Medicare-Medicaid Plan 2015 List of Covered Drugs (Formulary)

Transcription

1 Medicare-Medicaid Plan 2015 List of Covered Drugs (Formulary) caid-mmaiformulary-1115 Version 25 November 1, 2015 H0073_14_11391a

2 caid-mmaiformulary-1115 Version 25 November 1, 2015 H0773_14_11391a Health Alliance Connect (Medicare-Medicaid Plan) 2015 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Health Alliance Connect. Health Alliance Medical Plans is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. Benefits, List of Covered Drugs, pharmacy and provider networks, and/or copayments may change from time to time throughout the year and on January 1 of each year. You can always check Health Alliance Connect s up-to-date List of Covered Drugs online at HealthAllianceConnect.org. You can ask for this information in other formats, such as Braille or large print. Call The call is free. Limitations, copayments, and restrictions may apply. For more information, call Health Alliance Connect Client Services or read the Health Alliance Connect Medicare- Medicaid Member Handbook. Copayments for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. You can get this document in Spanish, or speak with someone about this information in other languages for free. Call The call is free. Puede obtener este documento en inglés o hablar con alguien sobre esta información en otro idioma de manera gratuita. Llame al La llamada es gratuita.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

3 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Health Alliance Connect. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. Health Alliance Connect will cover all medically necessary drugs on the Drug List if: your doctor or other prescriber says you need them to get better or stay healthy, and you fill the prescription at a Health Alliance Connect network pharmacy. Health Alliance Connect may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at HealthAllianceConnect.org or call Client Services at Does the Drug List ever change? Yes. Health Alliance Connect may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Health Alliance Connect before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

4 (For more information on these drug rules, see question 5.) We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check Health Alliance Connect s up to date Drug List online at HealthAllianceConnect.org. You can also call Client Services to check the current Drug List at What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. We will send you a letter to tell you how we can work with you and your doctor or other prescriber to find a drug on the list that would be similar. This letter will also tell you how you can request an exception. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you receive this letter, contact your provider to discuss next steps. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor must get approval from Health Alliance Connect before you fill your prescription. If you don t get approval, Health Alliance Connect may not cover the drug. Quantity limits: Sometimes Health Alliance Connect limits the amount of a drug you can get.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

5 Step therapy: Sometimes Health Alliance Connect requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables that start on page 1. You can also get more information by visiting our web site at HealthAllianceConnect.org. You can also ask for an exception from these limits. Please see question 10 for more information on exceptions. If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Health Alliance Connect member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 10 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 1 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor about what to do next.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

6 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it by searching the name. To search by medical condition, find the section labeled List of drugs by medical condition on page 1. Then find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Client Services at and ask about it. If you learn that Health Alliance Connect will not cover the drug, you can do one of these things: Ask Client Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the health plan to make an exception to cover your drug. Please see question 10 for more information about exceptions. 10. What if you are a new Health Alliance Connect member and can t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Health Alliance Connect. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover a 30-day supply of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

7 the drug requires prior approval by Health Alliance Connect, or you are taking a drug that is part of a step therapy restriction. If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 91 days. You may refill the drug multiple times during the 91 days. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. You may also receive a one-time emergency supply of drugs if you have a level of service change such as a discharge from a long-term care facility. 11. Can you ask for an exception to cover your drug? Yes. You can ask Health Alliance Connect to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug. For example, Health Alliance Connect may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call Health Alliance Client Services. A Client Services representative will work with you and your provider to help you ask for an exception.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

8 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). Health Alliance Connect covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. You can buy OTC drugs without a prescription. Health Alliance Connect covers some OTC drugs. You can read the Health Alliance Connect Drug List to see what OTC drugs are covered. 16. Does Health Alliance Connect cover OTC non-drug products? Health Alliance Connect covers some OTC non-drug products. You can read the Health Alliance Connect Drug List to see what OTC non-drug products are covered. 17. What is your copayment? You can read the Health Alliance Connect Drug List to learn about the copayment for each drug. Health Alliance Connect members living in nursing homes or other long-term care facilities will have no copayments. Some members getting long-term care in the community will also have no copayments. Tier 1/$0- Part D Generic Drugs These drugs are the lowest prescription cost drugs on our formulary. Tier 2/$0-$6.35 (depending on your level of Extra Help)- Part D Brand Drugs These are drugs typically cost more than Tier 1 and some many have special rules, like preauthorization, before you can take them Tier 3/$0- Non-Part D Generic Drugs These are generic drugs that are covered by your medical benefit, not your drug benefit.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

9 Tier 4/$0-Non-Part D Brand Drugs These drugs typically cost more than Tier 3 Tier 5/$0-Generic Over-the-Counter Drugs These are the lowest cost OTC drugs on our Drug List Tier 6/$0-Brand Over-the-Counter Drugs These are brand name OTC drugs, and cost more than Tier 5 List of Covered Drugs The list of covered drugs, that begins on page 1, gives you information about the drugs covered by Health Alliance Connect. 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 name of the drug. Brand name drugs are capitalized (e.g., CHANTIX) and generic drugs are listed in lower-case italics (e.g., acetaminophen). The information in the necessary actions, restrictions, or limits on use column tells you if Health Alliance Connect has any rules for covering your drug. EX = Excluded Part D drug, this drug is not covered under a Part D plan, it may be covered under Part B LA = Limited Access drug, this drug may only be available from some places NM = Non Mail-order drug, only available from a walk-in/drive-thru pharmacy = Preauthorization required, must get approval from Health Alliance Connect before the drug is covered BvD = Preauthorization required to decide if the be covered by Part D or Part B = Preauthorization required for the first time it is prescribed QL = Quantity Limit applies, you may only be able to get a certain amount of this drug ST = Step-Therapy required, you may have to take a lower-tier drug first before Health Alliance Connect will cover a drug at a higher tier Note, when you see an * next to a drug means the drug is not a Part D drug. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs. These drugs also have different rules for? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

