepted 09/5/07 Upper Peninsula Health Plan is an HMO plan with a Medicare contract. Enrollment in Upper Peninsula depends on contract renewal. mean by going to page

7 LEGEND NAME Preferred Generics Generics 3 Preferred Brands Non-Preferred Brands 5 Specialty SYMBOL NAME DESCRIPTION QL Quantity Limit There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. PA ST Prior Authorization Step Therapy You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. 7

8 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) Analgesics Nonsteroidal Anti-inflammatory Drugs diclofenac potassium 50 mg tablet diclofenac sodium 3 % gel (gram) diclofenac sodium (5 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 00 mg tab er h) diflunisal 500 mg tablet etodolac (00 mg capsule, 300 mg capsule, 00 mg tablet, 500 mg tablet) fenoprofen calcium 600 mg tablet flurbiprofen (50 mg tablet, 00 mg tablet) ibuprofen 00 mg/5ml oral susp ibuprofen (00 mg tablet, 600 mg tablet, 800 mg tablet) indomethacin (5 mg capsule, 50 mg capsule) ketoprofen (50 mg capsule, 75 mg capsule) ketorolac tromethamine (5 mg/ml vial, 30mg/ml() vial, 30 mg/ml cartridge, 60 mg/ ml cartridge) PA PA ketorolac tromethamine 0 mg tablet PA, QL (0 PER 30 DAYS) meclofenamate sodium (50 mg capsule, 00 mg capsule) mefenamic acid 50 mg capsule meloxicam (7.5 mg tablet, 5 mg tablet) nabumetone (500 mg tablet, 750 mg tablet) naproxen (50 mg tablet, 375 mg tablet, 500 mg tablet) naproxen (5 mg/5ml oral susp, 375 mg tablet dr, 500 mg tablet dr) 8

9 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) naproxen sodium (75 mg tablet, 550 mg tablet) oxaprozin 600 mg tablet piroxicam (0 mg capsule, 0 mg capsule) sulindac (50 mg tablet, 00 mg tablet) tolmetin sodium 00 mg capsule tolmetin sodium 600 mg tablet Opioid Analgesics, Long-acting EMBEDA (ER MG CAPSULE, ER 30-. MG CAPSULE, ER 50- MG CAPSULE, ER 60-. MG CAPSULE, ER MG CAPSULE, ER 00- MG CAPSULE) fentanyl ( mcg/hr patch td7, 5 mcg/hr patch td7, 5mcg/hr patch td7, 37.5mcg/hr patch td7, 50mcg/hr patch td7, 6.5mcg/hr patch td7, 75mcg/hr patch td7, 00 mcg/hr patch td7) fentanyl 87.5mcg/hr patch td7 5 hydromorphone hcl (6 mg tab er h, 3 mg tab er h) methadone hcl (5 mg/5 ml solution, 5 mg tablet, 0 mg/5 ml solution, 0 mg tablet) methadone hcl (0 mg/ml vial, 0 mg/ml syringe) morphine sulfate (0 mg cap er pel, 0 mg cap er pel, 30 mg cap er pel, 50 mg cap er pel, 60 mg cap er pel, 80 mg cap er pel, 00 mg tablet er) morphine sulfate 00 mg cap er pel 5 morphine sulfate (5 mg tablet er, 30 mg tablet er, 60 mg tablet er, 00 mg tablet er) 3 5 9

10 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) oxymorphone hcl (5 mg tab er h, 7.5 mg tab er h, 0 mg tab er h, 5 mg tab er h, 0 mg tab er h, 30 mg tab er h, 0 mg tab er h) XTAMPZA ER (ER 9 MG CAPSULE, ER 3.5 MG CAPSULE, ER 8 MG CAPSULE, ER 7 MG CAPSULE, ER 36 MG CAPSULE) 3 Opioid Analgesics, Short-acting ABSTRAL (00 MCG TAB, 00 MCG TAB, 300 MCG TAB, 00 MCG TAB, 600 MCG TAB, 800 MCG TAB) acetaminophen with codeine phosphate (0- mg/5 solution, 300mg/.5 solution) acetaminophen with codeine phosphate (300mg-30mg tablet, 300mg-60mg tablet, 300mg-5mg tablet) butorphanol tartrate 0 mg/ml spray butorphanol tartrate ( mg/ml vial, mg/ml vial) codeine sulfate (5 mg tablet, 30 mg tablet, 60 mg tablet) DURAMORPH (5 MG/0 ML AMPUL, 0 MG/0 ML AMPUL) fentanyl citrate (00 mcg lozenge hd, 00 mcg lozenge hd) fentanyl citrate (600 mcg lozenge hd, 800 mcg lozenge hd, 00 mcg lozenge hd, 600 mcg lozenge hd) FENTORA (00 MCG TABLET, 00 MCG TABLET, 00 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET) 5 PA PA 5 PA 5 PA 0

11 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 5 mg-35mg tablet, hydrocodone/acetaminophen 5 mg- 300mg tablet, hydrocodone/acetaminophen mg tablet, hydrocodone/acetaminophen mg tablet, hydrocodone/acetaminophen 0mg- 35mg tablet, hydrocodone/acetaminophen 0mg-300mg tablet) hydrocodone-acetaminophen ( mg tablet, 5-35 mg tablet, 0-35 mg tablet) hydrocodone-acetaminophen ( mg/5 ml solution,.5-08 mg/5 ml solution, 5-7 mg/0 ml solution,.5-35 mg tablet, mg tablet, mg tablet) hydrocodone-acetaminophen ( mg/5 ml solution,.5-08 mg/5 ml solution, 5-7 mg/0 ml solution,.5-35 mg tablet, mg tablet, mg tablet) hydrocodone-acetaminophen mg tablet hydromorphone hcl ( mg/ml liquid, mg/ml syringe, mg tablet, mg tablet, 8 mg tablet) hydromorphone hcl/pf (hcl/pf 0 mg/ml ampul, hcl/pf 0 mg/ml vial) ibuprofen/oxycodone hcl (ibuprofen/oxycodone 00 mg-5mg tablet, ibuprofen/oxycodone 00mg-5mg tablet) LAZANDA (00 MCG SPRAY, 300 MCG SPRAY, 00 MCG SPRAY) morphine sulfate ( mg/ml cartridge, mg/ml syringe, mg/ml syringe, mg/ml cartridge, 5 mg/ml syringe, 8 mg/ml syringe, 0 mg/ml syringe, 0 mg/5 ml solution, 5 mg tablet, 0 mg/5 ml solution, 30 mg tablet, 00 mg/5ml solution) nalbuphine hcl (0 mg/ml vial, 0 mg/ml ampul, 0 mg/ml vial, 0 mg/ml ampul) oxycodone hcl 0 mg/ml oral conc 5 PA

