McLaren Advantage (HMO) (Diamond & Sapphire plans) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission 16357 v.18 This formulary was updated on 10/25/2016. For more recent information or other questions, please contact McLaren Advantage (HMO) Customer Service at (888) 327-0671, or for TTY users, 711, Monday through Friday, 8 a.m. to 8 p.m., or visit www.mclarenadvantage.org. 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 McLaren Health Plan. When it refers to plan or our plan, it means McLaren Advantage (HMO) Diamond or Sapphire plan. H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. H0141_MIMHMO295
This document includes the list of the drugs (formulary) for our plan which is current as of 10/25/2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the 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 1, 2017, and from time to time during the year. What is the McLaren Advantage (HMO) Formulary? A formulary is a list of covered drugs selected by McLaren Advantage (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. McLaren Advantage (HMO) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a McLaren Advantage (HMO) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 2
Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 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 H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 3
10/25/2016. To get updated information about the drugs covered by McLaren Advantage (HMO), please contact us. Our contact information appears on the front and back cover pages. Mid-year non-maintenance formulary changes occurring after the date the formulary was last updated will be distributed via appropriate member materials and will also be posted on our website, www.mclarenadvantage.org. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 13. 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 number 13. 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 146. 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 H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 4
the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? McLaren Advantage (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: McLaren Advantage (HMO) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, McLaren Advantage (HMO) limits the amount of the drug that we will cover. For example, McLaren Advantage (HMO) provides 30 tablets per prescription for Atorvastatin 80 mg. This may be in addition to a standard one-month or three-month supply. H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 5
Step Therapy: In some cases, McLaren Advantage (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, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, McLaren Advantage (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 13. 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 McLaren Advantage (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 McLaren Advantage (HMO) s formulary? on page 7 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 Customer Service and ask if your drug is covered. If you learn that McLaren Advantage (HMO) does not cover your drug, you have two options: H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 6
You can ask Customer Service for a list of similar drugs that are covered by McLaren Advantage (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 McLaren Advantage (HMO). You can ask McLaren Advantage (HMO) to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the McLaren Advantage (HMO) Formulary? You can ask us 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, McLaren Advantage (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. H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 7
Generally, McLaren Advantage (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 72 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 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 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 H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 8
that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 91-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 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 9
New members in our plan may be taking drugs that aren t on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. Please contact Customer Service if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception. During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our plan. If you are a current member affected by a formulary change from one year to the next, we will provide you with the opportunity to request a formulary exception in advance for the following year. When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn t on our formulary, or that has coverage restrictions or limits (but is otherwise considered a Part D drug ), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 10