10 appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Client Services at You can also read the Member Handbook to learn how to appeal a decision. Name of drug Analgesics What the (tier level) Necessary actions, restrictions, or limits on use Analgesics, Miscellaneous acetaminophen * (Acetaminophen) $0 (Tier 5) ; QL 480 in 1 day; solution acetaminophen * (Acetaminophen) $0 (Tier 5) ; drops: 80mg/0.8ml acetaminophen with codeine (Vopac) $0 (Tier 1) QL 180 in 30 days; tablet: 300mg-60mg Here are the meanings of the codes used in the Necessary actions, restrictions or limits on use column: EX = Excluded Part D drug, this drug is not covered under a Part D plan, it may be covered under Part B LA = Limited Access drug, this drug may only be available from some places NM = Non Mail-order drug, only available from a walk-in/drive-thru pharmacy = Preauthorization required, must get approval from Health Alliance Connect before the drug is covered BvD = Preauthorization required to decide if the be covered by Part D or Part B = Preauthorization required for the first time it is prescribed QL = Quantity Limit applies, you may only be able to get a certain amount of this drug? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

11 ST = Step-Therapy required, you may have to take a lower-tier drug first before Health Alliance Connect will cover a drug at a higher tier Note, when you see a * next to a drug, it means the drug is not a Part D drug.? If you have questions, please call Health Alliance Connect at , Monday through Friday, 8 a.m. 8 p.m. TTY/TDD users should call 711 or The call is free. For more information, visit HealthAllianceConnect.org.

12 What the Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution (Acetaminophen with $0 (Tier 1) QL (4500 per 30 days) Codeine) acetaminophen-codeine oral tablet (Tylenol-Codeine $0 (Tier 1) QL (360 per 30 days) mg, mg No.3) acetaminophen-codeine oral tablet (Tylenol-Codeine $0 (Tier 1) QL (180 per 30 days) mg No.3) buprenorphine hcl injection (Buprenorphine HCl) $0 (Tier 1) butalbital-acetaminop-caf-cod oral capsule (Fioricet with $0 (Tier 1) mg Codeine) butalbital-acetaminophen-caff oral capsule (Esgic) $0 (Tier 1) butalbital-acetaminophen-caff oral tablet (Esgic) $0 (Tier 1) mg butalbital-aspirin-caffeine oral capsule (Fiorinal) $0 (Tier 1) butorphanol tartrate injection (Butorphanol $0 (Tier 1) Tartrate) butorphanol tartrate nasal (Butorphanol $0 (Tier 1) QL (5 per 28 days) Tartrate) CAPITAL WITH CODEINE codeine sulfate oral tablet (Codeine Sulfate) $0 (Tier 1) QL (180 per 30 days) codeine-butalbital-asa-caffein oral capsule (Fiorinal with $0 (Tier 1) mg Codeine #3) dihydrocodeine-aspirin-caff (Synalgos-Dc) $0 (Tier 1) QL (300 per 30 days) DISKETS $0 (Tier 1) QL (90 per 30 days) DURAMORPH (PF) fentanyl citrate (Actiq) ; QL (120 per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr (Duragesic) $0 (Tier 1) QL (20 per 30 days) 1

13 What the fentanyl transdermal patch 72 hour 12 (Duragesic) $0 (Tier 1) QL (10 per 30 days) mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour hydrocodone-acetaminophen oral solution (Hycet) $0 (Tier 1) QL (2700 per 30 days) hydrocodone-acetaminophen oral tablet (Norco) $0 (Tier 1) QL (240 per 30 days) mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen (Ibudone) $0 (Tier 1) QL (150 per 30 days) hydromorphone (pf) injection solution 10 (Hydromorphone $0 (Tier 1) mg/ml HCl/PF) hydromorphone (pf) injection solution 4 (Dilaudid) $0 (Tier 1) mg/ml hydromorphone injection solution (Hydromorphone $0 (Tier 1) HCl) hydromorphone injection syringe 2 mg/ml (Hydromorphone $0 (Tier 1) HCl) hydromorphone oral liquid (Dilaudid) $0 (Tier 1) QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) $0 (Tier 1) QL (180 per 30 days) hydromorphone oral tablet 8 mg (Dilaudid) $0 (Tier 1) QL (120 per 30 days) ibuprofen-oxycodone (Ibuprofen/Oxycodon $0 (Tier 1) QL (28 per 30 days) e HCl) INFUMORPH P/F INJECTION SOLUTION 25 MG/ML LAZANDA levorphanol tartrate (Levorphanol $0 (Tier 1) QL (180 per 30 days) Tartrate) methadone hcl oral concentrate 10 mg/ml (Methadose) $0 (Tier 1) QL (1800 per 30 days) methadone hcl oral tablet,soluble 40 mg (Diskets) $0 (Tier 1) QL (90 per 30 days) methadone injection (Methadone HCl) $0 (Tier 1) methadone oral (Methadone HCl) $0 (Tier 1) QL (1800 per 30 days) methadone oral (Diskets) $0 (Tier 1) QL (360 per 30 days) 2

14 What the $0 (Tier 1) morphine (pf) injection solution (Morphine Sulfate/PF) morphine (pf) intravenous (Morphine $0 (Tier 1) Sulfate/PF) morphine concentrate oral solution (Msir) $0 (Tier 1) QL (200 per 30 days) morphine concentrate oral syringe (Morphine Sulfate) $0 (Tier 1) QL (200 per 30 days) morphine injection solution 15 mg/ml, 8 (Morphine Sulfate) $0 (Tier 1) mg/ml morphine injection syringe 10 mg/ml, 2 (Morphine Sulfate) $0 (Tier 1) mg/ml morphine intramuscular (Morphine Sulfate) $0 (Tier 1) morphine intravenous (Morphine Sulfate) $0 (Tier 1) morphine intravenous solution 25 mg/ml, (Morphine Sulfate) $0 (Tier 1) 50 mg/ml morphine intravenous (Morphine Sulfate) $0 (Tier 1) morphine oral capsule,extend.release (Kadian) $0 (Tier 1) QL (60 per 30 days) pellets 100 mg, 20 mg, 50 mg, 60 mg, 80 mg morphine oral capsule,extend.release (Kadian) $0 (Tier 1) QL (120 per 30 days) pellets 30 mg morphine oral solution 10 mg/5 ml (Msir) $0 (Tier 1) QL (700 per 30 days) morphine oral solution 20 mg/5 ml (Msir) $0 (Tier 1) QL (300 per 30 days) MORPHINE ORAL TABLET $0 (Tier 1) QL (180 per 30 days) morphine oral tablet extended release 100 (MS Contin) $0 (Tier 1) QL (120 per 30 days) mg, 60 mg morphine oral tablet extended release 15 (MS Contin) $0 (Tier 1) QL (180 per 30 days) mg, 200 mg morphine oral tablet extended release 30 (MS Contin) $0 (Tier 1) QL (60 per 30 days) mg morphine rectal (Morphine Sulfate) $0 (Tier 1) morphine sulfate-pf injection solution 0.5 mg/ml (Morphine Sulfate/PF) morphine sulfate-pf injection solution 1 mg/ml (Morphine Sulfate/PF) $0 (Tier 1) 3

