AlphaCare of New York 2015 Comprehensive Formulary (List of Covered Drugs)

Transcription

1 AlphaCare of New York 015 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 07/16/015. For more recent information or other questions, please contact AlphaCare of New York, Member Services at or for TTY users, 711, Monday - Sunday from 8:00 AM 8:00 PM 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 AlphaCare of New York. When it refers to plan or our plan, it means AlphaCare Renew, AlphaCare Reliance or AlphaCare Total. This document includes a list of the drugs (formulary) for our plan which is current as of August 1, 015. 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, premium and/or copayments/coinsurance may change on January 1, 016. Formulary ID: 15471, Version Number: 14 Effective: August 1, 015 1

2 What is the AlphaCare of New York Comprehensive Formulary? A formulary is a list of covered drugs selected by AlphaCare 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. AlphaCare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a AlphaCare 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 015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 015 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 August 1, 015. To get updated information about the drugs covered by AlphaCare, please contact us. Our contact information appears on the front and back cover pages. In the event of any mid-year non-maintenance formulary changes, AlphaCare will mail you an errata sheet to update your printed formulary. 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 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 I-1. 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.

3 What are generic drugs? AlphaCare 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: AlphaCare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from AlphaCare before you fill your prescriptions. If you don t get approval, AlphaCare may not cover the drug. Quantity Limits: For certain drugs, AlphaCare limits the amount of the drug that AlphaCare will cover. For example, AlphaCare provides 18 tablets per 8 days for sumatriptan. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, AlphaCare 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, AlphaCare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AlphaCare 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. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask AlphaCare 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 AlphaCare of New York formulary? on page 4 for information about how to request an exception. [What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. AlphaCare pays for certain OTC drugs. AlphaCare will provide these OTC drugs at no cost to you. The cost to AlphaCare of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap. 3

4 Generic Name COVERED OVER-THE-COUNTER (OTC) DRUGS DRUG (Reference Brand Name) Dosage Form cetirizine hydrochloride (Zyrtec) Chewable Tablets, Solution, Tablets cetirizine hydrochloride/ pseudoephedrine hydrochloride (Zyrtec-D) 1 Hour Tablets loratadine (Claritin) Solution, Tablets loratadine/ pseudoephedrine sulfate (Claritin-D) 1 Hour Tablets 4 Hour Tablets ketotifen fumarate (Zaditor) Drops 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. If you learn that AlphaCare does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by AlphaCare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by AlphaCare You can ask AlphaCare 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 AlphaCare of New York Formulary? You can ask AlphaCare 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 waive coverage restrictions or limits on your drug. For example, for certain drugs AlphaCare 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, AlphaCare 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. 4

5 You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering 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 4 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. 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 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. 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 while you pursue a formulary exception. Members with levels-of-care changes may contact us (or have their doctor or prescriber contact us) to request transitional supplies of medication during their transitions of care. AlphaCare will not supply a transition fill for any drugs that are not Part D-approved drugs. For more information For more detailed information about your AlphaCare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about AlphaCare 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 ( ) 4 hours a day/7 days a week. TTY users should call Or, visit 5

6 AlphaCare of New York s Formulary The comprehensive formulary that begins on page 13 provides coverage information about the drugs covered by AlphaCare. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR) and generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if AlphaCare has any special requirements for coverage of your drug. 6

7 The following abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION PA PA BvD Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Utilization Management Restrictions You (or your physician) are required to get prior authorization from AlphaCare before you fill your prescription for this drug. Without prior approval, AlphaCare may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from AlphaCare to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, AlphaCare may not cover this drug. PA-HRM Prior Authorization Restriction for High Risk Medications This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 yrs or older are required to get prior authorization from AlphaCare before you fill your prescription for this drug. Without prior approval, AlphaCare may not cover this drug PA NSO QL ST HI LA Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction If you are a new member, you (or your physician) are required to get prior authorization from AlphaCare before you fill your prescription for this drug. Without prior approval, AlphaCare may not cover this drug. AlphaCare limits the amount of this drug that is covered per prescription, or within a specific time frame. Before AlphaCare will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. Other Special Requirements for Coverage Home Infusion Drug Limited Access Drug This prescription drug is covered under our medical benefit. For more information, call Member Services at or for TTY users call 711, Monday - Sunday from 8:00 AM 8:00 PM. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at or 7

8 for TTY users call 711, Monday - Sunday from 8:00 AM 8:00 PM. STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION DESCRIPTION adh. patch adhesive patch aer br act aerosol, breath activated aer pow aerosol, powder aer pow ba aerosol powder, breath activated aer refill aerosol refill aer w/adap aerosol with adapter ampul ampule blkbaginj bulk bag injection cap dr mp capsule, delayed release multiphasic cap ds pk capsule, dose pack cap er 1h capsule, 1 hour extended release cap er 4h capsule, 4 hour extended release cap er deg capsule, extended release degradable cap er pel capsule, extended release pellets cap mphase capsule, multiphasic cap.sa 4h capsule, 4 hour sustained action cap.sr 1h capsule, 1 hour sustained release cap.sr 4h capsule, 4 hour sustained release cap4h pct capsule, 4 hour controlled-onset pellets cap4h pel capsule, 4 hour sustained release pellets cap sprink capsule, sprinkle cap sr pel capsule sustained release pellets cap w/dev capsule with device capsule dr capsule, delayed release capsule er capsule, extended release capsule sa capsule, sustained action cmb cappad combination: capsule, pad cmb ont fm combination: ointment, foam cmb ont lt combination: ointment, lotion cmb tabpad combination: tablet, pad combo. pkg combination package cpmp 1hr capsule, 1 hour multiphasic cpmp 4hr capsule, 4 hour multiphasic cpmp capsule, multiphasic, 30%-70% cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package 8