12 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) oxycodone hcl (5 mg/5 ml solution, 5 mg capsule, 5 mg tablet, 0 mg tablet, 5 mg tablet, 0 mg tablet, 30 mg tablet) oxycodone hcl/acetaminophen (hcl/acetaminophen 5 mg-35mg tablet, hcl/acetaminophen mg tablet, hcl/acetaminophen 0mg-35mg tablet) oxycodone-acetaminophen (.5-35 mg tablet, mg tablet, 5-35 mg tablet, 0-35 mg tablet) oxycodone-acetaminophen 5-35 mg/5 ml solution oxycodone-aspirin mg tablet tramadol hcl 50 mg tablet tramadol hcl/acetaminophen mg tablet Anesthetics Local Anesthetics lidocaine 5 % adh. patch PA lidocaine 5 % oint. (g) lidocaine hcl % solution lidocaine hcl ( % jelly(ml), % jel/pf app, % jel (ml), 5 mg/ml vial, 0 mg/ml vial, 0 mg/ml solution) lidocaine hcl/pf (hcl/pf 5 mg/ml vial, hcl/pf 0 mg/ml vial, hcl/pf 0 mg/ml ampul, hcl/pf 0 mg/ml vial) lidocaine/prilocaine (lidocaine/prilocaine.5 cream (g), lidocaine/prilocaine.5 kit) QL (30 PER 30 DAYS)

13 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium 333 mg tablet dr disulfiram (50 mg tablet, 500 mg tablet) VIVITROL (380 MG VIAL + DILUENT, 380 MG VIAL) Opioid Dependence Treatments buprenorphine hcl ( mg tab subl, 8 mg tab subl) buprenorphine hcl/naloxone hcl mg-0.5mg tab subl buprenorphine hcl/naloxone hcl 8 mg- mg tab subl naltrexone hcl 50 mg tablet 5 3 QL (360 PER 30 DAYS) 3 QL (90 PER 30 DAYS) SUBOXONE MG-3 MG SL FILM 3 QL (60 PER 30 DAYS) SUBOXONE MG-0.5 MG SL FILM 3 QL (360 PER 30 DAYS) SUBOXONE MG- MG SL FILM 3 QL (80 PER 30 DAYS) SUBOXONE 8 MG- MG SL FILM 3 QL (90 PER 30 DAYS) Opioid Reversal Agents naloxone hcl (0. mg/ml vial, 0. mg/ml syringe, mg/ml syringe) NARCAN MG NASAL SPRAY Smoking Cessation Agents bupropion hcl 50 mg tab er h QL (60 PER 30 DAYS) CHANTIX (0.5 MG TABLET, MG CONT MONTH BOX, MG TABLET, STARTING MONTH BOX) QL (50 PER 365 DAYS) NICOTROL CARTRIDGE INHALER QL (688 PER 365 DAYS) NICOTROL NS 0 MG/ML SPRAY 3 QL (360 PER 365 DAYS) 3

14 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) Antibacterials Aminoglycosides amikacin sulfate 500 mg/ml vial gentamicin sulfate 0.3 % drops gentamicin sulfate (0. % oint. (g), 0. % cream (g), 0.3 % oint. (g), 0 mg/ml vial) gentamicin sulfate in sodium chloride, isoosmotic (60 mg/50ml piggyback, 80 mg/50ml piggyback, 80mg/00ml piggyback, 00mg/0.l piggyback) gentamicin sulfate/pf (sulfate/pf 60 mg/6 ml vial port, sulfate/pf 00mg/0ml vial port) neomycin sulfate 500 mg tablet neomycin sulfate/polymyxin b sulfate (/polymyxin 0-00k/ml ampul, /polymyxin 0-00k/ml vial) paromomycin sulfate 50 mg capsule streptomycin sulfate g vial tobramycin 0.3 % drops tobramycin sulfate (. g vial, 0 mg/ml vial, 0 mg/ml vial) TOBREX 0.3% EYE OINTMENT Antibacterials, Other bacitracin (500 unit/g oint. (g), unit vial) BACTROBAN NASAL % OINTMENT chloramphenicol sod succinate g vial CLEOCIN 00 MG VAGINAL OVULE clindamycin hcl (75 mg capsule, 50 mg capsule, 300 mg capsule) clindamycin palmitate hcl 75 mg/5 ml soln recon

15 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) clindamycin phosphate ( % lotion, % med. swab, % gel (gram), % solution, % cream/appl, 50 mg/ml vial) clindamycin phosphate % foam clindamycin phosphate/d5w 300mg/50ml piggyback clindamycin phosphate/dextrose 5 % in water (phosphate/d5w 900mg/50ml piggyback, phosphate/d5w 600mg/50ml piggyback) colistin (colistimethate na) 50 mg vial dapsone 5 % gel (gram) daptomycin 500 mg vial 5 linezolid 00 mg/5ml susp recon 5 QL (800 PER 8 DAYS) linezolid 600 mg tablet 5 QL (56 PER 8 DAYS) linezolid in dextrose 5% 600mg/300 piggyback methenamine hippurate g tablet metronidazole ( % gel w/pump, % gel (gram)) metronidazole (0.75 % gel (gram), 0.75 % cream (g), 0.75 % gel w/appl, 0.75 % lotion, 50 mg tablet, 375 mg capsule, 500 mg tablet) metronidazole/sodium chloride 500mg/0.l piggyback mupirocin % oint. (g) neomycin/bacit/p-myx/hydrocort 3.5-0k- oint. (g) neomycin/polymyxin b/hydrocort 3.5-0k-0 drops susp nitrofurantoin 5 mg/5 ml oral susp QL (700 PER 365 DAYS) nitrofurantoin macrocrystal 00 mg capsule QL (360 PER 365 DAYS) nitrofurantoin macrocrystal 5 mg capsule QL (0 PER 365 DAYS) 5

