2015 Comprehensive Formulary

Transcription

1 01 Medicare Plus Blue SM PPO Assure & Prescription Blue SM PDP Option B 01 Comprehensive Formulary List of covered drugs Updated December 1, 01 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS THAT WE COVER IN THIS PLAN This formulary was updated on December 1, 01. For more recent information or other questions, please contact us, Medicare Plus Blue PPO at , Monday through Friday, 8 a.m. to 8 p.m. TTY users should call 711. Or call Prescription Blue PDP Customer Service at , Monday through Friday, 8 a.m. to 8 p.m. TTY users should call 711. From October 1 through February 1, hours are from 8 a.m. to 8 p.m., seven days a week. Or visit Medicare Plus Blue and Prescription Blue are PPO and PDP plans with a Medicare contract. Enrollment in Medicare Plus Blue and Prescription Blue depends on contract renewal. Enrollment DB 18 DEC 1 H97 S8_C_1CompFormAB CMS Accepted Formulary 1, version 1

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 Blue Cross Blue Shield. When it refers to plan or our plan, it means Medicare Plus Blue or Prescription Blue. This document includes a list of the drugs (formulary) for our plan which is current as of December 1, 01. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 016, and from time to time during the year. To request this document in an alternate format, please call Customer Service (phone numbers are printed on the front and back covers of this booklet).

3 What is the Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B Formulary? A formulary is a list of covered drugs selected by Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B 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. Medicare Plus Blue / Prescription Blue will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Medicare Plus Blue or Prescription Blue 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 01 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 01 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60 day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of December 1, 01. To get updated information about the drugs covered by Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid year non maintenance formulary change, we will send out an errata sheet to notify you of this change. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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, Hypertension, Cholesterol. If you know what your drug is used for, look for the category name in the list that begins on page 1. 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 Index 1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Medicare Plus Blue / Prescription Blue cover 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. i

4 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: Medicare Plus Blue / Prescription Blue require you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Medicare Plus Blue or Prescription Blue before you fill your prescriptions. If you don t get approval, Medicare Plus Blue / Prescription Blue may not cover the drug. Quantity Limits: For certain drugs, Medicare Plus Blue / Prescription Blue limit the amount of the drug that Medicare Plus Blue / Prescription Blue will cover. For example, Medicare Plus Blue / Prescription Blue provide two s per day for Celebrex 00 mg. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, Medicare Plus Blue / Prescription Blue require 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, Medicare Plus Blue / Prescription Blue may not cover B unless you try A first. If A does not work for you, Medicare Plus Blue / Prescription Blue 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 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains 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 Medicare Plus Blue / Prescription Blue 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 Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B formulary? on page ii 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 Medicare Plus Blue / Prescription Blue do not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Medicare Plus Blue / Prescription Blue. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Medicare Plus Blue / Prescription Blue. You can ask Medicare Plus Blue / Prescription Blue 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 Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B Formulary? You can ask Medicare Plus Blue / Prescription Blue 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 your drug even if it is not on our formulary. If approved, this drug will be covered at a pre determined cost sharing level, and you would not be able to ask us to provide the drug at a lower cost sharing level. You can ask us to cover a formulary drug at a lower cost sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Medicare Plus Blue / Prescription Blue 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, Medicare Plus Blue / Prescription Blue 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. ii

5 You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting 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. 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 1 day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 1 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 9 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 1 day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you move into (or out of) a long term care facility, you will continue to have access to your medications during the transition. If needed, limits on early prescription refills will be waived to assure that your medications are available through a new pharmacy provider when you are moving to or from a long term care facility. Contact Customer Service if you require assistance in your transition. For more detailed information about our Transition Policy, refer to your Evidence of Coverage or visit our website at forms documents.html. For more information For more detailed information about your Medicare Plus Blue / Prescription Blue prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Medicare Plus Blue / Prescription Blue, please contact us. Our contact information, along with the date we last update the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), hours a day / 7 days a week. TTY users should call Or, visit Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by Medicare Plus Blue / Prescription Blue. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., VYTORIN) and generic drugs are listed in lower case italics (e.g., simvastatin). The information in the column tells you if Medicare Plus Blue / Prescription Blue have any special requirements for coverage of your drug. iii

6 Descriptions Medicare Plus Blue PPO Assure & Prescription Blue PDP Option B Costs Up to a 1 day supply Up to a 90 day supply** 1 Description Preferred Generic Non Preferred Generic Preferred Brand Name Non Preferred Brand Name Specialty At long term care, preferred At preferred retail retail At standard cost sharing At out of At the plan s cost sharing retail (in network), network mail order (in network) cost sharing and standard pharmacies* service pharmacies or (in network) retail the plan s mail pharmacies cost sharing order service (in network) pharmacies See your Evidence of Coverage for member cost share details See your Evidence of Coverage for member cost share details 90 day supply is not available *Out of network pharmacy coverage is limited to certain situations. Consult your Evidence of Coverage for details. **Most pharmacies will fill a 90 day supply of medication. Check with your pharmacist. Notes Code Definitions Symbol Definition B/D This prescription drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. GC Gap Coverage. We provide coverage of this prescription drug in Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. LA Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Medicare Plus Blue Customer Service at , Monday through Friday, 8 a.m. 8 p.m. TTY users should call 711. Or call Prescription Blue PDP Customer Service at , Monday through Friday, 8 a.m. 8 p.m. TTY users should call 711. From October 1 through February 1, hours are from 8 a.m. to 8 p.m., seven days a week. PA Prior Authorization. The plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don't get approval, we may not cover the drug. QL Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your condition before we will cover another drug for that condition. For example, if drug A and drug B both treat your medical condition, we may not cover drug B unless you try drug A first. If drug A does not work for you, we will then cover drug B. iv