9 ABBREVIATION dehp fr bg dis needle disk w/dev disp syrin drops susp drps hpvis emul adhes emul packt emulsn(g) foam/appl. froz.piggy g gel/pf app gel (gm) gel (ml) gel md pmp gel w/appl gel w/pump gran pack hfa aer ad infus. btl insuln pen ip soln irrig soln iv soln. jel jelly/app jel/pf app kit cl&crm kt crm le kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape mg ml muc er 1h ndl fr inj DESCRIPTION di(-ethylhexyl)phthalate free bag disposable needle disk with inhalation device disposable syringe drops, suspension drops, hyperviscous emulsion adhesive emulsion packet emulsion (grams) foam with applicator frozen piggyback gram gel with prefilled applicator gel (grams) gel (milliliters) gel in metered dose pump gel with applicator gel with pump granule pack hfa aerosol adapter infusion bottle insulin pen intraperitoneal solution irrigating solution intravenous solution jelly jelly with applicator jelly with pre-filled applicator kit: cleanser and cream kit: cream, lotion emollient kit: lotion, cream emollient kit: ointment, lotion emollient lotion, extended release lozenge handle medicated heated patch mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram milliliter mucoadhesive system, 1 hour extended release needle for injection 9

10 ABBREVIATION nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td4 patch td7 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 4h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 1h tab er 4h tab er prt tab er seq tab disper tab ds pk tab er 4 tab mphase DESCRIPTION nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 4 hour transdermal patch, 7 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal suppository suspension, 4 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, 1 hour extended release tablet, 4 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 4 hour extended release tablet, multiphasic 10

11 ABBREVIATION tab part tab rap dr tab rapdis tab subl tab.sr 1h tab.sr 4h tabergr4hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 1hr tbmp 4hr u vag ring DESCRIPTION tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 1 hour sustained release tablet, 4 hour sustained release tablet, 4 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack tablet, rapid disintegrating dose pack tablet, 3-month dose pack tablet, 1 hour multiphasic tablet, 4 hour multiphasic unit vaginal ring 11

12 Tier 1 Tier Tier 3 Tier 4 Tier 5 Tier Drug Type Preferred Generic Non-Preferred Generic Preferred Brand Non-Preferred Brand Specialty (Generic, Brand) In-Network Pharmacy 1 Month (30 $.00 copay $8.00 copay $40.00 copay $90.00 copay 33% coinsurance In-Network Pharmacy 3 Months (90 $6.00 copay $4.00 copay $10.00 copay $70.00 copay 33% coinsurance Out-of-Network Pharmacy 1 Month (30 $.00 copay $8.00 copay $40.00 copay $90.00 copay 33% coinsurance Long Term Care Pharmacy 1 Month (31 $.00 copay $8.00 copay $40.00 copay $90.00 copay 33% coinsurance 1

13 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution (Acetaminophen with QL (700 per 30 Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine No.3) QL (360 per 30 mg, mg acetaminophen-codeine oral tablet (Tylenol-Codeine No.3) QL (180 per 30 mg buprenorphine hcl injection (Buprenorphine HCl) butalb-acetaminophen-caffeine oral capsule mg (Esgic) PA-HRM; QL (180 per 30 butalbital-acetaminop-caf-cod (Fioricet with Codeine) PA-HRM; QL (180 per 30 butalbital-acetaminophen (Tencon) PA-HRM; QL (180 per 30 butalbital-acetaminophen-caff oral tablet mg (Esgic) PA-HRM; QL (180 per 30 butalbital-aspirin-caffeine oral capsule (Fiorinal) PA-HRM; QL (180 per 30 butorphanol tartrate nasal (Butorphanol Tartrate) QL (5 per 8 BUTRANS 3 QL (4 per 8 codeine sulfate oral tablet (Codeine Sulfate) QL (180 per 30 codeine-butalbital-asa-caffein oral capsule mg (Fiorinal with Codeine #3) PA-HRM; QL (180 per 30 DURAMORPH (PF) 4 fentanyl citrate (Actiq) 5 PA; QL (10 per 30 fentanyl transdermal patch 7 hour 100 (Duragesic) PA; QL (0 per 30 mcg/hr fentanyl transdermal patch 7 hour 1 (Duragesic) PA; QL (10 per 30 mcg/hr, 5 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour hydrocodone-acetaminophen oral solution (Hycet) QL (700 per 30 hydrocodone-acetaminophen oral tablet mg, mg, mg (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 13