16 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) nitrofurantoin macrocrystal 50 mg capsule QL (70 PER 365 DAYS) nitrofurantoin monohyd/m-cryst 00 mg capsule QL (80 PER 365 DAYS) polymyxin b sulfate 500k unit vial PRIMSOL 50 MG/5 ML ORAL SOLN silver sulfadiazine % cream (g) SIVEXTRO (00 MG VIAL, 00 MG TABLET) 5 QL (6 PER 30 DAYS) SSD % CREAM SYNERCID 500 MG VIAL 5 tigecycline 50 mg vial 5 trimethoprim 00 mg tablet vancomycin hcl ( g vial, g vial port, 0 g vial, 5 mg capsule, 50 mg capsule, 500 mg vial, 500 mg vial port) VANDAZOLE VAGINAL 0.75% GEL XIFAXAN (00 MG TABLET, 550 MG TABLET) 5 PA Beta-lactam, Cephalosporins AVYCAZ.5 GRAM VIAL 5 cefaclor (50 mg capsule, 500 mg tab er h, 500 mg capsule) cefadroxil ( g tablet, 50 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon) cefazolin sodium ( g vial, 0 g vial, 0 g vial, 00 g bulkbaginj, 300g bulkbaginj, 500 mg vial) cefdinir (5 mg/5ml susp recon, 50 mg/5ml susp recon, 300 mg capsule) cefepime hcl ( g vial, g vial) cefixime (00 mg/5ml susp recon, 00 mg/5ml susp recon) 6

17 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) cefotaxime sodium ( g vial, g vial, 500 mg vial) cefotetan disodium ( g vial, g vial) cefoxitin sodium ( g vial, g vial, 0 g vial) cefpodoxime proxetil (50 mg/5 ml susp recon, 00 mg tablet, 00 mg tablet) cefpodoxime proxetil 00 mg/5ml susp recon cefprozil (5 mg/5ml susp recon, 50 mg tablet, 50 mg/5ml susp recon, 500 mg tablet) ceftazidime ( g vial, g vial, 6 g vial) ceftriaxone sodium ( g vial, g vial port, g vial port, g vial, 0 g vial, 00 g bulkbaginj, 50 mg vial, 500 mg vial) cefuroxime axetil (50 mg tablet, 500 mg tablet) cefuroxime sodium (.5 g vial, 7.5 g vial, 750 mg vial) cephalexin (5 mg/5ml susp recon, 50 mg tablet, 50 mg capsule, 50 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 750 mg capsule) SUPRAX (00 MG TABLET CHEWABLE, 00 MG TABLET CHEWABLE, 00 MG CAPSULE, 500 MG/5 ML SUSPENSION) 3 TEFLARO (00 MG VIAL, 600 MG VIAL) 5 Beta-lactam, Other AZACTAM-ISO-OSMOTIC DEXTROSE ( GM/50 ML, GM/50 ML) aztreonam g vial doripenem 500 mg vial imipenem/cilastatin sodium (imipenem/cilastatin 50 mg vial, imipenem/cilastatin 500 mg vial) 7

18 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) INVANZ GM VIAL meropenem ( g vial, 500 mg vial) VABOMERE GRAM VIAL 5 Beta-lactam, Penicillins amoxicillin (5 mg tab chew, 5 mg/5ml susp recon, 00 mg/5ml susp recon, 50 mg capsule, 50 mg tab chew, 50 mg/5ml susp recon, 00 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet) amoxicillin/potassium clavulanate (amoxicillin/potassium mg tab chew, amoxicillin/potassium /5 susp recon, amoxicillin/potassium /5 susp recon, amoxicillin/potassium 50-5 mg tablet, amoxicillin/potassium 00-57mg tab chew, amoxicillin/potassium 00-57mg/5 susp recon, amoxicillin/potassium mg tablet, amoxicillin/potassium /5 susp recon, amoxicillin/potassium mg tablet, amoxicillin/potassium tab er h) ampicillin sodium ( g vial, 0 g vial) ampicillin sodium 5 mg vial ampicillin sodium/sulbactam sodium (sodium/sulbactam.5 g vial, sodium/sulbactam 3 g vial, sodium/sulbactam 5 g vial) ampicillin trihydrate (50 mg capsule, 500 mg capsule) ampicillin trihydrate (5 mg/5ml susp recon, 50 mg/5ml susp recon) AUGMENTIN MG/5 ML 5 BICILLIN C-R (. MILLION UNIT, SYRINGE) BICILLIN L-A (600,000 UNIT/ML,,00,000 UNITS,,00,000 UNITS) 8

19 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) dicloxacillin sodium (50 mg capsule, 500 mg capsule) nafcillin sodium g vial nafcillin sodium 0 g vial 5 oxacillin sodium 0 g vial penicillin g potassium (g 5mm unit vial, g 0mm unit vial) penicillin g potassium/dextrose-water (pen g pot/dextrose-water mm/50ml froz.piggy, pen g pot/dextrose-water 3mm/50ml froz.piggy) penicillin g sodium 5mm unit vial 5 penicillin v potassium (5 mg/5ml soln recon, 50 mg/5ml soln recon) penicillin v potassium (50 mg tablet, 500 mg tablet) piperacillin sodium/tazobactam sodium (sodium/tazobactam.5 g vial port, sodium/tazobactam.5 g vial, sodium/tazobactam g vial, sodium/tazobactam g vial port, sodium/tazobactam.5 g vial, sodium/tazobactam.5 g vial port, sodium/tazobactam 0.5 g vial) ZOSYN (.5 GM/50 ML BAG, GM/50 ML) Macrolides AZASITE % EYE DROPS azithromycin ( g packet, 00 mg/5ml susp recon, 00 mg/5ml susp recon, 50 mg tablet, 500 mg vial port, 500 mg tablet, 500 mg vial, 600 mg tablet) clarithromycin (5 mg/5ml susp recon, 50 mg/5ml susp recon, 50 mg tablet, 500 mg tab er h, 500 mg tablet) DIFICID 00 MG TABLET 5 9