again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover. If a new member is a resident of a long-term care facility (like a nursing home), we will cover at least 91 and up to a 98 day transition supply, consistent with the dispensing increments (unless the prescription is written for fewer days). We will cover more than one refill of these drugs during the first 90 days a new member is enrolled in our plan. If the resident has been enrolled in our plan for more than 90 days and needs a drug that isn t on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception. Please note that our transition policy applies only to those drugs that are Part D drugs and bought at a network pharmacy. The transition policy can t 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 McLaren Advantage (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 11
If you have questions about McLaren Advantage (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 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov. McLaren Advantage (HMO) s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 146. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin sodium). The information in the Requirements/Limits column tells you if McLaren Advantage (HMO) has any special requirements for coverage of your drug. on this table mean by going to the LEGEND at the beginning of this table. H0141_MIMHMO295 CMS File & Use: 11/24/2015 McLaren Advantage (HMO) is a coordinated care plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. 12
LEGEND TIER NAME 1 Generics 2 Preferred Brands 3 Non-Preferred Brands 4 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 LA Prior Authorization Step Therapy Limited Access 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. This prescription drug is limited to certain pharmacies. 13
Analgesics Nonsteroidal Anti-inflammatory Drugs celecoxib (100 mg, 200 mg, 400 mg, 50 mg) 1 QL (60 PER 30 diclofenac potassium 50 mg tablet 1 diclofenac sodium (100 mg tab er 24h, 1 25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr) diclofenac sodium 1 % gel (gram) 1 ST diclofenac sodium/misoprostol (50 1 tab ir, 75 tab ir) etodolac (200 mg capsule, 300 mg 1 capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tab er 24h, 500 mg tablet, 600 mg tab er 24h) fenoprofen calcium 400 mg capsule 3 FLECTOR 1.3% PATCH 3 PA flurbiprofen (100 mg, 50 mg) 1 ibuprofen (100 mg/5ml oral susp, 400 1 mg tablet, 600 mg tablet, 800 mg tablet) ketoprofen (50 mg, 75 mg) 1 meloxicam (15 mg, 7.5 mg) 1 nabumetone (500 mg, 750 mg) 1 14
naproxen (125 mg/5ml oral susp, 250 1 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet, 500 mg tablet dr) naproxen sodium (275 mg, 550 mg) 1 oxaprozin 600 mg tablet 1 piroxicam (10 mg, 20 mg) 1 sulindac (150 mg, 200 mg) 1 tolmetin sodium 400 mg capsule 1 VOLTAREN 1% GEL 3 ST Opioid Analgesics, Long-acting EMBEDA (ER 20-0.8 MG, ER 80-3.2 MG) 2 QL (120 PER 30 EMBEDA (ER 30-1.2 MG, ER 50-2 MG) 2 QL (60 PER 30 EMBEDA ER 100-4 MG CAPSULE 2 QL (90 PER 30 EMBEDA ER 60-2.4 MG CAPSULE 2 QL (180 PER 30 fentanyl (100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr) 1 QL (15 PER 30 levorphanol tartrate 2 mg tablet 3 QL (120 PER 30 methadone hcl 10 mg tablet 1 QL (360 PER 30 15
methadone hcl 5 mg tablet 1 QL (180 PER 30 morphine sulfate (100 mg er, 15 mg er, 200 mg er, 30 mg er, 60 mg er) 1 QL (90 PER 30 morphine sulfate (120 mg cpmp 24hr, 30 mg cap er pel, 30 mg cpmp 24hr, 45 mg cpmp 24hr, 60 mg cap er pel, 60 mg cpmp 24hr, 75 mg cpmp 24hr, 90 mg cpmp 24hr) 1 QL (30 PER 30 NUCYNTA ER (ER 100 MG, ER 150 MG, 2 QL (60 PER 30 ER 200 MG, ER 250 MG, ER 50 MG) OPANA ER (ER 10 MG, ER 15 MG, ER 20 MG, ER 30 MG, ER 40 MG, ER 5 MG, ER 7.5 MG) OXYCONTIN (10 MG, 15 MG, 20 MG, 30 MG, 40 MG) 2 QL (60 PER 30 2 QL (60 PER 30 OXYCONTIN (60 MG, 80 MG) 2 QL (120 PER 30 tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mg tab er 24h, 200 mg tbmp 24hr) ZOHYDRO ER (ER 10 MG, ER 15 MG, ER 20 MG, ER 30 MG, ER 40 MG, ER 50 MG) Opioid Analgesics, Short-acting ABSTRAL (100 MCG TAB, 200 MCG TAB, 300 MCG TAB, 400 MCG TAB, 600 MCG TAB, 800 MCG TAB) 1 QL (30 PER 30 3 PA, QL (60 PER 30 4 PA, QL (120 PER 30 16