7 Name ANTI -INFECTIVES AMINOGLYCOSIDES amikacin injection 1,000 mg/ ml, 00 mg/ ml BETHKIS INHALATION FOR NEBULIZATION gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/0 ml, 70 mg/0 ml, 80 mg/100 ml, 80 mg/0 ml, 90 mg/100 ml GENTAMICIN IN NACL (ISO-OSM) PIGGYBACK 100 MG/0 ML, 10 MG/100 ML gentamicin injection gentamicin sulfate (ped) (pf) injection gentamicin sulfate (pf) intravenous 100 mg/10 ml, 80 mg/8 ml GENTAMICIN SULFATE (PF) 60 MG/6 ML B/D PA Name STREPTOMYCIN R TOBI INHALATION FOR NEBULIZATION TOBI PODHALER INHALATION CAPSULE TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in 0. % nacl inhalation for nebulization tobramycin in 0.9 % nacl intravenous piggyback 80 mg/100 ml tobramycin sulfate injection ANTIFUNGALS ABELCET SUSPENSION AMBISOME SUSPENSION FOR RECONSTITUTIO N amphotericin b injection recon soln B/D PA PA PA B/D PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

8 Name CANCIDAS clotrimazole mucous membrane troche CRESEMBA CRESEMBA ORAL CAPSULE ERAXIS(WATER DILUENT) fluconazole in dextrose(iso-o) intravenous piggyback fluconazole in nacl (iso-osm) intravenous piggyback fluconazole oral suspension for reconstitution fluconazole oral flucytosine oral griseofulvin microsize oral suspension griseofulvin microsize oral griseofulvin ultramicrosize oral B/D PA Name itraconazole oral ketoconazole oral NOXAFIL NOXAFIL ORAL SUSPENSION NOXAFIL ORAL,DELAYE D RELEASE (DR/EC) nystatin oral suspension nystatin oral ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL SPORANOX ORAL terbinafine hcl oral voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral ANTIMALARIALS atovaquoneproguanil oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - QL (90 per 90

9 Name chloroquine phosphate oral COARTEM ORAL DARAPRIM ORAL hydroxychloroquine oral mefloquine oral PRIMAQUINE ORAL quinine sulfate oral ANTIPARASITICS/ANTHELMINTIC S ALBENZA ORAL ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL atovaquone oral suspension BILTRICIDE ORAL ivermectin oral MEPRON ORAL SUSPENSION paromomycin oral Name STROMECTOL ORAL tinidazole oral ANTIRETROVIRALS abacavir oral abacavirlamivudinezidovudine oral APTIVUS ORAL CAPSULE APTIVUS ORAL ATRIPLA ORAL COMPLERA ORAL CRIXIVAN ORAL CAPSULE 00 MG, 00 MG didanosine oral,delayed release(dr/ec) EDURANT ORAL EMTRIVA ORAL CAPSULE EMTRIVA ORAL EPIVIR HBV ORAL EPIVIR ORAL EPZICOM ORAL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

10 Name Name EVOTAZ ORAL lamivudine oral FUZEON lamivudinezidovudine oral INTELENCE ORAL 100 MG, 00 MG INTELENCE ORAL MG INVIRASE ORAL CAPSULE INVIRASE ORAL ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL ISENTRESS ORAL,CHEWAB LE 100 MG ISENTRESS ORAL,CHEWAB LE MG KALETRA ORAL KALETRA ORAL 100- MG KALETRA ORAL 00-0 MG lamivudine oral LEXIVA ORAL SUSPENSION LEXIVA ORAL nevirapine oral suspension nevirapine oral nevirapine oral extended release hr NORVIR ORAL CAPSULE NORVIR ORAL NORVIR ORAL PREZCOBIX ORAL PREZISTA ORAL SUSPENSION PREZISTA ORAL 10 MG, 7 MG PREZISTA ORAL 600 MG, 800 MG RESCRIPTOR ORAL : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

11 Name Name RESCRIPTOR ORAL, DISPERSIBLE RETROVIR REYATAZ ORAL CAPSULE 10 MG, 00 MG, 00 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY ORAL stavudine oral stavudine oral recon soln STRIBILD ORAL SUSTIVA ORAL CAPSULE SUSTIVA ORAL TIVICAY ORAL TRIUMEQ ORAL TRIZIVIR ORAL TRUVADA ORAL TYBOST ORAL TYZEKA ORAL VIDEX GRAM PEDIATRIC ORAL VIDEX GRAM PEDIATRIC ORAL VIRACEPT ORAL VIRAMUNE XR ORAL EXTENDED RELEASE HR 100 MG VIRAMUNE XR ORAL EXTENDED RELEASE HR 00 MG VIREAD ORAL POWDER VIREAD ORAL VITEKTA ORAL ZIAGEN ORAL zidovudine oral zidovudine oral syrup zidovudine oral ANTITUBERCULARS : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