15 What the nalbuphine injection (Nalbuphine HCl) $0 (Tier 1) nortemp oral (Acetaminophen) $0 (Tier 4) OFIRMEV oxycodone hcl-acetaminophen oral (Oxycodone $0 (Tier 1) QL (1800 per 30 days) solution mg/5 ml HCl/Acetaminophen) oxycodone hcl-acetaminophen oral tablet (Xolox) $0 (Tier 1) QL (240 per 30 days) mg, mg, mg, mg oxycodone hcl-aspirin (Percodan) $0 (Tier 1) QL (240 per 30 days) oxycodone oral capsule (Oxycodone HCl) $0 (Tier 1) QL (180 per 30 days) oxycodone oral concentrate (Oxycodone HCl) $0 (Tier 1) QL (180 per 30 days) oxycodone oral solution (Oxycodone HCl) $0 (Tier 1) QL (1300 per 30 days) oxycodone oral tablet (Percolone) $0 (Tier 1) QL (180 per 30 days) oxycodone oral tablet,oral only,ext.rel.12 (Oxycodone HCl) $0 (Tier 1) QL (60 per 30 days) hr oxycodone-acetaminophen oral tablet (Xolox) $0 (Tier 1) QL (240 per 30 days) mg, mg, mg, mg, mg oxycodone-acetaminophen oral tablet (Xolox) $0 (Tier 1) QL (180 per 30 days) mg oxycodone-aspirin (Percodan) $0 (Tier 1) QL (240 per 30 days) oxymorphone oral tablet (Opana) $0 (Tier 1) QL (180 per 30 days) oxymorphone oral tablet extended release (Opana ER) $0 (Tier 1) QL (60 per 30 days) 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release (Opana ER) $0 (Tier 1) QL (120 per 30 days) 12 hr 30 mg, 40 mg PRIALT q-pap oral liquid (Tylenol Sore Throat) $0 (Tier 4) ; QL (480 per 1 day) SYNALGOS-DC QL (300 per 30 days) tramadol oral capsule,er biphase 24 hr (Conzip) $0 (Tier 1) ST; QL (60 per 30 days) 4

16 What the tramadol oral capsule,er biphase 24 hr (Conzip) $0 (Tier 1) ST; QL (60 per 30 days) tramadol oral tablet (Ultram) $0 (Tier 1) QL (240 per 30 days) tramadol oral tablet extended release 24 hr 100 mg (Ultram ER) $0 (Tier 1) ST; QL (90 per 30 days) tramadol oral tablet extended release 24 hr 200 mg, 300 mg (Ultram ER) $0 (Tier 1) ST; QL (30 per 30 days) tramadol oral tablet, er multiphase 24 hr (Ultram ER) $0 (Tier 1) ST; QL (30 per 30 days) tramadol-acetaminophen (Ultracet) $0 (Tier 1) ST; QL (240 per 30 days) xylon 10 (Ibudone) $0 (Tier 1) QL (150 per 30 days) Nonsteroidal Anti-Inflammatory Agents aspirin oral tablet,chewable (Bayer Chewable $0 (Tier 4) Aspirin) aspirin oral tablet,delayed release (dr/ec) (Ecotrin) $0 (Tier 4) 81 mg aspir-low (Ecotrin) $0 (Tier 4) CALDOLOR INTRAVENOUS RECON SOLN celecoxib (Celebrex) $0 (Tier 1) choline,magnesium salicylate (Choline Sal/Mag $0 (Tier 1) Salicylate) COMFORT C-IBUPROFEN $0 (Tier 1) COMFORT C-MELOXICAM $0 (Tier 1) COMFORT C-NAPROXEN $0 (Tier 1) diclofenac potassium (Cataflam) $0 (Tier 1) diclofenac sodium oral tablet extended (Voltaren-XR) $0 (Tier 1) release 24 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) $0 (Tier 1) release (dr/ec) diclofenac sodium topical gel (Solaraze) $0 (Tier 1) diclofenac-misoprostol (Arthrotec 50) $0 (Tier 1) 5

17 diflunisal (Diflunisal) $0 (Tier 1) ECOTRIN LOW STRENGTH $0 (Tier 4) etodolac (Etodolac) $0 (Tier 1) fenoprofen oral tablet (Fenoprofen $0 (Tier 1) Calcium) flurbiprofen (Ansaid) $0 (Tier 1) ibuprofen oral (Ibuprofen) $0 (Tier 1) ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen) $0 (Tier 1) mg ketoprofen oral capsule (Ketoprofen) $0 (Tier 1) ketoprofen oral capsule,ext rel. pellets 24 (Ketoprofen) $0 (Tier 1) hr 200 mg ketorolac injection (Toradol) $0 (Tier 1) QL (20 per 23 days) meclofenamate oral (Meclofenamate $0 (Tier 1) Sodium) mefenamic acid (Ponstel) $0 (Tier 1) meloxicam (Mobic) $0 (Tier 1) nabumetone (Nabumetone) $0 (Tier 1) naproxen oral suspension (Naprosyn) $0 (Tier 1) naproxen oral tablet (Naprosyn) $0 (Tier 1) naproxen oral tablet,delayed release (Ec-Naprosyn) $0 (Tier 1) (dr/ec) naproxen sodium oral tablet 275 mg, 550 (Anaprox) $0 (Tier 1) mg NEOPROFEN (IBUPROFEN LYSN)(PF) oxaprozin (Daypro) $0 (Tier 1) piroxicam (Feldene) $0 (Tier 1) salsalate (Salsalate) $0 (Tier 1) sulindac oral (Sulindac) $0 (Tier 1) tolmetin (Tolmetin Sodium) $0 (Tier 1) VOLTAREN TOPICAL 6