acetaminophen with codeine 300mg- 60mg tablet 1 QL (180 PER 30 acetaminophen with codeine phosphate (120-12mg/5, 1 QL (2700 PER 30 300mg/12.5) acetaminophen with codeine phosphate (300mg-15mg, 300mg- 30mg) 1 QL (360 PER 30 butorphanol tartrate (1 mg/ml vial, 10 1 mg/ml spray, 2 mg/ml vial) codeine sulfate (15 mg, 30 mg, 60 mg) 1 QL (180 PER 30 DURAMORPH (10 ML, 5 ML) 1 PA - TO CONFIRM PART D COVERAGE fentanyl citrate (1200 mcg, 1600 mcg, 4 PA, QL (120 PER 200 mcg, 400 mcg, 600 mcg, 800 30 mcg) hydrocodone bitartrate/acetaminophen (10mg- 300mg, 10mg-325mg, 7.5-300 mg, 7.5-325 mg) hydrocodone bitartrate/acetaminophen (2.5-108/5, 5-217mg/10, 7.5-325/15) hydrocodone bitartrate/acetaminophen (5 mg- 300mg, 5 mg-325mg) 1 QL (180 PER 30 1 QL (3600 PER 30 1 QL (360 PER 30 17
hydrocodone/ibuprofen (10mg- 200mg, 7.5-200 mg) 1 QL (150 PER 30 hydromorphone hcl (2 mg, 4 mg, 8 mg) 1 QL (180 PER 30 hydromorphone hcl 1 mg/ml liquid 1 QL (1440 PER 30 hydromorphone hcl 2 mg/ml syringe 1 hydromorphone hcl/pf (10 mg/ml ampul, 10 mg/ml vial) 1 PA - TO CONFIRM PART D COVERAGE 4 PA, QL (30 PER 30 LAZANDA (100 MCG, 300 MCG, 400 MCG) morphine sulfate 10 mg/5 ml solution 1 QL (2700 PER 30 morphine sulfate 100 mg/5ml solution 1 QL (270 PER 30 morphine sulfate 15 mg tablet 3 QL (240 PER 30 morphine sulfate 20 mg/5 ml solution 1 QL (1350 PER 30 morphine sulfate 30 mg tablet 3 QL (180 PER 30 oxycodone hcl (10 mg, 15 mg, 20 mg, 30 mg) 1 QL (180 PER 30 oxycodone hcl 5 mg tablet 1 QL (360 PER 30 oxycodone hcl/acetaminophen (2.5-325 mg, 5 mg-325mg) 1 QL (360 PER 30 18
oxycodone hcl/acetaminophen 10mg- 325mg tablet 1 QL (180 PER 30 oxycodone hcl/acetaminophen 5-325/5 ml solution 1 QL (1860 PER 30 oxycodone hcl/acetaminophen 7.5-325 mg tablet 1 QL (240 PER 30 oxycodone hcl/aspirin 4.8355-325 tablet 1 QL (360 PER 30 tramadol hcl 50 mg tablet 1 QL (240 PER 30 tramadol hcl/acetaminophen 37.5-325mg tablet 1 QL (240 PER 30 Anesthetics Local Anesthetics lidocaine 5 % adh. patch 1 PA, QL (90 PER 30 lidocaine 5 % oint. (g) 1 lidocaine hcl (2 % jel (ml), 2 % jel/pf 1 app, 2 % jelly(ml), 2 % solution, 4 % solution, 40 mg/ml solution) lidocaine/prilocaine (2.5 cream (g), 2.5 kit) 1 Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/ Anti-craving acamprosate calcium 333 mg tablet dr 1 19
disulfiram (250 mg, 500 mg) 1 Opioid Dependence Treatments buprenorphine hcl (2 mg tab, 8 mg 1 PA tab) buprenorphine hcl/naloxone hcl 1 PA (/naloxone 2 mg-0.5mg tab, /naloxone 8 mg-2 mg tab) BUTRANS (10, 15, 20, 5, 7.5) 2 QL (4 PER 28 naltrexone hcl 50 mg tablet 1 SUBOXONE (12 MG-3 MG, 2 MG-0.5 3 PA MG, 4 MG-1 MG, 8 MG-2 MG) VIVITROL (380 MG, 380 MG + 4 DILUENT) ZUBSOLV 11.4-2.9 MG TABLET SL 3 QL (30 PER 30 ZUBSOLV 2.9-0.71 MG TABLET SL 3 QL (150 PER 30 Opioid Reversal Agents naloxone hcl (0.4 mg/ml vial, 1 mg/ml syringe) Smoking Cessation Agents bupropion hcl 150 mg tablet er 1 CHANTIX (0.5 MG TABLET, 1 MG 2 CONT MONTH BOX, 1 MG TABLET, STARTING MONTH BOX) 2 20
NICOTROL CARTRIDGE INHALER 3 NICOTROL NS 10 MG/ML SPRAY 3 Antibacterials Aminoglycosides amikacin sulfate (1000mg/4ml, 500 1 mg/2ml) gentamicin sulfate (0.1 % cream, 0.1 3 % oint.) gentamicin sulfate (0.3 % drops, 0.3 % 1 oint. (g), 40 mg/ml vial) gentamicin sulfate in sodium chloride, 1 iso-osmotic (gentamic100mg/0.1l, gentamic120mg/0.1l, gentamic60 mg/50ml, gentamic80 mg/50ml, gentamic80mg/100ml) gentamicin sulfate in sodium chloride, 3 iso-osmotic (gentamic70 mg/50ml, gentamic90mg/100ml) gentamicin sulfate/pf (100mg/10ml 1 port, 20 mg/2 ml, 60 mg/6 ml port, 80 mg/8 ml port) neomycin sulfate 500 mg tablet 1 paromomycin sulfate 250 mg capsule 1 streptomycin sulfate 1 g vial 3 tobramycin 0.3 % drops 1 21
tobramycin/sodium chloride 80mg/100ml piggyback Antibacterials, Other bacitracin 500 unit/g oint. (g) 3 bacitracin/polymyxin b sulfate 500-1 10k/g oint. (g) chloramphenicol sod succ 1 g vial 3 clindamycin hcl (150 mg, 300 mg, 75 1 mg) clindamycin phosphate (1 % gel 1 (gram), 1 % lotion, 1 % med. swab, 1 % solution, 150 mg/ml vial, 2 % cream/appl, 300 mg/2ml vial port, 600 mg/4ml vial port, 900mg/6ml vial port) clindamycin phosphate/dextrose 5 % 1 in water (300mg/50ml, 600mg/50ml, 900mg/50ml) CLINDESSE 2% VAGINAL CREAM 3 colistin (colistimethate na) 150 mg 1 vial CUBICIN 500 MG VIAL 4 DALVANCE 500 MG VIAL 4 linezolid (100 mg/5ml susp recon, 600 4 PA mg tablet) linezolid 600mg/300 iv soln 4 3 22
linezolid-0.9% sodium chloride 4 600mg/300 iv soln methenamine hippurate 1 g tablet 1 metronidazole (0.75 % cream (g), 0.75 1 % gel (gram), 0.75 % gel w/appl, 0.75 % lotion, 1 % gel (gram), 1 % gel w/pump, 250 mg tablet, 375 mg capsule, 500 mg tablet) metronidazole/sodium chloride 1 500mg/0.1l piggyback mupirocin 2 % oint. (g) 1 neomycin su/bacitra/polymyxin 1 3.5mg-400 oint. (g) neomycin sulfate/polymyxin b sulfate 1 (ampul, vial) neomycin/polymyxn b/gramicidin 1 1.75mg-10k drops nitrofurantoin 25 mg/5 ml oral susp 3 PA, QL (7200 PER 365 nitrofurantoin macrocrystal (100 mg, 50 mg) 3 PA, QL (360 PER 365 nitrofurantoin macrocrystal 25 mg capsule 1 QL (90 PER 365 OVER TIME) nitrofurantoin monohyd/m-cryst 100 mg capsule 3 QL (90 PER 365 OVER TIME) polymyxin b sulf/trimethoprim 10000-1 1/ml drops 23