12 Name CAPASTAT CYCLOSERINE ORAL CAPSULE DAPSONE ORAL ethambutol oral isoniazid injection isoniazid oral isoniazid oral MYCOBUTIN ORAL CAPSULE PASER ORAL GRANULES DR FOR SUSP IN PACKET PRIFTIN ORAL pyrazinamide oral rifabutin oral rifampin intravenous recon soln rifampin oral RIFATER ORAL SIRTURO ORAL PA Name TRECATOR ORAL ANTIVIRALS acyclovir oral acyclovir oral suspension 00 mg/ ml acyclovir oral acyclovir sodium intravenous recon soln acyclovir sodium intravenous acyclovir topical ointment adefovir oral amantadine hcl oral amantadine hcl oral amantadine hcl oral BARACLUDE ORAL cidofovir intravenous DAKLINZA ORAL entecavir oral famciclovir oral foscarnet intravenous B/D PA B/D PA PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6

13 Name ganciclovir sodium intravenous recon soln HARVONI ORAL HEPSERA ORAL moderiba dose pack oral s,dose pack moderiba oral OLYSIO ORAL CAPSULE REBETOL ORAL RELENZA DISKHALER INHALATION BLISTER WITH DEVICE ribasphere oral ribasphere oral 00 mg, 00 mg ribasphere oral 600 mg ribasphere ribapak oral s,dose pack ribavirin oral ribavirin oral 00 mg rimantadine oral B/D PA PA PA QL (60 per fill) Name SOVALDI ORAL TAMIFLU ORAL CAPSULE 0 MG TAMIFLU ORAL CAPSULE MG, 7 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTIO N TECHNIVIE ORAL valacyclovir oral VALCYTE ORAL valganciclovir oral VIEKIRA PAK ORAL S,DOSE PACK VIRAZOLE INHALATION CEPHALOSPORINS cefaclor oral cefaclor oral extended release 1 hr cefadroxil oral : 1-Preferred Generic -Specialty s : B/D - Prior Authorization, Part D vs. Part B only Limited Availability PA - Prior Authorization QL - Quantity Limit -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand 7 PA QL (90 per 180 QL (0 per 180 QL (0 per 180 PA PA GC Gap Coverage LA - ST - Step Therapy

14 Name Name cefadroxil oral suspension for reconstitution 0 mg/ ml, 00 mg/ ml CEFOTETAN IN DEXTROSE, ISO- OSM PIGGYBACK cefadroxil oral cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/0 ml, gram/0 ml cefotetan injection recon soln cefotetan intravenous recon soln cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 00 g, 00 mg cefazolin intravenous recon soln cefdinir oral cefoxitin in dextrose, iso-osm intravenous piggyback cefoxitin intravenous recon soln cefpodoxime oral suspension for reconstitution cefdinir oral suspension for reconstitution CEFEPIME IN DEXTROSE % PIGGYBACK cefepime in dextrose,iso-osm intravenous piggyback cefpodoxime oral cefprozil oral suspension for reconstitution cefprozil oral ceftazidime injection recon soln ceftibuten oral cefepime injection recon soln cefixime oral suspension for reconstitution cefotaxime injection recon soln 1 gram, gram, 00 mg ceftibuten oral suspension for reconstitution ceftriaxone in dextrose,iso-os intravenous piggyback : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 8

15 Name Name ceftriaxone injection recon soln 1 gram, 10 gram, gram, 0 mg, 00 mg ceftriaxone intravenous recon soln cefuroxime axetil oral cefuroxime sodium injection recon soln 1. gram, 70 mg cefuroxime sodium intravenous recon soln cephalexin oral 0 mg, 00 mg cephalexin oral suspension for reconstitution cephalexin oral FORTAZ IN DEXTROSE % PIGGYBACK FORTAZ 1 GRAM, 6 GRAM FORTAZ MAXIPIME MAXIPIME MEFOXIN IN DEXTROSE (ISO- OSM) PIGGYBACK SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N SUPRAX ORAL,CHEWAB LE TAZICEF TAZICEF TEFLARO ZERBAXA ZINACEF IN STERILE WATER PIGGYBACK ZINACEF 1. GRAM, 70 MG MACROLIDES : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 9

16 Name azithromycin intravenous recon soln azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral clarithromycin oral suspension for reconstitution clarithromycin oral clarithromycin oral extended release hr DIFICID ORAL E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTIO N ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTIO N ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTIO N QL (180 per 90 QL (0 per fill) Name ery-tab oral,delayed release (dr/ec) erythrocin (as stearate) oral 0 mg ERYTHROCIN erythromycin ethylsuccinate oral erythromycin oral KETEK ORAL ZMAX ORAL SUSPENSION,EXT ENDED REL RECON MISCELLANEOUS ANTI- INFECTIVES AZACTAM IN DEXTROSE (ISO- OSM) PIGGYBACK aztreonam injection recon soln baciim intramuscular recon soln bacitracin intramuscular recon soln QL (0 per 10 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 10