20 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) ERY-TAB (DR 50 MG TABLET, DR 333 MG TABLET, DR 500 MG TABLET) 3 ERYPED 00 MG/5 ML SUSPENSION 5 ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500 MG ADDVNT VL) ERYTHROCIN 50 MG FILMTAB erythromycin base (5 mg/gram oint. (g), 5 mg/g oint. (g)) erythromycin base (50 mg tablet, 50 mg capsule dr, 500 mg tablet) erythromycin base/ethyl alcohol (base/ethanol % med. swab, base/ethanol % solution, base/ethanol % gel (gram)) erythromycin ethylsuccinate (00 mg/5ml susp recon, 00 mg tablet) PCE (333 MG TABLET, 500 MG TABLET) ZMAX G/60 ML ORAL SUSPENSION Quinolones BAXDELA (300 MG VIAL, 50 MG TABLET) 5 BESIVANCE 0.6% SUSP ciprofloxacin (50 mg/5ml sus mc rec, 500 mg/5ml sus mc rec) ciprofloxacin hcl (0.3 % drops, 50 mg tablet, 500 mg tablet, 750 mg tablet) ciprofloxacin hcl 00 mg tablet ciprofloxacin lactate 00mg/0ml vial ciprofloxacin in 5 % dextrose 00mg/0.l piggyback ciprofloxacin/ciprofloxacin hcl (ciprofloxacin/ciprofloxa 500 mg tbmp hr, ciprofloxacin/ciprofloxa 000 mg tbmp hr) gatifloxacin 0.5 % drops 0

21 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) levofloxacin (5 mg/ml vial, 50mg/0ml solution, 500mg/0ml solution) levofloxacin (0.5 % drops, 50 mg tablet, 500 mg tablet, 750 mg tablet) levofloxacin/dextrose 5 % in water ( 5 % 500mg/0.l piggyback, 5 % 750mg/.5l piggyback) moxifloxacin hcl (0.5 % drops, 00 mg tablet) moxifloxacin/sod.ace,sul/water 00mg/.5l piggyback ofloxacin (0.3 % drops, 300 mg tablet, 00 mg tablet) VIGAMOX 0.5% EYE DROPS 3 Sulfonamides sulfacetamide sodium (0 % drops, 0 % oint. (g)) sulfadiazine 500 mg tablet sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 00-0mg/5 oral susp, sulfamethoxazole/trimethoprim /0 oral susp) sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 00mg-80mg tablet, sulfamethoxazole/trimethoprim mg tablet) sulfamethoxazole/trimethoprim 80-6mg/ml vial Tetracyclines demeclocycline hcl (50 mg tablet, 300 mg tablet) DORYX MPC DR 0 MG TABLET

22 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) doxycycline hyclate (0 mg tablet, 50 mg capsule, 75 mg tablet, 75 mg tablet dr, 00 mg capsule, 00 mg tablet, 00 mg tablet dr, 00 mg vial, 50 mg tablet) doxycycline hyclate (50 mg tablet dr, 50 mg tablet dr, 00 mg tablet dr) doxycycline monohydrate (75 mg capsule, 50 mg capsule) doxycycline monohydrate (5 mg/5 ml susp recon, 50 mg capsule, 50 mg tablet, 75 mg tablet, 00 mg tablet, 00 mg capsule, 50 mg tablet) minocycline hcl (50 mg tablet, 50 mg capsule, 75 mg capsule, 75 mg tablet, 00 mg capsule, 00 mg tablet) tetracycline hcl (50 mg capsule, 500 mg capsule) VIBRAMYCIN 50 MG/5 ML SYRUP Anticonvulsants Anticonvulsants, Other APTIOM (00 MG TABLET, 00 MG TABLET, 600 MG TABLET, 800 MG TABLET) BRIVIACT (0 MG/ML ORAL SOLN, 0 MG TABLET, 5 MG TABLET, 50 MG TABLET, 75 MG TABLET, 00 MG TABLET) BRIVIACT 50 MG/5 ML VIAL FYCOMPA (0.5 MG/ML ORAL SUSP, MG TABLET, MG TABLET, 6 MG TABLET, 8 MG TABLET, 0 MG TABLET, MG TABLET) levetiracetam (500 mg tab er h, 750 mg tab er h) 5 5

23 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) levetiracetam (00 mg/ml solution, 50 mg tablet, 500 mg/5ml solution, 500 mg tablet, 750 mg tablet, 000 mg tablet) levetiracetam 500 mg/5ml vial levetiracetam in sodium chloride, iso-osmotic ((iso-os) 500mg/0.l piggyback, (iso-os) 000mg/00 piggyback, (iso-os) 500mg/00 piggyback) SPRITAM (50 MG TABLET, 500 MG TABLET, 750 MG TABLET,,000 MG TABLET) Calcium Channel Modifying Agents CELONTIN 300 MG KAPSEAL ethosuximide (50 mg/5ml solution, 50 mg capsule) LYRICA (5 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 00 MG CAPSULE, 50 MG CAPSULE, 00 MG CAPSULE, 5 MG CAPSULE) 3 QL (90 PER 30 DAYS) LYRICA 300 MG CAPSULE 3 QL (60 PER 30 DAYS) LYRICA 0 MG/ML ORAL SOLUTION 3 QL (900 PER 30 DAYS) zonisamide (5 mg capsule, 50 mg capsule, 00 mg capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam (0.5 mg tablet, mg tablet, mg tablet) clonazepam 0.5 mg tab rapdis QL (90 PER 30 DAYS) clonazepam mg tab rapdis QL (300 PER 30 DAYS) clonazepam (0.5 mg odt, 0.5 mg odt, mg odt) DIASTAT.5 MG PEDI SYSTEM DIASTAT ACUDIAL ( MG KT, MG) QL (90 PER 30 DAYS) 3