SIVEXTRO 200 MG TABLET 4 PA SIVEXTRO 200 MG VIAL 4 SYNERCID 500 MG VIAL 4 trimethoprim 100 mg tablet 1 TYGACIL 50 MG VIAL 3 vancomycin hcl (1 g, 1 g port, 10 g, 5 1 g, 500 mg, 500 mg port, 750 mg) vancomycin hcl (125 mg, 250 mg) 4 VANDAZOLE VAGINAL 0.75% GEL 1 ZYVOX 100 MG/5 ML SUSPENSION 4 PA Beta-lactam, Cephalosporins cefaclor (250 mg, 500 mg) 1 cefadroxil (1 g tablet, 250 mg/5ml 1 susp recon, 500 mg capsule, 500 mg/5ml susp recon) cefazolin sodium (1 g vial, 10 g vial, 1 100 g bulkbaginj, 20 g vial, 300g bulkbaginj, 500 mg vial) cefdinir (125 mg/5ml susp recon, 250 1 mg/5ml susp recon, 300 mg capsule) cefepime hcl (1, 2) 1 cefotaxime sodium (1 g, 2 g, 500 mg) 1 cefoxitin sodium (1, 10, 2) 1 24
cefpodoxime proxetil (100 mg tablet, 1 100 mg/5ml susp recon, 200 mg tablet, 50 mg/5 ml susp recon) cefprozil (125 mg/5ml susp recon, 250 1 mg tablet, 250 mg/5ml susp recon, 500 mg tablet) ceftazidime (1, 2, 6) 1 ceftriaxone sodium (1 g vial, 1 g vial 1 port, 10 g vial, 100 g bulkbaginj, 2 g vial, 2 g vial port, 250 mg vial, 500 mg vial) ceftriaxone sodium/dextrose, isoosmotic (1 ml, 2 ml) 1 cefuroxime axetil (250 mg, 500 mg) 1 cefuroxime sodium (1.5 g, 7.5 g, 7.5g, 1 750 mg) cephalexin (125 mg/5ml susp recon, 1 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule, 750 mg capsule) SUPRAX (100 MG TABLET CHEWABLE, 3 200 MG TABLET CHEWABLE, 400 MG CAPSULE) TEFLARO (400 MG, 600 MG) 3 Beta-lactam, Other AZACTAM-ISO-OSMOTIC DEXTROSE (1 ML, 2 ML) 3 25
aztreonam (1, 2) 1 imipenem/cilastatin sodium (250 mg, 1 500 mg) INVANZ 1 GM VIAL 3 meropenem (1 g, 500 mg) 1 Beta-lactam, Penicillins amoxicillin (125 mg/5ml susp recon, 1 200 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 875 mg tablet) amoxicillin/potassium clavulanate 1 (200-28.5/5 susp recon, 200-28.5mg tab chew, 250-125 mg tablet, 400-57mg tab chew, 400-57mg/5 susp recon, 500-125 mg tablet, 600-42.9/5 susp recon, 875-125 mg tablet) ampicillin sodium (1 g, 1 g port, 10 g, 1 2 g, 250 mg, 500 mg) ampicillin sodium/sulbactam na 1.5 g 3 vial ampicillin sodium/sulbactam sodium 1 (1.5 port, 3, 3 port) ampicillin trihydrate (125, 250) 3 ampicillin trihydrate (250 mg, 500 1 mg) BICILLIN L-A (1,200,000 UNITS, 3 2,400,000 UNITS, 600,000 UNIT/ML) 26
dicloxacillin sodium (250 mg, 500 mg) 1 nafcillin sodium (1, 10, 2) 1 penicillin g potassium (20mm, 5mm) 1 penicillin g potassium/dextrose-water 3 (2mm/50ml froz.piy, 3mm/50ml froz.piy) penicillin g sodium 5mm unit vial 3 penicillin v potassium (125 mg/5ml 1 soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) piperacillin sodium/tazobactam 1 sodium (2.25, 3.375, 3.375 port, 4.5, 4.5 port, 40.5) ZOSYN (2.25 GM/50 ML BAG, 3.375 3 GM/50 ML, 4.5 GM/100 ML BAG) Macrolides azithromycin (100 mg/5ml susp recon, 1 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 500 mg vial, 500 mg vial port, 600 mg tablet) azithromycin 1 g packet 3 clarithromycin (125 mg/5ml susp 1 recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tab er 24h, 500 mg tablet) DIFICID 200 MG TABLET 4 27
E.E.S. 200 MG/5 ML GRANULES 3 ERY-TAB (250 MG, 333 MG, 500 MG) 3 ERYPED 200 MG/5 ML SUSPENSION 3 ERYPED 400 MG/5 ML SUSPENSION 3 ERYTHROCIN 250 MG FILMTAB 3 ERYTHROCIN LACTOBIONATE (500 3 MG ADDVNT VL, 500 MG VIAL) erythromycin base (250 mg capsule 3 dr, 250 mg tablet, 500 mg tablet) erythromycin base 5 mg/g oint. (g) 1 erythromycin base/ethyl alcohol (2 % 1 med. swab, 2 % solution) ILOTYCIN 0.5% EYE OINTMENT 1 Quinolones AVELOX IV 400 MG/250 ML 2 BESIVANCE 0.6% SUSP 3 ciprofloxacin (250, 500) 1 ciprofloxacin hcl (0.3 % drops, 250 mg 1 tablet, 500 mg tablet, 750 mg tablet) ciprofloxacin hcl 100 mg tablet 3 ciprofloxacin lactate (200mg/20ml, 1 400mg/40ml) ciprofloxacin lactate/dextrose 5 % in 1 water (200mg/0.1l, 400mg/0.2l) 28
levofloxacin (25 mg/ml vial, 250 mg 1 tablet, 250mg/10ml solution, 500 mg tablet, 500mg/20ml solution, 750 mg tablet) levofloxacin/dextrose 5 % in water 1 (250mg/50ml, 500mg/0.1l, 750mg/.15l) MOXEZA 0.5% EYE DROPS 3 moxifloxacin hcl 400 mg tablet 1 moxifloxacin/sod.ace,sul/water 3 400mg/.25l piggyback ofloxacin 0.3 % drops 1 ofloxacin 400 mg tablet 3 VIGAMOX 0.5% EYE DROPS 2 Sulfonamides silver sulfadiazine 1 % cream (g) 1 SSD 1% CREAM 1 sulfacetamide sodium (10 % drops, 10 1 % suspension) sulfadiazine 500 mg tablet 3 sulfamethoxazole/trimethoprim (200-1 40mg/5 oral susp, 400mg-80mg tablet, 800-160 mg tablet, 800-160/20 oral susp) sulfamethoxazole/trimethoprim 80-3 16mg/ml vial 29