14 hydrocodone-acetaminophen oral tablet (Norco) QL (360 per mg,.5-35 mg, 5-35 mg, mg hydrocodone-ibuprofen (Ibudone) QL (150 per 30 hydromorphone (pf) injection solution 10 (Hydromorphone mg/ml HCl/PF) hydromorphone (pf) injection solution 4 (Dilaudid) mg/ml hydromorphone injection solution (Hydromorphone HCl) hydromorphone injection syringe mg/ml (Hydromorphone HCl) hydromorphone oral liquid (Dilaudid) QL (100 per 30 hydromorphone oral tablet mg, 4 mg (Dilaudid) QL (180 per 30 hydromorphone oral tablet 8 mg (Dilaudid) QL (40 per 30 LAZANDA 5 PA; QL (30 per 30 levorphanol tartrate (Levorphanol Tartrate) QL (180 per 30 methadone hcl oral tablet,soluble 40 mg (Diskets) QL (90 per 30 methadone injection (Methadone HCl) methadone oral (Methadone HCl) QL (1800 per 30 methadone oral (Diskets) QL (360 per 30 morphine concentrate oral solution (Msir) QL (00 per 30 morphine concentrate oral syringe (Morphine Sulfate) morphine injection solution 10 mg/ml (Morphine Sulfate) morphine injection solution 15 mg/ml, 8 (Morphine Sulfate) HI mg/ml morphine injection syringe (Morphine Sulfate) morphine intramuscular (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine intravenous solution 5 mg/ml, (Morphine Sulfate) HI 50 mg/ml morphine intravenous (Morphine Sulfate) morphine oral solution 10 mg/5 ml (Msir) QL (700 per 30 morphine oral solution 0 mg/5 ml (Msir) QL (300 per 30 MORPHINE ORAL TABLET QL (180 per 30 morphine oral tablet extended release 100 (MS Contin) QL (10 per 30 mg, 30 mg, 60 mg morphine oral tablet extended release 15 mg, 00 mg (MS Contin) QL (180 per 30 14

15 morphine rectal (Morphine Sulfate) NUCYNTA 3 QL (181 per 30 NUCYNTA ER 3 QL (60 per 30 oxycodone hcl-acetaminophen oral (Oxycodone QL (1800 per 30 solution 5-35 mg/5 ml oxycodone hcl-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg HCl/Acetaminophen) (Xolox) QL (360 per 30 oxycodone hcl-acetaminophen oral tablet (Xolox) QL (40 per mg oxycodone hcl-aspirin (Percodan) QL (360 per 30 oxycodone oral concentrate (Oxycodone HCl) QL (180 per 30 oxycodone oral solution (Oxycodone HCl) QL (1300 per 30 oxycodone oral tablet (Percolone) QL (180 per 30 oxycodone-acetaminophen oral tablet 10- (Xolox) QL (360 per mg,.5-35 mg, 5-35 mg, mg oxycodone-acetaminophen oral tablet 10- (Xolox) QL (180 per mg oxycodone-acetaminophen oral tablet 7.5- (Xolox) QL (40 per mg oxycodone-aspirin (Percodan) QL (360 per 30 OXYCONTIN ORAL TABLET,ORAL 3 QL (60 per 30 ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL 3 QL (10 per 30 ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet (Opana) QL (180 per 30 oxymorphone oral tablet extended release (Opana ER) QL (60 per 30 1 hr 10 mg, 15 mg, 0 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release (Opana ER) QL (10 per 30 1 hr 30 mg, 40 mg tramadol oral tablet (Ultram) QL (40 per 30 tramadol-acetaminophen (Ultracet) QL (40 per 30 xylon 10 (Ibudone) QL (150 per 30 Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 4 HI 15

16 celecoxib (Celebrex) QL (60 per 30 choline,magnesium salicylate (Choline Sal/Mag Salicylate) COMFORT PAC-IBUPROFEN 1 COMFORT PAC-MELOXICAM 1 COMFORT PAC-NAPROXEN 1 diclofenac potassium (Cataflam) diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) diclofenac sodium topical gel (Solaraze) 5 diclofenac-misoprostol (Arthrotec 50) diflunisal (Diflunisal) etodolac (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR 3 PA flurbiprofen (Ansaid) ibuprofen oral (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen) 1 mg indomethacin oral capsule 5 mg (Indomethacin) PA-HRM; QL (40 per 30 indomethacin oral capsule 50 mg (Indomethacin) PA-HRM; QL (10 per 30 indomethacin oral capsule, extended release (Indomethacin) PA-HRM; QL (60 per 30 indomethacin sodium (Indocin I.V.) PA-HRM ketoprofen oral capsule (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 4 (Ketoprofen) hr 00 mg ketorolac injection cartridge 15 mg/ml (Toradol) QL (40 per 30 ketorolac injection cartridge 30 mg/ml (Toradol) QL (0 per 30 ketorolac injection solution 15 mg/ml (Ketorolac QL (40 per 30 Tromethamine) ketorolac injection solution 30 mg/ml (1 ml) (Ketorolac Tromethamine) QL (0 per 30 16

17 ketorolac intramuscular solution (Ketorolac QL (0 per 30 Tromethamine) ketorolac oral (Ketorolac QL (0 per 30 Tromethamine) mefenamic acid (Ponstel) meloxicam oral suspension (Mobic) meloxicam oral tablet (Mobic) 1 nabumetone (Nabumetone) naproxen oral suspension (Naprosyn) naproxen oral tablet (Naprosyn) 1 naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) naproxen sodium oral tablet 75 mg, 550 (Anaprox) 1 mg piroxicam (Feldene) salsalate (Salsalate) sulindac oral (Sulindac) tolmetin (Tolmetin Sodium) VOLTAREN TOPICAL 3 Anesthetics Local Anesthetics glydo (Lidocaine HCl) lidocaine (pf) injection solution (Xylocaine-MPF) PA BvD; (PA for ESRD Only) lidocaine hcl injection solution (Xylocaine) PA BvD; (PA for ESRD Only) lidocaine hcl laryngotracheal (Xylocaine) lidocaine hcl mucous membrane gel (Lidocaine HCl) lidocaine hcl mucous membrane jelly in (Lidocaine HCl) applicator lidocaine hcl mucous membrane solution (Xylocaine) lidocaine hcl urethral (Lidocaine HCl) lidocaine topical adhesive (Lidoderm) PA patch,medicated lidocaine topical ointment (Lidocaine) PA BvD; (PA for ESRD Only) 17

