Anthem MediBlue Dual Advantage (HMO SNP) 2016 Formulary (List of Covered Drugs)

Transcription

1 Anthem MediBlue Dual Advantage (H SNP) 06 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 06. For more recent information or other questions, please contact Anthem MediBlue Dual Advantage (H SNP) Customer Service at or, for TTY users, 7, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday (except holi from February through September 0, or visit Y0_6_7_U_7 CMS Accepted 6/8/06 69MUSENMUB _7 H9_00 Core_69_v_606_

2 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 Anthem Blue Cross and Blue Shield. When it refers to plan or our plan, it means Anthem MediBlue Dual Advantage (H SNP). This document includes a list of the drugs (formulary) for our plan which is current as of June, 06. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/ coinsurance may change on January, 07 and from time to time during the year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Effective Date June, 06 Core_69_v_606_

3 What is the Anthem MediBlue Dual Advantage (H SNP) formulary? A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan 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 06 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 06 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 forumulary 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 Administration (FDA) 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 June, 06. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (nonmaintenance change) is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated 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 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Medications. If you know what your drug is used for, look for the category name in the list that begins on page 8. 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 60. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan 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: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, our plan may not cover the drug. Quantity : For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 0 tablets per prescription for irbesartan 7mg tablets. This may be in addition to a standard one-month or three-month supply. Effective Date June, 06 Core_69_v_606_

4 Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, our plan may not cover B unless you try A first. If A does not work for you, our plan will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan 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 Anthem MediBlue Dual Advantage (H SNP)'s formulary? on page for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan 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 Anthem MediBlue Dual Advantage (H SNP)'s formulary? You can ask our plan 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 predetermined 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, our plan 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, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, 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 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. Effective Date June, 06 Core_69_v_606_

5 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 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-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 a 98-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 -day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. During the time when you are getting a temporary supply of a drug, you should talk to your prescriber or prescribing physician to decide what to do when your supply runs out. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you while you pursue a formulary exception. Please refer to the Evidence of Coverage for more information about exceptions. For more information For more detailed information about our plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, 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 -800-MEDICARE ( ), hours a day/7 days a week. TTY users should call Or, visit Our plan s formulary The formulary on page 8 provides coverage information about some of the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 60. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lowercase italics (e.g., atenolol). The information in the column tells you if our plan has any special requirements for coverage of your drug. QLL - Quantity : Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition. B/D - Part B vs. Part D: This drug may be covered under either your Part D prescripton drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday (except holi from February through September 0. TTY/TDD users should call 7. INJ - Injectable: The drug is available in injectable form. Effective Date June, 06 Core_69_v_606_

6 - Mail Orders: Prescription drugs available through mail order. Effective Date June, 06 6 Core_69_v_606_

7 Cost-sharing for a one-month supply of a covered Part D prescription drug during the Initial Coverage Stage: Cost-Sharing : Preferred Generic Network Pharmacy cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Generic Network Pharmacy cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Preferred Brand Network Pharmacy cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Nonpreferred Brand Network Pharmacy cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Specialty * Network Pharmacy cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing 6: Select Care s Network Pharmacy cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) or Long-Term-Care Pharmacy (-day supply) $0.00 $ $.00 $ $7.0 - The amount you pay is determined by the covered Part D prescription and your low-income subsidy coverage. Please refer to your LIS Rider for the specific amount you pay. $ $7.0 - The amount you pay is determined by the covered Part D prescription and your low-income subsidy coverage. Please refer to your LIS Rider for the specific amount you pay. $ $7.0 - The amount you pay is determined by the covered Part D prescription and your low-income subsidy coverage. Please refer to your LIS Rider for the specific amount you pay. Please refer to our Evidence of Coverage for more information for cost sharing. * A long-term supply is not available for drugs in the : Specialty ** Mail-Order Pharmacy Mail-order service allows you to order a 0 90-day supply of drugs. The drugs available through our plan s mail-order service are marked as mail-order drugs in our drug list. $0.00 Effective Date June, 06 7 Core_69_v_606_

8 Covered Medications by Therapeutic Category Legend Generic drugs are shown in lower-case italics (e.g. atenolol) Brand-name drugs are shown in capital letters (e.g. CRESTOR) QLL - Quantity : Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR - Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST - Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition. B/D - Part B vs Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA - Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday (except holi from February through September 0 TTY/TDD users should call 7. INJ - Injectable: The drug is available in injectable form. - Mail Order: Prescription drugs available through mail order. Name Anti - Infectives abacavir abacavir-lamivudinezidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 00 mg/ ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amantadine hcl oral capsule amantadine hcl oral tablet AMBISOME amikacin injection solution, 000 mg/ ml, 00 mg/ ml amoxicillin oral capsule amoxicillin oral suspension for reconstitution ; QLL (60 per 0 ; QLL (60 per 0 B/D PAR; B/D PAR; ; QLL (80 per B/D PAR; Name amoxicillin oral tablet amoxicillin oral tablet,chewable mg, 0 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/ ml, 00-7 mg/ ml, mg/ ml amoxicillin-pot clavulanate oral suspension for reconstitution 0-6. mg/ ml amoxicillin-pot clavulanate oral tablet 0- mg amoxicillin-pot clavulanate oral tablet 00- mg, 87- mg amoxicillin-pot clavulanate oral tablet extended release hr amoxicillin-pot clavulanate oral tablet,chewable amphotericin b ampicillin oral capsule ampicillin oral suspension for reconstitution ampicillin sodium injection ampicillin sodium intravenous B/D PAR; Core_69_v_606_ 8 Effective Date June, 06