Tetracyclines demeclocycline hcl (150 mg, 300 mg) 1 doxycycline hyclate (100 mg capsule, 1 100 mg tablet, 100 mg vial, 20 mg tablet, 50 mg capsule) doxycycline monohydrate (100 mg 1 capsule, 100 mg tablet, 150 mg capsule, 150 mg tablet, 50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet) minocycline hcl (100 mg capsule, 100 1 mg tablet, 50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet) tetracycline hcl (250 mg, 500 mg) 3 Anticonvulsants Anticonvulsants, Other BRIVIACT (10 MG TABLET, 10 MG/ML 4 ORAL SOLN, 100 MG TABLET, 25 MG TABLET, 50 MG TABLET, 75 MG TABLET) BRIVIACT 50 MG/5 ML VIAL 3 FYCOMPA 0.5 MG/ML ORAL SUSP 3 levetiracetam (100 mg/ml solution, 1 1000 mg tablet, 250 mg tablet, 500 mg tablet, 500 mg/5ml solution, 500 mg/5ml vial, 750 mg tablet) 30
levetiracetam in sodium chloride, isoosmotic (1000mg/100, 1500mg/100, 500mg/0.1l) POTIGA (200 MG, 300 MG, 400 MG, 50 MG) Calcium Channel Modifying Agents CELONTIN 300 MG KAPSEAL 3 ethosuximide (250 mg capsule, 250 1 mg/5ml solution) LYRICA (100 MG CAPSULE, 150 MG 2 CAPSULE, 20 MG/ML ORAL SOLUTION, 200 MG CAPSULE, 225 MG CAPSULE, 25 MG CAPSULE, 300 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE) zonisamide (100 mg, 25 mg, 50 mg) 1 Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT 2.5 MG PEDI SYSTEM 3 QL (5 PER 30 DIASTAT ACUDIAL 12.5-15-20 MG 3 QL (40 PER 30 DIASTAT ACUDIAL 5-7.5-10 MG KT 3 QL (20 PER 30 diazepam 12.5-15-20 kit 3 QL (40 PER 30 diazepam 2.5 mg kit 3 QL (5 PER 30 3 3 31
diazepam 5-7.5-10mg kit 3 QL (20 PER 30 divalproex sodium (125 mg cap 1 sprink, 125 mg tablet dr, 250 mg tab er 24h, 250 mg tablet dr, 500 mg tab er 24h, 500 mg tablet dr) gabapentin (100 mg capsule, 250 1 mg/5ml solution, 300 mg capsule, 300 mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet) GABITRIL (12 MG, 16 MG) 3 ONFI (10 MG, 20 MG) 3 PA - FOR NEW QL (60 PER 30 ONFI 2.5 MG/ML SUSPENSION 3 PA - FOR NEW QL (480 PER 30 phenobarbital (100 mg tablet, 15 mg tablet, 16.2 mg tablet, 20 mg/5 ml 3 PA - FOR NEW STARTS ONLY elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet) primidone (250 mg, 50 mg) 1 SABRIL 500 MG POWDER PACKET 3 SABRIL 500 MG TABLET 4 tiagabine hcl (2 mg, 4 mg) 1 32
valproic acid (as sodium salt) 1 (valproate sodium) (250 mg/5ml solution, 500 mg/5ml vial, 500mg/10ml solution) valproic acid 250 mg capsule 1 Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) FYCOMPA (10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG) lamotrigine (100 mg tab rapdis, 100 mg tablet, 150 mg tablet, 200 mg tab rapdis, 200 mg tablet, 25 mg tab rapdis, 25 mg tablet, 25 mg tb chw dsp, 5 mg tb chw dsp, 50 mg tab rapdis) topiramate (100 mg tablet, 15 mg cap sprink, 200 mg tablet, 25 mg cap sprink, 25 mg tablet, 50 mg tablet) Sodium Channel Agents APTIOM (200 MG, 400 MG, 600 MG, 3 800 MG) BANZEL (40 MG/ML SUSPENSION, 400 4 MG TABLET) BANZEL 200 MG TABLET 3 1 3 1 1 33
carbamazepine (100 mg cpmp 12hr, 1 100 mg tab chew, 100 mg tab er 12h, 100 mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 300 mg cpmp 12hr, 400 mg tab er 12h) DILANTIN 30 MG CAPSULE 3 fosphenytoin sodium (100mg pe/2, 1 500 pe/10) oxcarbazepine (150 mg tablet, 300 1 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) PEGANONE 250 MG TABLET 3 phenytoin (100 mg/4ml oral susp, 125 1 mg/5ml oral susp, 50 mg tab chew) phenytoin sodium extended (100 mg, 1 200 mg, 300 mg) TEGRETOL XR 100 MG TABLET 3 VIMPAT (10 MG/ML SOLUTION, 100 2 MG TABLET, 150 MG TABLET, 200 MG TABLET, 200 MG/20 ML VIAL, 50 MG TABLET) Antidementia Agents Antidementia Agents, Other ergoloid mesylates 1 mg tablet 2 PA 34
Cholinesterase Inhibitors donepezil hcl (10 mg tab rapdis, 10 1 mg tablet, 23 mg tablet, 5 mg tab rapdis, 5 mg tablet) EXELON (13.3, 4.6, 9.5) 2 galantamine hbr (12 mg tablet, 16 mg 1 cap24h pel, 24 mg cap24h pel, 4 mg tablet, 8 mg cap24h pel, 8 mg tablet) galantamine hbr 4 mg/ml solution 3 rivastigmine (13.3mg/24h, 3 4.6mg/24hr, 9.5mg/24hr) rivastigmine tartrate (1.5 mg, 3 mg, 1 4.5 mg, 6 mg) N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (10 mg tablet, 2 3 PA mg/ml solution, 5 mg tablet, 5 mg-10 mg tab ds pk) NAMENDA (10 MG TABLET, 2 MG/ML 2 PA SOLUTION, 5 MG TABLET, 5-10 MG TITRATION PK) NAMENDA XR (14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE, 7 MG CAPSULE, TITRATION PACK) 2 PA Antidepressants Antidepressants, Other bupropion hcl (100 mg er, 150 mg er, 200 mg er, 75 mg) 1 QL (60 PER 30 35