24 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) divalproex sodium (5 mg tablet dr, 5 mg cap dr spr, 50 mg tab er h, 50 mg tablet dr, 500 mg tablet dr, 500 mg tab er h) gabapentin (00 mg capsule, 300 mg capsule, 00 mg capsule) gabapentin (50 mg/5ml solution, 300 mg/6ml solution, 600 mg tablet, 800 mg tablet) GABITRIL ( MG TABLET, 6 MG TABLET) ONFI (.5 MG/ML SUSPENSION, 0 MG TABLET, 0 MG TABLET) phenobarbital (5 mg tablet, 6. mg tablet, 0 mg/5 ml elixir, 30 mg tablet, 3. mg tablet, 60 mg tablet, 6.8 mg tablet, 97.mg tablet, 00 mg tablet) 5 PA - FOR NEW STARTS ONLY primidone (50 mg tablet, 50 mg tablet) SABRIL (500 MG TABLET, 500 MG POWDER PACKET) tiagabine hcl ( mg tablet, mg tablet, mg tablet, 6 mg tablet) 5 PA - FOR NEW STARTS ONLY valproic acid 50 mg capsule valproic acid (as sodium salt) (valproate sodium) (salt) 50 mg/5ml solution, salt) 500mg/0ml solution) valproic acid (as sodium salt) 500 mg/5ml vial vigabatrin 500 mg powd pack 5 PA - FOR NEW STARTS ONLY Glutamate Reducing Agents felbamate 600 mg/5ml oral susp 5 felbamate (00 mg tablet, 600 mg tablet) LAMICTAL TAB START KIT (BLUE) LAMICTAL TAB START KIT (GREEN) 5 LAMICTAL TB START KIT (ORANGE) lamotrigine 5(8)-00 tab ds pk 5

25 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) lamotrigine (5 mg tablet, 00 mg tablet, 50 mg tablet, 00 mg tablet) lamotrigine (5 mg tb chw dsp, 5()-00 tab ds pk, 5mg (35) tab ds pk, 5 mg tb chw dsp) topiramate (5 mg cap sprink, 5 mg cap sprink) topiramate (5 mg tablet, 50 mg tablet, 00 mg tablet, 00 mg tablet) Sodium Channel Agents BANZEL (0 MG/ML SUSPENSION, 00 MG TABLET, 00 MG TABLET) carbamazepine (00 mg tab er h, 00 mg cpmp hr, 00 mg/5ml oral susp, 00 mg tab chew, 00 mg tablet, 00 mg tab er h, 00 mg cpmp hr, 300 mg cpmp hr) carbamazepine 00 mg tab er h DILANTIN 30 MG CAPSULE fosphenytoin sodium 00mg pe/ vial oxcarbazepine 300 mg/5ml oral susp oxcarbazepine (50 mg tablet, 300 mg tablet, 600 mg tablet) PEGANONE 50 MG TABLET phenytoin (50 mg tab chew, 00 mg/ml oral susp, 5 mg/5ml oral susp) phenytoin sodium extended (00 mg capsule, 00 mg capsule, 300 mg capsule) VIMPAT (0 MG/ML SOLUTION, 50 MG TABLET, 00 MG TABLET, 50 MG TABLET, 00 MG/0 ML VIAL, 00 MG TABLET) 5 5

26 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) Antidementia Agents Antidementia Agents, Other ergoloid mesylates mg tablet PA NAMZARIC (7 MG CAPSULE, MG CAPSULE, MG CAPSULE, 8 MG CAPSULE) Cholinesterase Inhibitors donepezil hcl (5 mg tab rapdis, 5 mg tablet, 0 mg tablet, 0 mg tab rapdis) galantamine hbr mg/ml solution galantamine hbr ( mg tablet, 8 mg caph pel, 8 mg tablet, mg tablet, 6 mg caph pel, mg caph pel) rivastigmine (.6mg/hr patch td, 9.5mg/hr patch td, 3.3mg/h patch td) rivastigmine tartrate (.5 mg capsule, 3 mg capsule,.5 mg capsule, 6 mg capsule) N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (7 mg cap spr, mg cap spr, mg cap spr, 8 mg cap spr ) memantine hcl ( mg/ml solution, 5 mg-0 mg tab ds pk) memantine hcl (5 mg tablet, 0 mg tablet) 3 QL (30 PER 30 DAYS) QL (30 PER 30 DAYS) NAMENDA XR TITRATION PACK 3 QL (56 PER 365 DAYS) NAMENDA XR (7 MG CAPSULE, MG CAPSULE, MG CAPSULE, 8 MG CAPSULE) 3 QL (30 PER 30 DAYS) 6

27 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) Antidepressants Antidepressants, Other bupropion hcl 300 mg tab er h QL (30 PER 30 DAYS) bupropion hcl (75 mg tablet, 00 mg tablet) bupropion hcl (00 mg tablet er, 00 mg tab er h, 50 mg tab er h, 50 mg tablet er, 50 mg tab er h, 00 mg tablet er, 00 mg tab er h) mirtazapine (7.5 mg tablet, 5 mg tablet, 5 mg tab rapdis, 30 mg tablet, 30 mg tab rapdis, 5 mg tablet, 5 mg tab rapdis) Monoamine Oxidase Inhibitors EMSAM (6 MG/ PATCH, 9 MG/ PATCH, MG/ PATCH) MARPLAN 0 MG TABLET phenelzine sulfate 5 mg tablet tranylcypromine sulfate 0 mg tablet QL (90 PER 30 DAYS) 5 ST, QL (30 PER 30 DAYS) SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide 0 mg/5 ml solution citalopram hydrobromide (0 mg tablet, 0 mg tablet, 0 mg tablet) desvenlafaxine succinate (5 mg tab er h, 50 mg tab er h) QL (30 PER 30 DAYS) desvenlafaxine succinate 00 mg tab er h QL (0 PER 30 DAYS) duloxetine hcl (0 mg capsule dr, 60 mg capsule dr) QL (60 PER 30 DAYS) duloxetine hcl 30 mg capsule dr QL (90 PER 30 DAYS) duloxetine hcl 0 mg capsule dr QL (90 PER 30 DAYS) escitalopram oxalate 5 mg/5 ml solution 7