9 Name ampicillin-sulbactam injection recon soln. gram, gram ampicillin-sulbactam injection recon soln gram ampicillin-sulbactam intravenous recon soln. gram ampicillin-sulbactam intravenous recon soln gram APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atovaquone atovaquone-proguanil ATRIPLA azithromycin intravenous recon soln 00 mg azithromycin intravenous recon soln 00 mg ( mg/ml) azithromycin oral packet azithromycin oral suspension for reconstitution 00 mg/ ml azithromycin oral suspension for reconstitution 00 mg/ ml azithromycin oral tablet aztreonam BARACLUDE ORAL SOLUTION BICILLIN C-R BICILLIN L-A CANCIDAS CAPASTAT CAYSTON cefaclor oral capsule cefaclor oral suspension for reconstitution mg/ ml, 0 mg/ ml, 7 mg/ ml cefaclor oral tablet extended release hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 0 mg/ ml, 00 mg/ ml cefadroxil oral tablet ; QLL (0 per 0 QLL (90 per 0 PAR; ; QLL (0 per 0 PAR; B/D PAR; PAR; ; LA Name cefazolin in dextrose (iso-os) intravenous piggyback gram/ 0 ml, gram/0 ml cefazolin injection recon soln gram, 00 mg cefazolin injection recon soln 0 gram, 00 gram, 0 gram, 00 g cefazolin intravenous cefdinir oral capsule cefdinir oral suspension for reconstitution cefepime cefepime in dextrose,iso-osm intravenous piggyback gram/ 0 ml cefepime in dextrose,iso-osm intravenous piggyback gram/ 00 ml cefotaxime injection recon soln gram, gram, 00 mg cefotaxime injection recon soln 0 gram cefotetan cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln gram cefoxitin intravenous recon soln 0 gram, gram cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet 00 mg cefpodoxime oral tablet 00 mg cefprozil oral suspension for reconstitution cefprozil oral tablet 0 mg cefprozil oral tablet 00 mg CEFTAZIDIME IN DW ceftazidime injection recon soln gram, gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln gram, gram, 0 mg, 00 mg Core_69_v_606_ 9 Effective Date June, 06

10 Name ceftriaxone injection recon soln 0 gram CEFTRIAXONE INJECTION RECON SOLN 00 GRAM ceftriaxone intravenous cefuroxime axetil oral tablet 0 mg cefuroxime axetil oral tablet 00 mg cefuroxime sodium injection recon soln. gram, 70 mg cefuroxime sodium intravenous vial cephalexin oral capsule 0 mg, 00 mg cephalexin oral suspension for reconstitution cephalexin oral tablet chloramphenicol sod succinate chloroquine phosphate oral tablet 0 mg chloroquine phosphate oral tablet 00 mg cidofovir ciprofloxacin (mixture) oral tablet, er multiphase hr, 000 mg ciprofloxacin (mixture) oral tablet, er multiphase hr 00 mg ciprofloxacin hcl oral tablet ciprofloxacin in % dextrose ciprofloxacin lactate intravenous solution 00 mg/ 0 ml ciprofloxacin lactate intravenous solution 00 mg/ 0 ml ciprofloxacin oral suspension clarithromycin oral suspension for reconstitution mg/ ml clarithromycin oral suspension for reconstitution 0 mg/ ml clarithromycin oral tablet B/D PAR; ; QLL ( per ; QLL ( per Name clarithromycin oral tablet extended release hr clindamycin hcl oral capsule clindamycin in % dextrose clindamycin phosphate injection clindamycin phosphate intravenous solution 00 mg/ ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/ ml clotrimazole mucous membrane COARTEM colistin (colistimethate na) COMPLERA CRIXIVAN ORAL CAPSULE 00 MG CRIXIVAN ORAL CAPSULE 00 MG CUBICIN DAKLINZA DAPSONE DARAPRIM demeclocycline dicloxacillin didanosine oral capsule,delayed release(dr/ec) mg didanosine oral capsule,delayed release(dr/ec) 00 mg didanosine oral capsule,delayed release(dr/ec) 0 mg didanosine oral capsule,delayed release(dr/ec) 00 mg DIFICID DORIBAX DOXY-00 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00 mg, 0 mg doxycycline hyclate oral tablet 0 mg doxycycline monohydrate oral tablet 00 mg ; QLL (8 per ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (80 per 0 PAR; ; QLL (0 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 PAR; Core_69_v_606_ 0 Effective Date June, 06