17 Name CAYSTON INHALATION FOR NEBULIZATION chloramphenicol sod succinate intravenous recon soln CLEOCIN IN % DEXTROSE PIGGYBACK 900 MG/0 ML clindamycin hcl oral clindamycin in % dextrose intravenous piggyback clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln clindamycin phosphate injection clindamycin phosphate intravenous 600 mg/ ml, 900 mg/6 ml colistin (colistimethate na) injection recon soln CUBICIN PA; QL (8 per 8 Name DALVANCE imipenem-cilastatin intravenous recon soln INVANZ INVANZ linezolid intravenous parenteral linezolid oral linezolid-0.9% sodium chloride intravenous parenteral meropenem intravenous recon soln metro i.v. intravenous piggyback metronidazole in nacl (iso-os) intravenous piggyback metronidazole oral metronidazole oral NEBUPENT INHALATION : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 11 B/D PA

18 Name neomycin oral PENTAM polymyxin b sulfate injection recon soln SIVEXTRO SIVEXTRO ORAL SYNERCID TYGACIL VANCOMYCIN IN DW PIGGYBACK VANCOMYCIN IN DEXTROSE ISO- OSM PIGGYBACK vancomycin intravenous recon soln vancomycin oral XIFAXAN ORAL ZYVOX PARENTERAL Name ZYVOX ORAL SUSPENSION FOR RECONSTITUTIO N ZYVOX ORAL PENICILLINS amoxicillin oral amoxicillin oral suspension for reconstitution amoxicillin oral amoxicillin oral,chewable 1 mg, 0 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral amoxicillin-pot clavulanate oral extended release 1 hr amoxicillin-pot clavulanate oral,chewable ampicillin oral ampicillin oral suspension for reconstitution : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

19 Name Name ampicillin sodium injection recon soln ampicillin sodium intravenous recon soln ampicillin-sulbactam injection recon soln ampicillin-sulbactam intravenous recon soln BICILLIN C-R R SYRINGE BICILLIN L-A R SYRINGE dicloxacillin oral nafcillin in dextrose iso-osm intravenous piggyback nafcillin injection recon soln PENICILLIN G POT IN DEXTROSE PIGGYBACK penicillin g potassium injection recon soln penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml penicillin g sodium injection recon soln penicillin v potassium oral recon soln penicillin v potassium oral nafcillin intravenous recon soln pfizerpen-g injection recon soln oxacillin in dextrose(iso-osm) intravenous piggyback piperacillintazobactam intravenous recon soln oxacillin injection recon soln oxacillin intravenous recon soln ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK QUINOLONES : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

20 Name ciprofloxacin (mixture) oral, er multiphase hr ciprofloxacin hcl oral ciprofloxacin in % dextrose intravenous piggyback ciprofloxacin lactate intravenous ciprofloxacin oral suspension,microcap sule recon levofloxacin in dw intravenous piggyback levofloxacin intravenous levofloxacin oral levofloxacin oral moxifloxacin oral ofloxacin oral 00 mg SULFONAMIDES AND COMBINATIONS sulfadiazine oral sulfamethoxazoletrimethoprim intravenous sulfamethoxazoletrimethoprim oral suspension QL (8 per 8 Name sulfamethoxazoletrimethoprim oral sulfatrim oral suspension TETRACYCLINES ARESTIN DENTAL CARTRIDGE demeclocycline oral doxy-100 intravenous recon soln doxycycline hyclate intravenous recon soln doxycycline hyclate oral doxycycline hyclate oral 100 mg, 0 mg doxycycline hyclate oral,delayed release (dr/ec) 10 mg doxycycline monohydrate oral 100 mg, 0 mg, 7 mg doxycycline monohydrate oral suspension for reconstitution MINOCIN KIT WITH WIPES COMBO PACK : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

21 Name minocycline oral minocycline oral morgidox oral VIBRAMYCIN ORAL SYRUP URINARY TRACT AGENTS methenamine hippurate oral methenamine mandelate oral nitrofurantoin macrocrystal oral 100 mg, 0 mg nitrofurantoin monohyd/m-cryst oral nitrofurantoin oral suspension PRIMSOL ORAL trimethoprim oral PA PA PA ANTINEOPLASTICS AND IMMUNOSUPPRESSANTS ADJUVANT THERAPY FUSILEV leucovorin calcium injection recon soln Name leucovorin calcium oral LEUKINE levoleucovorin calcium intravenous MESNEX ORAL ALKYLATING AGENTS BICNU BUSULFEX cyclophosphamide intravenous recon soln CYCLOPHOSPHA MIDE ORAL CAPSULE dacarbazine intravenous recon soln LEUKERAN ORAL LOMUSTINE ORAL CAPSULE melphalan hcl intravenous recon soln MUSTARGEN : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1 B/D PA B/D PA

22 Name TREANDA 180 MG/ ML VALCHLOR TOPICAL GEL ZANOSAR ANTIMETABOLITES adrucil intravenous ALIMTA cladribine intravenous cytarabine (pf) injection cytarabine injection DEPOCYT (PF) INTRATHECAL SUSPENSION floxuridine injection recon soln fludarabine intravenous recon soln fludarabine intravenous fluorouracil intravenous. gram/0 ml, gram/100 ml, 00 mg/10 ml PA B/D PA B/D PA B/D PA B/D PA B/D PA Name gemcitabine intravenous recon soln gemcitabine intravenous mercaptopurine oral methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection methotrexate sodium injection methotrexate sodium oral NIPENT PURIXAN ORAL SUSPENSION RHEUMATREX ORAL S,DOSE PACK TABLOID ORAL HORMONAL AGENTS anastrozole oral bicalutamide oral exemestane oral 1 B/D PA; GC B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 16