18 Anesthetics Local Anesthetics cocaine topical solution 4 % (Cocaine HCl) $0 (Tier 1) glydo (Lidocaine HCl) $0 (Tier 1) lidocaine (pf) injection solution (Xylocaine-MPF) $0 (Tier 1) BvD lidocaine (pf) intravenous syringe 100 (Lidocaine HCl/PF) $0 (Tier 1) mg/5 ml (2%) lidocaine hcl injection solution 10 mg/ml (Xylocaine) $0 (Tier 1) BvD (1 %) lidocaine hcl injection solution 20 mg/ml (Xylocaine) $0 (Tier 1) (2 %) lidocaine hcl laryngotracheal (Xylocaine) $0 (Tier 1) lidocaine hcl mucous membrane gel (Lidocaine HCl) $0 (Tier 1) lidocaine hcl mucous membrane jelly in (Lidocaine HCl) $0 (Tier 1) applicator lidocaine hcl mucous membrane solution (Xylocaine) $0 (Tier 1) lidocaine hcl urethral (Lidocaine HCl) $0 (Tier 1) LIDOCAINE HCL-PF INJECTION BvD SOLUTION 15 MG/ML (1.5 %) lidocaine topical adhesive patch,medicated (Lidoderm) $0 (Tier 1) lidocaine topical ointment (Lidocaine) $0 (Tier 1) lidocaine-prilocaine topical (EMLA) $0 (Tier 1) lidocaine-prilocaine topical kit (Relador Pak) $0 (Tier 1) BvD lidocaine-tetracaine (Pliaglis) $0 (Tier 1) BvD PLIAGLIS BvD RELADOR K $0 (Tier 1) SYNERA Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral) $0 (Tier 1) buprenorphine hcl sublingual (Subutex) $0 (Tier 1) QL (90 per 30 days) 7

19 buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c (Zyban) $0 (Tier 1) CAMPRAL CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH K CHANTIX STARTING MONTH BOX QL (90 per 30 days) disulfiram (Antabuse) $0 (Tier 1) naloxone (Naloxone HCl) $0 (Tier 1) naltrexone hcl (Revia) $0 (Tier 1) naltrexone (Revia) $0 (Tier 1) NICODERM CQ $0 (Tier 4) nicorelief buccal gum (Nicorette) $0 (Tier 4) nicorette buccal gum 2 mg (Nicorette) $0 (Tier 4) NICORETTE BUCCAL GUM 4 MG $0 (Tier 4) NICORETTE BUCCAL LOZENGE $0 (Tier 4) nicotine (polacrilex) buccal gum (Nicorette) $0 (Tier 4) QL (360 per 30 days) nicotine (polacrilex) buccal lozenge 4 mg (Nicorette) $0 (Tier 4) nicotine transdermal patch 24 hour 14 (Nicoderm Cq) $0 (Tier 4) mg/24 hr, 22 mg/24 hr, 7 mg/24 hr nicotine transdermal patch 24 hour 21 (Nicoderm Cq) $0 (Tier 4) QL (31 per 31 days) mg/24 hr NICOTROL QL (480 per 30 days) NICOTROL NS QL (720 per 365 days) 8

20 VIVITROL Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg (Xanax) $0 (Tier 1) QL (120 per 30 days) alprazolam oral tablet 2 mg (Xanax) $0 (Tier 1) QL (90 per 30 days) alprazolam oral tablet extended release 24 (Xanax XR) $0 (Tier 1) QL (120 per 30 days) hr 0.5 mg, 1 mg alprazolam oral tablet extended release 24 (Xanax XR) $0 (Tier 1) QL (150 per 30 days) hr 2 mg alprazolam oral tablet extended release 24 (Xanax XR) $0 (Tier 1) QL (90 per 30 days) hr 3 mg alprazolam oral tablet,disintegrating 0.25 (Alprazolam) $0 (Tier 1) QL (120 per 30 days) mg, 0.5 mg, 1 mg alprazolam oral tablet,disintegrating 2 mg (Alprazolam) $0 (Tier 1) QL (90 per 30 days) chlordiazepoxide hcl (Chlordiazepoxide $0 (Tier 1) QL (120 per 30 days) HCl) clonazepam oral tablet (Klonopin) $0 (Tier 1) clonazepam oral tablet,disintegrating (Clonazepam) $0 (Tier 1) clorazepate dipotassium (Tranxene T-Tab) $0 (Tier 1) QL (90 per 30 days) diazepam injection (Diazepam) $0 (Tier 1) diazepam intensol (Diazepam) $0 (Tier 1) diazepam oral solution (Diazepam) $0 (Tier 1) diazepam oral tablet (Valium) $0 (Tier 1) QL (120 per 30 days) diazepam rectal (Diastat) $0 (Tier 1) estazolam (Estazolam) $0 (Tier 1) QL (30 per 30 days) flurazepam (Flurazepam HCl) $0 (Tier 1) QL (30 per 30 days) lorazepam injection solution (Ativan) $0 (Tier 1) lorazepam injection syringe (Ativan) $0 (Tier 1) lorazepam oral tablet 0.5 mg (Ativan) $0 (Tier 1) QL (120 per 30 days) lorazepam oral tablet 1 mg (Ativan) $0 (Tier 1) QL (90 per 30 days) lorazepam oral tablet 2 mg (Ativan) $0 (Tier 1) QL (60 per 30 days) 9

21 midazolam (pf) injection (Midazolam HCl/PF) $0 (Tier 1) midazolam (pf) injection syringe 2 mg/2 (Midazolam HCl/PF) $0 (Tier 1) ml (1 mg/ml) midazolam oral syrup 2 mg/ml (Midazolam HCl) $0 (Tier 1) ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 20 MG oxazepam (Oxazepam) $0 (Tier 1) QL (120 per 30 days) quazepam (Doral) temazepam (Restoril) $0 (Tier 1) QL (30 per 30 days) triazolam (Halcion) $0 (Tier 1) QL (30 per 30 days) Antibacterials Aminoglycosides amikacin (Amikacin Sulfate) $0 (Tier 1) BETHKIS gentamicin in nacl (iso-osm) intravenous (Gentamicin In Nacl, $0 (Tier 1) piggyback Iso-Osm) gentamicin injection solution (Garamycin) $0 (Tier 1) gentamicin sulfate (ped) (pf) (Gentamicin $0 (Tier 1) Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin $0 (Tier 1) solution Sulfate/PF) neomycin (Neomycin Sulfate) $0 (Tier 1) streptomycin intramuscular (Streptomycin $0 (Tier 1) Sulfate) TOBI PODHALER INHALATION tobramycin in % nacl (Tobi) 10