28 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) escitalopram oxalate (5 mg tablet, 0 mg tablet, 0 mg tablet) FETZIMA 0-0 MG TITRATION PAK ST, QL (56 PER 365 DAYS) FETZIMA (ER 0 MG CAPSULE, ER 0 MG CAPSULE, ER 80 MG CAPSULE, ER 0 MG CAPSULE) fluoxetine hcl (0 mg capsule, 0 mg capsule, 0 mg capsule) ST, QL (30 PER 30 DAYS) fluoxetine hcl 90 mg capsule dr QL ( PER 8 DAYS) fluoxetine hcl (0 mg tablet, 0 mg tablet, 0 mg/5 ml solution, 60 mg tablet) fluvoxamine maleate (5 mg tablet, 50 mg tablet, 00 mg tablet) maprotiline hcl (5 mg tablet, 50 mg tablet, 75 mg tablet) nefazodone hcl (50 mg tablet, 00 mg tablet, 50 mg tablet, 00 mg tablet, 50 mg tablet) NYMALIZE 30 MG/0 ML SOLUTION 5 paroxetine hcl (.5 mg tab er h, 5 mg tab er h, 37.5 mg tab er h) paroxetine hcl (0 mg tablet, 0 mg tablet, 30 mg tablet, 0 mg tablet) PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY paroxetine mesylate 7.5 mg capsule QL (30 PER 30 DAYS) PAXIL 0 MG/5 ML SUSPENSION PA - FOR NEW STARTS ONLY sertraline hcl 0 mg/ml oral conc sertraline hcl (5 mg tablet, 50 mg tablet, 00 mg tablet) trazodone hcl (50 mg tablet, 00 mg tablet, 50 mg tablet, 300 mg tablet) TRINTELLIX (5 MG TABLET, 0 MG TABLET, 0 MG TABLET) QL (30 PER 30 DAYS) 8

29 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) venlafaxine hcl (5 mg tablet, 37.5 mg cap er h, 37.5 mg tab er, 37.5 mg tablet, 50 mg tablet, 75 mg tab er, 75 mg cap er h, 75 mg tablet, 00 mg tablet, 50 mg cap er h, 50 mg tab er, 5 mg tab er ) VENLAFAXINE HCL ER (ER 37.5 MG TAB, ER 75 MG TAB, ER 50 MG TAB, ER 5 MG TAB) VIIBRYD 0-0 MG STARTER PACK QL (60 PER 365 DAYS) VIIBRYD (0 MG TABLET, 0 MG TABLET, 0 MG TABLET) QL (30 PER 30 DAYS) Tricyclics amitriptyline hcl (0 mg tablet, 5 mg tablet, 50 mg tablet, 75 mg tablet, 00 mg tablet, 50 mg tablet) amitriptyline hcl/chlordiazepoxide (amitriptyline/chlordiazepoxide.5mg-5mg tablet, amitriptyline/chlordiazepoxide 5 mg- 0mg tablet) amoxapine (5 mg tablet, 50 mg tablet, 00 mg tablet, 50 mg tablet) clomipramine hcl (5 mg capsule, 50 mg capsule, 75 mg capsule) desipramine hcl (0 mg tablet, 5 mg tablet, 50 mg tablet, 75 mg tablet, 00 mg tablet, 50 mg tablet) doxepin hcl (0 mg/ml oral conc, 0 mg capsule, 5 mg capsule, 50 mg capsule, 75 mg capsule, 00 mg capsule, 50 mg capsule) imipramine hcl (0 mg tablet, 5 mg tablet, 50 mg tablet) nortriptyline hcl (0 mg capsule, 5 mg capsule, 50 mg capsule, 75 mg capsule) PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY nortriptyline hcl 0 mg/5 ml solution PA - FOR NEW STARTS ONLY 9

30 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) perphenazine/amitriptyline hcl (perphenazine/amitriptyline mg-0 mg tablet, perphenazine/amitriptyline mg-5 mg tablet, perphenazine/amitriptyline mg-5 mg tablet, perphenazine/amitriptyline mg-0mg tablet, perphenazine/amitriptyline mg-50 mg tablet) PA - FOR NEW STARTS ONLY protriptyline hcl (5 mg tablet, 0 mg tablet) PA - FOR NEW STARTS ONLY trimipramine maleate (5 mg capsule, 50 mg capsule, 00 mg capsule) PA - FOR NEW STARTS ONLY Antiemetics Antiemetics, Other meclizine hcl (.5 mg tablet, 5 mg tablet) PA palonosetron hcl 0.5mg/5ml vial PHENERGAN (.5 MG, 5 MG, 50 MG) PA prochlorperazine 5 mg supp.rect prochlorperazine edisylate (5 mg/ml vial, 0 mg/ ml vial) prochlorperazine maleate (5 mg tablet, 0 mg tablet) promethazine hcl (6.5mg/5ml syrup,.5 mg supp.rect,.5 mg tablet, 5 mg/ml vial, 5 mg tablet, 5 mg/ml ampul, 5 mg supp.rect, 50 mg/ml ampul, 50 mg supp.rect, 50 mg tablet, 50 mg/ml vial) PA scopolamine mg/3 day patch td 3 PA TRANSDERM-SCOP.5 MG/3 DAY PA Emetogenic Therapy Adjuncts ALOXI 0.5 MG/5 ML VIAL ANZEMET 00 MG TABLET 5 PA - Part B vs D Determination, QL (5 PER 30 DAYS) ANZEMET 50 MG TABLET PA - Part B vs D Determination, QL (5 PER 30 DAYS) 30