23 Name FARESTON ORAL FASLODEX R SYRINGE FIRMAGON KIT W DILUENT SYRINGE flutamide oral letrozole oral leuprolide subcutaneous kit LUPRON DEPOT ( MONTH) R SYRINGE KIT. MG LUPRON DEPOT ( MONTH) R SYRINGE KIT LUPRON DEPOT (6 MONTH) R SYRINGE KIT LUPRON DEPOT R SYRINGE KIT 7. MG LUPRON DEPOT- PED R KIT 11. MG, 1 MG Name MEGACE ES ORAL SUSPENSION megestrol oral suspension 00 mg/10 ml (10 ml), 00 mg/10 ml (0 mg/ml), 6 mg/ ml PA PA megestrol oral PA NILANDRON ORAL SOLTAMOX ORAL SUPPRELIN LA IMPLANT KIT tamoxifen oral TRELSTAR R SUSPENSION FOR RECONSTITUTIO N VANTAS IMPLANT KIT XTANDI ORAL CAPSULE ZOLADEX IMPLANT ZYTIGA ORAL IMMUNOMODULATORS ARCALYST PA QL (1. per 0 PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 17

24 Name ASTAGRAF XL ORAL CAPSULE,EXTEN DED RELEASE HR 0. MG, 1 MG ASTAGRAF XL ORAL CAPSULE,EXTEN DED RELEASE HR MG AZASAN ORAL azathioprine oral CELLCEPT cyclosporine intravenous cyclosporine modified oral cyclosporine modified oral cyclosporine oral GAZYVA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA PA gengraf oral B/D PA gengraf oral B/D PA Name ILARIS (PF) mycophenolate mofetil oral mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral mycophenolate sodium oral,delayed release (dr/ec) NEORAL ORAL CAPSULE NEORAL ORAL NULOJIX POMALYST ORAL CAPSULE PROGRAF RAPAMUNE ORAL REVLIMID ORAL CAPSULE 10 MG, 1 MG, MG, MG REVLIMID ORAL CAPSULE. MG, 0 MG PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA B/D PA PA B/D PA B/D PA LA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 18

25 Name RITUXAN CONCENTRATE SANDIMMUNE SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SIMULECT PA B/D PA B/D PA B/D PA B/D PA sirolimus oral B/D PA tacrolimus oral 0. mg, 1 mg tacrolimus oral mg TECFIDERA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10 MG (1)- 0 MG (6) TECFIDERA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10 MG, 0 MG THALOMID ORAL CAPSULE B/D PA B/D PA PA PA; QL (6 per 1 PA MISCELLANEOUS ANTINEOPLASTIC AGENTS Name ABRAXANE SUSPENSION FOR RECONSTITUTIO N AFINITOR DISPERZ ORAL FOR SUSPENSION AFINITOR ORAL amifostine crystalline intravenous recon soln ARRANON ARZERRA AVASTIN azacitidine injection recon soln BELEODAQ bexarotene oral bleomycin injection recon soln BLINCYTO KIT PA PA PA PA PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 19

26 Name Name BOSULIF ORAL CAMPTOSAR 00 MG/1 ML CAPRELSA ORAL carboplatin intravenous cisplatin intravenous CLOLAR COMETRIQ ORAL CAPSULE CYRAMZA DACOGEN daunorubicin intravenous DAUNOXOME decitabine intravenous recon soln dexrazoxane hcl intravenous recon soln PA PA DOCEFREZ 0 MG docetaxel intravenous 10 mg/ml, 10 mg/7 ml (0 mg/ml), 160 mg/16 ml (10 mg/ml), 0 mg/ ml (10 mg/ml), 0 mg/ml (1 ml), 80 mg/ ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous recon soln doxorubicin intravenous doxorubicin, pegliposomal intravenous suspension DROXIA ORAL CAPSULE ELLENCE ELOXATIN 100 MG/0 ML EMCYT ORAL CAPSULE epirubicin intravenous recon soln 0 mg B/D PA B/D PA B/D PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 0

27 Name Name epirubicin intravenous idarubicin intravenous ERBITUX IFEX B/D PA ERIVEDGE ORAL CAPSULE ERWINAZE R PA ifosfamide intravenous recon soln ifosfamide intravenous B/D PA B/D PA ETOPOPHOS ifosfamide-mesna intravenous kit 1-1 gram B/D PA etoposide intravenous IMBRUVICA ORAL CAPSULE PA FARYDAK ORAL CAPSULE PA INLYTA ORAL PA GILOTRIF ORAL PA; QL (1 per 1 IRESSA ORAL GLEEVEC ORAL HALAVEN HERCEPTIN HEXALEN ORAL CAPSULE hydroxyurea oral IBRANCE ORAL CAPSULE ICLUSIG ORAL B/D PA PA PA irinotecan intravenous 100 mg/ ml, 0 mg/ ml irinotecan intravenous 00 mg/ ml ISTODAX IXEMPRA JAKAFI ORAL B/D PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1