22 tobramycin in 0.9 % nacl (Tobramycin/Sodium $0 (Tier 1) Chloride) tobramycin sulfate injection solution (Nebcin) $0 (Tier 1) Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) $0 (Tier 1) chloramphenicol sod succinate (Chloramphenicol $0 (Tier 1) Sod Succ) clindamycin hcl (Cleocin HCl) $0 (Tier 1) clindamycin in 5 % dextrose (Cleocin Phosphate $0 (Tier 1) In D5w) clindamycin palmitate hcl (Cleocin Palmitate) $0 (Tier 1) clindamycin phosphate injection (Cleocin Phosphate) $0 (Tier 1) clindamycin phosphate intravenous (Cleocin Phosphate) $0 (Tier 1) solution CLINDAMYCIN PHOSPHATE ORAL CAPSULE 150 MG, 300 MG, 75 MG colistin (colistimethate na) (Coly-Mycin M $0 (Tier 1) Parenteral) CUBICIN DALVANCE LINCOCIN linezolid intravenous (Zyvox) linezolid oral (Zyvox) methenamine hippurate (Hiprex) $0 (Tier 1) methenamine mandelate oral tablet 1 gram (Methenamine $0 (Tier 1) Mandelate) MONUROL nitrofurantoin macrocrystal oral capsule (Macrodantin) $0 (Tier 1) ; QL (56 per 28 days) 11

23 ORBACTIV polymyxin b sulfate (Polymyxin B Sulfate) $0 (Tier 1) PRIMSOL SIVEXTRO SYNERCID trimethoprim (Trimethoprim) $0 (Tier 1) 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 mg (Vancomycin HCl/D5W) vancomycin oral capsule (Vancocin HCl) VIBATIV INTRAVENOUS RECON SOLN XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS RENTERAL SOLUTION ZYVOX ORAL SUSPENSION FOR RECONSTITUTION ZYVOX ORAL TABLET Cephalosporins AVYCAZ QL (6 per 30 days) ; QL (56 per 28 days) 12

24 CEDAX cefaclor oral capsule (Cefaclor) $0 (Tier 1) cefaclor oral suspension for reconstitution (Cefaclor) $0 (Tier 1) 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr (Cefaclor) $0 (Tier 1) cefadroxil oral capsule (Cefadroxil) $0 (Tier 1) cefadroxil oral suspension for (Cefadroxil) $0 (Tier 1) reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet (Cefadroxil) $0 (Tier 1) cefazolin in dextrose (iso-os) intravenous (Cefazolin Sodium) $0 (Tier 1) piggyback 1 gram/50 ml cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml (Cefazolin Sodium/Dextrose, Iso) $0 (Tier 1) cefazolin injection recon soln (Ancef) $0 (Tier 1) cefazolin injection recon soln 100 gram, (Cefazolin Sodium) $0 (Tier 1) 300 g cefazolin intravenous (Cefazolin Sodium) $0 (Tier 1) cefdinir (Cefdinir) $0 (Tier 1) cefditoren pivoxil (Spectracef) $0 (Tier 1) cefepime (Maxipime) $0 (Tier 1) CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK cefixime (Suprax) $0 (Tier 1) cefotaxime (Claforan) $0 (Tier 1) cefotetan (Cefotetan Disodium) $0 (Tier 1) cefotetan in dextrose, iso-osm (Cefotetan $0 (Tier 1) Disod/Dextrose, Iso) cefoxitin (Mefoxin) $0 (Tier 1) 13

25 cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml cefpodoxime (Cefoxitin Sodium/Dextrose, Iso) (Cefpodoxime Proxetil) What the $0 (Tier 1) $0 (Tier 1) cefprozil (Cefprozil) $0 (Tier 1) ceftazidime (Fortaz) $0 (Tier 1) CEFTAZIDIME IN D5W ceftazidime injection recon soln 1 gram (Fortaz) ceftazidime injection recon soln 2 gram, 6 (Fortaz) $0 (Tier 1) gram ceftibuten (Cedax) $0 (Tier 1) CEFTIN ORAL SUSPENSION FOR RECONSTITUTION ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml (Ceftriaxone Na/Dextrose, Iso) CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML ceftriaxone injection recon soln (Rocephin) ceftriaxone intravenous recon soln 1 gram (Ceftriaxone Na/Dextrose, Iso) CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM CEFUROXIME AXETIL ORAL $0 (Tier 1) SUSPENSION FOR RECONSTITUTION 125 MG/5 ML cefuroxime axetil oral tablet (Ceftin) $0 (Tier 1) cefuroxime sodium injection recon soln 1.5 (Zinacef) $0 (Tier 1) gram, 750 mg cefuroxime sodium intravenous (Zinacef) $0 (Tier 1) 14

26 cefuroxime-dextrose (iso-osm) (Cefuroxime Sodium/Dextrose, Iso) What the $0 (Tier 1) cephalexin oral capsule (Keflex) $0 (Tier 1) cephalexin oral suspension for (Cephalexin) $0 (Tier 1) reconstitution cephalexin oral tablet (Cephalexin) $0 (Tier 1) FORTAZ INJECTION RECON SOLN 1 GRAM FORTAZ INTRAVENOUS KEFLEX ORAL CAPSULE 750 MG MAXIPIME SUPRAX TEFLARO ZERBAXA ZINACEF IN STERILE WATER ZINACEF INTRAVENOUS RECON SOLN Macrolides azithromycin (Zithromax) $0 (Tier 1) clarithromycin oral suspension for (Biaxin) $0 (Tier 1) reconstitution clarithromycin oral tablet (Biaxin) $0 (Tier 1) clarithromycin oral tablet extended release (Biaxin XL) $0 (Tier 1) 24 hr DIFICID ST 15