11 Name doxycycline monohydrate oral tablet 0 mg, 0 mg, 7 mg e.e.s. 00 oral tablet EDURANT EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir EPIVIR HBV ORAL SOLUTION EPIVIR ORAL SOLUTION EPZICOM ery-tab oral tablet,delayed release (dr/ec) 0 mg, mg erythrocin (as stearate) oral tablet 0 mg ERYTHROCIN INTRAVENOUS RECON SOLN 00 MG erythromycin ethylsuccinate oral tablet erythromycin oral capsule, delayed release(dr/ec) erythromycin oral tablet ethambutol EVOTAZ famciclovir oral tablet mg, 0 mg famciclovir oral tablet 00 mg fluconazole in dextrose(iso-o) FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 00 MG/0 ML fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/ 00 ml ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (870 per 0 PAR; ; QLL (960 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL ( per 7 Name fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/ 00 ml fluconazole oral suspension for reconstitution 0 mg/ml fluconazole oral suspension for reconstitution 0 mg/ml fluconazole oral tablet 00 mg fluconazole oral tablet 0 mg, 0 mg fluconazole oral tablet 00 mg flucytosine foscarnet FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/ 00 ml, 60 mg/0 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 00 MG/0 ML, 0 MG/00 ML gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/ 0 ml, 80 mg/00 ml, 80 mg/ 0 ml, 90 mg/00 ml gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 00 mg/ 0 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml GENVOYA GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET 0 MG B/D PAR ; QLL (60 per 0 ; QLL (0 per 0 Core_69_v_606_ Effective Date June, 06

12 Name griseofulvin microsize oral suspension griseofulvin ultramicrosize HARVONI hydroxychloroquine oral imipenem-cilastatin intravenous recon soln 0 mg imipenem-cilastatin intravenous recon soln 00 mg INTELENCE ORAL TABLET 00 MG INTELENCE ORAL TABLET 00 MG INTELENCE ORAL TABLET MG INVANZ GM ADD- VANTAGE VIAL INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 00 MG ISENTRESS ORAL TABLET,CHEWABLE MG isoniazid injection isoniazid oral solution isoniazid oral tablet 00 mg isoniazid oral tablet 00 mg itraconazole ivermectin oral KALETRA ORAL SOLUTION KALETRA ORAL TABLET 00- MG KALETRA ORAL TABLET 00-0 MG KETEK PAR; ; QLL (8 per 8 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (70 per 0 PAR; ; QLL (80 per 0 ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (0 per Name ketoconazole oral LAMISIL ORAL TABLET lamivudine oral solution lamivudine oral tablet 00 mg lamivudine oral tablet 0 mg lamivudine oral tablet 00 mg lamivudine-zidovudine levofloxacin in dw intravenous piggyback 0 mg/0 ml levofloxacin in dw intravenous piggyback 00 mg/00 ml, 70 mg/0 ml levofloxacin oral tablet LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET LINCOCIN lincomycin injection linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet linezolid-0.9% sodium chloride MALARONE mefloquine meropenem methenamine hippurate methenamine mandelate metro i.v. metronidazole in nacl (iso-os) metronidazole oral capsule metronidazole oral tablet minocycline oral capsule 00 mg, 0 mg minocycline oral capsule 7 mg minocycline oral tablet moxifloxacin ; QLL (0 per 0 ; QLL (900 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL ( per ; QLL (800 per 0 ; QLL (0 per 0 PAR; ; QLL (800 per PAR; ; QLL (8 per ; QLL ( per Core_69_v_606_ Effective Date June, 06

13 Name MYCAMINE nafcillin nafcillin in dextrose iso-osm intravenous piggyback gram/ 0 ml nafcillin in dextrose iso-osm intravenous piggyback gram/ 00 ml NEBUPENT neomycin nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release hr 00 mg nevirapine oral tablet extended release hr 00 mg nitrofurantoin macrocrystal oral capsule 00 mg, 0 mg nitrofurantoin monohyd/mcryst NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet ODEFSEY ofloxacin oral tablet 00 mg OLYSIO oxacillin in dextrose(iso-osm) intravenous piggyback gram/ 0 ml oxacillin in dextrose(iso-osm) intravenous piggyback gram/ 0 ml oxacillin injection oxacillin intravenous paromomycin PASER B/D PAR; ; QLL (00 per 0 ; QLL (60 per 0 ; QLL (0 per 0 PAR; PAR; ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (60 per 0 PAR; ; QLL (60 per 0 QLL (0 per 0 PAR; Name PENICILLIN G POT IN DEXTROSE penicillin g potassium penicillin g procaine intramuscular syringe. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium penicillin v potassium oral recon soln penicillin v potassium oral tablet 0 mg penicillin v potassium oral tablet 00 mg PENTAM pfizerpen-g piperacillin-tazobactam polymyxin b sulfate PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 0 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 7 MG PRIFTIN PRIMAQUINE pyrazinamide RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 0 MG, 00 MG REYATAZ ORAL CAPSULE 00 MG ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (60 per 0 ; QLL (00 per 0 ; QLL (60 per 80 ; QLL (80 per 0 ; QLL (60 per 0 ; QLL (60 per 0 ; QLL (0 per 0 Core_69_v_606_ Effective Date June, 06