18 lidocaine-prilocaine topical (EMLA) PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical kit (Lidocaine/Prilocaine) PA BvD LIDODERM 4 PA Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral) buprenorphine hcl sublingual (Subutex) PA; QL (90 per 30 buprenorphine-naloxone (Buprenorphine PA; QL (90 per 30 HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c (Zyban) CHANTIX 3 QL (168 per 84 CHANTIX CONTINUING MONTH 3 QL (56 per 8 BOX CHANTIX CONTINUING MONTH PAK 3 QL (56 per 8 CHANTIX STARTING MONTH BOX 3 QL (53 per 8 disulfiram (Antabuse) naloxone (Naloxone HCl) naltrexone hcl (Revia) naltrexone (Revia) NICOTROL 4 ZUBSOLV SUBLINGUAL TABLET PA; QL (90 per MG, MG ZUBSOLV SUBLINGUAL TABLET MG 3 PA; QL (60 per 30 Antianxiety Agents Benzodiazepines alprazolam oral tablet (Xanax) QL (90 per 30 alprazolam oral tablet extended release 4 (Xanax XR) QL (90 per 30 hr 0.5 mg alprazolam oral tablet extended release 4 (Xanax XR) QL (60 per 30 hr 1 mg, mg, 3 mg alprazolam oral tablet,disintegrating (Alprazolam) QL (90 per 30 chlordiazepoxide hcl (Chlordiazepoxide HCl) QL (10 per 30 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) QL (90 per 30 clonazepam oral tablet mg (Klonopin) QL (300 per 30 18

19 clonazepam oral tablet,disintegrating (Clonazepam) QL (90 per mg, 0.5 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating (Clonazepam) QL (300 per 30 mg clorazepate dipotassium oral tablet 15 mg (Tranxene T-Tab) QL (10 per 30 clorazepate dipotassium oral tablet 3.75 (Tranxene T-Tab) QL (60 per 30 mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT MG diazepam injection (Diazepam) QL (10 per 8 diazepam intensol (Diazepam) QL (100 per 30 diazepam oral solution (Diazepam) QL (100 per 30 diazepam oral tablet (Valium) QL (10 per 30 diazepam rectal (Diastat Acudial) estazolam oral tablet 1 mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 estazolam oral tablet mg (Estazolam) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 19

20 flurazepam oral capsule 15 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 flurazepam oral capsule 30 mg (Flurazepam HCl) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 lorazepam oral solution (Ativan) QL (150 per 30 lorazepam injection solution (Ativan) QL ( per 30 lorazepam injection syringe (Ativan) QL ( per 30 lorazepam oral tablet (Ativan) QL (90 per 30 midazolam (pf) injection (Midazolam HCl/PF) QL ( per 30 midazolam (pf) injection syringe mg/ (Midazolam HCl/PF) QL ( per 30 ml (1 mg/ml) midazolam oral syrup mg/ml (Midazolam HCl) QL (10 per 30 ONFI ORAL SUSPENSION 4 PA NSO; QL (480 per 30 ONFI ORAL TABLET 10 MG, 0 MG 4 PA NSO; QL (60 per 30 temazepam oral capsule 15 mg,.5 mg, 30 mg (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 0

21 temazepam oral capsule 7.5 mg (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (10 per 30 triazolam oral tablet 0.15 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (10 per 30 triazolam oral tablet 0.5 mg (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 Antibacterials Aminoglycosides BETHKIS 5 PA BvD gentamicin in nacl (iso-osm) intravenous (Gentamicin In Nacl, HI piggyback Iso-Osm) gentamicin injection solution (Garamycin) HI gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) HI gentamicin sulfate (pf) intravenous (Gentamicin Sulfate/PF) HI solution neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) TOBI PODHALER INHALATION 5 QL (4 per 8 1

22 tobramycin in 0.5 % nacl (Tobi) 5 PA BvD tobramycin in 0.9 % nacl (Tobramycin/Sodium HI Chloride) tobramycin sulfate injection solution (Nebcin) HI Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) chloramphenicol sod succinate (Chloramphenicol Sod HI Succ) clindamycin hcl (Cleocin HCl) clindamycin in 5 % dextrose (Cleocin Phosphate In HI D5w) clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) HI clindamycin phosphate intravenous (Cleocin Phosphate) HI solution colistin (colistimethate na) (Coly-Mycin M HI Parenteral) CUBICIN 5 HI linezolid intravenous (Zyvox) 5 HI methenamine hippurate (Hiprex) methenamine mandelate oral tablet 1 (Methenamine gram Mandelate) nitrofurantoin macrocrystal oral capsule (Macrodantin/Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 30 nitrofurantoin monohyd/m-cryst (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 30