27 ERYPED 200 ERYPED 400 ERYTHROCIN erythromycin base oral tablet,delayed (Erythromycin Base) $0 (Tier 1) release (dr/ec) 250 mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) (Eryped 200) $0 (Tier 1) (Eryped 200) (Erythromycin $0 (Tier 1) Ethylsuccinate) (Erythromycin Base) $0 (Tier 1) erythromycin oral tablet (Erythromycin Base) $0 (Tier 1) erythromycin stearate oral tablet 250 mg (Erythromycin $0 (Tier 1) Stearate) erythromycin-sulfisoxazole (Ery $0 (Tier 1) E-Succ/Sulfisoxazole) KETEK PCE ZMAX Miscellaneous B-Lactam Antibiotics AZACTAM IN DEXTROSE (ISO-OSM) aztreonam (Azactam) $0 (Tier 1) 16

28 CAYSTON DORIBAX imipenem-cilastatin (Primaxin) $0 (Tier 1) INVANZ meropenem (Merrem) $0 (Tier 1) Penicillins amoxicillin oral capsule (Amoxicillin) $0 (Tier 1) amoxicillin oral suspension for (Amoxil) $0 (Tier 1) reconstitution amoxicillin oral tablet (Amoxicillin) $0 (Tier 1) amoxicillin oral tablet, er multiphase 24 hr (Moxatag) $0 (Tier 1) amoxicillin oral tablet,chewable 125 mg, (Amoxicillin) $0 (Tier 1) 250 mg amoxicillin-pot clavulanate oral (Augmentin) $0 (Tier 1) suspension for reconstitution amoxicillin-pot clavulanate oral tablet (Augmentin) $0 (Tier 1) amoxicillin-pot clavulanate oral tablet (Augmentin XR) $0 (Tier 1) extended release 12 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassiu $0 (Tier 1) tablet,chewable m Clav) ampicillin (Ampicillin $0 (Tier 1) Trihydrate) ampicillin sodium injection recon soln (Totacillin-N) $0 (Tier 1) ampicillin sodium intravenous recon soln (Totacillin-N) $0 (Tier 1) ampicillin-sulbactam injection (Unasyn) $0 (Tier 1) ampicillin-sulbactam intravenous recon (Unasyn) $0 (Tier 1) soln AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML 17

29 BICILLIN C-R BICILLIN L-A dicloxacillin (Dicloxacillin $0 (Tier 1) Sodium) MOXATAG nafcillin in dextrose iso-osm (Nafcillin In Dextrose,Iso-Osm) nafcillin injection (Unipen) $0 (Tier 1) nafcillin intravenous recon soln (Nallpen) $0 (Tier 1) oxacillin in dextrose(iso-osm) (Oxacillin $0 (Tier 1) Sodium/Dextrose, Iso) oxacillin injection recon soln (Oxacillin Sodium) $0 (Tier 1) oxacillin intravenous recon soln (Oxacillin Sodium) $0 (Tier 1) penicillin g pot in dextrose (Pen G $0 (Tier 1) Pot/Dextrose-Water) penicillin g potassium (Penicillin G $0 (Tier 1) Potassium) penicillin g procaine (Penicillin G $0 (Tier 1) Procaine) penicillin v potassium (Penicillin V $0 (Tier 1) Potassium) piperacillin-tazobactam (Zosyn) $0 (Tier 1) TIMENTIN INTRAVENOUS RECON SOLN 31 GRAM Quinolones AVELOX IN NACL (ISO-OSMOTIC) CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 18

30 ciprofloxacin (Cipro) $0 (Tier 1) ciprofloxacin (mixture) (Cipro XR) $0 (Tier 1) ciprofloxacin hcl oral (Cipro) $0 (Tier 1) ciprofloxacin in 5 % dextrose (Cipro I.V.) $0 (Tier 1) ciprofloxacin lactate intravenous solution (Cipro I.V.) $0 (Tier 1) 400 mg/40 ml FACTIVE levofloxacin in d5w intravenous piggyback (Levaquin) $0 (Tier 1) levofloxacin intravenous (Levofloxacin) $0 (Tier 1) levofloxacin oral (Levaquin) $0 (Tier 1) moxifloxacin-sod.ace,sul-water (Moxifloxacin/Sod.A $0 (Tier 1) ce,sul/water) NOROXIN ofloxacin oral (Ofloxacin) $0 (Tier 1) Sulfonamides sulfadiazine oral (Sulfadiazine) $0 (Tier 1) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Tr $0 (Tier 1) intravenous imethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Tr $0 (Tier 1) suspension imethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) $0 (Tier 1) sulfasalazine (Azulfidine) $0 (Tier 1) sulfatrim (Sulfamethoxazole/Tr $0 (Tier 1) imethoprim) sulfazine (Azulfidine) $0 (Tier 1) sulfazine ec (Azulfidine) $0 (Tier 1) Tetracyclines demeclocycline oral (Demeclocycline $0 (Tier 1) HCl) doxycycline hyclate oral capsule 100 mg (Morgidox) $0 (Tier 1) doxycycline hyclate 100 mg tab f/c (Doryx) $0 (Tier 1) 19

31 doxycycline hyclate intravenous (Doxycycline $0 (Tier 1) Hyclate) doxycycline hyclate oral capsule 100 mg (Adoxa) $0 (Tier 1) doxycycline hyclate oral capsule 50 mg (Morgidox) $0 (Tier 1) doxycycline hyclate oral tablet 100 mg, 50 (Adoxa) $0 (Tier 1) mg doxycycline hyclate oral tablet 20 mg (Doryx) $0 (Tier 1) doxycycline hyclate oral tablet,delayed (Doryx) $0 (Tier 1) release (dr/ec) doxycycline monohydrate oral capsule (Adoxa) $0 (Tier 1) doxycycline monohydrate oral suspension (Vibramycin) $0 (Tier 1) for reconstitution doxycycline monohydrate oral tablet (Adoxa) $0 (Tier 1) MINOCIN INTRAVENOUS minocycline oral capsule (Minocin) $0 (Tier 1) minocycline oral tablet (Minocycline HCl) $0 (Tier 1) minocycline oral tablet extended release (Minocycline HCl) $0 (Tier 1) 24 hr tetracycline (Ala-Tet) $0 (Tier 1) TYGACIL VIBRAMYCIN ORAL SYRUP Anticancer Agents Anticancer Agents ABRAXANE ADCETRIS AFINITOR 20