14 Name REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg ribavirin oral capsule ribavirin oral tablet 00 mg rifabutin rifampin intravenous rifampin oral RIFATER rimantadine SELZENTRY SIRTURO SOVALDI stavudine oral capsule mg stavudine oral capsule 0 mg stavudine oral capsule 0 mg stavudine oral capsule 0 mg stavudine oral recon soln STREPTOMYCIN INTRAMUSCULAR STRIBILD STROMECTOL sulfadiazine oral sulfamethoxazole-trimethoprim intravenous sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 0 MG SUSTIVA ORAL TABLET SYNAGIS SYNERCID TAMIFLU ; QLL (0 per 0 ; QLL (0 per 0 PAR; ; LA PAR; ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (60 per 0 ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (0 per 0 PAR; ; LA Name TECHNIVIE TEFLARO INTRAVENOUS RECON SOLN 00 MG TEFLARO INTRAVENOUS RECON SOLN 600 MG terbinafine hcl oral tetracycline tinidazole oral tablet 0 mg tinidazole oral tablet 00 mg TIVICAY tobramycin in 0. % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ TRUVADA TYBOST TYGACIL TYZEKA valacyclovir valganciclovir VANCOMYCIN 70 MG/ 0 ML BAG VANCOMYCIN IN DW INTRAVENOUS PIGGYBACK GRAM/00 ML VANCOMYCIN IN DW INTRAVENOUS PIGGYBACK 00 MG/00 ML vancomycin intravenous VANCOMYCIN INTRAVENOUS 70 MG PAR; ; QLL (6 per 8 ; QLL (0 per 0 ; QLL (60 per 0 B/D PAR; ; QLL (80 per 8 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 PAR; ; QLL (0 per Core_69_v_606_ Effective Date June, 06

15 Name vancomycin oral capsule mg vancomycin oral capsule 0 mg VIDEX GRAM PEDIATRIC VIDEX GRAM PEDIATRIC VIEKIRA PAK VIRACEPT ORAL TABLET 0 MG VIRACEPT ORAL TABLET 6 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE HR 00 MG VIRAZOLE VIREAD ORAL POWDER VIREAD ORAL TABLET 0 MG, 0 MG, 00 MG VIREAD ORAL TABLET 00 MG VITEKTA voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 00 mg voriconazole oral tablet 0 mg ZEPATIER ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZITHROMAX ORAL PACKET ZITHROMAX ORAL TABLET 0 MG PAR; ; QLL (0 per PAR; ; QLL (80 per ; QLL (00 per 0 ; QLL (00 per 0 PAR; ; QLL (00 per 0 ; QLL (0 per 0 PAR; ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 ; QLL (960 per 0 ; QLL (80 per 0 ; QLL (90 per 0 ; QLL (60 per 0 Name ZITHROMAX Z-PAK ZMAX ZYVOX INTRAVENOUS PARENTERAL SOLUTION 00 MG/00 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/00 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION PAR; ; QLL (800 per Antineoplastic / Immunosuppressant s ABRAXANE adrucil intravenous solution. gram/0 ml adrucil intravenous solution gram/00 ml, 00 mg/0 ml AFINITOR PAR; AFINITOR DISPERZ PAR; ALECENSA ALIMTA PAR; ALKERAN ORAL B/D PAR; amifostine crystalline PAR; anastrozole ; QLL (0 per 0 ARRANON ARZERRA PAR; AVASTIN PAR; azacitidine PAR; azathioprine B/D PAR; azathioprine sodium B/D PAR BELEODAQ PAR; BENDEKA bexarotene PAR; bicalutamide BICNU bleomycin BLINCYTO PAR; BOSULIF ORAL TABLET 00 MG BOSULIF ORAL TABLET 00 MG BUSULFEX PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 CAPRELSA ORAL TABLET 00 MG PAR; ; LA; QLL (90 per 0 Core_69_v_606_ Effective Date June, 06