23 SYNERCID 5 HI trimethoprim (Trimethoprim) vancomycin in d5w intravenous piggyback (Vancomycin HCl/D5W) vancomycin intravenous recon soln 1,000 (Vancomycin HCl) mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 (Vancomycin mg HCl/D5W) vancomycin oral capsule (Vancocin HCl) 5 XIFAXAN ORAL TABLET 00 MG 5 PA; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG 5 ST; QL (60 per 30 ZYVOX ORAL 5 Cephalosporins cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 15 mg/5 ml, 50 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet (Cefadroxil) cefazolin in dextrose (iso-os) intravenous (Cefazolin Sodium) HI piggyback 1 gram/50 ml cefazolin in dextrose (iso-os) intravenous (Cefazolin HI piggyback gram/50 ml Sodium/Dextrose, Iso) cefazolin injection recon soln (Ancef) HI cefazolin injection recon soln 100 gram, (Cefazolin Sodium) HI 300 g cefazolin intravenous (Cefazolin Sodium) HI cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) HI CEFEPIME IN DEXTROSE 5 % 4 HI CEFEPIME IN DEXTROSE,ISO-OSM 4 HI INTRAVENOUS PIGGYBACK cefotaxime (Claforan) HI cefoxitin (Mefoxin) HI cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml (Cefoxitin Sodium/Dextrose, Iso) HI 3

24 cefpodoxime (Cefpodoxime Proxetil) cefprozil (Cefprozil) ceftazidime (Fortaz) HI ceftazidime intravenous recon soln 1 (Ceftazidime) HI gram, gram ceftibuten (Cedax) ceftriaxone in dextrose,iso-os intravenous (Ceftriaxone HI piggyback 1 gram/50 ml Na/Dextrose, Iso) CEFTRIAXONE IN DEXTROSE,ISO-OS HI INTRAVENOUS PIGGYBACK GRAM/50 ML ceftriaxone injection recon soln (Rocephin) HI ceftriaxone intravenous recon soln 1 gram (Ceftriaxone HI Na/Dextrose, Iso) CEFTRIAXONE INTRAVENOUS HI RECON SOLN GRAM cefuroxime axetil oral tablet (Ceftin) cefuroxime sodium injection recon soln (Zinacef) HI 1.5 gram, 750 mg cefuroxime sodium intravenous (Zinacef) HI cefuroxime-dextrose (iso-osm) (Cefuroxime HI Sodium/Dextrose, Iso) cephalexin oral capsule (Keflex) 1 cephalexin oral suspension for (Cephalexin) 1 reconstitution cephalexin oral tablet (Cephalexin) 1 MEFOXIN IN DEXTROSE (ISO-OSM) 4 HI SUPRAX ORAL TABLET 4 SUPRAX ORAL TABLET,CHEWABLE 4 TEFLARO 4 HI Macrolides azithromycin intravenous (Zithromax) HI azithromycin oral (Zithromax) clarithromycin oral suspension for (Biaxin) reconstitution clarithromycin oral tablet (Biaxin) clarithromycin oral tablet extended release 4 hr (Biaxin XL) 4

25 DIFICID 5 QL (0 per 10 ERYTHROCIN 4 HI erythromycin base oral tablet,delayed (Erythromycin Base) release (dr/ec) 50 mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral (Eryped 00) suspension for reconstitution erythromycin ethylsuccinate oral tablet (Erythromycin Ethylsuccinate) erythromycin oral capsule,delayed (Erythromycin Base) release(dr/ec) erythromycin oral tablet (Erythromycin Base) erythromycin stearate oral tablet 50 mg (Erythromycin Stearate) Miscellaneous B-Lactam Antibiotics aztreonam (Azactam) HI CAYSTON 5 LA imipenem-cilastatin (Primaxin) HI INVANZ 4 HI meropenem (Merrem) HI Penicillins amoxicillin oral capsule (Amoxicillin) 1 amoxicillin oral suspension for (Amoxil) 1 reconstitution amoxicillin oral tablet (Amoxicillin) 1 amoxicillin oral tablet,chewable 15 mg, (Amoxicillin) 1 50 mg amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution amoxicillin-pot clavulanate oral tablet (Augmentin) amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable Clav) ampicillin (Ampicillin Trihydrate) 1 ampicillin sodium injection recon soln (Totacillin-N) HI ampicillin sodium intravenous recon soln (Totacillin-N) HI 5

26 ampicillin-sulbactam injection recon soln (Unasyn) HI ampicillin-sulbactam intravenous (Unasyn) HI BICILLIN C-R 4 BICILLIN L-A 4 dicloxacillin (Dicloxacillin Sodium) nafcillin in dextrose iso-osm (Nafcillin In 4 HI Dextrose,Iso-Osm) nafcillin injection (Unipen) HI nafcillin intravenous recon soln (Nallpen) HI oxacillin in dextrose(iso-osm) (Oxacillin HI Sodium/Dextrose, Iso) oxacillin injection recon soln (Oxacillin Sodium) HI oxacillin intravenous recon soln (Oxacillin Sodium) HI penicillin g pot in dextrose (Pen G Pot/Dextrose- HI Water) penicillin g potassium (Penicillin G Potassium) HI penicillin g procaine (Penicillin G Procaine) penicillin v potassium (Penicillin V Potassium) piperacillin-tazobactam intravenous recon (Zosyn) HI soln Quinolones ciprofloxacin (Cipro) ciprofloxacin hcl oral (Cipro) 1 ciprofloxacin in 5 % dextrose (Cipro I.V.) HI ciprofloxacin lactate intravenous solution (Cipro I.V.) HI 400 mg/40 ml levofloxacin in d5w intravenous piggyback (Levaquin) HI levofloxacin intravenous (Levofloxacin) HI levofloxacin oral solution (Levaquin) levofloxacin oral tablet (Levaquin) 1 moxifloxacin (Avelox) ofloxacin oral (Ofloxacin) Sulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim intravenous (Sulfamethoxazole/Trim ethoprim) HI 6