32 AFINITOR DISPERZ ALIMTA INTRAVENOUS RECON SOLN anastrozole (Arimidex) $0 (Tier 1) ARRANON ARZERRA AVASTIN azacitidine (Vidaza) BELEODAQ bexarotene (Targretin) bicalutamide (Casodex) $0 (Tier 1) BICNU bleomycin (Bleomycin Sulfate) $0 (Tier 1) BvD BLINCYTO BOSULIF BUSULFEX INTRAVENOUS CAPRELSA carboplatin intravenous solution (Carboplatin) $0 (Tier 1) cisplatin (Cisplatin) $0 (Tier 1) cladribine (Cladribine) $0 (Tier 1) BvD CLOLAR 21

33 COMETRIQ cyclophosphamide intravenous recon soln (Cyclophosphamide) $0 (Tier 1) CYCLOPHOSPHAMIDE ORAL CAPSULE cyclophosphamide oral tablet (Cyclophosphamide) $0 (Tier 1) BvD CYRAMZA cytarabine (Cytarabine) $0 (Tier 1) BvD cytarabine (pf) injection recon soln (Cytarabine/PF) $0 (Tier 1) BvD cytarabine (pf) injection solution (Cytarabine/PF) $0 (Tier 1) BvD dacarbazine intravenous recon soln (Dtic-Dome IV) $0 (Tier 1) DACOGEN dactinomycin (Dactinomycin) $0 (Tier 1) daunorubicin intravenous (Cerubidine) $0 (Tier 1) DAUNOXOME decitabine (Dacogen) $0 (Tier 1) DEPOCYT (PF) BvD DOCEFREZ docetaxel intravenous solution (Taxotere) $0 (Tier 1) doxorubicin hcl intravenous recon soln 10 (Doxorubicin HCl) $0 (Tier 1) BvD mg doxorubicin hcl peg-liposomal intravenous (Doxil) $0 (Tier 1) BvD suspension 2 mg/ml doxorubicin, peg-liposomal (Doxil) $0 (Tier 1) BvD DROXIA ELIGARD 22

34 ELOXATIN INTRAVENOUS SOLUTION ELSR EMCYT epirubicin intravenous solution 50 mg/25 (Ellence) $0 (Tier 1) ml ERBITUX ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous (Etoposide) $0 (Tier 1) exemestane (Aromasin) $0 (Tier 1) FARESTON FARYDAK FASLODEX FIRMAGON KIT W DILUENT SYRINGE floxuridine (FUDR) $0 (Tier 1) BvD fludarabine (Fludara) $0 (Tier 1) fluorouracil intravenous solution 2.5 (Fluorouracil) $0 (Tier 1) BvD gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide (Flutamide) $0 (Tier 1) FOLOTYN 23

35 GAZYVA gemcitabine intravenous recon soln 1 gram (Gemzar) $0 (Tier 1) GILOTRIF GLEEVEC HALAVEN HERCEPTIN HEXALEN hydroxyurea (Hydrea) $0 (Tier 1) IBRANCE ICLUSIG idarubicin (Idamycin Pfs) $0 (Tier 1) ifosfamide intravenous recon soln (Ifex) $0 (Tier 1) ifosfamide intravenous solution (Ifex) $0 (Tier 1) ifosfamide-mesna (Ifosfamide/Mesna) $0 (Tier 1) IMBRUVICA INLYTA IRESSA irinotecan intravenous solution (Camptosar) $0 (Tier 1) ISTODAX IXEMPRA 24

36 JAKAFI JEVTANA KADCYLA KEYTRUDA KYPROLIS LENVIMA letrozole (Femara) $0 (Tier 1) LEUKERAN leuprolide (Leuprolide Acetate) $0 (Tier 1) lomustine (Gleostine) LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT LYNRZA LYSODREN ; QL (60 per 30 days) BvD BvD 25

37 MARQIBO MATULANE MEGACE ES megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml (Megace Es) $0 (Tier 1) megestrol oral tablet (Megestrol Acetate) $0 (Tier 1) MEKINIST melphalan hcl intravenous (Alkeran) $0 (Tier 1) mercaptopurine (Purinethol) $0 (Tier 1) methotrexate sodium (pf) injection recon (Methotrexate $0 (Tier 1) soln Sodium/PF) methotrexate sodium (pf) injection (Methotrexate $0 (Tier 1) solution Sodium) methotrexate sodium injection (Methotrexate $0 (Tier 1) Sodium) methotrexate sodium oral (Methotrexate $0 (Tier 1) BvD Sodium) mitomycin intravenous recon soln (Mitomycin) $0 (Tier 1) mitoxantrone (Mitoxantrone HCl) $0 (Tier 1) MUSTARGEN NEXAVAR NILANDRON ONCASR OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML 26

38 oxaliplatin intravenous solution 100 mg/20 (Eloxatin) $0 (Tier 1) ml paclitaxel (Paclitaxel) $0 (Tier 1) pentostatin (Pentostatin) $0 (Tier 1) PERJETA PHOTOFRIN POMALYST PROLEUKIN PURIXAN REVLIMID ORAL CAPSULE 10 MG, 20 MG, 25 MG, 5 MG REVLIMID ORAL CAPSULE 15 MG, 2.5 MG RITUXAN SOLTAMOX SPRYCEL STIVARGA SUTENT SYLVANT SYNRIBO TABLOID ; QL (21 per 28 days) ; LA BvD 27

39 TAFINLAR tamoxifen (Tamoxifen Citrate) $0 (Tier 1) TARCEVA TARGRETIN ORAL TARGRETIN TOPICAL TASIGNA TEMODAR INTRAVENOUS teniposide (Teniposide) thiotepa (Thiotepa) $0 (Tier 1) toposar intravenous (Etoposide) $0 (Tier 1) topotecan intravenous (Hycamtin) $0 (Tier 1) TORISEL TREANDA INTRAVENOUS RECON SOLN TREANDA INTRAVENOUS SOLUTION TRELSTAR tretinoin (chemotherapy) (Tretinoin) TREXALL TRISENOX TYKERB BvD 28