16 Name CAPRELSA ORAL TABLET 00 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine CLOLAR COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG[]-0 MG[]) COMETRIQ ORAL CAPSULE 0 MG/DAY(80 MG[]-0 MG[]) COMETRIQ ORAL CAPSULE 60 MG/DAY (0 MG []/DAY) COSMEGEN COTELLIC cyclophosphamide oral capsule cyclosporine intravenous cyclosporine modified cyclosporine oral capsule CYRAMZA cytarabine cytarabine (pf) injection solution 00 mg/ ml (0 mg/ ml), gram/0 ml (00 mg/ ml) cytarabine (pf) injection solution 0 mg/ml dacarbazine DARZALEX daunorubicin intravenous solution decitabine dexrazoxane hcl intravenous recon soln 0 mg dexrazoxane hcl intravenous recon soln 00 mg DOCEFREZ INTRAVENOUS RECON SOLN 0 MG PAR; ; LA; QLL (0 per 0 B/D PAR; PAR; ; QLL (6 per 8 PAR; ; QLL ( per 8 PAR; ; QLL (8 per 8 PAR; ; LA; QLL (90 per 0 B/D PAR; B/D PAR B/D PAR; B/D PAR; PAR; ; LA Name docetaxel intravenous solution 0 mg/ml, 60 mg/6 ml (0 mg/ml), 60 mg/8 ml (0 mg/ ml), 0 mg/ ml (0 mg/ml) docetaxel intravenous solution 0 mg/ml ( ml), 80 mg/ ml (0 mg/ml), 80 mg/8 ml (0 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous solution ELITEK EMCYT EMPLICITI ENVARSUS XR epirubicin intravenous solution 00 mg/00 ml epirubicin intravenous solution 0 mg/ ml ERBITUX ERIVEDGE ERWINAZE ETOPOPHOS etoposide intravenous exemestane FARESTON FARYDAK ORAL CAPSULE 0 MG FARYDAK ORAL CAPSULE MG, 0 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 0 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln PAR; B/D PAR; B/D PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; PAR; PAR; Core_69_v_606_ 6 Effective Date June, 06

17 Name fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN FUSILEV GAZYVA gemcitabine intravenous recon soln gram, 00 mg gemcitabine intravenous recon soln gram gemcitabine intravenous solution gram/6. ml (8 mg/ml), 00 mg/.6 ml (8 mg/ml) gemcitabine intravenous solution gram/.6 ml (8 mg/ml) gengraf GILOTRIF GLEEVEC ORAL TABLET 00 MG GLEEVEC ORAL TABLET 00 MG GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE ICLUSIG ORAL TABLET MG ICLUSIG ORAL TABLET MG idarubicin IFEX ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 00 mg imatinib oral tablet 00 mg PAR; B/D PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 Name IMBRUVICA INLYTA ORAL TABLET MG INLYTA ORAL TABLET MG IRESSA irinotecan intravenous solution 00 mg/ ml, 0 mg/ ml irinotecan intravenous solution 00 mg/ ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 0 MG JAKAFI ORAL TABLET MG JAKAFI ORAL TABLET 0 MG JAKAFI ORAL TABLET MG JAKAFI ORAL TABLET MG JEVTANA KADCYLA KEYTRUDA LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG []/DAY) LENVIMA ORAL CAPSULE MG (0 MG[] - MG[])/DAY, 0 MG/DAY (0 MG []/DAY) LENVIMA ORAL CAPSULE MG (0 MG[] - MG[])/DAY letrozole leucovorin calcium injection recon soln 00 mg, 00 mg, 0 mg, 0 mg leucovorin calcium injection recon soln 00 mg leucovorin calcium oral tablet 0 mg, mg PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (7 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (00 per 0 PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (90 per 0 ; QLL (0 per 0 Core_69_v_606_ 7 Effective Date June, 06

18 Name leucovorin calcium oral tablet mg, mg LEUKERAN leuprolide subcutaneous kit LONSURF LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.7 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7. MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7. MG (PED) LYNPARZA LYSODREN MATULANE megestrol oral suspension 00 mg/0 ml (0 ml), 800 mg/0 ml (0 ml) megestrol oral suspension 00 mg/0 ml (0 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0. MG MEKINIST ORAL TABLET MG melphalan hcl mercaptopurine mesna MESNEX ORAL methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral mitomycin mitoxantrone MUSTARGEN mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution PAR; PAR; PAR; ; QLL ( per 8 PAR; PAR; ; QLL ( per 8 PAR; ; QLL (80 per 0 PAR PAR; PAR; PAR; ; QLL (90 per 0 PAR; ; QLL (0 per 0 B/D PAR; B/D PAR; Name mycophenolate mofetil oral tablet NEXAVAR NILANDRON NINLARO NIPENT NULOJIX octreotide acetate injection solution,000 mcg/ml, 00 mcg/ml octreotide acetate injection solution 00 mcg/ml, 00 mcg/ ml, 0 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 0 mcg/ml ( ml) octreotide acetate injection syringe 00 mcg/ml ( ml) ODOMZO ONCASPAR OPDIVO oxaliplatin intravenous recon soln 00 mg oxaliplatin intravenous recon soln 0 mg oxaliplatin intravenous solution paclitaxel PERJETA POMALYST ORAL CAPSULE MG POMALYST ORAL CAPSULE MG POMALYST ORAL CAPSULE MG, MG PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 0 MG B/D PAR; PAR; ; LA; QLL (0 per 0 ; QLL (0 per 0 PAR; ; QLL ( per 8 PAR; PAR; PAR; PAR; PAR; PAR; ; LA; QLL (0 per 0 PAR; PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 B/D PAR; PAR; B/D PAR; PAR; ; LA; QLL (60 per 0 Core_69_v_606_ 8 Effective Date June, 06