27 sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Trim suspension ethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) 1 sulfasalazine (Azulfidine) sulfatrim (Sulfamethoxazole/Trim ethoprim) sulfazine (Azulfidine) sulfazine ec (Azulfidine) Tetracyclines doxycycline hyclate oral capsule 100 mg (Morgidox) doxycycline hyclate 100 mg tab f/c (Doryx) doxycycline hyclate intravenous (Doxycycline Hyclate) HI doxycycline hyclate oral capsule 100 mg (Adoxa) doxycycline hyclate oral capsule 50 mg (Morgidox) doxycycline hyclate oral tablet 100 mg (Adoxa) doxycycline hyclate oral tablet 0 mg (Doryx) doxycycline monohydrate oral capsule (Adoxa) doxycycline monohydrate oral suspension for reconstitution (Vibramycin) doxycycline monohydrate oral tablet (Adoxa) minocycline oral capsule (Minocin) minocycline oral tablet (Minocycline HCl) tetracycline (Ala-Tet) TYGACIL 5 HI Anticancer Agents Anticancer Agents ABRAXANE 5 HI ADCETRIS 5 PA NSO; QL (4 per 1 AFINITOR DISPERZ 5 PA NSO; QL (11 per 8 AFINITOR ORAL TABLET 10 MG 5 PA NSO; QL (56 per 8 AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG ALIMTA INTRAVENOUS RECON SOLN 5 PA NSO; QL (8 per 8 5 HI 7

28 anastrozole (Arimidex) ARRANON 5 HI ARZERRA 5 PA NSO; HI AVASTIN 5 PA NSO; HI azacitidine (Vidaza) 5 BELEODAQ 5 PA NSO bicalutamide (Casodex) bleomycin (Bleomycin Sulfate) PA BvD BLINCYTO 5 PA NSO; QL (140 per 365 BOSULIF ORAL TABLET 100 MG 5 PA NSO; QL (10 per 30 BOSULIF ORAL TABLET 500 MG 5 PA NSO; QL (30 per 30 CAPRELSA ORAL TABLET 100 MG 5 PA NSO; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG 5 PA NSO; QL (30 per 30 carboplatin intravenous solution (Carboplatin) HI cisplatin (Cisplatin) HI COMETRIQ 5 PA NSO; QL (11 per 8 cyclophosphamide intravenous recon soln (Cyclophosphamide) PA BvD CYCLOPHOSPHAMIDE ORAL 4 PA BvD; ST CAPSULE cyclophosphamide oral tablet (Cyclophosphamide) PA BvD; ST CYRAMZA 5 PA NSO cytarabine (Cytarabine) PA BvD cytarabine (pf) injection recon soln (Cytarabine/PF) PA BvD cytarabine (pf) injection solution (Cytarabine/PF) PA BvD dacarbazine intravenous recon soln (Dtic-Dome IV) HI dactinomycin (Dactinomycin) HI decitabine (Dacogen) 5 HI doxorubicin hcl intravenous recon soln 10 (Doxorubicin HCl) PA BvD mg doxorubicin hcl peg-liposomal intravenous (Doxil) 5 PA BvD suspension mg/ml 8

29 doxorubicin, peg-liposomal (Doxil) 5 PA BvD DROXIA 3 ELIGARD SUBCUTANEOUS SYRINGE 4 QL (1 per 84.5 MG ELIGARD SUBCUTANEOUS SYRINGE 4 QL (1 per MG ELIGARD SUBCUTANEOUS SYRINGE 5 QL (1 per MG ELIGARD SUBCUTANEOUS SYRINGE 4 QL (1 per MG EMCYT 3 epirubicin intravenous solution 50 mg/5 (Ellence) HI ml ERBITUX INTRAVENOUS SOLUTION 5 PA NSO; HI ERIVEDGE 5 PA NSO; QL (30 per 30 ETOPOPHOS 4 HI etoposide intravenous (Etoposide) HI exemestane (Aromasin) FARESTON 5 FARYDAK 5 PA NSO; QL (6 per 1 FASLODEX 5 FIRMAGON KIT W DILUENT 4 SYRINGE floxuridine (FUDR) PA BvD fludarabine (Fludara) HI fluorouracil intravenous solution.5 (Fluorouracil) PA BvD gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide (Flutamide) GAZYVA 5 PA NSO; QL (40 per 8 gemcitabine intravenous recon soln 1 (Gemzar) 5 HI gram GILOTRIF 5 PA NSO; QL (30 per 30 GLEEVEC ORAL TABLET 100 MG 5 PA NSO; QL (90 per 30 9