bupropion hcl (150 mg tab er, 300 mg tab er) 1 QL (30 PER 30 bupropion hcl 100 mg tablet 1 QL (120 PER 30 mirtazapine (15 mg tab rapdis, 15 mg tablet, 30 mg tab rapdis, 30 mg tablet, 45 mg tab rapdis, 45 mg tablet, 7.5 mg tablet) 1 QL (30 PER 30 Monoamine Oxidase Inhibitors EMSAM (12, 6, 9) 4 MARPLAN 10 MG TABLET 3 phenelzine sulfate 15 mg tablet 1 tranylcypromine sulfate 10 mg tablet 1 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibito BRINTELLIX (10 MG, 20 MG, 5 MG) 3 QL (30 PER 30 citalopram hydrobromide (10 mg, 20 mg, 40 mg) 1 QL (30 PER 30 citalopram hydrobromide 10 mg/5 ml solution 1 QL (600 PER 30 duloxetine hcl (20 mg, 30 mg, 60 mg) 1 QL (60 PER 30 escitalopram oxalate (10 mg, 20 mg, 5 mg) 1 QL (30 PER 30 escitalopram oxalate 5 mg/5 ml solution 1 QL (600 PER 30 36
FETZIMA (ER 120 MG, ER 20 MG, ER 40 MG, ER 80 MG) 3 QL (30 PER 30 FETZIMA 20-40 MG TITRATION PAK 3 QL (28 PER 28 fluoxetine hcl (10 mg capsule, 10 mg tablet) 1 QL (30 PER 30 fluoxetine hcl (20 mg capsule, 20 mg tablet) 1 QL (120 PER 30 fluoxetine hcl 20 mg/5 ml solution 1 QL (600 PER 30 fluoxetine hcl 40 mg capsule 1 QL (60 PER 30 fluoxetine hcl 90 mg capsule dr 1 QL (4 PER 28 fluvoxamine maleate (25 mg, 50 mg) 1 QL (30 PER 30 fluvoxamine maleate 100 mg tablet 1 QL (90 PER 30 maprotiline hcl (25 mg, 50 mg, 75 mg) 3 QL (90 PER 30 nefazodone hcl (100 mg, 150 mg, 200 3 mg, 50 mg) nefazodone hcl 250 mg tablet 1 paroxetine hcl (10 mg tablet, 12.5 mg tab er 24h, 20 mg tablet, 40 mg tablet) 1 QL (30 PER 30 paroxetine hcl (25 mg tab er 24h, 30 mg tablet, 37.5 mg tab er 24h) 1 QL (60 PER 30 37
PAXIL 10 MG/5 ML SUSPENSION 3 QL (900 PER 30 PRISTIQ (ER 100 MG, ER 25 MG, ER 50 3 QL (30 PER 30 MG) sertraline hcl (25 mg, 50 mg) 1 QL (30 PER 30 sertraline hcl 100 mg tablet 1 QL (60 PER 30 sertraline hcl 20 mg/ml oral conc 1 QL (300 PER 30 trazodone hcl (100 mg, 150 mg, 300 1 mg, 50 mg) TRINTELLIX (10 MG, 20 MG, 5 MG) 3 QL (30 PER 30 venlafaxine hcl (100 mg tablet, 25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 24h, 75 mg tab er 24, 75 mg tablet) 1 QL (90 PER 30 venlafaxine hcl (150 mg cap er 24h, 150 mg tab er 24, 37.5 mg cap er 24h, 37.5 mg tab er 24) VENLAFAXINE HCL ER (ER 150 MG TAB, ER 37.5 MG TAB) 1 QL (30 PER 30 1 QL (30 PER 30 VENLAFAXINE HCL ER 75 MG TAB 1 QL (90 PER 30 38
VIIBRYD (10 MG TABLET, 10-20 MG STARTER PACK, 10-20-40 MG STARTER PK, 20 MG TABLET, 40 MG TABLET) Tricyclics amitriptyline hcl (10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg) amoxapine (100 mg, 150 mg, 25 mg, 50 mg) clomipramine hcl (25 mg, 50 mg, 75 mg) desipramine hcl (10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg) doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 100 mg capsule, 150 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) imipramine hcl (10 mg, 25 mg, 50 mg) 3 nortriptyline hcl (10 mg, 25 mg, 50 1 mg, 75 mg) nortriptyline hcl 10 mg/5 ml solution 3 protriptyline hcl (10 mg, 5 mg) 1 SURMONTIL (100 MG, 25 MG, 50 MG) 3 trimipramine maleate (100 mg, 25 mg, 50 mg) 3 QL (30 PER 30 3 PA - FOR NEW STARTS ONLY 3 3 PA - FOR NEW STARTS ONLY 1 3 PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY 3 PA - FOR NEW STARTS ONLY 39
Antiemetics Antiemetics, Other chlorpromazine hcl (10 mg, 100 mg, 200 mg, 25 mg, 50 mg) 1 PA - FOR NEW STARTS ONLY chlorpromazine hcl 25 mg/ml ampul 3 PA - FOR NEW STARTS ONLY hydroxyzine hcl (10 mg tablet, 10 3 PA mg/5 ml solution, 25 mg tablet, 50 mg tablet, 50 mg/25ml solution) meclizine hcl (12.5 mg, 25 mg) 1 metoclopramide hcl (10 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg/ml vial) 1 metoclopramide hcl 10 mg tab rapdis 4 perphenazine (16 mg, 2 mg, 4 mg, 8 mg) 1 PA - FOR NEW STARTS ONLY PHENERGAN (12.5 MG, 25 MG) 3 PA prochlorperazine 25 mg supp.rect 1 prochlorperazine edisylate (10 mg/2 1 ml, 5 mg/ml) prochlorperazine maleate (10 mg, 5 1 mg) promethazine hcl (12.5 mg supp.rect, 12.5 mg tablet, 25 mg supp.rect, 25 mg tablet, 50 mg tablet, 6.25mg/5ml syrup) 3 PA 40
Emetogenic Therapy Adjuncts ALOXI 0.25 MG/5 ML VIAL 3 dronabinol (10 mg, 2.5 mg, 5 mg) 1 PA - TO CONFIRM PART D COVERAGE EMEND (125 MG CAPSULE, 40 MG CAPSULE, 80 MG CAPSULE, TRIPACK) 3 PA - TO CONFIRM PART D COVERAGE granisetron hcl 1 mg tablet 1 PA - TO CONFIRM PART D COVERAGE ondansetron (4 mg tab, 8 mg tab) 1 PA - TO CONFIRM PART D COVERAGE ondansetron hcl (24 mg tablet, 4 mg tablet, 4 mg/5 ml solution, 8 mg tablet) ondansetron hcl/pf (4 ml ampul, 4 ml syringe, 4 ml vial) Antifungals 1 PA - TO CONFIRM PART D COVERAGE 1 AMBISOME 50 MG VIAL 4 PA - TO CONFIRM PART D COVERAGE amphotericin b 50 mg vial 3 PA - TO CONFIRM PART D COVERAGE CANCIDAS (50 MG, 70 MG) 4 41