19 Name REVLIMID ORAL CAPSULE MG,. MG, 0 MG, MG REVLIMID ORAL CAPSULE MG RITUXAN SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 0 MG SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE. MG SUTENT ORAL CAPSULE MG, 7. MG, 0 MG SYNRIBO TABLOID tacrolimus oral capsule 0. mg, mg tacrolimus oral capsule mg TAFINLAR TAGRISSO ORAL TABLET 0 MG TAGRISSO ORAL TABLET 80 MG tamoxifen TARCEVA ORAL TABLET 00 MG, 0 MG TARCEVA ORAL TABLET MG TARGRETIN PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 PAR; PAR; B/D PAR B/D PAR; B/D PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (90 per 0 PAR; ; QLL (0 per 0 PAR; B/D PAR; B/D PAR; PAR; ; QLL (0 per 0 PAR; ; LA; QLL (60 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (90 per 0 PAR; Name TASIGNA TAXOTERE INTRAVENOUS SOLUTION 0 MG/ML ( ML), 80 MG/ ML (0 MG/ ML) THALOMID ORAL CAPSULE 00 MG, 0 MG THALOMID ORAL CAPSULE 0 MG, 00 MG thiotepa toposar topotecan TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE. MG/ ML,.7 MG/ ML TRELSTAR INTRAMUSCULAR SYRINGE. MG/ ML tretinoin (chemotherapy) oral capsule TRISENOX TYKERB UNITUXIN VECTIBIX VELCADE vinblastine intravenous solution VINCASAR PFS INTRAVENOUS SOLUTION MG/ML vincasar pfs intravenous solution mg/ ml vincristine vinorelbine PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 ; QLL ( per 68 ; QLL ( per 68 PAR; ; LA; QLL (80 per 0 PAR; PAR; Core_69_v_606_ 9 Effective Date June, 06

20 Name VOTRIENT PAR; ; QLL (0 per 0 XALKORI PAR; ; QLL (60 per 0 XGEVA PAR; ; QLL (.7 per 8 XTANDI PAR; ; QLL (0 per 0 YERVOY PAR; YONDELIS ZALTRAP PAR; ZANOSAR ZELBORAF PAR; ; QLL (0 per 0 ZOLINZA PAR; ; QLL (0 per 0 ZORTRESS ORAL TABLET 0. MG ZORTRESS ORAL TABLET 0. MG, 0.7 MG ZYDELIG B/D PAR; B/D PAR; PAR; ; QLL (60 per 0 ZYKADIA PAR; ; QLL (0 per 0 ZYTIGA PAR; ; QLL (0 per 0 Autonomic / Cns s, Neurology / Psych ABILIFY MAINTENA ; QLL ( per 8 acetaminophen-codeine oral solution 0 mg- mg / ml ( ml), 0 mg- mg /0 ml (0 ml), 00 mg-0 mg /. ml acetaminophen-codeine oral solution 0- mg/ ml acetaminophen-codeine oral tablet 00- mg acetaminophen-codeine oral QLL (00 per 0 ; QLL (00 per 0 ; QLL (90 per 0 ; QLL (60 per tablet 00-0 mg acetaminophen-codeine oral tablet mg ADASUVE alprazolam oral tablet amitriptyline 0 ; QLL (80 per 0 ; QLL (90 per 0 PAR; Name amoxapine oral tablet 00 mg, 0 mg amoxapine oral tablet 0 mg, mg AMPYRA APOKYN APTIOM ORAL TABLET 00 MG, 00 MG, 600 MG APTIOM ORAL TABLET 800 MG aripiprazole oral solution aripiprazole oral tablet 0 mg aripiprazole oral tablet mg aripiprazole oral tablet mg aripiprazole oral tablet 0 mg, 0 mg aripiprazole oral tablet mg aripiprazole oral tablet, disintegrating 0 mg aripiprazole oral tablet, disintegrating mg ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING MG/.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 66 MG/. ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 88 MG/. ML AZILECT baclofen BANZEL ORAL SUSPENSION PAR; ; LA; QLL (60 per 0 PAR; ; LA ST; ST; ; QLL (900 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (90 per 0 ; QLL (60 per 0 PAR; ; QLL (.6 per 0 PAR; ; QLL (. per 0 PAR; ; QLL (. per 0 PAR; ; QLL (00 per 0 Core_69_v_606_ 0 Effective Date June, 06