28 Name Name JEVTANA KADCYLA KEYTRUDA KEYTRUDA LENVIMA ORAL CAPSULE lipodox 0 intravenous suspension lipodox intravenous suspension PA B/D PA PA B/D PA B/D PA NEXAVAR ORAL ONCASPAR OPDIVO oxaliplatin intravenous recon soln oxaliplatin intravenous paclitaxel intravenous concentrate PERJETA PA LYNPARZA ORAL CAPSULE LYSODREN ORAL MATULANE ORAL CAPSULE MEKINIST ORAL mesna intravenous mitomycin intravenous recon soln mitoxantrone intravenous concentrate PA PA B/D PA PROLEUKIN SPRYCEL ORAL STIVARGA ORAL SUTENT ORAL CAPSULE SYNRIBO TAFINLAR ORAL CAPSULE TARCEVA ORAL PA PA PA : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

29 Name Name TARGRETIN ORAL CAPSULE TASIGNA ORAL CAPSULE thiotepa injection recon soln toposar intravenous topotecan intravenous recon soln TORISEL TREANDA TREANDA MG/0. ML TRELSTAR DEPOT R SUSPENSION FOR RECONSTITUTIO N TRELSTAR R SYRINGE TRELSTAR LA R SUSPENSION FOR RECONSTITUTIO N PA PA PA PA tretinoin (chemotherapy) oral TRISENOX TYKERB ORAL UNITUXIN VALSTAR INTRAVESICAL VECTIBIX VELCADE VIDAZA vinblastine intravenous vincasar pfs intravenous vincristine intravenous vinorelbine intravenous VOTRIENT ORAL XALKORI ORAL CAPSULE PA B/D PA B/D PA B/D PA PA PA; QL (6 per 1 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

30 Name XGEVA YERVOY ZALTRAP ZELBORAF ORAL ZINECARD (AS HCL) ZOLINZA ORAL CAPSULE ZORTRESS ORAL 0. MG ZORTRESS ORAL 0. MG, 0.7 MG ZYDELIG ORAL ZYKADIA ORAL CAPSULE CARDIOVASCULAR, HYPERTENSION, CHOLESTEROL ACE-INHIBITORS AND COMBINATIONS benazepril oral PA PA PA; QL (0 per 0 B/D PA B/D PA PA PA Name benazeprilhydrochlorothiazide oral captopril oral captoprilhydrochlorothiazide oral enalapril maleate oral enalaprilat intravenous injectable enalaprilhydrochlorothiazide oral fosinopril oral fosinoprilhydrochlorothiazide oral lisinopril oral lisinoprilhydrochlorothiazide oral moexipril oral moexiprilhydrochlorothiazide oral perindopril erbumine oral quinapril oral quinaprilhydrochlorothiazide oral ramipril oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

31 Name trandolapril oral ALPHA-ADRENERGIC AGENTS CARDURA XL ORAL EXTENDED RELEASE HR clonidine (pf) epidural clonidine hcl oral clonidine transdermal patch weekly doxazosin oral DURACLON (PF) EPIDURAL,000 MCG/10 ML prazosin oral terazosin oral QL (90 per 90 ; QL (1 per 8 ANGIOTENSIN II RECEPTOR BLOCKERS AND COMBINATIONS amlodipinevalsartan oral amlodipinevalsartan-hcthiazid oral BENICAR HCT ORAL BENICAR ORAL Name candesartan oral candesartanhydrochlorothiazid oral EDARBI ORAL EDARBYCLOR ORAL eprosartan oral irbesartan oral irbesartanhydrochlorothiazide oral losartan oral losartanhydrochlorothiazide oral telmisartan oral telmisartanamlodipine oral telmisartanhydrochlorothiazid oral valsartan oral valsartanhydrochlorothiazide oral ANTI-COAGULANTS/HEMOSTASIS AGENTS : 1-Preferred Generic -Specialty s -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

32 Name Name AGGRENOX ORAL CAPSULE, ER MULTIPHASE 1 HR AMICAR ORAL 1,000 MG aminocaproic acid intravenous anagrelide oral enoxaparin subcutaneous syringe 0 mg/0. ml, 0 mg/0. ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml, mg/0. ml, 7. mg/0.6 ml aspirin-dipyridamole oral, er multiphase 1 hr BRILINTA ORAL cilostazol oral clopidogrel oral COUMADIN ORAL dipyridamole intravenous EFFIENT ORAL ELIQUIS ORAL enoxaparin subcutaneous enoxaparin subcutaneous syringe 100 mg/ml, 10 mg/0.8 ml, 10 mg/ml fondaparinux subcutaneous syringe. mg/0. ml FRAGMIN FRAGMIN SYRINGE 10,000 ANTI-XA UNIT/ML, 1,00 ANTI-XA UNIT/0. ML, 1,000 ANTI- XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.7 ML, 7,00 ANTI-XA UNIT/0. ML FRAGMIN SYRINGE,00 ANTI-XA UNIT/0. ML,,000 ANTI- XA UNIT/0. ML heparin (porcine) in % dex intravenous parenteral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6

33 Name heparin (porcine) in nacl (pf) intravenous parenteral 1,000 unit/00 ml,,000 unit/1,000 ml heparin (porcine) injection cartridge heparin (porcine) injection HEPARIN(PORCIN E) IN 0.% NACL PARENTERAL 1,00 UNIT/0 ML heparin(porcine) in 0.% nacl intravenous parenteral,000 unit/0 ml,,000 unit/00 ml heparin, porcine (pf) injection heparin, porcine (pf) injection syringe INTEGRILIN IPRIVASK jantoven oral pentoxifylline oral extended release PRADAXA ORAL CAPSULE Name REOPRO warfarin oral XARELTO ORAL XARELTO ORAL S,DOSE PACK BETA BLOCKERS AND COMBINATIONS acebutolol oral atenolol oral atenololchlorthalidone oral betaxolol oral bisoprolol fumarate oral bisoprololhydrochlorothiazide oral BREVIBLOC IN NACL (ISO-OSM) PARENTERAL BREVIBLOC 100 MG/10 ML (10 MG/ML) BYSTOLIC ORAL 10 MG ST; QL (60 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 7