ciclopirox (0.77 % gel (gram), 1 % 1 shampoo, 8 % solution) ciclopirox olamine (0.77 % cream (g), 1 0.77 % suspension) clotrimazole (1 % cream (g), 10 mg 1 troche) CRESEMBA (186 MG CAPSULE, 372 4 PA MG VIAL) econazole nitrate 1 % cream (g) 1 fluconazole (10 mg/ml susp recon, 1 100 mg tablet, 150 mg tablet, 200 mg tablet, 40 mg/ml susp recon, 50 mg tablet) fluconazole in dextrose, iso-osmotic 1 (200mg/0.1l, 400mg/0.2l) flucytosine (250 mg, 500 mg) 4 griseofulvin ultramicrosize (125 mg, 1 250 mg) griseofulvin, microsize 125 mg/5ml 1 oral susp itraconazole 100 mg capsule 1 ketoconazole (2 % cream (g), 2 % 1 shampoo, 200 mg tablet) ketoconazole 2 % foam 3 MYCAMINE (100 MG, 50 MG) 4 NATACYN EYE DROPS 3 42
NOXAFIL 40 MG/ML SUSPENSION 4 PA nystatin (100000/g cream (g), 1 100000/g oint. (g), 100000/g powder, 100000/ml oral susp, 150mm unit powder(ea), 500k unit tablet, 500mm unit powder(ea), 50mm unit powder(ea)) terbinafine hcl 250 mg tablet 1 terconazole (0.4 % cream/appl, 0.8 % 1 cream/appl, 80 mg supp.vag) voriconazole (200 mg tablet, 200 4 PA mg/5ml susp recon, 50 mg tablet) voriconazole 200 mg vial 1 PA Antigout Agents allopurinol (100 mg, 300 mg) 1 ALOPRIM 500 MG VIAL 3 colchicine 0.6 mg tablet 2 QL (120 PER 30 COLCRYS 0.6 MG TABLET 2 probenecid 500 mg tablet 1 probenecid/colchicine 500-0.5 mg 1 tablet ULORIC (40 MG, 80 MG) 2 43
Antimigraine Agents butalbital/acetaminophen/caffeine/c odeine phosphate (50-300-30, 50-325- 30) 3 PA, QL (180 PER 30 codeine/butalbital/asa/caffein 30-50- 325 capsule 3 PA, QL (180 PER 30 ergotamine tartrate/caffeine 2-3 100mg supp.rect MIGRANAL NASAL SPRAY 2 Serotonin (5-HT) 1b/1d Receptor Agonists almotriptan malate (12.5 mg, 6.25 mg) 3 QL (12 PER 30 naratriptan hcl (1 mg, 2.5 mg) 1 QL (18 PER 30 rizatriptan benzoate (10 mg tab rapdis, 10 mg tablet, 5 mg tab rapdis, 1 QL (18 PER 30 5 mg tablet) sumatriptan (20 mg, 5 mg) 3 QL (12 PER 30 sumatriptan succinate (100 mg, 25 mg, 50 mg) 1 QL (18 PER 30 sumatriptan succinate (4 cartridge, 4 pen injctr, 6 cartridge) 3 QL (4 PER 30 sumatriptan succinate (6 syringe, 6 vial) 1 sumatriptan succinate 6 mg/0.5ml pen injctr 1 QL (4 PER 30 44
Antimyasthenic Agents Parasympathomimetics guanidine hcl 125 mg tablet 3 MESTINON 180 MG TIMESPAN 2 MESTINON 60 MG/5 ML SYRUP 3 pyridostigmine bromide 180 mg 2 tablet er pyridostigmine bromide 60 mg tablet 1 Antimycobacterials Antimycobacterials, Other dapsone (100 mg, 25 mg) 1 rifabutin 150 mg capsule 1 Antituberculars CAPASTAT SULFATE 1 GM VIAL 3 ethambutol hcl (100 mg, 400 mg) 1 isoniazid (100 mg, 300 mg) 1 isoniazid 100 mg/ml vial 3 PASER GRANULES 4 GM PACKET 3 PRIFTIN 150 MG TABLET 3 pyrazinamide 500 mg tablet 1 rifampin (150 mg capsule, 300 mg 1 capsule, 600 mg vial) 45
SIRTURO 100 MG TABLET 4 TRECATOR 250 MG TABLET 3 Antineoplastic Antineoplastics other hydroxyprogesterone caproate 250 mg/ml vial Antineoplastics 4 PA - FOR NEW STARTS ONLY Alkylating Agents BUSULFEX 60 MG/10 ML VIAL 4 cyclophosphamide (25 mg, 50 mg) 3 PA - TO CONFIRM PART D COVERAGE GLEOSTINE (10 MG, 100 MG, 40 MG) 3 GLEOSTINE 5 MG CAPSULE 2 HEXALEN 50 MG CAPSULE 4 PA - FOR NEW STARTS ONLY LEUKERAN 2 MG TABLET 2 LOMUSTINE (10 MG, 100 MG, 40 MG) 3 MATULANE 50 MG CAPSULE 4 PA - FOR NEW STARTS ONLY melphalan hcl 50 mg vial 4 MUSTARGEN 10 MG VIAL 3 thiotepa 15 mg vial 4 46
VALCHLOR 0.016% GEL 4 Antiandrogens bicalutamide 50 mg tablet 1 flutamide 125 mg capsule 1 NILANDRON 150 MG TABLET 4 nilutamide 150 mg tablet 4 XTANDI 40 MG CAPSULE 4 PA - FOR NEW QL (120 PER 30 ZYTIGA 250 MG TABLET 4 PA - FOR NEW QL (120 PER 30 Antiangiogenic Agents POMALYST (1 MG, 2 MG, 3 MG, 4 MG) 4 PA - FOR NEW QL (21 PER 28 REVLIMID (10 MG, 2.5 MG, 5 MG) 4 PA - FOR NEW QL (30 PER 30 REVLIMID (15 MG, 20 MG, 25 MG) 4 PA - FOR NEW QL (21 PER 28 47
THALOMID (100 MG, 50 MG) 4 PA - FOR NEW QL (30 PER 30 THALOMID (150 MG, 200 MG) 4 PA - FOR NEW QL (60 PER 30 ZALTRAP (100 MG/4 ML, 200 MG/8 ML) 4 Antiestrogens/Modifiers EMCYT 140 MG CAPSULE 3 FARESTON 60 MG TABLET 4 SOLTAMOX 10 MG/5 ML SOLN 3 tamoxifen citrate (10 mg, 20 mg) 1 Antimetabolites fluorouracil (1 g/20 ml, 2.5 g/50ml, 5 g/100 ml, 500mg/10ml) 1 PA - TO CONFIRM PART D COVERAGE FOLOTYN (20 MG/ML, 40 MG/2 ML) 4 hydroxyurea 500 mg capsule 1 LONSURF 15 MG-6.14 MG TABLET 4 PA - FOR NEW QL (300 PER 30 48
mercaptopurine 50 mg tablet 1 PURIXAN 20 MG/ML ORAL SUSP 4 TABLOID 40 MG TABLET 3 Antineoplastics, Other ABRAXANE 100 MG VIAL 4 ALECENSA 150 MG CAPSULE 4 PA - FOR NEW QL (240 PER 30 ALIMTA (100 MG, 500 MG) 4 amifostine crystalline 500 mg vial 4 ARRANON 250 MG/50 ML VIAL 4 azacitidine 100 mg vial 4 BELEODAQ 500 MG VIAL 4 BICNU 100 MG VIAL 3 bleomycin sulfate (15, 30) 1 PA - TO CONFIRM PART D COVERAGE carboplatin (10 mg/ml, 150 mg) 1 cisplatin 1 mg/ml vial 1 cladribine 10 mg/10ml vial 4 PA - TO CONFIRM PART D COVERAGE CLOLAR 20 MG/20 ML VIAL 4 COSMEGEN 0.5 MG VIAL 4 49