21 Name BANZEL ORAL TABLET 00 MG BANZEL ORAL TABLET 00 MG benztropine injection benztropine oral BRINTELLIX ORAL TABLET 0 MG BRINTELLIX ORAL TABLET 0 MG BRINTELLIX ORAL TABLET MG bromocriptine buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet mg buprenorphine hcl sublingual tablet 8 mg buprenorphine-naloxone sublingual tablet -0. mg buprenorphine-naloxone sublingual tablet 8- mg bupropion hcl oral tablet 00 mg bupropion hcl oral tablet 7 mg bupropion hcl oral tablet extended release 00 mg bupropion hcl oral tablet extended release 0 mg, 00 mg bupropion hcl oral tablet extended release hr 0 mg bupropion hcl oral tablet extended release hr 00 mg buspirone oral tablet 0 mg, mg, mg buspirone oral tablet 0 mg, 7. mg butorphanol tartrate injection solution mg/ml butorphanol tartrate injection solution mg/ml PAR; ; QLL (80 per 0 PAR; ; QLL (0 per 0 PAR; PAR; ST; ; QLL (60 per 0 ST; ; QLL (0 per 0 ST; ; QLL (0 per 0 ; QLL (0 per 0 QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (90 per 0 ; QLL ( per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (90 per 0 ; QLL ( per 0 ; QLL (0 per 0 ; QLL (0 per 0 Name butorphanol tartrate nasal carbamazepine oral capsule, er multiphase hr carbamazepine oral suspension 00 mg/ ml carbamazepine oral suspension 00 mg/0 ml carbamazepine oral tablet carbamazepine oral tablet extended release hr 00 mg carbamazepine oral tablet extended release hr 00 mg, 00 mg carbamazepine oral tablet, chewable carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release -00 mg carbidopa-levodopa oral tablet extended release 0-00 mg carbidopa-levodopa oral tablet, disintegrating CELONTIN ORAL CAPSULE 00 MG chlorpromazine citalopram oral solution citalopram oral tablet 0 mg citalopram oral tablet 0 mg citalopram oral tablet 0 mg clomipramine clonazepam oral tablet 0. mg clonazepam oral tablet mg clonazepam oral tablet mg clonazepam oral tablet, disintegrating 0. mg clonazepam oral tablet, disintegrating 0. mg ; QLL ( per 8 PAR; ; QLL (600 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (0 per 0 PAR; PAR; ; QLL (00 per 0 PAR; ; QLL (600 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (800 per 0 PAR; ; QLL (00 per 0 Core_69_v_606_ Effective Date June, 06

22 Name clonazepam oral tablet, disintegrating 0. mg clonazepam oral tablet, disintegrating mg clonazepam oral tablet, disintegrating mg clorazepate dipotassium clozapine oral tablet 00 mg clozapine oral tablet 00 mg clozapine oral tablet mg clozapine oral tablet 0 mg clozapine oral tablet, disintegrating 00 mg clozapine oral tablet, disintegrating. mg clozapine oral tablet, disintegrating 0 mg clozapine oral tablet, disintegrating 00 mg clozapine oral tablet, disintegrating mg COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML cyclobenzaprine oral tablet dantrolene desipramine oral DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE HR 00 MG DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE HR 0 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 00 MG PAR; ; QLL (00 per 0 PAR; ; QLL (600 per 0 PAR; ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (70 per 0 ; QLL ( per 0 ; QLL (080 per 0 ; QLL (0 per 0 QLL (70 per 0 QLL (60 per 0 QLL (80 per 0 QLL ( per 0 QLL (080 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL ( per 8 PAR; ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 Name DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 00 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG dextroamphetamine oral tablet 0 mg dextroamphetamine oral tablet mg dextroamphetamineamphetamine oral tablet 0 mg,. mg, mg, 0 mg, mg, 7. mg dextroamphetamineamphetamine oral tablet 0 mg diazepam intensol diazepam oral concentrate diazepam oral solution mg/ ml ( mg/ml) diazepam oral solution mg/ ml ( mg/ml, ml) diazepam oral tablet 0 mg diazepam oral tablet mg diazepam oral tablet mg diazepam rectal kit mg diazepam rectal kit. mg, mg diclofenac potassium diclofenac sodium oral tablet extended release hr diclofenac sodium oral tablet, delayed release (dr/ec) mg diclofenac sodium oral tablet, delayed release (dr/ec) 0 mg, 7 mg ; QLL (0 per 0 QLL (0 per 0 QLL (0 per 0 ; QLL (80 per 0 ; QLL (90 per 0 PAR; ; QLL (90 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (00 per 0 PAR; QLL (00 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (600 per 0 PAR; ; QLL (0 per 0 ; QLL ( per Core_69_v_606_ Effective Date June, 06