30 GLEEVEC ORAL TABLET 400 MG 5 PA NSO; QL (60 per 30 HALAVEN 5 PA NSO; QL (4 per 8 HERCEPTIN 5 PA NSO HEXALEN 5 hydroxyurea (Hydrea) IBRANCE 5 PA NSO; QL (1 per 8 ICLUSIG ORAL TABLET 15 MG 5 PA NSO; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG 5 PA NSO; QL (30 per 30 ifosfamide intravenous recon soln (Ifex) PA BvD ifosfamide intravenous solution (Ifex) PA BvD ifosfamide-mesna (Ifosfamide/Mesna) 5 PA BvD IMBRUVICA 5 PA NSO; QL (10 per 30 INLYTA ORAL TABLET 1 MG 5 PA NSO; QL (180 per 30 INLYTA ORAL TABLET 5 MG 5 PA NSO; QL (60 per 30 ISTODAX 5 PA NSO IXEMPRA 5 HI JAKAFI 5 PA NSO; QL (60 per 30 JEVTANA 5 HI KADCYLA INTRAVENOUS RECON 5 PA NSO SOLN KEYTRUDA INTRAVENOUS RECON 5 PA NSO SOLN KYPROLIS 5 PA NSO; QL (6 per 8 LENVIMA 5 PA NSO letrozole (Femara) LEUKERAN 4 leuprolide (Leuprolide Acetate) lomustine (Gleostine) 30

31 LUPRON DEPOT 5 QL (1 per 8 LUPRON DEPOT (3 MONTH) 5 QL (1 per 84 LUPRON DEPOT (4 MONTH) 5 QL (1 per 84 LUPRON DEPOT (6 MONTH) 5 QL (1 per 168 LUPRON DEPOT-PED 5 QL (1 per 8 LUPRON DEPOT-PED (3 MONTH) 5 QL (1 per 84 INTRAMUSCULAR SYRINGE KIT LYNPARZA 5 PA NSO; QL (480 per 30 LYSODREN 3 MARQIBO 5 PA NSO; QL (4 per 8 MATULANE 5 MEGACE ES 5 megestrol oral suspension (Megace) megestrol oral tablet (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; QL (90 per 30 MEKINIST ORAL TABLET MG 5 PA NSO; QL (30 per 30 melphalan hcl intravenous (Alkeran) 5 HI mercaptopurine (Purinethol) methotrexate sodium (pf) injection recon (Methotrexate PA BvD soln Sodium/PF) methotrexate sodium (pf) injection (Methotrexate Sodium) PA BvD solution methotrexate sodium injection (Methotrexate Sodium) PA BvD methotrexate sodium oral (Methotrexate Sodium) PA BvD; ST mitomycin intravenous recon soln (Mitomycin) PA BvD mitoxantrone (Mitoxantrone HCl) HI MUSTARGEN 3 HI NEXAVAR 5 PA NSO; QL (10 per 30 NILANDRON 3 ONCASPAR 5 PA NSO OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML 5 PA NSO 31

32 oxaliplatin intravenous solution 100 (Eloxatin) 5 HI mg/0 ml paclitaxel (Paclitaxel) HI PERJETA 5 PA NSO POMALYST 5 PA NSO; QL (1 per 8 PROLEUKIN 5 HI PURIXAN 5 REVLIMID 5 PA NSO; LA; QL (1 per 8 RITUXAN 5 PA NSO; HI SOLTAMOX 4 SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 0 MG 5 PA NSO; QL (60 per 30 STIVARGA 5 PA NSO; QL (84 per 8 SUTENT 5 PA NSO; QL (30 per 30 SYLVANT 5 PA NSO SYNRIBO 5 PA NSO; QL (8 per 8 TABLOID 3 TAFINLAR 5 PA NSO; QL (10 per 30 tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 5 MG 5 PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 150 MG 5 PA NSO; QL (90 per 30 TARGRETIN ORAL 5 PA NSO; QL (40 per 30 TARGRETIN TOPICAL 5 PA NSO; QL (60 per 8 TASIGNA 5 PA NSO; QL (11 per 8 TEMODAR INTRAVENOUS 5 PA NSO; (vial only) 3

33 toposar intravenous (Etoposide) HI topotecan intravenous (Hycamtin) 5 HI TORISEL 5 PA BvD; QL (4 per 8 TREANDA INTRAVENOUS RECON 5 SOLN TREANDA INTRAVENOUS 5 SOLUTION TRELSTAR INTRAMUSCULAR 5 QL (1 per 168 SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR 5 QL (1 per 84 SYRINGE 11.5 MG/ ML TRELSTAR INTRAMUSCULAR 5 QL (1 per 168 SYRINGE.5 MG/ ML TRELSTAR INTRAMUSCULAR 5 QL (1 per 8 SYRINGE 3.75 MG/ ML tretinoin (chemotherapy) (Tretinoin) 5 (capsule: 10mg) TREXALL 4 PA BvD; ST TYKERB 5 VALSTAR 5 VECTIBIX INTRAVENOUS 5 PA NSO; HI SOLUTION VELCADE 5 PA NSO; HI vinblastine intravenous (Vinblastine Sulfate) PA BvD vincristine (Vincristine Sulfate) PA BvD vincristine sulfate intravenous solution 1 (Vincristine Sulfate) PA BvD mg/ml vinorelbine intravenous solution (Navelbine) HI VOTRIENT 5 PA NSO; QL (10 per 30 XALKORI 5 PA NSO; QL (60 per 30 XTANDI 5 PA NSO; QL (10 per 30 YERVOY INTRAVENOUS SOLUTION 5 PA NSO ZALTRAP INTRAVENOUS SOLUTION 5 PA NSO ZELBORAF 5 PA NSO; QL (40 per 30 33