34 Name BYSTOLIC ORAL. MG, MG BYSTOLIC ORAL 0 MG ST; QL (90 per 90 ST; QL (180 per 90 carvedilol oral COREG CR ORAL CAPSULE, ER MULTIPHASE HR esmolol intravenous INNOPRAN XL ORAL CAPSULE,EXTEN DED RELEASE HR labetalol intravenous labetalol intravenous syringe 0 mg/ ml ( mg/ml) QL (90 per 90 labetalol oral metoprolol succinate oral extended release hr metoprolol tahydrochlorothiaz oral metoprolol tartrate intravenous metoprolol tartrate intravenous syringe metoprolol tartrate oral ; QL (180 per 90 Name nadolol oral nadololbendroflumethiazide oral pindolol oral propranolol intravenous propranolol oral,extended release hr propranolol oral propranolol oral propranololhydrochlorothiazid oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 8 sorine oral sotalol af oral SOTALOL sotalol oral timolol maleate oral CALCIUM CHANNEL BLOCKERS AND COMBINATIONS afeditab cr oral extended release amlodipine oral amlodipineatorvastatin oral ; QL (90 per 90

35 Name Name amlodipinebenazepril oral diltiazem hcl oral,extended release hr AZOR ORAL QL (90 per 90 diltiazem hcl oral CARDENE IV IN DEXTROSE PIGGYBACK CARDENE IV IN SODIUM CHLORIDE PIGGYBACK 0 MG/00 ML CARDIZEM LA ORAL EXTENDED RELEASE HR 10 MG diltiazem hcl oral extended release hr dilt-xr oral,ext release degradable felodipine oral extended release hr isradipine oral matzim la oral extended release hr ; QL (90 per 90 cartia xt oral,extended release hr diltiazem hcl intravenous recon soln diltiazem hcl intravenous diltiazem hcl oral, extended release diltiazem hcl oral,ext release degradable diltiazem hcl oral,extended release 1 hr nicardipine intravenous nicardipine oral nifedical xl oral extended release hr nifedipine oral extended release nifedipine oral extended release hr nisoldipine oral extended release hr ; QL (90 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 9

36 Name TARKA ORAL, IR & ER, BIPHASIC HR taztia xt oral, extended release trandolaprilverapamil oral, ir & er, biphasic hr verapamil intravenous verapamil intravenous syringe verapamil oral, hr er pellet ct verapamil oral,ext rel. pellets hr QL (90 per 90 ; QL (90 per 90 verapamil oral verapamil oral extended release CARBONIC ANHYDRASE INHIBITORS acetazolamide oral, extended release acetazolamide oral acetazolamide sodium injection recon soln methazolamide oral Name CARDIOVASCULAR TREATMENT ADENOCARD SYRINGE adenosine intravenous adenosine intravenous syringe amiodarone intravenous amiodarone intravenous syringe amiodarone oral CORLANOR ORAL CORVERT DIBENZYLINE ORAL CAPSULE digitek oral 1 mcg digitek oral 0 mcg digox oral 1 mcg digox oral 0 mcg digoxin injection digoxin oral 0 mcg/ml digoxin oral 1 mcg : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 0 QL (180 per 90 ; QL (90 per 90 1 PA; GC ; QL (90 per 90 1 PA; GC ; QL (90 per 90

37 Name digoxin oral 0 mcg dobutamine in dw intravenous parenteral 1,000 mg/0 ml (,000 mcg/ml), 0 mg/0 ml (1 mg/ml), 00 mg/0 ml (,000 mcg/ml) dobutamine intravenous dopamine in % dextrose intravenous dopamine intravenous flecainide oral ibutilide fumarate intravenous ISUPREL LANOXIN LANOXIN ORAL 1 MCG LANOXIN ORAL 187. MCG, 0 MCG LANOXIN ORAL 6. MCG LANOXIN PEDIATRIC 1 PA; GC QL (90 per 90 PA Name LEVOPHED (BITARTRATE) mexiletine oral midodrine oral milrinone in % dextrose intravenous piggyback milrinone intravenous MULTAQ ORAL NATRECOR NEXTERONE NITROPRESS norepinephrine bitartrate intravenous NORPACE CR ORAL CAPSULE, EXTENDED RELEASE NORTHERA ORAL CAPSULE pacerone oral 100 mg, 00 mg, 00 mg : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 1 QL (180 per 90

38 Name phenoxybenzamine oral procainamide injection propafenone oral,extended release 1 hr propafenone oral quinidine gluconate injection quinidine gluconate oral extended release quinidine sulfate oral RANEXA ORAL EXTENDED RELEASE 1 HR REMODULIN TIKOSYN ORAL CAPSULE DIURETICS amiloride oral amiloridehydrochlorothiazide oral bumetanide injection bumetanide oral B/D PA Name chlorothiazide oral chlorothiazide sodium intravenous recon soln chlorthalidone oral mg, 0 mg eplerenone oral ethacrynate sodium intravenous recon soln furosemide injection furosemide injection syringe furosemide oral 10 mg/ml, 0 mg/ ml furosemide oral hydrochlorothiazide oral hydrochlorothiazide oral indapamide oral methyclothiazide oral metolazone oral spironolactone oral : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