cytarabine 20 mg/ml vial 1 PA - TO CONFIRM PART D COVERAGE cytarabine/pf (2 g/20 ml, 20 mg/ml) 1 PA - TO CONFIRM PART D COVERAGE cytarabine/pf 100 mg/5ml vial 1 dacarbazine (100 mg, 200 mg) 1 daunorubicin hcl (20 mg, 5 mg/ml) 1 DAUNOXOME 50 MG (2 MG/ML) VIAL 4 decitabine 50 mg vial 4 dexrazoxane hcl (250 mg, 500 mg) 4 DOCEFREZ 20 MG VIAL 4 docetaxel (140 mg/7ml, 160 mg/8ml, 4 160mg/16ml, 20 mg/2 ml, 200mg/20ml, 20mg/ml(1), 80 mg/4 ml, 80 mg/8 ml) doxorubicin hcl (10 mg, 10 mg/5 ml, 2 mg/ml, 20 mg/10ml, 50 mg/25ml) doxorubicin hcl peg-liposomal 2 mg/ml vial ELITEK (1.5 MG, 7.5 MG) 4 epirubicin hcl (200 mg, 200mg/0.1l, 1 50 mg, 50 mg/25ml) ERWINAZE 10,000 UNITS VIAL 4 1 PA - TO CONFIRM PART D COVERAGE 4 50
FARYDAK (10 MG, 15 MG, 20 MG) 4 PA - FOR NEW QL (6 PER 21 FASLODEX 250 MG/5 ML SYRINGE 4 fludarabine phosphate (50 mg, 50 1 mg/2 ml) gemcitabine hcl (1 g, 1 g/26.3ml, 2 g, 1 2 g/52.6ml, 200 mg, 200mg/5.26) HALAVEN 1 MG/2 ML VIAL 4 idarubicin hcl 1 mg/ml vial 4 ifosfamide (1 g, 1 g/20 ml, 3 g, 1 3g/60ml) ISTODAX (10 MG KIT, 10 MG VIAL) 4 IXEMPRA (15 MG, 45 MG) 4 JEVTANA 60 MG/1.5 ML KIT 4 leucovorin calcium (10 mg, 15 mg) 3 leucovorin calcium (10 mg/ml vial, 1 100 mg vial, 200 mg vial, 25 mg tablet, 350 mg vial, 5 mg tablet, 50 mg vial, 500 mg vial, 500mg/50ml vial) mesna 100 mg/ml vial 1 MESNEX 400 MG TABLET 4 mitomycin (20 mg, 40 mg, 5 mg) 1 mitoxantrone hcl 2 mg/ml vial 1 51
NINLARO (2.3 MG, 3 MG, 4 MG) 4 PA - FOR NEW QL (3 PER 28 NIPENT 10 MG VIAL 4 ONCASPAR (3,750 UNIT/5 ML, 750 4 UNIT/ML) oxaliplatin (100 mg, 100mg/20ml, 50 1 mg, 50 mg/10ml) paclitaxel 6 mg/ml vial 1 PROLEUKIN 22 MILLION UNIT VIAL 4 SYNRIBO 3.5 MG/ML VIAL 4 TAXOTERE (20 MG/ML, 80 MG/4 ML) 4 TORISEL 25 MG KIT 4 TREANDA (100 MG, 180 MG/2 ML, 25 4 MG, 45 MG/0.5 ML) TRISENOX 10 MG/10 ML AMPULE 3 vinblastine sulfate 1 mg/ml vial 3 PA - TO CONFIRM PART D COVERAGE vincristine sulfate (1 mg/ml, 2 mg/2 1 ml) vinorelbine tartrate (10 mg/ml, 50 1 mg/5 ml) ZANOSAR 1 GM POWDER VIAL 3 52
Aromatase Inhibitors, 3rd Generation anastrozole 1 mg tablet 1 exemestane 25 mg tablet 1 letrozole 2.5 mg tablet 1 Enzyme Inhibitors ETOPOPHOS 100 MG VIAL 3 etoposide 20 mg/ml vial 1 irinotecan hcl (100 mg/5ml, 40 mg/2 1 ml, 500mg/25ml) topotecan hcl (4 mg, 4 mg/4 ml) 4 Molecular Target Inhibitors AFINITOR (10 MG, 2.5 MG, 5 MG, 7.5 MG) 4 PA - FOR NEW QL (30 PER 30 AFINITOR DISPERZ (2 MG, 5 MG) 4 PA - FOR NEW QL (60 PER 30 AFINITOR DISPERZ 3 MG TABLET 4 PA - FOR NEW QL (90 PER 30 BOSULIF 100 MG TABLET 4 PA - FOR NEW QL (120 PER 30 53
BOSULIF 500 MG TABLET 4 PA - FOR NEW QL (30 PER 30 CABOMETYX (20 MG, 40 MG, 60 MG) 4 PA - FOR NEW STARTS ONLY CAPRELSA 100 MG TABLET 4 PA - FOR NEW QL (60 PER 30 CAPRELSA 300 MG TABLET 4 PA - FOR NEW QL (30 PER 30 COMETRIQ 100 MG DAILY-DOSE PK 4 PA - FOR NEW QL (56 PER 28 COMETRIQ 140 MG DAILY-DOSE PK 4 PA - FOR NEW QL (112 PER 28 COMETRIQ 60 MG DAILY-DOSE PACK 4 PA - FOR NEW QL (84 PER 28 COTELLIC 20 MG TABLET 4 PA - FOR NEW LA, QL (90 PER 30 54
ERIVEDGE 150 MG CAPSULE 4 PA - FOR NEW QL (30 PER 30 GILOTRIF (20 MG, 30 MG, 40 MG) 4 PA - FOR NEW QL (30 PER 30 GLEEVEC 100 MG TABLET 4 PA - FOR NEW QL (90 PER 30 GLEEVEC 400 MG TABLET 4 PA - FOR NEW QL (60 PER 30 IBRANCE (100 MG, 125 MG, 75 MG) 4 PA - FOR NEW QL (21 PER 28 ICLUSIG 15 MG TABLET 4 PA - FOR NEW QL (60 PER 30 ICLUSIG 45 MG TABLET 4 PA - FOR NEW QL (30 PER 30 imatinib mesylate (100 mg, 400 mg) 4 PA - FOR NEW STARTS ONLY 55
IMBRUVICA 140 MG CAPSULE 4 PA - FOR NEW QL (120 PER 30 INLYTA 1 MG TABLET 4 PA - FOR NEW QL (180 PER 30 INLYTA 5 MG TABLET 4 PA - FOR NEW QL (120 PER 30 IRESSA 250 MG TABLET 4 PA - FOR NEW QL (60 PER 30 JAKAFI (10 MG, 15 MG, 20 MG, 25 MG, 5 MG) 4 PA - FOR NEW QL (60 PER 30 LENVIMA (14 MG, 20 MG) 4 PA - FOR NEW QL (60 PER 30 LENVIMA (18 MG, 8 MG) 4 PA - FOR NEW STARTS ONLY LENVIMA 10 MG DAILY DOSE 4 PA - FOR NEW QL (30 PER 30 56
LENVIMA 24 MG DAILY DOSE 4 PA - FOR NEW QL (90 PER 30 LYNPARZA 50 MG CAPSULE 4 PA - FOR NEW QL (480 PER 30 MEKINIST 0.5 MG TABLET 4 PA - FOR NEW QL (90 PER 30 MEKINIST 2 MG TABLET 4 PA - FOR NEW QL (30 PER 30 NEXAVAR 200 MG TABLET 4 PA - FOR NEW QL (120 PER 30 ODOMZO 200 MG CAPSULE 4 PA - FOR NEW LA, QL (30 PER 30 SPRYCEL (100 MG, 140 MG, 50 MG, 70 MG, 80 MG) 4 PA - FOR NEW QL (30 PER 30 57
STIVARGA 40 MG TABLET 4 PA - FOR NEW QL (84 PER 28 SUTENT (25 MG, 37.5 MG, 50 MG) 4 PA - FOR NEW QL (30 PER 30 SUTENT 12.5 MG CAPSULE 4 PA - FOR NEW QL (90 PER 30 TAFINLAR (50 MG, 75 MG) 4 PA - FOR NEW QL (120 PER 30 TARCEVA (100 MG, 150 MG) 4 PA - FOR NEW QL (30 PER 30 TARCEVA 25 MG TABLET 4 PA - FOR NEW QL (60 PER 30 TASIGNA (150 MG, 200 MG) 4 PA - FOR NEW QL (120 PER 30 58