34 ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG Drug Name Drug Tier Requirements/Limits 4 QL (1 per 84 4 QL (1 per 8 ZOLINZA 5 ZYDELIG 5 PA NSO; QL (60 per 30 ZYKADIA 5 PA NSO; QL (140 per 8 ZYTIGA 5 PA NSO; QL (10 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0.4 mg/ml (Atropine Sulfate) atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate) mg/ml propantheline (Propantheline Bromide) Anticonvulsants Anticonvulsants APTIOM 4 ST BANZEL 4 ST carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr carbamazepine oral suspension (Tegretol) carbamazepine oral tablet (Tegretol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr carbamazepine oral tablet,chewable (Carbamazepine) CELONTIN ORAL CAPSULE 300 MG 3 DILANTIN 3 divalproex oral capsule, sprinkle (Depakote Sprinkle) divalproex oral tablet extended release 4 (Depakote ER) hr divalproex oral tablet,delayed release (Depakote) (dr/ec) ethosuximide (Zarontin) felbamate (Felbatol) 34

35 fosphenytoin (Cerebyx) HI FYCOMPA 4 ST gabapentin oral capsule (Neurontin) gabapentin oral solution (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 1 MG, 16 3 MG LAMICTAL ORAL TABLET, 4 CHEWABLE DISPERSIBLE MG lamotrigine oral tablet (Lamictal) lamotrigine oral tablet extended release (Lamictal XR) 4hr lamotrigine oral tablet, chewable (Lamictal) dispersible lamotrigine oral tablets,dose pack 5 mg (Lamictal (Blue)) (35) levetiracetam intravenous (Keppra) HI levetiracetam oral solution (Keppra) levetiracetam oral tablet (Keppra) levetiracetam oral tablet extended release (Keppra XR) 4 hr LYRICA ORAL CAPSULE 3 QL (90 per 30 LYRICA ORAL SOLUTION 3 QL (900 per 30 oxcarbazepine (Trileptal) OXTELLAR XR 4 ST PEGANONE 3 phenobarbital oral elixir (Phenobarbital) QL (1500 per 30 phenobarbital oral tablet 100 mg, 15 mg, (Phenobarbital) QL (90 per mg, 3.4 mg, 60 mg, 64.8 mg, 97. mg phenobarbital oral tablet 30 mg (Phenobarbital) QL (00 per 30 phenobarbital sodium injection solution (Phenobarbital Sodium) QL ( per 30 phenytoin oral suspension 15 mg/5 ml (Dilantin-15) phenytoin oral (Dilantin) phenytoin sodium (Phenytoin Sodium) HI phenytoin sodium extended (Dilantin) 35

36 POTIGA ORAL TABLET 00 MG, ST; QL (90 per 30 MG, 400 MG POTIGA ORAL TABLET 50 MG 4 ST; QL (70 per 30 primidone (Mysoline) QUDEXY XR 4 ST SABRIL 5 tiagabine (Gabitril) topiramate oral capsule, sprinkle (Topamax) topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) topiramate oral tablet (Topamax) TRILEPTAL ORAL SUSPENSION 4 TROKENDI XR 4 ST valproate sodium (Depacon) HI valproic acid (Depakene) valproic acid (as sodium salt) oral solution 50 mg/5 ml (Depakene) VIMPAT INTRAVENOUS 4 ST; QL (00 per 5 VIMPAT ORAL SOLUTION 4 ST; QL (100 per 30 VIMPAT ORAL TABLET 4 ST; QL (60 per 30 zonisamide (Zonegran) Antidementia Agents Antidementia Agents donepezil oral tablet (Aricept) QL (30 per 30 donepezil oral tablet,disintegrating (Aricept Odt) QL (30 per 30 EXELON TRANSDERMAL PATCH 4 QL (30 per 30 HOUR 4.6 MG/4 HR, 9.5 MG/4 HR galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (30 per 30 4 hr galantamine oral solution (Razadyne) QL (00 per 30 galantamine oral tablet (Razadyne) QL (60 per 30 NAMENDA ORAL SOLUTION 3 QL (360 per 30 NAMENDA ORAL TABLET 3 QL (60 per 30 NAMENDA TITRATION PAK 3 QL (49 per 8 NAMENDA XR ORAL CAP,SPRINKLE,ER 4HR DOSE PACK 3 QL (8 per 8 36

37 NAMENDA XR ORAL 3 QL (30 per 30 CAPSULE,SPRINKLE,ER 4HR rivastigmine tartrate (Exelon) QL (60 per 30 Antidepressants Antidepressants amitriptyline (Amitriptyline HCl) PA NSO-HRM amoxapine (Amoxapine) BRINTELLIX 4 ST bupropion hcl oral tablet (Wellbutrin) bupropion hcl oral tablet extended release (Wellbutrin SR) bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr citalopram oral solution (Citalopram Hydrobromide) citalopram oral tablet (Celexa) 1 QL (30 per 30 clomipramine (Anafranil) PA NSO-HRM desipramine oral (Norpramin) doxepin oral (Doxepin HCl) PA NSO-HRM duloxetine oral capsule,delayed (Irenka) QL (60 per 30 release(dr/ec) 0 mg, 60 mg duloxetine oral capsule,delayed (Irenka) QL (30 per 30 release(dr/ec) 30 mg duloxetine oral capsule,delayed (Irenka) 4 QL (30 per 30 release(dr/ec) 40 mg EMSAM 4 QL (30 per 30 escitalopram oxalate (Lexapro) FETZIMA 4 ST fluoxetine oral capsule (Prozac) 1 fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) fluoxetine oral solution (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 0 mg (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 MG fluvoxamine oral capsule,extended release (Luvox CR) 4hr fluvoxamine oral tablet (Fluvoxamine Maleate) imipramine hcl (Tofranil) PA NSO-HRM 37