31 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) aprepitant 5mg-80mg cap ds pk PA - Part B vs D Determination, QL (6 PER 30 DAYS) aprepitant 5 mg capsule PA - Part B vs D Determination, QL ( PER 30 DAYS) aprepitant 0 mg capsule PA - Part B vs D Determination, QL ( PER 30 DAYS) aprepitant 80 mg capsule PA - Part B vs D Determination, QL (8 PER 30 DAYS) CINVANTI 30 MG/8 ML VIAL dronabinol (.5 mg capsule, 5 mg capsule, 0 mg capsule) PA, QL (60 PER 30 DAYS) EMEND 5 MG POWDER PACKET PA - Part B vs D Determination, QL (6 PER 30 DAYS) granisetron hcl mg tablet PA - Part B vs D Determination, QL (30 PER 30 DAYS) granisetron hcl ( mg/ml() vial, mg/ml vial) granisetron hcl/pf (hcl/pf mg/ml() vial, hcl/pf 00 mcg/ml vial) ondansetron ( mg tab rapdis, 8 mg tab rapdis) PA - Part B vs D Determination ondansetron hcl mg/5 ml solution PA - Part B vs D Determination, QL (50 PER 30 DAYS) ondansetron hcl ( mg tablet, 8 mg tablet) PA - Part B vs D Determination ondansetron hcl mg tablet PA - Part B vs D Determination, QL ( PER 8 DAYS) ondansetron hcl/pf (hcl/pf mg/ ml ampul, hcl/pf mg/ ml vial, hcl/pf mg/ ml syringe) palonosetron hcl 0.5mg/ml vial QL (0 PER 30 DAYS) SANCUSO 3. MG/ HR PATCH 5 QL ( PER 30 DAYS) SYNDROS 5 MG/ML SOLUTION 5 PA, QL (0 PER 30 DAYS) Antifungals ABELCET 00 MG/0 ML VIAL 5 PA - Part B vs D Determination 3

32 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) AMBISOME 50 MG VIAL 5 PA - Part B vs D Determination amphotericin b 50 mg vial PA - Part B vs D Determination CANCIDAS (IV 50 MG VIAL, IV 70 MG VIAL) 5 caspofungin acetate (50 mg vial, 70 mg vial) 5 ciclopirox (0.77 % gel (gram), % shampoo) ciclopirox 8 % solution PA ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) clotrimazole % cream (g) clotrimazole ( % solution, 0 mg troche) CRESEMBA (86 MG CAPSULE, 37 MG VIAL) econazole nitrate % cream (g) EXELDERM (CREAM, SOLUTION) fluconazole (0 mg/ml susp recon, 0 mg/ml susp recon, 50 mg tablet, 00 mg tablet, 50 mg tablet, 00 mg tablet) fluconazole in sodium chloride, iso-osmotic (00mg/0.l pggybk btl, 00mg/0.l piggyback, 00mg/0.l pggybk btl, 00mg/0.l piggyback) flucytosine (50 mg capsule, 500 mg capsule) 5 griseofulvin ultramicrosize (5 mg tablet, 50 mg tablet) griseofulvin, microsize 5 mg/5ml oral susp griseofulvin, microsize 500 mg tablet itraconazole 00 mg capsule PA JUBLIA 0% TOPICAL SOLUTION 3 ketoconazole % foam ketoconazole ( % cream (g), % shampoo, 00 mg tablet) 5 3

33 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) miconazole nitrate 00 mg supp.vag naftifine hcl ( % cream (g), % cream (g)) NAFTIN (% GEL, % GEL) NATACYN EYE DROPS NOXAFIL (0 MG/ML SUSPENSION, DR 00 MG TABLET) nystatin (50mm unit powder(ea), 50mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, 00000/ml oral susp, 00000/g powder, 00000/g cream (g), 00000/g oint. (g)) nystatin/triamcinolone acetonide (nystatin/triamcin cream (g), nystatin/triamcin oint. (g)) ONMEL 00 MG TABLET 5 PA oxiconazole nitrate % cream (g) OXISTAT % LOTION SPORANOX 0 MG/ML SOLUTION 5 PA 5 terbinafine hcl 50 mg tablet QL (8 PER 80 DAYS) terconazole (0. % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) voriconazole (00 mg vial, 00 mg/5ml susp recon) voriconazole (50 mg tablet, 00 mg tablet) Antigout Agents allopurinol (00 mg tablet, 300 mg tablet) colchicine (0.6 mg capsule, 0.6 mg tablet) 3 COLCRYS 0.6 MG TABLET 3 probenecid 500 mg tablet probenecid/colchicine mg tablet 5 33

34 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) ULORIC (0 MG TABLET, 80 MG TABLET) 3 ST Antimigraine Agents Ergot Alkaloids dihydroergotamine mesylate 0.5mg/spry spray/pump dihydroergotamine mesylate ( mg/ml ampul, mg/ml vial) ergotamine tartrate/caffeine -00mg supp.rect ergotamine tartrate/caffeine mg-00mg tablet 5 QL (8 PER 30 DAYS) 5 5 Serotonin (5-HT) b/d Receptor Agonists eletriptan hydrobromide (0 mg tablet, 0 mg tablet) QL ( PER 30 OVER TIME) frovatriptan succinate.5 mg tablet QL ( PER 30 DAYS) naratriptan hcl ( mg tablet,.5 mg tablet) QL (9 PER 30 DAYS) rizatriptan benzoate (5 mg tablet, 5 mg tab rapdis, 0 mg tablet, 0 mg tab rapdis) QL (8 PER 30 DAYS) sumatriptan (5 mg spray, 0 mg spray) QL ( PER 30 DAYS) sumatriptan succinate ( mg/0.5ml pen injctr, mg/0.5ml cartridge) sumatriptan succinate (5 mg tablet, 50 mg tablet, 00 mg tablet) sumatriptan succinate (6 mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml cartridge, 6 mg/0.5ml vial) sumatriptan succ/naproxen sod 85mg-500mg tablet QL (8 PER 30 DAYS) QL (9 PER 30 DAYS) QL (5 PER 30 DAYS) 5 QL (9 PER 30 OVER TIME) zolmitriptan (.5 mg tablet, 5 mg tablet) QL ( PER 30 DAYS) 3