39 Name spironolactonhydrochlorothiaz oral torsemide oral triamterenehydrochlorothiazid oral triamterenehydrochlorothiazid oral LIPID LOWERING AGENTS omega- acid ethyl esters oral LIPID-LOWERING AGENTS ADVICOR ORAL, ER MULTIPHASE HR ALTOPREV ORAL EXTENDED RELEASE HR ANTARA ORAL CAPSULE 0 MG, 90 MG atorvastatin oral cholestyramine (with sugar) oral powder cholestyramine (with sugar) oral powder in packet cholestyramine light oral powder ST; QL (180 per 90 ST; QL (90 per 90 QL (90 per 90 ; QL (90 per 90 Name cholestyramine light oral powder in packet COLESTID FLAVORED ORAL PACKET colestipol oral granules colestipol oral packet colestipol oral CRESTOR ORAL fenofibrate micronized oral fenofibrate nanocrystallized oral fenofibrate oral 160 mg, mg fenofibric acid (choline) oral,delayed release(dr/ec) 1 mg fenofibric acid (choline) oral,delayed release(dr/ec) mg fenofibric acid oral FENOGLIDE ORAL fluvastatin oral 0 mg ST; QL (90 per 90 QL (90 per 90 QL (90 per 90 QL (90 per 90 QL (70 per 90 QL (90 per 90 ; QL (60 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

40 Name fluvastatin oral 0 mg fluvastatin oral extended release hr gemfibrozil oral JUXTAPID ORAL CAPSULE KYNAMRO SYRINGE LESCOL XL ORAL EXTENDED RELEASE HR LIPOFEN ORAL CAPSULE 10 MG LIPOFEN ORAL CAPSULE 0 MG lovastatin oral 10 mg, 0 mg lovastatin oral 0 mg niacin oral extended release hr niacor oral pravastatin oral prevalite oral powder prevalite oral powder in packet ; QL (180 per 90 1 ST; GC; QL (90 per 90 PA PA ST; QL (90 per 90 QL (90 per 90 QL (70 per 90 ; QL (70 per 90 ; QL (180 per 90 ; QL (90 per 90 Name SIMCOR ORAL, ER MULTIPHASE HR simvastatin oral TRIGLIDE ORAL 160 MG VASCEPA ORAL CAPSULE VYTORIN ORAL VYTORIN 10-0 ORAL VYTORIN 10-0 ORAL VYTORIN ORAL WELCHOL ORAL POWDER IN PACKET WELCHOL ORAL ZETIA ORAL MISCELLANEOUS ANTIHYPERTENSIVES CORLOPAM DEMSER ORAL CAPSULE epoprostenol (glycine) intravenous recon soln ST ; QL (90 per 90 QL (90 per 90 : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - ST; QL (90 per 90 ST; QL (90 per 90 ST; QL (90 per 90 ST; QL (90 per 90 QL (90 per 90

41 Name FLOLAN hydralazine injection hydralazine oral minoxidil oral PROGLYCEM ORAL SUSPENSION TEKTURNA HCT ORAL TEKTURNA ORAL VECAMYL ORAL veletri intravenous recon soln VENTAVIS INHALATION FOR NEBULIZATION QL (90 per 90 QL (90 per 90 PA B/D PA NITRATES AND COMBINATIONS BIDIL ORAL DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE ISORDIL ORAL ISORDIL TITRADOSE ORAL MG Name isosorbide dinitrate oral isosorbide dinitrate oral extended release isosorbide mononitrate oral isosorbide mononitrate oral extended release hr nitro-bid transdermal ointment NITRO-DUR TRANSDERMAL PATCH HOUR nitroglycerin in % dextrose intravenous nitroglycerin intravenous nitroglycerin oral, extended release nitroglycerin transdermal patch hour nitroglycerin translingual aerosol,spray nitroglycerin translingual spray,non-aerosol : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA -

42 Name NITROSTAT SUBLINGUAL CENTRAL NERVOUS SYSTEM ANTICONVULSANTS APTIOM ORAL BANZEL ORAL SUSPENSION BANZEL ORAL carbamazepine oral, er multiphase 1 hr carbamazepine oral suspension 100 mg/ ml carbamazepine oral carbamazepine oral extended release 1 hr carbamazepine oral,chewable CELONTIN ORAL CAPSULE 00 MG CEREBYX clonazepam oral clonazepam oral,disintegrating diazepam rectal kit Name DILANTIN 0 MG ORAL CAPSULE divalproex oral, sprinkle divalproex oral extended release hr divalproex oral,delayed release (dr/ec) epitol oral ethosuximide oral ethosuximide oral felbamate oral suspension felbamate oral fosphenytoin injection FYCOMPA ORAL MG, MG, 6 MG, 8 MG gabapentin oral gabapentin oral gabapentin oral 600 mg, 800 mg GABITRIL ORAL 1 MG, 16 MG : 1-Preferred Generic -Non-Preferred Generic -Preferred Brand -Non-Preferred Brand -Specialty s : B/D - Prior Authorization, Part D vs. Part B only GC Gap Coverage LA - 6