23 Name diclofenac sodium topical gel % diflunisal dihydroergotamine injection DILANTIN INFATABS DILANTIN ORAL CAPSULE 0 MG diskets divalproex oral capsule, sprinkle divalproex oral tablet extended release hr divalproex oral tablet,delayed release (dr/ec) mg, 0 mg divalproex oral tablet,delayed release (dr/ec) 00 mg donepezil oral tablet 0 mg, mg donepezil oral tablet, disintegrating doxepin oral duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg duramorph (pf) injection solution 0. mg/ml duramorph (pf) injection solution mg/ml EMSAM endocet oral tablet 0- mg, 7.- mg endocet oral tablet - mg entacapone epitol EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG QLL (000 per 0 QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 PAR; ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (80 per 0 QLL (80 per 0 PAR; ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (60 per 0 ; QLL (80 per 0 Name EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet mg ethosuximide oral capsule ethosuximide oral solution etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release hr EXELON ORAL CAPSULE. MG,. MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET 0 MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS, DOSE PACK felbamate oral suspension felbamate oral tablet 00 mg felbamate oral tablet 600 mg FELBATOL ORAL TABLET 00 MG ; QLL (0 per 0 ; QLL (80 per 0 PAR; ; QLL (600 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ST; ; QLL (70 per 0 ST; ; QLL (7 per 0 ST; ; QLL (60 per 0 ST; ; QLL (60 per 0 ST; ; QLL (80 per 0 ST; ; QLL (0 per 0 ST; ; QLL (90 per 0 ST; ; QLL (6 per 6 Core_69_v_606_ Effective Date June, 06

24 Name fenoprofen oral tablet fentanyl citrate fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, mcg/hr, 0 mcg/hr, 7 mcg/ hr FETZIMA ORAL CAPSULE,EXT REL HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG fluoxetine oral capsule 0 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule 0 mg fluoxetine oral solution fluoxetine oral tablet 0 mg fluoxetine oral tablet 0 mg fluphenazine decanoate fluphenazine hcl injection fluphenazine hcl oral flurbiprofen fluvoxamine oral tablet 00 mg fluvoxamine oral tablet mg fluvoxamine oral tablet 0 mg fosphenytoin FYCOMPA ORAL TABLET 0 MG, MG PAR; ; QLL (0 per 0 ST; ; QLL ( per 0 PAR; ; QLL (6 per 6 PAR; ; QLL (0 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (90 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (600 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (0 per 0 Name FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 00 mg gabapentin oral capsule 00 mg gabapentin oral capsule 00 mg gabapentin oral solution 0 mg/ ml gabapentin oral solution 0 mg/ ml ( ml), 00 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET MG GABITRIL ORAL TABLET 6 MG galantamine oral capsule,ext rel. pellets hr galantamine oral solution galantamine oral tablet GEODON INTRAMUSCULAR GILENYA GLATOPA guanfacine oral tablet extended release hr guanidine haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate oral ; QLL (80 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL ( per 0 ; QLL (080 per 0 ; QLL (60 per 0 ; QLL (70 per 0 ; QLL (60 per 0 QLL (60 per 0 ; QLL (80 per 0 ; QLL ( per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 Core_69_v_606_ Effective Date June, 06

25 Name HETLIOZ hydrocodone-acetaminophen oral solution.-67 mg/ ml hydrocodone-acetaminophen oral solution 7.- mg/ ml hydrocodone-acetaminophen oral tablet 0- mg, - mg, 7.- mg hydrocodone-ibuprofen oral tablet 0-00 mg, -00 mg, mg hydromorphone (pf) injection solution mg/ml hydromorphone (pf) injection solution 0 mg/ml hydromorphone (pf) injection solution mg/ml hydromorphone injection solution hydromorphone injection syringe mg/ml hydromorphone injection syringe mg/ml hydromorphone injection syringe mg/ml hydromorphone oral tablet mg, mg hydromorphone oral tablet 8 mg ibuprofen oral suspension ibuprofen oral tablet 00 mg, 600 mg, 800 mg ibuprofen-oxycodone imipramine hcl INVEGA ORAL TABLET EXTENDED RELEASE HR. MG INVEGA ORAL TABLET EXTENDED RELEASE HR MG INVEGA ORAL TABLET EXTENDED RELEASE HR 6 MG PAR; ; QLL (0 per 0 QLL (700 per 0 ; QLL (700 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (80 per 0 QLL (80 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (8 per PAR; ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 Name INVEGA ORAL TABLET EXTENDED RELEASE HR 9 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.7 ML, 6 MG/ML, MG/. ML, 78 MG/0. ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 9 MG/0. ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 7 MG/0.87 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 0 MG/. ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 6 MG/.7 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 89 MG/.6 ML KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 00 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE HR 0 MG lamotrigine oral tablet 00 mg, 0 mg, 00 mg lamotrigine oral tablet mg lamotrigine oral tablet, chewable dispersible LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 60 MG ; QLL (0 per 0 ; QLL ( per 8 ; QLL ( per 8 ; QLL (0.87 per 90 ; QLL (. per 90 ; QLL (.7 per 90 ; QLL (.6 per 90 ; QLL (0 per 0 ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (7 per 0 Core_69_v_606_ Effective Date June, 06