35 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) Antimyasthenic Agents Parasympathomimetics guanidine hcl 5 mg tablet MESTINON 60 MG/5 ML SYRUP 5 pyridostigmine bromide 60 mg tablet pyridostigmine bromide 80 mg tablet er Antimycobacterials Antimycobacterials, Other dapsone (5 mg tablet, 00 mg tablet) rifabutin 50 mg capsule Antituberculars CAPASTAT SULFATE GM VIAL ethambutol hcl (00 mg tablet, 00 mg tablet) isoniazid (50 mg/5 ml solution, 00 mg/ml vial) isoniazid (00 mg tablet, 300 mg tablet) PASER GRANULES GM PACKET PRIFTIN 50 MG TABLET pyrazinamide 500 mg tablet rifampin (50 mg capsule, 300 mg capsule) rifampin 600 mg vial RIFATER TABLET SIRTURO 00 MG TABLET 5 TRECATOR 50 MG TABLET 35

36 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) Antineoplastics Alkylating Agents BICNU 00 MG VIAL 5 busulfan 60 mg/0ml vial 5 carboplatin (0 mg/ml vial, 50 mg vial) cisplatin mg/ml vial cyclophosphamide (5 mg capsule, 50 mg capsule) dacarbazine 00 mg vial GLEOSTINE 5 MG CAPSULE HEXALEN 50 MG CAPSULE 5 ifosfamide g vial KISQALI FEMARA CO-PACK (00 MG, 00 MG, 600 MG) LEUKERAN MG TABLET 5 MATULANE 50 MG CAPSULE 5 melphalan hcl 50 mg vial 5 MUSTARGEN 0 MG VIAL 5 oxaliplatin 00 mg vial oxaliplatin 00mg/0ml vial thiotepa 5 mg vial 5 TREANDA (5 MG VIAL, 00 MG VIAL) 5 PA - Part B vs D Determination 5 PA - FOR NEW STARTS ONLY, QL (9 PER 8 DAYS) VALCHLOR 0.06% GEL 5 PA - FOR NEW STARTS ONLY YONDELIS MG VIAL 5 ZANOSAR GM POWDER VIAL 5 Antiandrogens bicalutamide 50 mg tablet 36

37 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) ERLEADA 60 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (0 PER 30 DAYS) flutamide 5 mg capsule nilutamide 50 mg tablet 5 XTANDI 0 MG CAPSULE 5 PA - FOR NEW STARTS ONLY ZYTIGA (50 MG TABLET, 500 MG TABLET) 5 PA - FOR NEW STARTS ONLY Antiangiogenic Agents POMALYST ( MG CAPSULE, MG CAPSULE, 3 MG CAPSULE, MG CAPSULE) REVLIMID (.5 MG CAPSULE, 5 MG CAPSULE, 0 MG CAPSULE, 5 MG CAPSULE, 0 MG CAPSULE, 5 MG CAPSULE) THALOMID (50 MG CAPSULE, 00 MG CAPSULE, 50 MG CAPSULE, 00 MG CAPSULE) 5 PA - FOR NEW STARTS ONLY 5 PA - FOR NEW STARTS ONLY 5 PA - FOR NEW STARTS ONLY Antiestrogens/Modifiers EMCYT 0 MG CAPSULE 5 FARESTON 60 MG TABLET 5 FASLODEX 50 MG/5 ML SYRINGE 5 SOLTAMOX 0 MG/5 ML SOLN tamoxifen citrate (0 mg tablet, 0 mg tablet) Antimetabolites ALIMTA (00 MG VIAL, 500 MG VIAL) 5 ARRANON 50 MG/50 ML VIAL 5 cladribine 0 mg/0ml vial 5 PA - Part B vs D Determination clofarabine 0 mg/0ml vial 5 cytarabine 0 mg/ml vial PA - Part B vs D Determination cytarabine/pf (cytarabine/pf g/0 ml vial, cytarabine/pf 0 mg/ml vial) PA - Part B vs D Determination 37

38 UPHP Advantage (HMO) (H6-00) and UPHP Choice (HMO) (H6-003) (List of Covered Drugs) DROXIA (00 MG CAPSULE, 300 MG CAPSULE, 00 MG CAPSULE) fluorouracil ( g/0 ml vial,.5 g/50ml vial, 5 g/00 ml vial, 500mg/0ml vial) PA - Part B vs D Determination FOLOTYN 0 MG/ ML VIAL 5 PA - FOR NEW STARTS ONLY gemcitabine hcl g vial hydroxyurea 500 mg capsule LONSURF 5 MG-6. MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (00 PER 8 DAYS) LONSURF 0 MG-8.9 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (80 PER 8 DAYS) mercaptopurine 50 mg tablet NIPENT 0 MG VIAL 5 PURIXAN 0 MG/ML ORAL SUSP 5 TABLOID 0 MG TABLET VYXEOS MG-00 MG VIAL 5 PA - FOR NEW STARTS ONLY XATMEP.5 MG/ML ORAL SOLUTION Antineoplastics, Other ABRAXANE 00 MG VIAL 5 azacitidine 00 mg vial 5 BELEODAQ 500 MG VIAL 5 PA - FOR NEW STARTS ONLY bleomycin sulfate 30 unit vial PA - Part B vs D Determination bortezomib 3.5 mg vial 5 PA - FOR NEW STARTS ONLY COSMEGEN 0.5 MG VIAL 5 COTELLIC 0 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (90 PER 30 DAYS) dactinomycin 0.5 mg vial 5 daunorubicin hcl (5 mg/ml vial, 0 mg vial) decitabine 50 mg vial 5 PA - FOR NEW STARTS ONLY 38

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