40 UNITUXIN VALSTAR VECTIBIX VELCADE vinblastine intravenous (Vinblastine Sulfate) $0 (Tier 1) BvD vincristine (Vincristine Sulfate) $0 (Tier 1) BvD vincristine sulfate intravenous solution 1 (Vincristine Sulfate) $0 (Tier 1) BvD mg/ml vinorelbine intravenous solution (Navelbine) $0 (Tier 1) VOTRIENT XALKORI XTANDI YERVOY ZALTRAP INTRAVENOUS BvD SOLUTION ZANOSAR ZELBORAF ZOLADEX ZOLINZA ZYDELIG 29

41 ZYKADIA ZYTIGA Anticholinergic Agents Antimuscarinics/Antispasmodics ATROPEN INTRAMUSCULAR PEN INJECTOR 0.5 MG/0.7 ML, 1 MG/0.7 ML, 2 MG/0.7 ML atropine 0.1 mg/ml syringe luer-jet syr (Atropine Sulfate) $0 (Tier 1) atropine injection solution (Atropine Sulfate) $0 (Tier 1) atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate) $0 (Tier 1) mg/ml edrophonium chloride-atropine (Edrophonium Chloride/Atropine) propantheline (Propantheline $0 (Tier 1) Bromide) Anticonvulsants Anticonvulsants APTIOM BANZEL carbamazepine (Tegretol) $0 (Tier 1) carbamazepine oral capsule, er multiphase (Carbatrol) $0 (Tier 1) 12 hr carbamazepine oral suspension (Tegretol) $0 (Tier 1) carbamazepine oral tablet extended (Tegretol XR) $0 (Tier 1) release 12 hr carbamazepine oral tablet,chewable (Carbamazepine) $0 (Tier 1) CELONTIN ORAL CAPSULE 300 MG ST 30

42 CEREBYX DILANTIN DILANTIN EXTENDED DILANTIN INFATABS DILANTIN-125 divalproex oral capsule, sprinkle (Depakote Sprinkle) $0 (Tier 1) divalproex oral tablet extended release 24 (Depakote ER) $0 (Tier 1) hr divalproex oral tablet,delayed release (Depakote) $0 (Tier 1) (dr/ec) EQUETRO ethosuximide (Zarontin) $0 (Tier 1) felbamate (Felbatol) $0 (Tier 1) fosphenytoin (Cerebyx) $0 (Tier 1) FYCOM ORAL TABLET gabapentin oral capsule (Neurontin) $0 (Tier 1) gabapentin oral solution (Neurontin) $0 (Tier 1) gabapentin oral tablet 600 mg, 800 mg (Neurontin) $0 (Tier 1) GABITRIL ORAL TABLET 12 MG, 16 MG GRALISE GRALISE 30-DAY STARTER CK HORIZANT ST ST 31

43 LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet (Lamictal) $0 (Tier 1) lamotrigine oral tablet extended release (Lamictal XR) $0 (Tier 1) 24hr 100 mg, 200 mg, 25 mg, 50 mg lamotrigine oral tablet extended release (Lamictal XR) 24hr 250 mg, 300 mg lamotrigine oral tablet, chewable (Lamictal) $0 (Tier 1) dispersible lamotrigine oral tablets,dose pack 25 mg (Lamictal (Blue)) $0 (Tier 1) (35) levetiracetam in nacl (iso-os) (Levetiracetam In $0 (Tier 1) Nacl (Iso-Os)) levetiracetam intravenous (Keppra) $0 (Tier 1) levetiracetam oral solution (Keppra) $0 (Tier 1) levetiracetam oral tablet (Keppra) $0 (Tier 1) levetiracetam oral tablet extended release (Keppra XR) $0 (Tier 1) 24 hr LYRICA oxcarbazepine (Trileptal) $0 (Tier 1) OXTELLAR XR PEGANONE phenobarbital (Phenobarbital) $0 (Tier 1) phenobarbital sodium injection solution (Phenobarbital $0 (Tier 1) Sodium) PHENYTEK phenytoin oral suspension 125 mg/5 ml (Dilantin-125) $0 (Tier 1) phenytoin oral (Dilantin) $0 (Tier 1) phenytoin sodium (Phenytoin Sodium) $0 (Tier 1) 32

44 phenytoin sodium extended (Dilantin) $0 (Tier 1) POTIGA primidone (Mysoline) $0 (Tier 1) SABRIL STAVZOR tiagabine (Gabitril) $0 (Tier 1) topiramate oral capsule, sprinkle (Topamax) $0 (Tier 1) topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) $0 (Tier 1) TRILEPTAL ORAL SUSPENSION TROKENDI XR valproate sodium (Depacon) $0 (Tier 1) valproic acid (Depakene) $0 (Tier 1) valproic acid (as sodium salt) oral (Depakene) $0 (Tier 1) solution 250 mg/5 ml VIMT INTRAVENOUS VIMT ORAL SOLUTION VIMT ORAL TABLET zonisamide (Zonegran) $0 (Tier 1) Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 5 mg (Aricept) $0 (Tier 1) donepezil oral tablet,disintegrating (Aricept Odt) $0 (Tier 1) galantamine oral capsule,ext rel. pellets 24 (Razadyne ER) $0 (Tier 1) hr galantamine oral solution (Razadyne) $0 (Tier 1) 33

45 galantamine oral tablet (Razadyne) $0 (Tier 1) memantine (Namenda) $0 (Tier 1) NAMENDA NAMENDA TITRATION K NAMENDA XR rivastigmine tartrate (Exelon) $0 (Tier 1) Antidepressants Antidepressants amitriptyline (Amitriptyline HCl) amitriptyline-chlordiazepoxide (Amitrip HCl/Chlordiazepoxid e) amoxapine (Amoxapine) $0 (Tier 1) APLENZIN BRINTELLIX ST BRISDELLE bupropion hcl oral tablet (Wellbutrin) $0 (Tier 1) bupropion hcl oral tablet extended release (Wellbutrin SR) $0 (Tier 1), 150 mg bupropion hcl oral tablet extended release (Wellbutrin XL) $0 (Tier 1) 24 hr citalopram oral solution (Citalopram $0 (Tier 1) QL (600 per 30 days) Hydrobromide) citalopram oral tablet (Celexa) $0 (Tier 1) QL (30 per 30 days) clomipramine (Anafranil) 34